Form In-113 - Vermont Income Adjustment Schedules - 2004 Page 2
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2*041131299*
Form IN-113, page 2
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Carried forward from
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_______________________________
Line 16A
Line 16B
17. IRA/Keogh/SEP/SIMPLE deduction:
A. Federal Amount $
B. VT Portion $
Self
__________________________________________00.
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0 0
0 0
Spouse ________________________________________17.
17.
18. Federal Education Deductions:
(Form 1040, Lines 23, 26, & 27 OR Form 1040A, Lines 16, 18, & 19 OR
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0 0
0 0
1040NR, Lines 24, 26, & 32 OR 1040NR-EZ, Lines 8 & 9). . . . . . . . . . . . 18.
18.
19. Employee Deductions: Medical Savings Account (Form 8853, Line 5)
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0 0
0 0
Reservists, Performing Artists, Fee-basis gov’t officials (1040, Line 24) 19.
19.
20. Self-Employment Deductions: Tax (1040, Line 30) and
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0 0
0 0
Health Insurance (1040, Line 31) OR 1040NR, Line 29 . . . . . . . . . . . . . . 20.
20.
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0 0
0 0
21. Health Savings Account (1040, Line 28 OR 1040NR, Line 27) . . . . . . . . . . 21.
21.
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0 0
0 0
22. Moving Expenses (1040, Line 29 OR 1040NR, Line 28) . . . . . . . . . . . . . 22.
22.
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0 0
0 0
23. Penalty on Early Withdrawal of Savings (1040, Line 33 OR 1040NR, Line 31)23.
23.
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0 0
0 0
24. Alimony Paid (1040, Line 34a) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24.
24.
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0 0
0 0
25. TOTAL ADJUSTMENTS (Add Lines 17 – 24) . . . . . . . . . . . . . . . . . . . . . 25.
25.
Check to indicate
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0 0
loss
26. Adjusted Gross Income (Subtract Line 25A from Line 16A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26.
Check to indicate
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0 0
loss
27. VT Portion of AGI (Subtract Line 25B from Line 16B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
27.
Check to indicate
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0 0
28. Non-VT Income (Subtract Line 27 from Line 26. Enter result here and on Schedule II, Line 30 below). .
loss
28.
Dates of VT residency in 2004: From ____________________________ to ____________________________
Name of state(s), Canadian province, or country during non-VT residency: ________________________________________________
SCHEDULE II. Adjustment for VT Exempt Income
Check to indicate
29. Adjusted Gross Income If Schedule I completed, enter Line 26.
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0 0
loss
Otherwise, enter Line 10 amount from IN-111 Section 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
29.
Check to indicate
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0 0
(Full-year VT residents enter 0 on Line 30)
loss
30. Non-Vermont Income . . . . . . . . . . . . . . . . . . . . . .
30.
(Enter amount from Line 28 above)
(Part-Year Residents: For Lines 31-37, enter only income included in Line 27, Schedule I)
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0 0
31. Military pay. Number of months on active duty____ (See Instructions) . 31.
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0 0
32. Lottery prizes from Vermont state-run lottery. . . . . . . . . . . . . . . . . . . . . . 32.
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0 0
33. Federal Employment Opportunity income adjustment . . . . . . . . . . . . . . . 33.
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0 0
34. Railroad Retirement income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34.
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0 0
35. VT State payments for support of developmentally disabled person(s) . 35.
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0 0
36. Americans with Disabilities Credit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36.
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0 0
37. Nonresident Commercial Film Income. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37.
Check to indicate
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0 0
loss
38. Total (Add Lines 30-37) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
38.
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Check to indicate
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0 0
loss
39. VT income (Subtract Line 38 from Line 29) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
39.
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%
40. INCOME ADJUSTMENT % (Divide Line 39 by Line 29) Enter here and on Form IN-111, Section 4, Line 21. See instructions. . . . . . . . . . . . . . . . . . . . $ $ 40.
Form IN-113
22
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