Form 200-02 - Delaware Individual Non-Resident Income Tax Return - 2004 Page 2

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2004 DELAWARE NON-RESIDENT FORM 200-02, PAGE 2
Delaware Source
Federal
Income/Loss
COLUMN 1
SECTION A - INCOME AND ADJUSTMENTS FROM FEDERAL RETURN
COLUMN 2
1.
Wages, salaries, tips, etc.................................................................................................................
00
00
1
2.
Interest...........................................................................................................................................
00
00
2
3.
Dividends........................................................................................................................................
00
00
3
4.
State refunds, credits or offsets of state & local income taxes.............................................................
4
00
00
5.
Alimony received.............................................................................................................................
5
00
00
6
6.
Business income or (loss) (See instructions).....................................................................................
00
00
7a
7a. Capital gain or (loss)........................................................................................................................
00
00
7b
00
00
7b. Other gains or (losses).....................................................................................................................
00
00
8.
IRA distributions..............................................................................................................................
8
00
00
9.
Taxable pensions and annuities........................................................................................................
9
00
00
10. Rents, royalties, partnerships, S corps, estates, trusts, etc................................................................
10
00
00
11
11.
Farm income or (loss)......................................................................................................................
00
00
12
12. Unemployment compensation (insurance)........................................................................................
00
00
13
13. Taxable Social Security Benefits.......................................................................................................
00
00
14
14. Other income (state nature and source)
00
00
15
15. Total income. Add Lines 1 through 14...............................................................................................
00
00
16
16. Total Federal Adjustments (See instructions).....................................................................................
00
00
17
17. Federal Adjusted Gross Income for Delaware purposes. Subtract Line 16 from 15..............................
COLUMN 1
COLUMN 2
SECTION B - DELAWARE MODIFICATIONS AND ADJUSTMENTS - ADDITIONS ( + )
18
00
00
18. Interest received on obligations of any state other than Delaware.......................................................
19
00
00
19. Fiduciary adjustment, oil depletion...................................................................................................
20
00
00
20. TOTAL - Add Lines 18 & 19.............................................................................................................
21
00
00
21.
Add Lines 17 & 20..........................................................................................................................
COLUMN 1
COLUMN 2
SECTION C - DELAWARE MODIFICATIONS AND ADJUSTMENTS - SUBTRACTIONS ( - )
00
00
22
22. Interest received on U.S. Obligations................................................................................................
00
00
23
23. Pension Exclusion/Retirement Exclusion (See instructions)...............................................................
00
00
24. Delaware State tax refund, Delaware Lottery......................................................................................
24
25. Fiduciary Adjustment, Work Opportunity Credit, Delaware NOL Carryforward.....................................
25
00
00
26. Taxable Social Security Benefits/Railroad Retirement Benefits/Higher Education Exclusion.................
26
00
00
27. TOTAL - Add Lines 22 through 26....................................................................................................
27
00
00
28. Subtract Line 27 from Line 21 and enter here....................................................................................
28
00
00
29. Exclusion for certain persons 60 and over or disabled (See instructions).............................................
29
00
00
Column 2. Subtract Line 29 from Line 28. This is your modified Delaware Source Income.
30A.
Enter on front side Line 42, Box A
.
................................................................................................................................
30A
00
Column 1. Subtract Line 29 from Line 28. This is your Delaware Adjusted Gross Income.
30B.
00
30B
Enter on front side Line 37 and Line 42, Box B.
.....................................................................
COLUMN 1
SECTION D - ITEMIZED DEDUCTIONS (ATTACH FEDERAL SCHEDULE A, FORM 1040)
00
31. Enter total Itemized Deductions (See instructions)...........................................................................
31
00
32
32. Enter Foreign Taxes Paid (See instructions).....................................................................................
00
33
33. Enter Charitable Mileage Deduction (See instructions).....................................................................
00
34. TOTAL - Add Lines 31, 32, and 33 .................................................................................................
34
00
35a. Enter State Income Tax included in Line 31 above (See Instructions)................................................
35a
35b. Enter Form 700 Tax Credit Adjustment (See instructions)................................................................
00
35b
36. Subtract Line 35a and 35b from Line 34. Enter here and on front, Line 38........................................
00
36
SECTION E - DIRECT DEPOSIT INFORMATION
If you would like your refund deposited directly
to your checking or savings account, complete boxes a, b and c below. See instructions for details.
a. Routing Number
b. Type:
Checking
Savings
DATE OF DEATH
SPOUSE
TAXPAYER
c. Account Number
/
/
/
/
Month
Day
Year
Month
Day
Year
NET BALANCE DUE (LINE 57):
NET REFUND (LINE 58):
ZERO (LINE 58):
DELAWARE DIVISION OF REVENUE
DELAWARE DIVISION OF REVENUE
DELAWARE DIVISION OF REVENUE
P.O. BOX 8752
P.O. BOX 8772
P.O. BOX 8711
WILMINGTON, DE 19899-8752
WILMINGTON, DE 19899-8772
WILMINGTON, DE 19899-8711
MAKE CHECK PAYABLE TO: DELAWARE DIVISION OF REVENUE
REMEMBER TO ATTACH APPROPRIATE SUPPORTING SCHEDULES WHEN FILING YOUR RETURN
(Rev 11/29/04)
AND KEEP A COPY OF THE RETURN FOR YOUR RECORDS
(Rev 08/17/04)

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