Form N-15 - Nonresident And Part-Year Resident Individual Income Tax Return - 2011 Page 2

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Form N-15 (Rev. 2011)
Page 2 of 4
Your Social Security Number
Your Spouse’s SSN
JCF112
Name(s) as shown on return
ID NO 01
Col. A - Total Income
Col. B - Hawaii Income
7
Wages, salaries, tips, etc. (attach Form(s) W-2) ..........
7
8
Interest income from the worksheet on page 39 of
the Instructions ............................................................
8
9
Ordinary dividends ......................................................
9
10
State income tax refund from the worksheet on
page 39 of the Instructions ..........................................
10
11
Alimony received .........................................................
11
If negative number, place a minus sign (-)
If negative number, place a minus sign (-)
-
-
12
Business or farm income or (loss) ...............................
12
13
-
-
Capital gain or (loss) from the worksheet on
page 39 of the Instructions .........................................
13
14
-
-
Supplemental gains or (losses)
(attach Schedule D-1) ................................................
14
15
IRA distributions ..........................................................
15
16
Pensions and annuities (see Instructions and
attach Schedule J, Form N-11/N-15/N-40) ..................
16
-
-
17
Rents, royalties, partnerships, estates, trusts, etc. ......
17
18
Unemployment compensation (insurance) ..................
18
19
-
-
Other income (state nature and source)
________________________________ ....................
19
-
-
†
20
Add lines 7 through 19 ..................... Total Income
20
21
Certain business expenses of reservists, performing
artists, and fee-basis government officials ..................
21
22
IRA deduction ..............................................................
22
23
Student loan interest deduction from the worksheet
on page 43 of the Instructions .....................................
23
24
Health savings account deduction ...............................
24
25
Moving expenses (attach Form N-139) .......................
25
26
Deductible part of self-employment tax .......................
26
27
Self-employed health insurance deduction ..................
27
28
Self-employed SEP, SIMPLE, and qualified plans .......
28
29
Penalty on early withdrawal of savings ........................
29
30
Alimony paid
(Enter name and SS No. of recipient)
________________________________ ....................
30
31
Payments to an individual housing account ..
31
32
First $5,881 of military reserve or Hawaii
national guard duty pay ................................
32
FORM N-15

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