Form Inc 250 - Individual Income Tax Return Page 2
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1
2Enter taxpayer's phone number in the boxes below
If taxpayer is deceased, en-
ter date of death in the boxes
at left (MMDDYY).
If
taxpayer spouse is
deceased, enter date of
death in the boxes.
SCHEDULE A - TAXABLE DIVIDENDS AND INTEREST
SCHEDULE B - NON-TAXABLE DIVIDENDS AND INTEREST
List taxable dividends from all sources, including holding companies and mutual funds. List all
DIVIDENDS from national and Tennessee chartered bank stock, credit unions, building or
bonds, notes, mortgages and other taxable interest. (See instructions on separate sheet for
savings and loan companies, Tennessee licensed insurance companies, and cemetery companies.
examples and explanations of taxable income.)
INTEREST on bonds of the U.S. Government and its agencies, Tennessee bonds, interest from
credit unions, certificates of deposit, accounts not represented by a written instrument, passbook
________________________________________________________
Please round to the nearest dollar
accounts, savings accounts, bank money market accounts, "NOW" accounts, and commercial paper
0 0
Dividends:
________________________________________________________
maturing in 6 months or less. (See instructions on separate sheet for examples and explanations of
nontaxable income).
0 0
________________________________________________________
0 0
__________________________________________________________________________________________________________________
Please round to the nearest dollar
0 0
0 0
Dividends:
__________________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________________
Interest:
Interest:
0 0
0 0
__________________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________________
0 0
0 0
__________________________________________________________________________________________________________________
0 0
0 0
TOTAL
TOTAL
TAXABLE
00
00
NON-TAXABLE
INCOME
INCOME
Under penalties of perjury, I declare that I have examined this report, and to the best of my knowledge and belief, it is true, correct and complete.
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