Form 40p - 2004 Individual Income Tax Return For Part-Year Residents

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OREGON
Form
2004
40P
For offi ce use only
Individual Income Tax Return
FOR PART-YEAR RESIDENTS
1
2
3
Oregon resident:
Fiscal year ending
mm
dd
yyyy
mm
dd
yyyy
To
From
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 SSN, if joint return
Spouse’s fi rst name and initial if joint return
Date of birth (mm/dd/yyyy)
–
–
Current mailing address
Telephone number
(
)
City
State
ZIP code
Country
If you fi led a return last year, and your
name or address is different, check here
•
•
Filing
Exemptions
Total
1
Single
Status
2
Married fi ling jointly
6a Yourself......
Regular
........ Severely disabled
.........
6a
Check
3
Married fi ling
6b Spouse ......
b
Regular
........ Severely disabled
...........
Spouse’s name
only
separately
one
•
6c All de pen dents
First names ________________________________
c
Spouse’s SSN
box
4
•
Head of household
6d Child(ren)
d
Person who qualifi es you
First names ________________________________
with a disability
•
5
Qualifying widow(er) with dependent child
Total
6e
•
•
7a
7d
•
Check
7b
7c
You fi led
7e
You
You attached
If there is a kicker refund,
You were:
all that
65 or older
Blind
Schedule
you want to donate your
fi led an
an Oregon
➛
apply
Spouse was:
65 or older
Blind
Form 24
kicker to the State School Fund
extension
WFC-N/P
Federal column
Oregon column
8 Wages, salaries, and other pay for work. Staple all Forms W-2 below ................
.00
.00
8
INCOME
.00
.00
9 Taxable interest income from federal Form 1040, line 8a ......................................
9
.00
.00
10 Dividend income from federal Form 1040, line 9a ..................................................
10
.00
.00
11 State and local income tax refunds from federal Form 1040, line 10......................
11
.00
.00
12 Alimony received from federal Form 1040, line 11 ..................................................
12
.00
.00
13 Business income or loss from federal Form 1040, line 12 ......................................
13
.00
.00
14 Capital gain or loss from federal Form 1040, line 13 ..............................................
14
Staple
W-2s,
.00
.00
15 Other gains or losses from federal Form 1040, line 14 ...........................................
15
payment,
16 IRA distributions from federal Form 1040, line 15b .................................................
.00
.00
16
and
.00
.00
17 Pensions and annuities from federal Form 1040, line 16b......................................
17
payment
voucher
.00
.00
18 Rents, royalties, partnerships, etc., from federal Form 1040, line 17......................
18
here
19 Farm income or loss from federal Form 1040, line 18 ............................................
.00
.00
19
.00
.00
20 Unemployment and other income from federal Form 1040, lines 19 through 21 ....
20
•
21 Total income. Add lines 8 through 20 ......................................................................
.00
.00
21a
21b
.00
.00
AD JUST MENTS
22 IRA or SEP and SIMPLE contributions, federal Form 1040, lines 25 and 32..........
22
TO INCOME
.00
.00
23 Education deductions from federal Form 1040, lines 23, 26, and 27......................
23
.00
.00
24 Moving expenses from federal Form 1040, line 29 .................................................
24
.00
.00
25 Deduction for self-employment tax from federal Form 1040, line 30 ......................
25
26 Self-employed health insurance deduction from federal Form 1040, line 31 ..........
.00
.00
26
.00
.00
27 Alimony paid from federal Form 1040, line 34a.......................................................
27
.00
.00
28 Other adjustments to income. Identify __________________________________
28
29 Total adjustments to income. Add lines 22 through 28 ............................................
.00
.00
29
•
•
30 Income after adjustments. Line 21 minus line 29..................................................
.00
.00
30a
30b
•
.00
.00
31 Interest on state and local government bonds outside of Oregon.........................
31
ADDITIONS
•
.00
.00
32 Federal election on interest and dividends of a minor child ..................................
32
•
.00
.00
33 Other additions. Identify ___________________________________________
33
•
.00
.00
34 Total additions. Add lines 31 through 33 .................................................................
34a
34b
•
35 Income after additions. Add lines 30 and 34...........................................................
.00
.00
35a
35b
Attach a copy of your federal Form 1040, 1040A, 1040EZ, 1040NR, or TeleFile Tax Record. Do not attach other federal sched ules.
REFUND
Oregon Department of Rev e nue
4
4
TAX-TO-PAY
Mail
Mail
REFUND
returns and
PO Box 14700
PO Box 14555
returns to
NO-TAX-DUE
returns to
Salem OR 97309-0930
Salem OR 97309-0940
➛
NOW GO TO THE BACK OF THE FORM
150-101-055 (Rev. 12-04)

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