Form N-15 (Rev. 2005)
Page 2 of 4
Your Social Security Number
Your Spouse's SSN
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Name(s) as shown on return
_____________________________________________________
MF052
If amount is negative (loss), shade the minus (-) in box. Example:
Col. A - Total Income
Col. B - Hawaii Income
l7l
7
Wages, salaries, tips, etc. (attach Form(s) W-2) .........
8
Interest income from the worksheet on page 37 of
the Instructions ............................................................
8l
9
Ordinary dividends ......................................................
9l
10
State income tax refund from the worksheet on
page 37 of the Instructions ..........................................
10l
11
Alimony received .........................................................
11
-
-
If negative number, place a minus sign (-)
If negative number, place a minus sign (-)
l12l
12
Business or farm income or (loss) ...............................
-
-
13
Capital gain or (loss) from the worksheet on
page 37 of the Instructions .........................................
13l
-
-
14
Supplemental gains or (losses)
(attach Schedule D-1) ................................................
14
15
IRA distributions ..........................................................
15l
16
Pensions and annuities
(see Instructions and
............................
16l
attach Schedule J, Form N-11/N-12/N-15/N-40)
-
-
17
Rents, royalties, partnerships, estates, trusts, etc. ....................
17l
18
Unemployment compensation (insurance). ................
18l
-
-
19
Other income (state nature and source)
________________________________ ....................
19l
-
-
➤
20
Add lines 7 through 19 ......................Total Income
20l
21
Educator expenses......................................................
21
22
Certain business expenses of reservists, performing artists, and
fee-basis government officials .............................................
22
23
IRA deduction..............................................................
23
24
Student loan interest deduction from the worksheet
on page 41 of the Instructions .....................................
24
25
Health savings account deduction...............................
25
26
Moving expenses (attach Form N-139) .......................
26
l27
27
One-half of self-employment tax .................................
28
Self-employed health insurance deduction ................
28
29
Self-employed SEP, SIMPLE, and qualified plans ......
29
30
Penalty on early withdrawal of savings .......................
30
31
Alimony paid
(Enter name and SS No. of recipient)
________________________________ ....................
31
]
32
Payments to an individual housing account ................
32l
ID No 01
FORM N-15
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