Form N-11/n-12/n-13/n-15 - Schedule X - Tax Credits For Hawaii Residents - 2003 Page 2

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Schedule X (Form N-11/N-12/N-13/N-15) (Rev. 2003)

Page 2

PART III: CREDIT FOR CHILD AND DEPENDENT CARE EXPENSES

Section A: Care Provider Information

(a) Care

(b) Address

(d) General Excise

(e) Amount paid

Provider’s name

(number, street, city, state and ZIP code)

(SSN or EIN)

Tax License Number

Section B: Employer-Paid Dependent Care Benefits

— (If you did not receive benefits, skip to line 16)

2 Enter the total amount of dependent care benefits you received from your employer for 2003. This amount

should be shown in Box 10 of your W-2 form(s)...........................................................................................................

3 Enter the amount forfeited, if any. (See the Instructions) ............................................................................................

4 Line 2 minus line 3........................................................................................................................................................

5 Enter the total amount of qualified expenses incurred in 2003 for the care of the qualifying person(s) .........

6 Enter the smaller of line 4 or 5.......................................................................................

7 Enter YOUR earned income.........................................................................................

8 If married filing a joint return, enter YOUR SPOUSE’S earned income (if student or

disabled, see Instructions); if married filing separately, see the instructions for the amount

to enter; all others, enter the amount from line 7 ...........................................................

9 Enter the smallest of line 6, 7, or 8 ................................................................................

10 Excluded benefits. Enter here the smaller of the following: (a) the amount from line 9, or (b) $5,000 ($2,500 if

married filing a separate return and you were required to enter your spouse’s earned income on line 8). ..................

11 Taxable benefits. Line 4 minus line 10. Also, include this amount on Form N-12, line 7; Form N-13, line 7;

or Form N-15, line 7. On the corresponding dotted line write “DCB”............................................................................

12 Enter $2,400 ($4,800 if two or more qualifying persons) .................................................

13 Enter the amount from line 10 ........................................................................................

14 Line 12 minus line 13. If zero or less, STOP. You cannot take the credit. Exception. If you paid 2002

expenses in 2003 (see Instructions).............................................................................................................................

15 Enter the amount of qualified expenses you incurred and paid in 2003. DO NOT include on this line any

excluded benefits shown on line 10..............................................................................................................................

Section C: Credit for Child and Dependent Care Expenses

(d) Qualified expenses

(a) Qualifying person’s name

(b) Relationship

you incurred and paid

security number

in 2003 for the person

listed in column (a)

17 Add the amounts in column (d) of line 16. DO NOT enter more than $2,400 for one

qualifying person or $4,800 for two or more persons. If you completed Section B,

enter the smaller of line 14 or line 15..............................................................................

18 Enter YOUR earned income.........................................................................................

19 If married filing a joint return, enter YOUR SPOUSE’S earned income (if student or

disabled, see the Instructions); all others, enter the amount from line 18 .......................

20 Enter the smallest of line 17, 18, or 19........................................................................................................................

21 Enter adjusted gross income from Form N-11, line 19; Form N-12, line 32;

Form N-13, line 11; or Form N-15, line 33, Column A .....................................................

22 Enter on line 22 the decimal amount shown below that applies to the amount on line 21.

If line 21 is:

Decimal amount is:

If line 21 is:

Decimal amount is:

Under $22,001

.25

$32,001 — 34,000

.19

$22,001 — 24,000