Schedule CO Individual (Long Form) - Page 2
Rev. Feb 19 13
B - TAXPAYER
C - SPOUSE
8.
DEDUCTIONS INDIVIDUALLY ALLOCATED (See instructions):
18
00
A) Contributions to governmental pension or retirement systems …….....................................……………………………………
00
(01)
(38)
B)
Contributions to individual retirement accounts (Do not exceed from $5,000 each):
Financial inst.
Account No.
Employer Ident. No.
Contribution
(02)
(05)
(03)
(06)
(04)
(07)
00
Total contributions to individual retirement accounts (Distribute the amount as it corresponds to the taxpayer and spouse)
00
(08)
(39)
C) Contributions to health savings accounts with a high annual deductible medical plan (See instructions):
Institution
Account No.
Employer Ident. No.
Contribution
_________________________
________________________
______________________
________________
(11)
(15)
Effective
Annual deductible
____________ Type of
1 Individual
2 Individual and age 55 or older
(09)
(12)
date
coverage:
3 Family
4 Family and age 55 or older
(16)
__________________
Institution
Employer Ident. No.
Account No.
Contribution
_________________________
_____________________
_______________________
________________
(13)
(17)
Effective
Annual deductible
____________ Type of
1 Individual
2 Individual and age 55 or older
(10)
(14)
date
coverage:
3 Family
4 Family and age 55 or older
(18)
__________________
Total contributions (Add the smaller amount between the contribution and the annual deductible of each account.
00
00
Distribute the amount as it corresponds to the taxpayer and spouse) ................................................................................
(19)
(40)
00
00
D) Educational Contribution Account (Complete line 23) (See instructions)…………………........................................…………
(20)
(41)
E)
Interest paid on students loans at university level (See instructions):
Financial inst.
Loan No.
Employer Ident. No.
Amount
(21)
(23)
(22)
(24)
00
00
Total interest paid on students loans .............................................................................................................................
(25)
(42)
00
00
(43)
F) Total deductions individually allocated (Add lines 8A through 8E, Columns B and C, respectively) ...........................................................
(26)
00
00
9.
(27)
(44)
Special Deduction for Certain Individuals (See instructions) …………………………………………………........................…
3,500
3,500
00
00
10.
PERSONAL EXEMPTION .........................................................................................................................................................
(28)
(45)
11.
EXEMPTION FOR DEPENDENTS (Complete Schedule A1 Individual, see instructions)
00
A)
__________ X $2,500 .........................................................................................................
(31)
(29)
00
B)
__________X $1,250 (Joint custody) ..................................................................................
(32)
(30)
00
C) Total exemption for dependents (Add lines 11A and 11B) ....................................................
(33)
00
00
(34)
(46)
D) Enter 50% of the total of line 11C in Columns B and C ........................................................................................................
00
00
12.
(35)
(47)
Additional Personal Exemption for Veterans (See instructions) ...........................................................................................
00
00
13.
(48)
Total Deductions and Exemptions (Add lines 7G, 8F, 9, 10, 11D and 12, Columns B and C, respectively) .........................
(36)
00
00
14.
NET TAXABLE INCOME (Subtract line 13 from line 6. If line 13 is larger than line 6, enter zero) ...........................................
(37)
(49)
15.
TAX:
1 Tax Table
2 Preferential rates (Schedule A2 Individual)
(01)
19
00
00
(09)
3 Nonresident alien
4 Schedule B4 Individual ..............................................................................................
(02)
16.
Gradual Adjustment Amount (Determine this adjustment if the amount indicated on line 14, Column B or C, or on
00
00
(10)
Schedule A2 Individual, line 10 is larger than $200,000) (Schedule P Individual, line 7) …………………………………........…
(03)
00
00
(11)
17.
(04)
REGULAR TAX BEFORE THE CREDIT (Add lines 15 and 16, Columns B and C, respectively) ………………........…………
18.
Credit for taxes paid to foreign countries, the United States, its territories and possessions (Submit Schedule C Individual)
00
00
(12)
(05)
(See instructions) .......................................................................................................................................................................
00
00
(13)
19.
NET REGULAR TAX (Subtract line 18 from line 17) ................................................................................................................
(06)
00
00
(14)
20.
(07)
Excess of Net Alternate Basic Tax over Net Regular Tax (Schedule O Individual, Part II, line 8) (See instructions) ….........…
00
00
(15)
21.
Tax Determined Individually (Add lines 19 and 20, Columns B and C, respectively) ………….…………....……..........………
(08)
22.
TOTAL TAX DETERMINED (Add the amounts of Columns B and C of line 21 and transfer to Part 3, line 19 of the Long Form) ............................................................
00
(16)
Continue in Part 3, line 19 of the Long Form.
57
23.
BENEFICIARIES OF EDUCATIONAL CONTRIBUTION ACCOUNTS (See instructions)
Date of Birth (Day/Month/Year)
(01)
Name, Initial
Last Name
Second Last Name
Social Security Number
Contributed Amount
Relationship
(Not to exceed from $500 each)
Account Number
Financial institution
Employer Identification Number
00
Name, Initial
Last Name
Second Last Name
(02)
Date of Birth (Day/Month/Year)
Contributed Amount
Social Security Number
Relationship
(Not to exceed from $500 each)
Financial institution
Account Number
Employer Identification Number
00
(03)
Name, Initial
Last Name
Second Last Name
Date of Birth (Day/Month/Year)
Social Security Number
Contributed Amount
Relationship
(Not to exceed from $500 each)
Financial institution
Account Number
Employer Identification Number
00
(10)
00
Total contributions (Add lines (01) through (03) and transfer to line 8D, Column B or C, as applicable) .....................................
Retention Period: Ten (10) years