Form 40n - Oregon Individual Income Tax Return - Nonresident - 2003
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1
2Oregon
Clear Form
Form
2003
Individual
40N
W
Income Tax
For office use only
Return
NONRESIDENT
Date received
Fiscal year ending
Oregon resident:
Mo
Day
Year
Mo
Day
Year
From
To
Last name
First name and initial
Birth year
Social Security No. (SSN)
For office
__ __ __ __
use only
–
–
Spouse’s last name if joint return
Spouse’s SSN, if joint return
Birth year
Spouse’s first name and initial if joint return
1
–
–
__ __ __ __
Current mailing address
Telephone number
2
(
)
City
State
ZIP code
3
If you filed a return last year, and this
address is different, check here ........
•
1
Single
Exemptions
Severely
Filing
•
Total
Regular
disabled
2
Status
Married filing jointly
6a
6a Yourself
3
Married filing separately
b
Check
6b Spouse
(Spouse’s name)
only one
c
6c All dependents
•
box
(Spouse’s Social Security number)
(First names)
d
4
Head of household
•
(Person who qualifies you)
6d Child(ren) with
(First names)
•
a disability
6e
Total
5
Qualifying widow(er) with dependent child
•
•
7a
Check if: You were:
7b
Check if you filed
7c Check if you filed an
65 or older
Blind
an extension...
Oregon Form 24 .......
Spouse was:
65 or older
Blind
Federal column
Oregon column
.00
.00
8 Wages, salaries, and other pay for work. Staple all Forms W-2 below ..................
INCOME
8
.00
.00
9 Taxable interest income from federal Form 1040, line 8a ........................................
9
.00
.00
10 Dividend income from federal Form 1040, line 9a ....................................................
10
.00
.00
11 State and local income tax refunds from federal Form 1040, line 10 ........................
11
.00
.00
12 Alimony received from federal Form 1040, line 11 ...................................................
12
.00
.00
13 Business income or loss from federal Form 1040, line 12 ........................................
13
.00
.00
14 Capital gain or loss from federal Form 1040, line 13a ..............................................
14
.00
.00
15 Other gains or losses from federal Form 1040, line 14 ............................................
15
Staple W-2
.00
.00
16 IRA distributions from federal Form 1040, line 15b ..................................................
16
and 1099
forms
.00
.00
17 Pensions and annuities from federal Form 1040, line 16b .......................................
17
showing
.00
.00
18 Rents, royalties, partnerships, etc., from federal Form 1040, line 17 ........................
18
Oregon
.00
.00
withholding
19 Farm income or loss from federal Form 1040, line 18 ..............................................
19
here
.00
.00
20 Unemployment and other income from federal Form 1040, lines 19 through 21 ......
20
•
.00
.00
21 Total income. Add lines 8 through 20 ......................................................................
21a
21b
.00
.00
ADJUSTMENTS
22 IRA or SEP and SIMPLE contributions, federal Form 1040, lines 24 and 30 ...........
22
TO INCOME
.00
.00
23 Education deductions from federal Form 1040, lines 23, 25, and 26 ........................
23
.00
.00
24 Moving expenses from federal Form 1040, line 27 ..................................................
24
.00
.00
25 Deduction for self-employment tax from federal Form 1040, line 28 ........................
25
.00
.00
26 Self-employed health insurance deduction from federal Form 1040, line 29 ............
26
.00
.00
27 Penalty on early withdrawal of savings from federal Form 1040, line 31 ..................
27
.00
.00
28 Alimony paid from federal Form 1040, line 32a ........................................................
28
.00
.00
29 Total adjustments to income. Add lines 22 through 28 .............................................
29
.00
•
.00
30 Income after adjustments. Line 21 minus line 29 ...................................................
•
30a
30b
.00
.00
•
31 Interest on state and local government bonds outside of Oregon ..........................
ADDITIONS
31
.00
.00
•
32 Federal election on interest and dividends of a minor child ....................................
32
.00
.00
•
33 Other additions. Identify _____________________________________________
33
.00
.00
•
34 Total additions. Add lines 31 through 33 ..................................................................
34a
34b
.00
.00
•
35 Income after additions. Add lines 30 and 34 ............................................................
35a
35b
Attach a copy of your federal Form 1040, 1040A, 1040EZ, 1040NR, or TeleFile Tax Record. Do not attach other federal schedules.
Oregon Department of Revenue
REFUND
Mail
TAX-TO-PAY
Mail
REFUND
returns and
PO Box 14555
PO Box 14700
returns to
NO-TAX-DUE
returns to
Salem OR 97309-0940
Salem OR 97309-0930
NOW GO TO THE BACK OF THE FORM.....
150-101-048 (Rev. 12-03) Web
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