Form 40s (Short Form) - Oregon Individual Income Tax Return (Full-Year Residents Only) - 2003
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1Oregon
Form
2003
40S
Individual
For office use only
Income Tax
Date received
FULL-YEAR
Return
RESIDENTS ONLY
SHORT FORM
Last name
Birth year
First name and initial
For office
Social Security No. (SSN)
use only
–
–
__ __ __ __
1
Spouse’s last name if joint return
Spouse’s first name and initial if joint return
Spouse’s SSN, if joint return
Birth year
–
–
__ __ __ __
2
Current mailing address
Telephone number
(
)
City
State
3
ZIP code
If you filed a return last year, and this
address is different, check here ..........
•
Single
1
Exemptions
Severely
Filing
•
Total
Regular
disabled
2
Status
Married filing jointly
6a
6a Yourself
3
Married filing separately
b
6b Spouse
Check
(Spouse’s name)
only one
c
6c All dependents
•
box
(Spouse’s Social Security number)
(First names)
d
4
Head of household
•
(Person who qualifies you)
6d Child(ren) with
(First names)
a disability
•
6e
5
Total
Qualifying widow(er) with dependent child
•
•
7a
Check if: You were:
7b
7c If someone else can claim you
Check if you filed
65 or older
Blind
Spouse was:
an extension
as a dependent, check here
65 or older
Blind
•
•
8 Wages ...
8a
.00
plus unemployment ...
8b
.00
.00
•
plus interest and dividends ....
8c
.00
....Total income (8a + 8b + 8c) .................................
8d
.00
•
9 2003 federal tax liability ($0–$3,500; see instructions for the correct amount) .............
9
.00
•
10 Standard deduction from the back of this form .............................................................
10
.00
11 Add lines 9 and 10 ..............................................................................................................................................
11
.00
•
•
12 Oregon taxable income.
...............................
Line 8d minus line 11. If line 11 is more than line 8d, fill in -0- ...
12
•
•
.00
13 Tax from tables. See instructions, page 10 ..................................................................
...............................
13
.00
•
14
Exemption credit.
Multiply your total exemptions on line 6e by $147 .........................
14
.00
•
15 Earned income credit. See instructions, page 10 .........................................................
15
Staple
.00
•
16 Child and dependent care credit. See instructions, page 10 ........................................
16
W-2
.00
17 Total credits. Add lines 14 through 16 ................................................................................................................
17
wage
.00
•
•
slips
18 Tax after credits. Line 13 minus line 17. If line 17 is more than line 13, fill in -0- ..........
...............................
18
here
.00
•
19 Surcharge. See instructions, page 10 ..........................................................................
19
•
•
.00
20 Net income tax. Add lines 18 and 19 ...........................................................................
...............................
20
.00
•
21 Oregon income tax withheld. Attach your Form(s) W-2 and 1099 .............................
21
•
.00
22 Working family child care credit. Attach Schedule WFC, see page 21 .......................
22
.00
23 Total payments. Add lines 21 and 22 ..................................................................................................................
23
.00
•
•
24
Refund.
If line 23 is more than line 20, you have a refund. Line 23 minus line 20 .......
..........
REFUND
24
•
•
.00
TAX TO PAY
25
Tax to pay.
....
If line 20 is more than line 23, you have tax to pay. Line 20 minus line 23 ....
25
•
.00
26 Oregon Nongame Wildlife ..............
$1 ....
$5 ....
$10 ....
26
CHARITABLE
Other $______
CHECKOFFS
.00
•
27 Child Abuse Prevention ..................
$1 ....
$5 ....
$10 ....
27
Other $______
I wish to
These will
.00
•
28 Alzheimer’s Disease Research .......
$1 ....
$5 ....
$10 ....
28
donate
Other $______
reduce
part of my
•
.00
29 Stop Domestic & Sexual Violence ..
$1 ....
$5 ....
$10 ....
29
your refund
Other $______
tax refund
•
.00
to the
30 AIDS/HIV Education and Services ..
$1 ....
$5 ....
$10 ....
30
Other $______
following
•
.00
•
31 Other charity. Enter code
____ ....
$1 ....
$5 ....
$10 ....
31
Other $______
fund(s)
.00
32 Total. Add lines 26 through 31. Total can’t be more than your refund on line 24 .................................................
32
.00
33
NET REFUND.
Line 24 minus line 32. This is your net refund ..............................................
NET REFUND
33
34 For direct deposit of your refund, see the instructions on page 12.
•
DIRECT
Type of Account:
Checking or
Savings
DEPOSIT
•
•
Routing No.
Account No.
Under penalties for false swearing, I declare that I have examined this return, including accompanying schedules and
I authorize the Department of Revenue
statements. To the best of my knowledge and belief it is true, correct, and complete. If prepared by a person other than
to discuss this return with this preparer.
the taxpayer, this declaration is based on all information of which the preparer has any knowledge.
Your signature
Date
License No.
Signature of preparer other than taxpayer
X
X
SIGN
HERE
Telephone No.
Spouse’s signature
(if filing jointly, BOTH must sign)
Date
Address
X
150-101-044 (Rev. 12-03)
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