Form 458 - Nebraska Schedule I - Income Statement - 2007
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NEBRASKA SCHEDULE I — Income Statement
FORM
TO BE FILED
• Attach this schedule to Nebraska Homestead Exemption Application
458
WITH COUNTY
or Certification of Status, Form 458
ASSESSOR
• Read instructions carefully
Applicant’s Name as Shown on Form 458
Applicant’s Social Security Number
This Income Statement is filed for (select one only, fill in oval completely, example:
):
Applicant
Applicant & Spouse
Spouse
Other Owner/Occupant
Spouse’s or Other Owner/Occupant’s Name
Spouse’s or Owner/Occupant’s Soc. Sec. No.
NOTE: Do not include other owner/occupant’s income on the income statement of the applicant/spouse listed above.
Each other owner/occupant’s income must be reported on a separate Nebraska Schedule I — Income Statement.
IF MARRIED DURING 2007, YOU MUST REPORT INCOME FOR BOTH YOU AND YOUR SPOUSE.
PART I — For Applicants Who
DID NOT FILE
a 2007 Federal Income Tax Return
• Complete Worksheet A on reverse side of white copy
• If you filed a 2007 federal income tax return, complete only Part II
Household Income: January 1 through December 31, 2007
$
1 Wages and salaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
2 Social security retirement income. If none, explain
______________________________________________
________________________________________________________________________________________________
2
________________________________________________________________________________________________
3 Tier I railroad retirement income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
4 Total pensions and annuities 4a______________________
4b Taxable amount . . . . . . . . . . . 4b
5 IRA distributions
5a______________________
5bTaxable amount . . . . . . . . . . . 5b
6 Tax exempt interest and dividends (must include all state and local bond income) . . . . . . . . . . . . . .
6
7 Taxable interest and dividends. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
8 Other income or adjustments (from line G, Worksheet A on reverse side of white copy). . . . . . . . .
8
9 TOTAL OF LINES 1 THROUGH 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
Caution: Do not include expenses reimbursed by insurance or paid by others
MEDICAL AND DENTAL EXPENSES –
10a Medical and dental expenses (see instructions) . . . . . . . . . . . . . . . . . . . . 10a
10b Multiply
LINE 9
by 4% (.04) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10b
10c Subtract line 10b from line 10a. If line 10b is more than line 10a enter -0-. . . . . . . . . . . . . . . . . . . . 10c
11 HOUSEHOLD INCOME (line 9 minus line 10c) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
PART II — For Applicants Who
FILED
a 2007 Federal Income Tax Return
• If you did not file a 2007 federal income tax return, please complete only Part I and Worksheet A.
Household Income: January 1 through December 31, 2007
1 Federal adjusted gross income (AGI) from line 37, Federal Form 1040;
1
line 21, Form 1040A or line 4, Form 1040EZ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2 Social security retirement income (see instructions for Part II, line 2) . . . . . . . . . . . . . . . . . . . . . . . .
2
3 Tier I railroad retirement income (see instructions for Part II, line 3) . . . . . . . . . . . . . . . . . . . . . . . . .
3
4 Nebraska adjustments increasing federal AGI (from line 12, Form 1040N) . . . . . . . . . . . . . . . . . . . .
4
5 Income from Nebraska obligations (from line 45b, Schedule I, Form 1040N) . . . . . . . . . . . . . . . . . .
5
6 TOTAL OF LINES 1 THROUGH 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
–
CAUTION: Do not include expenses reimbursed by insurance or paid by others
MEDICAL AND DENTAL EXPENSES
7a Medical and dental expenses (see instructions) . . . . . . . . . . . . . . . . . . . . . . 7a
LINE 6, Part II,
7b Multiply
by 4% (.04). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7b
7c Subtract line 7b from line 7a. If line 7b is more than line 7a enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . 7c
8 HOUSEHOLD INCOME (line 6 minus line 7c) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
Under penalties of law, I declare that I have examined this schedule, and that it is, to the best of my knowledge and belief, correct and complete.
sign
(
)
here
Signature of Person Whose Income is Shown
(Spouse’s Signature if Income Included)
Date
Daytime Phone
FILE FORM 458 AND THIS SCHEDULE WITH YOUR COUNTY ASSESSOR AFTER FEBRUARY 1 AND ON OR BEFORE JUNE 30
RETAIN CANARY COPY FOR YOUR RECORDS
Nebraska Department of Revenue
Form No. 2-655-1994 Rev. 12-2007 Supersedes 2-655-1994 Rev. 12-2006
Printed with soy ink on recycled paper
Authorized by Section 77-3510 and 77-3528
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