Form 40 Draft - Oregon Individual Income Tax Return - 2011 Page 6
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17OREGON FORM 40F 2-D BARCODE RETURN - W/BC INDEXES
1040
2011
(99)
Department of the Treasury—Internal Revenue Service
U.S. Individual Income Tax Return
OMB No. 1545-0074
IRS Use Only—Do not write or staple in this space.
See separate instructions.
For the year Jan. 1–Dec. 31, 2011, or other tax year beginning
, 2011, ending
, 20
Your social security number
Your first name and initial
Last name
If a joint return, spouse’s first name and initial
Last name
Spouse’s social security number
Home address (number and street). If you have a P.O. box, see instructions.
Apt. no.
Make sure the SSN(s) above
▲
and on line 6c are correct.
City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions).
Presidential Election Campaign
Check here if you, or your spouse if filing
jointly, want $3 to go to this fund. Checking
Foreign country name
Foreign province/county
Foreign postal code
a box below will not change your tax or
refund.
You
Spouse
1
Single
4
Head of household (with qualifying person). (See instructions.) If
Filing Status
168
171
2
Married filing jointly (even if only one had income)
the qualifying person is a child but not your dependent, enter this
169
Check only one
child’s name here.
3
Married filing separately. Enter spouse’s SSN above
▶
170
box.
and full name here.
5
Qualifying widow(er) with dependent child
▶
172
}
Boxes checked
6a
Yourself. If someone can claim you as a dependent, do not check box 6a .
.
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.
Exemptions
on 6a and 6b
b
Spouse
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No. of children
(4) ✓ if child under age 17
on 6c who:
Dependents:
c
(2) Dependent’s
(3) Dependent’s
• lived with you
qualifying for child tax credit
hip to you
(1) First nam
(see instructions)
• did not live with
FOR VENDOR USE ONLY
you due to divorce
173
or separation
If more than four
with Barcode Indexes
(see instructions)
174
dependents, see
Dependents on 6c
175
instructions and
not entered above
check here
176
▶
Add numbers on
177
d
To
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lines above
▶
7
Wages, salaries, tips, etc. Attach Form(s) W-2
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7
Income
178
8a
Taxable interest. Attach Schedule B if required .
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8a
179
b
Tax-exempt interest. Do not include on line 8a .
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8b
180
Attach Form(s)
9 a
Ordinary dividends. Attach Schedule B if required
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9a
181
W-2 here. Also
b
Qualified dividends
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9b
182
attach Forms
W-2G and
10
Taxable refunds, credits, or offsets of state and local income taxes
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10
183
1099-R if tax
11
Alimony received .
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11
184
was withheld.
12
Business income or (loss). Attach Schedule C or C-EZ .
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12
185
13
Capital gain or (loss). Attach Schedule D if required. If not required, check here
13
186
▶
If you did not
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Other gains or (losses). Attach Form 4797 .
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14
187
get a W-2,
15 a
IRA distributions .
15a
b Taxable amount
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15b
188
see instructions.
16 a
Pensions and annuities
16a
b Taxable amount
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16b
189
17
Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E
17
190
Enclose, but do
18
Farm income or (loss). Attach Schedule F .
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18
191
not attach, any
19
Unemployment compensation .
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19
192
payment. Also,
20 a
Social security benefits
20a
b Taxable amount
.
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20b
please use
194
193
Form 1040-V.
21
Other income. List type and amount
21
195
22
Combine the amounts in the far right column for lines 7 through 21. This is your total income
22
▶
196
23
Educator expenses
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23
197
Adjusted
24
Certain business expenses of reservists, performing artists, and
DRAFT
Gross
fee-basis government officials. Attach Form 2106 or 2106-EZ
24
198
Income
25
Health savings account deduction. Attach Form 8889
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25
199
26
Moving expenses. Attach Form 3903 .
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26
200
27
Deductible part of self-employment tax. Attach Schedule SE .
27
201
28
Self-employed SEP, SIMPLE, and qualified plans
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28
202
29
Self-employed health insurance deduction
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29
203
30
Penalty on early withdrawal of savings .
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30
204
31 a
Alimony paid
b Recipient’s SSN
31a
▶
205
32
IRA deduction .
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32
206
33
Student loan interest deduction .
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33
207
34
Tuition and fees. Attach Form 8917 .
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34
208
35
Domestic production activities deduction. Attach Form 8903
35
209
36
Add lines 23 through 35 .
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36
210
37
Subtract line 36 from line 22. This is your adjusted gross income
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37
▶
211
1040
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions.
Form
(2011)
Cat. No. 11320B
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