DISABLED VETERANS’ HOUSEHOLD INCOME WORKSHEET (Side 2)
0.00
20.
TOTAL FROM LINE 19………………………………………………………………20. $_________________
STEP E.
Adjustments to Income. Complete lines 21 through 25 (if applicable).
Section 17072 and following sections of the Revenue and Taxation Code provide for an “adjusted gross income”
which means, in the case of an individual, gross income minus the following deductions:
21.
Forfeited interest penalty…………………………………………. 21. $___________________
22.
Alimony paid……………………………………………………….. 22. $___________________
23.
Individual retirement arrangement such as Keogh
(HR 10), or Simplified Employee Plan (SEP) subject
to certain limitations………………………………………………... 23. $___________________
24.
Employee business expenses…………………………………….. 24. $___________________
25.
Moving expenses and deductions of expenses
(already taken) for the production of income
(or loss) reported in Items7 (rental), 8 (business),
and 9 (sale of capital assets) included in “Income”…………… 25. $___________________
STEP F.
Adjustments to Income.
0.00
26.
Add lines 21 through 25………………………………………………………………26. $__________________
STEP G.
Total Household Income
27.
Subtract line 26 from line 20………………………………………………………….27. $_________________
STEP H.
Please sign and date this form. Enter your telephone number.
I hereby declare the foregoing facts to be true and correct to the best of my knowledge. I make this
statement under penalty of perjury under the Laws of the State of California.
____________________________________________________________
_____________________________
SIGNATURE
DATE
____________________________________________________________
DAYTIME TELEPHONE NUMBER