Form 1040cm - Territorial Individual Income Tax Return 2004
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4DIVISION OF REVENUE AND TAXATION
COMMONWEALTH OF THE NORTHERN MARIANA ISLANDS
TERRITORIAL INDIVIDUAL INCOME TAX RETURN
1040CM
Form
2004
For the year Jan. 1- Dec. 31, 2004, or other tax year beginning
, 2004, ending __________________20, ____________
Your first name and initial
Last Name
Your social security number
Spouse’s social security number
If a joint return, spouse’s first name and intitial
Last Name
Apt. No.
Home Address (number and street). If you have a P.O. Box, see page 16.
IMPORTANT !
City, town or post office, state, and ZIP code. If you have foreign address, see page 16.
You must enter SSN(s) above
1.
Single
2.
Married filing joint return (even if only one had income)
3.
Married filing separate return. Enter spouse’s social security no. above and full name here. (See page 4 and 29.)
4.
Head of household (with qualifying person). (See page 17.) If the qualifying person is a child but not your
dependent, enter this child’s name here.
5.
Qualifying widow(er) with dependent child (year spouse died
) (See page 17.)
6a.
Yourself. If your parent (or someone else) can claim you as a dependent on his or her tax return, do not check box 6a...............
No. of boxeschecked
6b.
Spouse.
on6a and 6b
No. of your children
c.
Dependents:
/
(2) Dependent’s social
(3) Dependent’s
(4)
If qualifying child for
\
on 6cwho:
(1) First Name
Last Name
security number
relationship to you
child tax credit (see page 18)
Ž lived with you
Ž did not live with
you due to divorce
or separation
(see page 18)
Dependents on 6c
not entered above
Add numbers
entered onlines
d
Total number of exemptions claimed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............................ . . . . . . . . . . . . . . . . . . . . . . . .
above
A.
B.
C.
INCOME WITHOUT
INCOME WITHIN
SOURCE OF INCOME
TOTAL INCOME
AND Income not subject to rebate
AND Income subject to rebate
7
Wages, salaries, tips, etc. Attach Form(s) W2 and W-2CM ..................................................
7
8a
Taxable interest. Attach Schedule B if required........................................................................
8a
Tax-exempt interest. DO NOT include on line 8a............................. [8b]
b
9a
Ordinary Dividends. Attach Schedule B if required.............................................................
9a
Qualified dividends (see page 20).......................................................... [9b]
b
10
Taxable refunds, credits, or offsets of state and local income taxes (see page 20)................
10
11
Alimony received................................................................................................................ ..............
11
12
Business income or (loss). Attach Schedule C or C-EZ.............................................................
12
13
Capital gain or (loss). Attach Schedule D if required. If not required, check here........
13
14
Other gains or (losses). Attach Form 4797 .................................................................................
14
15a IRA distributions
b Taxable amount (see page 22)
15b
15a
16a
16a Pensions and annuities
b Taxable amount (see page 22)
16b
17
Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E 17
(see important instructions on page 77)
18
Farm income or (loss). Attach Schedule F.....................................................................................
18
19
Unemployment compensation..........................................................................................................
19
20a Social security benefits 20a
b Taxable amount (see page 24)
20b
21a Gambling winnings. Attach Form(s) W-2G................................................................................
21a
b Other income. List type and amount (see page 24)..................................................................
21b
22a Total Income. Add amounts shown in all columns for lines 7 through 21b .....................
22a
b. Allocable percentage (see instructions on page 77)..................................................................
22b
%
%
100%
23 Educator expenses (see page 26)........................................................................................................
23
24 Certain business expenses of reservists, performing artists, and
fee-basis government official. Attach Form 2106 or 2106-EZ............................................................. 24
25 IRA deduction (see page 26)....................................................................................................... 25
26 Student loan interest deduction (see page 28)............................................................................
26
27 Tuition and fees deduction (see page 29)...................................................................................
27
28 Health savings account deduction. Attach Form 8889......................................................................... 28
29. Moving expenses. Attach Form 3903.................................................................................................... 29
30 One-half of self-employment tax. Attach Schedule SE......................................................................... 30
31 Self-employed health insurance deduction (see page 30)...................................................................
31
32 Self-employed SEP, SIMPLE, and qualified plans................................................................................ 32
33 Penalty on early withdrawal of savings.................................................................................................
33
34a Alimony paid
b Recipient’s SSN
................................. 34a
35 Add lines 23 through 34a..........................................................................................................................................................................................................................
35
36 Subtract line 35 from line 22a, col. C. This is your adjusted gross income.................................................................................................................................
36
For Disclosure, Privacy Act and Paperwork Reduction Act Notice, see page 75
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