Form 40n - Individual Income Tax Return October - 2001

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Clear Form
Oregon
2001 40
Form
Individual
N
Income Tax
For office use only
Return
Date received
NONRESIDENT
Fiscal year ending
Oregon resident:
Mo
Day
Year
Mo
Day
Year
From
To
Last name
First name and initial
Birth year
For office
Social Security No. (SSN)
use only
1
Spouse’s last name if different and joint return
Spouse’s first name and initial if joint return
Spouse’s SSN, if joint return
Spouse’s
birth year
2
Current mailing address
Telephone number
(
)
3
City
State
ZIP code
If you filed a return in 2000, and this
address is different, check here
•
1
Single
Severely
Exemptions
•
Filing
Regular
disabled
Total
2
Married filing jointly
Status
6a Yourself
6a
3
Married filing separately
Check
6b Spouse
b
(Spouse’s name)
only one
•
c
6c All dependents
box
(Spouse’s Social Security number)
(First names)
4
Head of household
•
d
6d Disabled
(Person who qualifies you)
children only
(First names)
•
6e
5
Qualifying widow(er) with dependent child
Total
•
•
7a
Check if:
You were:
65 or older
Blind
7b
Check if you filed an extension
Spouse was:
•
•
65 or older
Blind
Federal column
Oregon column
8 Wages, salaries, and other pay for work. Staple all Forms W-2 below
8
INCOME
9 Taxable interest income 9a
plus dividend income 9b
9
10
10 State and local income tax refunds from federal Form 1040, line 10
11
11 Alimony received from federal Form 1040, line 11
12 Business income or loss from federal Form 1040, line 12
12
13 Capital gain or loss from federal Form 1040, line 13
13
14
14 Other gains or losses from federal Form 1040, line 14
15
15 IRA distributions from federal Form 1040, line 15b
Staple W-2 and
16 Pensions and annuities from federal Form 1040, line 16b
16
1099 forms
17 Rents, royalties, partnerships, etc., from federal Form 1040, line 17
17
showing
18
18 Farm income or loss from federal Form 1040, line 18
Oregon
withholding
19
19 Unemployment and other income from federal Form 1040, lines 19 through 21
here
•
20 Total income. Add lines 8 through 19
20a
20b
21 IRA or SEP and SIMPLE contributions, federal Form 1040, lines 23 and 29
21
ADJUSTMENTS
TO INCOME
22
22 Student loan interest deduction from federal form 1040, line 24
23
23 Archer MSA deduction from federal Form 1040, line 25
24 Moving expense from federal Form 1040, line 26
24
25 Deduction for self-employment tax from federal Form 1040, line 27
25
26
26 Self-employed health insurance deduction from federal Form 1040, line 28
27
27 Penalty on early withdrawal of savings from federal Form 1040, line 30
28 Alimony paid from federal Form 1040, line 31a
28
29 Total adjustments to income. Add lines 21 through 28
29
•
30a
30b
30 Income after adjustments. Line 20 minus line 29
•
31
31 Interest on government bonds of states other than Oregon
ADDITIONS
•
32 Federal election on interest and dividends of a minor child
32
•
33 Other additions. Identify
33
•
34a
34b
34 Total additions. Add lines 31 through 33
•
35a
35b
35 Income after additions. Add lines 30 and 34
Mail tax-to-pay returns to:
Mail refund returns and no-tax-due returns to:
Oregon Department of Revenue, PO Box 14555, Salem OR 97309-0940
REFUND, PO Box 14700, Salem OR 97309-0930
150-101-048 (Rev. 10-01) Web
NOW GO TO THE BACK OF THE FORM

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