Form Ia 1040a - Iowa Individual Income Tax Short Form - 2011

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2011 IA 1040A
Iowa Individual Income Tax Short Form
Fill in all information below.
For full-year Iowa residents only.
Check this box if you or your spouse were 65 or older as of 12/31/11.
STEP 1:
Fill in all spaces. You MUST fill in your Social Security Number.
Your last name
Your first name/middle initial
Your Social Security Number
Spouse Social Security Number
Spouse’s last name
Spouse’s first name/middle initial
Residence on 12/31/11
County No.
School District No.
Current mailing address (number and street, apartment, lot, or suite number) or PO Box
You must answer these questions
Dependent children for whom an exemption is claimed in Step 3
How many have health care coverage?
_______
City, State, ZIP
(including Medicaid or hawk-i)
How many do not have health care coverage? _______
STEP 2: Filing Status: Mark one box only.
1
Single: Were you claimed as a dependent on another person’s Iowa return?
YES
NO
LNONNO
2
Married filing a joint return.
5
Head of household with qualifying person. If qualifying person is not claimed as a dependent on this return, enter the person’s name and
6
Qualifying widow(er) with dependent child.
SSN here. Name:
SSN:
L
STEP 3
40
a. Personal Credit: Enter 1 (Enter 2 if filing joint or head of household.) .................. _______
X $ _________ = $ __________
YOU
20
L
b. Enter 1 for each person who is 65 or older and/or 1 for each person who is blind .... _______
X $ _________ = $ __________
Exemption
(and spouse if
L
40
c. Dependents: Enter 1 for each dependent .................................................................... _______
X $ _________ = $ __________
filing jointly)
Credits
d. Enter first names of dependents here: ____________________________________
e. TOTAL $ ______________
1. Total wages, salaries, tips, and unemployment compensation. See instructions. ................................... 1 .
__________________ .00
STEP 4
2. Taxable interest. If more than $1,500, complete Schedule B. ...................................................................... 2 .
__________________ .00
Figure
3. Taxable dividends. If more than $1,500, complete Schedule B. .................................................................. 3 .
__________________ .00
your
4. Net income. Add lines 1, 2, and 3.
................................................................................................................... 4 . L __________________ .00
income
5. Federal income tax refund received in 2011. .................................................................................................... 5 . L __________________ .00
6. TOTAL. Add lines 4 and 5. ................................................................................................................................... 6 .
__________________ .00
7. Federal tax payment information.
a . L ___________ .00
(a) Federal tax withheld ..............................................
b. L ___________ .00 7 .
__________________ .00
(b) Additional paid in 2011 for 2010 and any prior year .
8. Income subject to tax. Subtract line 7 from line 6. If greater than $100,000 you must use IA 1040 long form. .. 8 .
__________________ .00
9. Tax from tables. See IA 1040A tax tables at ................................................................ 9 . L __________________ .00
STEP 5
10. Total exemption credits from Step 3. ............................................................................................................... 1 0 .
__________________ .00
Figure
11. BALANCE. Subtract line 10 from line 9. If less than zero, enter zero. ..................................................... 11. L __________________ .00
your
12. Multiply line 11 by your school district surtax rate. See 2011 school district surtax list. ..................... 12. L __________________ .00
tax,
13. Fish and Wildlife Fund Contribution. $1 or more supports the Wildlife Diversity Program. ................. 13. L __________________ .00
credits
and
14. State Fairgrounds Renovation Contribution. $1 or more helps renovate the fairgrounds. ................... 14. L __________________ .00
checkoff
15. Volunteer Firefighters/Veterans Trust Fund. $1 or more shared by two organizations. ........................ 15. L __________________ .00
contri-
butions
16. Child Abuse Prevention. $1 or more. ............................................................................................................... 16. L __________________ .00
17. Total Tax and Contributions. Add lines 11 through 16. ............................................................................... 1 7 .
__________________ .00
18. Iowa income tax withheld from Box 17 of your W-2 form(s). ...................................................................... 18. L __________________ .00
19. Iowa Earned Income Tax Credit. (federal EITC credit $
X .07) See instructions ............ 19. L __________________ .00
20. Total credits. Add lines 18 and 19. .................................................................................................................. 2 0 .
__________________ .00
21. If line 20 is more than line 17, subtract line 17 from line 20. This is your REFUND. ............................ 21. L __________________ .00
STEP 6
Figure
eFile at or mail to Iowa Income Tax Refund Processing, Hoover State Office Bldg, Des Moines IA 50319-0120
your
22. If line 20 is less than line 17, subtract line 20 from line 17. This is the AMOUNT OF TAX YOU OWE. ...... 22. L __________________ .00
refund
23. Penalty. .................................................................................................................................................................. 23. L __________________ .00
or
24. Interest. ................................................................................................................................................................. 24. L __________________ .00
amount
due
25. TOTAL AMOUNT DUE. Add lines 22, 23, and 24 and enter here. ............................................................ 25. L __________________ .00
ePay at or mail to Iowa Income Tax Processing, PO Box 9187, Des Moines IA 50306-9187. Write check to: Treasurer, State of Iowa
This checkoff does not
POLITICAL CHECKOFF.
$1.50 to Democratic Party
$1.50 to Democratic Party
L
L
SPOUSE
$1.50 to Republican Party
YOU
increase the amount of tax you owe or decrease
$1.50 to Republican Party
$1.50 to Campaign Fund
$1.50 to Campaign Fund
your refund.
I (We), the undersigned, declare under penalty of perjury that I (we) have examined this return, including all accompanying schedules and statements, and, to the best of my (our) knowledge and
belief, it is a true, correct, and complete return. Declaration of preparer (other than taxpayer) is based on all information of which the preparer has any knowledge.
Your Signature
Date
Preparer’s Signature
Date
Spouse’s Signature
Date
Address
*1141001019999*
Daytime Telephone Number
Daytime Telephone Number
Verify your Social Security Number(s)
Recheck your math
Attach all W-2s.
Mailing Addresses: See lines 21 and 25 above. This return is due April 30, 2012.
41-080 (08/24/11)

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