Form 39r - Idaho Supplemental Schedule For Form 40 - 2012 Page 2
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2Form 39R - 2012
Page 2
EFO00088p2 07-30-12
Name(s) as shown on return
Social Security Number
.
D. Credit for Income Tax Paid to Other States. See instructions, page 24.
This credit is being claimed for taxes paid to:
__________________________________
(State name)
1. Idaho tax, Form 40, line 20 ........................................................................
1
00
.
Include a copy of the
2. Federal adjusted gross income earned in other state adjusted for
income tax return and a
2
Idaho modifications. See instructions .......................................................
00
separate Form 39R for
each state for which a
3
00
3. Idaho adjusted income. See instructions ..................................................
credit is claimed.
4
4. Divide line 2 by line 3. Enter percentage here ...........................................
%
.
5. Multiply line 1 by line 4. Enter amount here .....................................................................................
5
00
6. Other state's tax due less its income tax credits ..............................................................................
6
00
.
7
7. Enter the smaller of lines 5 or 6 here and on Form 40, line 22 ........................................................
00
E. Credits for Contributions to Idaho Educational Entities, Idaho Youth and Rehabilitation
Facilities, and Live Organ Donation Expenses. See instructions, page 24.
. .
00
1. Credit for contributions to Idaho educational entities .......................................................................
1
.
00
2. Credit for contributions to Idaho youth and rehabilitation facilities ...................................................
2
00
3. Credit for live organ donation expenses ...........................................................................................
3
00
4. Total credits. Add lines 1 through 3. Enter total here and on Form 40, line 23 ...............................
4
F. Maintaining a Home for a Family Member Age 65 or Older, or a Family Member With a
Developmental Disability. See instructions, page 25.
1. Did you maintain a home for an immediate family member age 65 or older and provide more than
Yes
No
one-half of his/her support? You and your spouse do not qualify ..................................................
2. Did you maintain a home for an immediate family member with a developmental disability and
Yes
No
provide more than one-half of his/her support? You and your spouse may qualify ........................
3. List each family member you are claiming:
Check here if
Name of Family Member
Social Security Number
Relationship to Person
Date of Birth of
developmentally
disabled
First Name
Last Name
of Family Member
Filing Return
Family Member
4. Total amount claimed ($100 for each qualifying member but not more than $300).
Enter here and on Form 40, line 43. (Credit cannot be claimed if you took $1,000 deduction
on Part B, line 15.) .................................................................................................................
4
00
G. Dependents: (Continued from Form 40, page 1, Line 6c)
Social Security Number
First Name
Last Name
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