Form N-13 - Individual Income Tax Return - Resident - 2012 Page 2

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Form N-13

Page 2

(Rev. 2012)

Name(s) as shown on return

Social Security Number(s)

JDF122

PART I

PART II

Interest Income

Ordinary Dividends

If you received more than $1,500 in interest, list the names of the payers

If you received more than $1,500 in ordinary dividends, list the names

and the amounts of interest on the lines below. See page 11 of the

of the payers and the amounts of the dividends on the lines below. See

Instructions for what interest to report.

page 11 of the Instructions for a definition of ordinary dividends.

Name of Payer

Amount

Name of Payer

Amount

Total interest income. Enter here and on

Total ordinary dividends. Enter here and on

Form N-13, line 8 (Whole dollars only) ................

Form N-13, line 9 (Whole dollars only) ................

16 Tax from Tax Table ...........................................................................................................................................Tax ä

16

17 Refundable Renewable Energy Technologies Income Tax Credit (attach Form N-342)

• 

17

Check type of energy system:

Solar

Wind .........................................

18 Refundable Food/Excise Tax Credit (attach Schedule X)

DHS, etc. exemptions 

Federal AGI 

18

19 Credit for Low-Income Household Renters (attach Schedule X) ............................

19

20 Credit for Child and Dependent Care Expenses (attach Schedule X) ....................

20

21 Credit for Child Passenger Restraint System(s) (attach a copy of the invoice) .......

21

22 Add lines 17 through 21 .............................................................................................. Total Refundable Credits ä

22

23 Line 16 minus line 22. If line 23 is zero or less, see Instructions. .......................................................................... ä

23

24 Carryover of the Nonrefundable Renewable Energy Technologies Income Tax Credit (For Systems

Installed and Placed in Service Before July 1, 2009) (attach Form N-323) ...........................................

24

25 Nonrefundable Renewable Energy Technologies Income Tax Credit (attach Form N-342)

• 

25

Check type of energy system:

Solar

Wind .......................................

26 Add lines 24 and 25 ...............................................................................................Total Nonrefundable Credits ä

26

27 Line 23 minus line 26 ...............................................................................................................................Balance ä

27

28 Total Hawaii income tax withheld (attach W-2s) (see page 14 of the Instructions for other attachments) ..

28

29 Amount paid with extension ....................................................................................

29

30 Add lines 28 and 29 .................................................................................................................... Total Payments ä

30

31 If line 30 is larger than line 27, enter the amount OVERPAID (line 30 minus line 27) (see page 14 of the Instructions) ..........

31

32 Contributions to (See page 14 of the Instructions): ...... Yourself

Spouse



32a Hawaii Schools Repairs and Maintenance Fund ......... 



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32b Hawaii Public Libraries Fund ........................................ 





32c Domestic and Sexual Violence / Child Abuse and Neglect Funds . 

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33 Add the amounts of the checked boxes on lines 32a through 32c and enter the total here ......................................

33

34a Line 31 minus line 33. This is the amount to be REFUNDED TO YOU. If filing late, see page 15 of Instructions ......

34a



Check here if this refund will ultimately be deposited to a foreign (non-U.S.) bank. Do not complete lines 34 b, c, or d.





b Routing number 

c Type: 

Checking 

Savings

d Account number 

35 If line 27 is larger than line 30, enter the AMOUNT YOU OWE (line 27 minus line 30). Send Form N-200V

35

with your payment. Make check or money order payable to the “Hawaii State Tax Collector”. ...................................

36 Estimated tax penalty. (See page 15 of Instructions) Do not include on line 31 or 35.



36

Check box if Form N-210 is attached ä

.........................................................

37 AMENDED RETURN ONLY – Amount paid (overpaid) on original return. (See Instructions) (Attach Sch. AMD) ...

38 AMENDED RETURN ONLY – Balance due (refund) with amended return. (See Instructions) (Attach Sch. AMD) .

If designating another person to discuss this return with the Hawaii Department of Taxation, complete the following. This is not a full power of

attorney. See page 16 of the Instructions.

Designee’s name ä

Phone no. ä

Identification number ä

DECLARATION — I declare, under the penalties set forth in section 231-36, HRS, that this return (including accompanying schedules or statements)

has been examined by me and, to the best of my knowledge and belief, is a true, correct, and complete return, made in good faith, for the taxable year

stated, pursuant to the Hawaii Income Tax Law, Chapter 235, HRS.

Your signature

Date

Spouse’s signature (if filing jointly, BOTH must sign)

Date

Preparer’s Signature

Preparer’s identification number

Check if

and date



Paid

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