Form N-11 (Rev. 2014)
Page 3 of 4
Your Social Security Number
Your Spouse’s SSN
JBF143
,
Name(s) as shown on return
25
If line 20 is $89,981 or less, multiply $1,144 by the total number of exemptions claimed on
line 6e. Otherwise, see page 22 of the Instructions. If you and/or your spouse are blind, deaf,
or disabled, place an X in the applicable box(es), and see page 22 of the Instructions.
Yourself
Spouse ............................................................................................... 25
Taxable Income. Line 24 minus line 25 (but not less than zero) ...................Taxable Income 26
26
27
Tax. Place an X if from
Tax Table;
Tax Rate Schedule; or
Capital Gains Tax
Worksheet on page 39 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 27
27a
If tax is from the Capital Gains Tax Worksheet, enter
the net capital gain from line 14 of that worksheet .......... 27a
28
Refundable Food/Excise Tax Credit
(attach Schedule X) DHS, etc. exemptions
.... 28
29
Credit for Low-Income Household
Renters (attach Schedule X) ............................................. 29
30
Credit for Child and Dependent
Care Expenses (attach Schedule X) ................................. 30
31
Credit for Child Passenger Restraint
System(s) (attach a copy of the invoice)............................ 31
32
Total refundable tax credits from
Schedule CR (attach Schedule CR) .................................. 32
Add lines 28 through 32 ................................................................. Total Refundable Credits 33
33
t
IF NEGATIVE, PLACE MINUS SIGN
-
34
Line 27 minus line 33. If line 34 is zero or less, see Instructions. .................................................. 34
35
Total nonrefundable tax credits (attach Schedule CR) .................................................................. 35
t
IF NEGATIVE, PLACE MINUS SIGN
-
Line 34 minus line 35 ................................................................................................. Balance 36
36
37
Hawaii State Income tax withheld (attach W-2s)
(see page 27 of the Instructions for other attachments) .................. 37
38
2014 estimated tax payments............................................ 38
39
Amount of estimated tax applied from 2013 return ........... 39
40
Amount paid with extension............................................... 40
Add lines 37 through 40 ................................................................................. Total Payments 41
41
42
If line 41 is larger than line 36, enter the amount OVERPAID (line 41 minus line 36) (see Instructions) .. 42
43
Contributions to (see page 28 of the Instructions): ........................
Yourself
Spouse
43a Hawaii Schools Repairs and Maintenance Fund .....................
$2
$2
43b Hawaii Public Libraries Fund ...................................................
$2
$2
43c Domestic and Sexual Violence / Child Abuse and Neglect Funds .............
$5
$5
44
Add the amounts of the Xs on lines 43a through 43c and enter the total here ............................. 44
45 Line 42 minus line 44 ........................................................................................................ 45
ID NO 99
FORM N-11