Form N-15 - Individual Income Tax Return Nonresident And Part-Year Resident - Hawaii Department Of Taxation - 2004

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Clear Form
STATE OF HAWAII — DEPARTMENT OF TAXATION
Form
DO NOT WRITE OR STAPLE IN THIS SPACE
2004
Individual Income Tax Return
N-15
NONRESIDENT and PART-YEAR RESIDENT
(Rev. 2004)
Calendar Year 2004
or other tax year beginning
, 2004 and ending
,
£
£
l
Check the applicable box:
Part-Year Resident
Nonresident
£
AMD UNP
008
PNT
INT
Check box if filing for the first time or if address has changed
Your first name and initial
Last name
Your social security number
If a joint return, spouse’s first name and initial
Last name
Spouse’s social security number
é IMPORTANT é
Present mailing or home address (Number and street, including apartment number or rural route)
You must enter your SSN(s).
City, town or post office, State and ZIP code. If you have a foreign address, see Instructions.
Your occupation / Spouse’s occupation
Note: Checking “Yes” will
HAWAII ELECTION
Do you want $2 to go to the Hawaii Election Campaign Fund? ............
Yes
No
not increase your tax or
CAMPAIGN FUND
If joint return, does your spouse want $2 to go to the fund? .................
Yes
No
reduce your refund.
If you are a nonresident, in what state or foreign country are you a resident? ________________________________
RESIDENCY STATUS
£
£
(Check only ONE box)
1
Single
4
Head of household (with qualifying person). If the qualifying
£
person is your child but not your dependent, enter this child’s
2
Married filing joint return (even if only one had income).
name here. ä
£
Married filing separate return. Enter spouse’s SSN above and
3
£
—
5
Qualifying widow(er) with dependent child (Year spouse died
_______ ).
—
full name here.
________________________________
Caution: If you can be claimed as a dependent on another person’s tax return (such as your parents’), do not check box 6a, but be sure to check the box below line 38.
£
£
}
Enter number of boxes
6a
Yourself .........................
Age 65 or over ..............................................................................
£
£
checked on 6a and 6b
6b
Spouse ..........................
Age 65 or over ..............................................................................
£
If you checked box 3 and 6b above, see the Instructions on page 8 and if your spouse meets the qualifications, check here
Enter number of
6c
your children listed
6c
Dependents:
If more than 2 dependents
2. Dependent’s social
1. First and last name
use attachment
security number
3. Relationship
Enter number of
and
6d
other dependents
6d
Add numbers
6e
entered in
6e Total number of exemptions claimed.........................................................................................................
boxes above
ATTACH A COPY OF YOUR FEDERAL INCOME TAX RETURN FOR 2004
Col. A - Total Income
Col. B - Hawaii Income
ROUND TO THE NEAREST DOLLAR
7
Wages, salaries, tips, etc. (attach Form(s) W-2) ........................................................
7l
00
00
8
Interest income from the worksheet on page 36 of the Instructions ............................
8l
00
00
9
Ordinary dividends...................................................................................................
9l
00
00
10
State income tax refund from the worksheet on page 36 of the Instructions................
10l
00
00
11
Alimony received .....................................................................................................
00
11
00
12
Business or farm income or (loss).............................................................................
12l
00
00
13
Capital gain or (loss) from the worksheet on page 36 of the Instructions.....................
13l
00
00
14
Supplemental gains or (losses) (attach Schedule D-1) ..............................................
14
00
00
15
IRA distributions ......................................................................................................
15l
00
00
16
Pensions and annuities
..............
16l
00
(see Instructions and attach Schedule J, Form N-11/N-12/N-15/N-40)
00
17
Rents, royalties, partnerships, estates, trusts, etc. ...................................................................
17l
00
00
18
Unemployment compensation (insurance). ..............................................................
18l
00
00
19
Other income (state nature and source)....................................................................
00
19l
00
20
Add lines 7 through 19.................................................................Total Income
20l
00
00
21
Deduction for clean-fuel vehicles ..............................................................................
21
00
00
22
Certain business expenses of reservists, performing artists, and fee-basis government officials.............
22
00
00
23
IRA deduction..........................................................................................................
23
00
00
24
Student loan interest deduction from the worksheet on page 40 of the Instructions.....
24
00
00
25
Health savings account deduction ............................................................................
25
00
00
26
Moving expenses (attach Form N-139) .....................................................................
26
00
00
27
One-half of self-employment tax...............................................................................
27
00
00
28
Self-employed health insurance deduction ...............................................................
28
00
00
29
Self-employed SEP, SIMPLE, and qualified plans.....................................................
29
00
00
30
Penalty on early withdrawal of savings......................................................................
00
30
00
31
Alimony paid
..................................................................
31
00
(Enter name and SS No. of recipient)
00
32
Payments to an individual housing account...............................................................
32l
00
00
33
First $1,750 of military reserve or Hawaii national guard duty pay ..............................
33l
00
00
34
Exceptional trees deduction (attach affidavit) (see page 18 of the Instructions)....
34l
00
00
35
Add lines 21 through 34......................................................Total Adjustments
35l
00
00
l36l
AGI
36
Line 20 minus line 35 ................................................Adjusted Gross Income
00
00
FORM N-15

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