Form Ia 1040 - Iowa Individual Income Tax Long Form - 2010 Page 3
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42010 IA 1040
Iowa Individual Income Tax Long Form
Reset Form
Print Form
or fiscal year beginning __/__ 2010 and ending __/__ /__
STEP 1: Fill in all spaces. You MUST fill in your Social Security Number.
Your last name
Your first name/middle initial
Fill in all information below.
Check this box if you or your spouse were
Spouse’s last name
Spouse’s first name/middle initial
65 or older as of 12/31/10.
•
•
Your Social Security Number
Spouse Social Security Number
Current mailing address (number and street, apartment, lot, or suite number) or PO Box
Residence on 12/31/10
•
•
City, State, ZIP
County No.
School District No.
STEP 2 Filing Status: Mark one box only.
You must answer these questions:
Dependent children for whom an exemption is claimed in Step 3
1
Single: Were you claimed as a dependent on another person’s Iowa return?
YES
NO
ONNO
•
How many have health care coverage?
_______
2
Married filing a joint return. (Two-income families may benefit by using status 3 or 4.)
(including Medicaid or hawk-i)
•
How many do not have health care coverage? _______
3
Married filing separately on this combined return. Spouse use column B.
4
Married filing separate returns. Spouse’s name:
SSN:
Income: $
5
Head of household with qualifying person. If qualifying person is not claimed as a dependent on this return, enter the person’s name and Social Security Number below.
6
Qualifying widow(er) with dependent child. Name:
SSN:
40
STEP 3
a. Personal Credit: Enter 1. (Enter 2 if filing joint or head of household.) ................. _______
X $ _________ = $ __________
YOU
20
b. Enter 1 for each person who is 65 or older and/or 1 for each person who is blind. ... _______
X $ _________ = $ __________
Exemptions
(and spouse if
filing jointly)
40
c. Dependents: Enter 1 for each dependent. ................................................................... _______
X $ _________ = $ __________
d. Enter first names of dependents here: ____________________________________
e. TOTAL $ ______________
40
a. Personal Credit: Enter 1. ............................................................................................... _______
X $ _________ = $ __________
20
b. Enter 1 if 65 or older and/or 1 if blind. ............................................................................ _______
X $ _________ = $ __________
SPOUSE
40
c. Dependents: Enter 1 for each dependent. ................................................................... _______
X $ _________ = $ __________
(If filing
status 3)
d. Enter first names of dependents here: ____________________________________
e. TOTAL $ ______________
B. Spouse/Status 3
A. You or Joint
B. Spouse/Status 3
A. You or Joint
STEP 4
1. Wages, salaries, tips, etc. ................................................................. 1. ______________ .00
______________ .00
2. Taxable interest income. If more than $1,500, complete Sch. B. ...... 2. ______________ .00
______________ .00
Gross
3. Ordinary dividend income. If more than $1,500, complete Sch. B. ...... 3. ______________ .00
______________ .00
Income
4. Alimony received .............................................................................. 4. ______________ .00
______________ .00
5. Business income/(loss) from federal Schedule C or C-EZ .............. 5. ______________ .00
______________ .00
6. Capital gain/(loss) from federal Sch. D if required for federal purposes . 6. ______________ .00
______________ .00
7. Other gains/(losses) from federal form 4797 .................................... 7. ______________ .00
______________ .00
8. Taxable IRA distributions .................................................................. 8. ______________ .00
______________ .00
9. Taxable pensions and annuities ....................................................... 9. ______________ .00
______________ .00
10. Rents, royalties, partnerships, estates, etc. ..................................... 10. ______________ .00
______________ .00
11. Farm income/(loss) from federal Schedule F ................................... 11. ______________ .00
______________ .00
12. Unemployment compensation. See instructions. ............................. 12. ______________ .00
______________ .00
13. Taxable Social Security benefits ...................................................... 13. ______________ .00
______________ .00
14. Other income, gambling income, bonus depreciation/section 179 adjustment ... 14. ______________ .00
______________ .00
15. GROSS INCOME. ADD lines 1-14. ........................................................................................................................... 15. _______________ .00
_______________ .00
STEP 5
16. Payments to an IRA, Keogh, or SEP ............................................... 16. ______________ .00
______________ .00
17. One-half of self-employment tax ...................................................... 17. ______________ .00
______________ .00
Adjust-
18. Health insurance deduction .............................................................. 18. ______________ .00
______________ .00
ments
19. Penalty on early withdrawal of savings ............................................ 19. ______________ .00
______________ .00
to
20. Alimony paid ..................................................................................... 20. ______________ .00
______________ .00
Income
21. Pension/retirement income exclusion .............................................. 21. ______________ .00
______________ .00
22. Moving expense deduction from federal form 3903 ......................... 22. ______________ .00
______________ .00
23. Iowa capital gain deduction. ............................................................. 23. ______________ .00
______________ .00
24. Other adjustments ............................................................................ 24. ______________ .00
______________ .00
25. Total adjustments. ADD lines 16-24. ........................................................................................................................ 25. _______________ .00
_______________ .00
26. NET INCOME. SUBTRACT line 25 from line 15. .................................................................................................... 26. _______________ .00
_______________ .00
STEP 6
27. Federal income tax refund / overpayment received in 2010 ............ 27. ______________ .00
______________ .00
28. Self-employment/household employment taxes .............................. 28. ______________ .00
______________ .00
Federal
29. Addition for federal taxes. ADD lines 27 and 28. ...................................................................................................... 29. _______________ .00
_______________ .00
Tax
30. Total. ADD lines 26 and 29. ...................................................................................................................................... 30. _______________ .00
_______________ .00
Addition
31. Federal tax withheld ......................................................................... 31. ______________ .00
______________ .00
and
Deduc-
32. Federal estimated tax payments made in 2010 ............................... 32. ______________ .00
______________ .00
tion
33. Additional federal tax paid in 2010 for 2009 and prior years ........... 33. ______________ .00
______________ .00
34. Deduction for federal taxes. ADD lines 31, 32, and 33. ............................................................................................ 34. _______________ .00
_______________ .00
35. BALANCE. SUBTRACT line 34 from line 30. Enter here and on line 36, side 2. .................................................... 35. _______________ .00
_______________ .00
L10
41-001a (07/23/10)
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