Form N-15 - Nonresident And Part-Year Resident Individual Income Tax Return - 2011 Page 3

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Form N-15 (Rev. 2011)
Page 3 of 4
Your Social Security Number
Your Spouse’s SSN
JCF113
Name(s) as shown on return
33
Exceptional trees deduction (attach affidavit)
33
(see page 20 of the Instructions) ................................
34
Add lines 21 through 33 ..........Total Adjustments
34
†
If negative number, place a minus sign (-)
If negative number, place a minus sign (-)
-
-
35
Line 20 minus line 34 .....Adjusted Gross Income
35
†
36
Ratio of Hawaii AGI to Total AGI. Divide line 35, Column B, by line 35, Column A (Compute to 3 decimal places and round to 2 decimal places) ..
36
CAUTION: If you can be claimed as a dependent on another person’s return, see the Instructions on page 20, and place an X here.
37
If you do not itemize deductions, enter zero on line 38 and go to line 39a. Otherwise go to page 20 of the Instructions and enter your Hawaii itemized deductions here.
37a
Medical and dental expenses ...............................................
(See Instr. on p. 26)
37a
Enter Federal AGI
(from Worksheet NR-1 or PY-1) .......................................
37b
37b
TOTAL ITEMIzED
Taxes (from Worksheet NR-2 or PY-2) ...................
DEDuCTIONS
38 If your adjusted gross income
37c
37c
Interest expense (from Worksheet NR-3 or PY-3) ...........
is above a certain amount, you
may not be able to deduct all of
37d
37d
your itemized deductions. See
Contributions (from Worksheet NR-4 or PY-4) .......
the Instructions on page 25.
37e
Casualty and theft losses
Enter total here and go to
37e
line 40.
(from Worksheet NR-5 or PY-5) .............................
37f
Miscellaneous deductions
37f
(from Worksheet NR-6 or PY-6) ..............................
39a
If you checked filing status box: 1 or 3 enter $2,000;
39a
2 or 5 enter $4,000; 4 enter $2,920 .................................
39b
Multiply line 39a by the ratio on line 36 .................................. Prorated Standard Deduction
† 39b
If negative number, place a minus sign (-)
-
40
40
Line 35, Column B minus line 38 or 39b, whichever applies. (This line MUST be filled in) ...........
41a
If line 35, Column B is $89,981 or less, multiply $1,040 by the total number of exemptions claimed on line 6e. Otherwise, see page 26 of the Instructions. If you and/or
your spouse are blind, deaf, or disabled, place an X in the applicable box(es)
Yourself
Spouse, and see the Instructions
.............41a
41b
Multiply line 41a by the ratio on line 36 ............................................. Prorated Exemption(s)
† 41b
42
Taxable Income. Line 40 minus line 41b (but not less than zero) ................ Taxable Income
† 42
43
Tax. Place an X if from:
Tax Table;
Tax Rate Schedule; or
Capital Gains Tax Worksheet on page 42 of the Instructions.
Place an X if tax from Forms N-2, N-103, N-152, N-168, N-312, N-318, N-338, N-344, N-405, N-586,
(
N-615, or N-814 is included.) ...................................................................................................... Tax
† 43
If tax is from the Capital Gains Tax Worksheet, enter
the net capital gain from line 8 of that worksheet
.............................................43a
44
Refundable Food/Excise Tax Credit
(See Instr. on p. 35)
(attach Schedule X) DHS, etc. exemptions
44
Enter Federal AGI
......
45
Credit for Low-Income Household
45
Renters (attach Schedule X) .............................................
46
Credit for Child and Dependent Care
ID NO 01
46
Expenses (attach Schedule X) ..........................................
47
Credit for Child Passenger Restraint
47
System(s) (attach a copy of the invoice)............................
48
Total refundable tax credits from
48
Schedule CR (attach Schedule CR) ..................................
49
Add lines 44 through 48 ................................................................Total Refundable Credits
† 49
If negative number, place a minus sign (-)
-
50 Line 43 minus line 49. If line 50 is zero or less, see Instructions.. ...................................
50
51 Total nonrefundable tax credits (attach Schedule CR) ....................................................
51
FORM N-15

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