Form 1040n - Schedule I - Nebraska Adjustments To Income - 2015
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1
2
3FORM 1040N
Nebraska Schedule I
— Nebraska Adjustments to Income
Schedule I
(Nebraska Schedule II reverse side.)
2015
• Attach this page to Form 1040N.
Name on Form 1040N
Name on Form 1040N
Social Security Number
Social Security Number
Nebraska Schedule I —
Nebraska Adjustments to Income for Nebraska Residents, Partial-Year Residents, and Nonresidents
• Attach additional pages if necessary.
Part A — Adjustments Increasing Federal AGI
1 Interest income from all state and local obligations exempt from federal tax
a List type:
b Amount: $
List type:
Amount:
Total interest income exempt from federal tax. Enter total of lines 1b .............................................................
1
00
2 Exempt interest income from Nebraska obligations
a List type:
b Amount: $
List type:
Amount:
Total exempt interest income from Nebraska obligations. Enter total of lines 2b ...........................................
2
00
3 Total taxable interest income. Enter the result of line 1 minus line 2 ..................................................................
3
00
4 Financial Institution Tax Credit claimed. Enter amount from line 25, Form 1040N .............................................
4
00
5 Nebraska College Savings Program recapture (see instructions) .......................................................................
5
00
6 Long-Term Care Savings Plan recapture (also subject to 10% penalty) (see instructions) ................................
6
00
7 Federal net operating loss deduction .................................................................................................................
7
00
8 S corporation or LLC Non-Nebraska loss ............................................................................................................
8
00
00
9 Total adjustments increasing federal AGI (total lines 3 through 8). Enter here and on line 12, Form 1040N .....
9
Part B — Adjustments Decreasing Federal AGI
10 State income tax refund deduction. Enter line 10, Federal Form 1040 ............................................................... 10
00
11 U.S. government obligations exempt for state purposes (list below or attach schedule)
a List type:
b Amount: $
List type:
Amount:
Total U.S. government obligations exempt for state purposes. Enter total of lines 11b .................................. 11
00
12 List fund name, total dividend, and percent of regulated investment company dividends from
a U.S. obligation:
b Total dividend: $
x c
d $
.
% =
a U.S. obligation:
b Total dividend: $
x c
.
% =
d $
Total regulated investment company dividends. Enter total of lines 12d ......................................................... 12
00
13 Total U.S. government obligations. Enter total of lines 11 and 12. ...................................................................... 13
00
14 Benefits paid by the Railroad Retirement Board (RRB) included in the federal AGI. Attach all Forms 1099
and W-2 from the RRB.
a List type:
b Amount: $
List type:
Amount:
Total benefits paid by the RRB included in federal AGI. Enter total of lines 14b ............................................. 14
00
15 Special capital gains/extraordinary dividend deduction [attach Form 4797N; a copy of Federal Schedule D;
and Form 8949 (or Federal Schedule B when claiming extraordinary dividend deduction)] (see instructions) ...... 15
00
16 Nebraska College Savings Program contribution (see instructions) ................................................................... 16
00
17 Nebraska Long-Term Care Savings Plan contribution ........................................................................................ 17
00
18 Nebraska Long-Term Care Savings Plan earnings ................................................................................................. 18
00
19 S corporation and LLC Non-Nebraska income (attach Nebraska Schedules K-1N, see instructions) .................... 19
00
20 Nonresident military servicemember active duty pay (attach active duty Form W-2, identifying the income as
attributable to another state, see instructions) ........................................................................................................ 20
21 Native American Indian Reservation income .......................................................................................................... 21
00
22 Claim of right repayment ......................................................................................................................................... 22
00
23 Nebraska NOL carryforward (attach a copy of the Nebraska NOL Worksheet for each loss year claimed on this line) 23
00
24 Nebraska agricultural revenue bond interest ........................................................................................................... 24
00
25 Interest from federally taxable Nebraska Investment Finance Association (NIFA) bonds ...................................... 25
00
26 Interest from federally taxable Build America Bonds issued by Nebraska governmental units ............................... 26
00
27 Social Security included in Federal AGI (see instructions) .................................................................................. 27
00
28 Military retirement. Form 1040N-MIL must be on file with the Department (see instructions) ............................. 28
00
29 Total adjustments decreasing federal AGI (total lines 10 and 13 through 28). Enter here and on
line 13, Form 1040N ............................................................................................................................................ 29
00
8-418-2015
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