Form Inc 250 - Individual Income Tax Return Page 2
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1
2SCHEDULE 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 com-
examples and explanations of taxable income.)
panies. Also, include all pass through income from a partnership or S corporation. INTEREST
on bonds of the U.S. Government and its agencies, Tennessee bonds, interest from credit
_________________________________________________________
Please round to the nearest dollar
unions, certificates of deposit, accounts not represented by a written instrument, passbook
Dividends:
0 0
_________________________________________________________
accounts, savings accounts, bank money market accounts, "NOW" accounts, and commer-
cial paper maturing in 6 months or less. (See instructions on separate sheet for examples and
0 0
_________________________________________________________
explanations of nontaxable income).
0 0
___________________________________________________________________________________________________________________
Please round to the nearest dollar
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
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:
0 0
___________________________________________________________________________________________________________________
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
___________________________________________________________________________________________________________________
0 0
0 0
___________________________________________________________________________________________________________________
0 0
0 0
TOTAL
TOTAL
TAXABLE
00
NON-TAXABLE
INCOME
00
INCOME
Enter on Line
1 on front also.
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.
If you use a paid
preparer and do
Date
Taxpayer's Signature
Spouse's Signature
not want forms
(
)
mailed to you next
Date
Tax Preparer's Signature
Telephone
year, check box at
right.
Zip
State
Preparer's Address
City
INTERNET (11-98)
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