Form Inc 250 - Individual Income Tax Return Page 2
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1
2If taxpayer is deceased,
Enter taxpayer's phone number in the boxes below
enter date of death in the
boxes at right
If taxpayer spouse is
deceased, enter date of
death in the boxes.
SCHEDULE A - TAXABLE DIVIDENDS AND INTEREST
SCHEDULE B - NON-TAXABLE DIVIDENDS AND INTEREST
List taxable dividends from all sources, including holding companies and mutual funds. Also,
DIVIDENDS from national and Tennessee chartered bank stock, credit unions, building or
include capital gain and non-dividend distributions. List all bonds, notes, mortgages, and
savings and loan companies, and Tennessee licensed insurance companies.
INTEREST on bonds of the U.S. Government and its agencies, Tennessee bonds,
other taxable interest.
interest from credit unions, certificates of deposit, accounts not represented by a
_____________________________________________________
written instrument, passbook accounts, savings accounts, bank money market
Please round to the nearest dollar
accounts, "NOW" accounts, and commercial paper maturing in 6 months or less.
Dividends:
0 0
_____________________________________________________
(See instructions on separate sheet for examples and explanations of nontaxable
0 0
_____________________________________________________
income).
0 0
__________________________________________________________________________________________________________
Please round to the nearest dollar
Dividends:
0 0
0 0
__________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________
0 0
Interest:
0 0
__________________________________________________________________________________________________________
Interest:
0 0
0 0
__________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________
0 0
0 0
GROSS
GROSS
TAXABLE
NON-TAXABLE
INCOME
00
00
Enter on Line
INCOME
1 on front also.
Remit amount calculated on Line 8 (front of return)
Under penalties of perjury, I declare that I have examined this report, and to the best of my knowledge and belief, it is true, correct and complete.
Date
Taxpayer's Signature
Spouse's Signature
(
)
Date
Tax Preparer's Signature
Telephone
Zip
State
Preparer's Address
City
(INTERNET 1-13)
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