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 bonds,
DIVIDENDS from national and Tennessee chartered bank stock, credit unions, building or savings and
notes, mortgages and other taxable interest. (See instructions on separate sheet for examples and
loan companies, Tennessee licensed insurance companies, and cemetery companies. Also, include all
explanations of taxable income.)
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 unions, certificates of deposit, accounts not
________________________________________________________
Please round to the nearest dollar
represented by a written instrument, passbook accounts, savings accounts, bank money market
Dividends:
0 0
________________________________________________________
accounts, "NOW" accounts, and commercial paper maturing in 6 months or less. (See instructions on
separate sheet for examples and explanations of nontaxable income).
0 0
________________________________________________________
0 0
__________________________________________________________________________________________________________________
Please round to the nearest dollar
0 0
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:
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
00
NON-TAXABLE
INCOME
INCOME
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 wish to
receive a return
Date
Taxpayer's Signature
Spouse's Signature
in the mail for
(
)
next tax year,
Tax Preparer's Signature
Date
Telephone
check box at
right.
Zip
State
Preparer's Address
City
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