Form 40 - 2004 Individual Income Tax Return Full-Year Residents Only
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1
22004
OREGON
Form
For office use only
40
Individual Income Tax Return
Fiscal year ending
2
3
1
FULL-YEAR RESIDENTS ONLY
Last name
First name and initial
Date of birth (mm/dd/yyyy)
Social Security No. (SSN)
–
–
Spouse’s last name if joint return
Spouse’s first name and initial if joint return
Date of birth (mm/dd/yyyy)
Spouse’s SSN, if joint return
–
–
Current mailing address
Telephone number
(
)
City
State
Country
ZIP code
If you filed a return last year, and your
name or address is different, check here
•
Filing
Exemptions
Status
•
Total
1
Single
Check
2
Married filing jointly
6a Yourself......
6a
Regular
........ Severely disabled
.........
only
one
3
Married filing
6b Spouse ......
Regular
........ Severely disabled
...........
b
Spouse’s name
box
separately
•
6c All de pen dents
c
Spouse’s SSN
First names ________________________________
4
•
Head of household
6d Child(ren)
d
Person who qualifies you
First names ________________________________
with a disability
•
5
Total
Qualifying widow(er) with dependent child
6e
•
•
7a
7d
•
Check
7b
7c
You filed
7e
You
You attached
If there is a kicker refund,
You were:
all that
65 or older
Blind
you want to donate your
filed an
Schedule
an Oregon
➛
apply
Spouse was:
65 or older
Blind
Form 24
kicker to the State School Fund
extension
WFC
Round to the nearest dollar
8 Federal adjusted gross income. Federal Form 1040, line 36; 1040A, line 21;
1040EZ, line 4; 1040NR, line 34; or TeleFile Tax Record, line I. See instructions .......................................
•
.00
8
•
.00
9 Interest and dividends on state and local government bonds outside of Oregon .....
ADDITIONS
9
•
.00
10 Other additions. Identify ______________________________________________
10
.00
11 Total additions. Add lines 9 and 10.................................................................................................................
11
.00
12 Income after additions. Add lines 8 and 11 ....................................................................................................
12
•
.00
13 2004 federal tax liability ($0–$4,000; see instructions for the correct amount) .........
SUB TRAC TIONS
13
•
.00
14 Social Security included on federal Form 1040, line 20b; or Form 1040A, line 14b
14
•
.00
Staple
15 Oregon income tax refund included in federal income..............................................
15
W-2s,
•
.00
16 Interest from U.S. government, such as Series EE and HH bonds ..........................
16
payment,
•
.00
17 Federal pension income (see instructions on page 25) ________% ........................
17
and
•
.00
payment
18 Other subtractions. Identify ___________________________________________
18
voucher
.00
19 Total subtractions. Add lines 13 through 18 ...................................................................................................
19
here
.00
20 Income after subtractions. Line 12 minus line 19...........................................................................................
20
If you are claiming itemized deductions, fill in lines 21–25. If you are claiming the standard deduction, fill in line 26 only.
DEDUCTIONS
•
.00
21 Itemized deductions from Schedule A, line 28 ..........................................................
21
•
.00
22 Special Oregon medical deduction (age restricted, see instructions, page 28) ........
22
.00
23 Total Oregon itemized deductions. Add lines 21 and 22 .............................................
23
•
.00
24 State income tax claimed as an itemized deduction from Schedule A, line 5 .....
24
25 Net Oregon itemized deductions. Line 23 minus line 24 ............................................
.00
25
Either line 25 or 26
OR
•
.00
26 Standard deduction from page 28.............................................................................
26
27 Total deductions. Line 25 or line 26, whichever is larger ...........................................................................
.00
27
•
28 Oregon taxable income. Line 20 minus line 27. If line 27 is more than line 20, fill in -0- .....................................
.00
28
•
.00
TAX
29 Tax. See pages 21 through 23 for t ax tables or charts and enter tax here .................
29
EITHER,
OR
NOT BOTH
•
30 Check if tax is from:
Form FIA-40 or
Worksheet FCG and enter tax here ....
.00
30
•
.00
31 Interest on certain installment sales......................................
31
32 Total tax. Add lines 29 and 31 OR add lines 30 and 31 .......................................................OREGON TAX
.00
32
➛
NOW GO TO THE BACK OF THE FORM
150-101-040 (Rev. 12-04)
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