Form N-11- Individual Income Tax Return Resident/schedule Cr - Schedule Of Tax Credits - 2014 Page 4

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Form N-11 (Rev. 2014)
Page 4 of 4
Your Social Security Number
Your Spouse’s SSN
JBF144
,
Name(s) as shown on return
46
Amount of line 45 to be applied to your
2015 ESTIMATED TAX ..................................................... 46
47a
Amount to be REFUNDED TO YOU (line 45 minus line 46) If fi ling late,
see page 28 of Instructions ........................................................................................................... 47a
Place an X in this box if this refund will ultimately be deposited to a foreign (non-U.S.) bank. Do not complete lines 47b, 47c, or 47d.
47b
Routing number
47c Type:
Checking
Savings
47d
Account number
48
AMOUNT YOU OWE (line 36 minus line 41). Send Form N-200V with your payment.
Make check or money order payable to the “Hawaii State Tax Collector”. ..................................... 48
49
Estimated tax penalty. (See page 29 of
Instructions.) Do not include on line 42 or 48. Place an X in
this box if Form N-210 is attached
................... 49
t
IF NEGATIVE, PLACE MINUS SIGN
-
50
AMENDED RETURN ONLY – Amount paid (overpaid) on original return. (See Instructions) (attach Sch. AMD) ....... 50
t
IF NEGATIVE, PLACE MINUS SIGN
-
51
AMENDED RETURN ONLY – Balance due (refund) with amended return. (See Instructions) (attach Sch. AMD) ..... 51
52 Did you fi le a federal Schedule C?
Yes
No
If yes, enter Hawaii gross receipts
your main business activity:
,
W
your main business product:
,
AND your HI Tax I.D. No. for this activity
53 Did you fi le a federal Schedule E
If yes, enter Hawaii gross rents received
for any rental activity?
Yes
No
W
AND your HI Tax I.D. No. for this activity
54 Did you fi le a federal Schedule F?
Yes
No
If yes, enter Hawaii gross receipts
your main business activity:
,
W
your main business product:
,
AND your HI Tax I.D. No. for this activity
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 30 of the Instructions.
Designee’s name
Phone no.
Identifi cation number
Note: Placing an X in the “Yes”
HAWAII ELECTION
Do you want $3 to go to the Hawaii Election Campaign Fund?
Yes
No
box will not increase your tax
CAMPAIGN FUND
If joint return, does your spouse want $3 to go to the fund?
Yes
No
or reduce your refund.
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 fi ling jointly, BOTH must sign)
Date

Your Occupation
Daytime Phone Number
Your Spouse’s Occupation
Daytime Phone Number
Date
Preparer’s identifi cation number
Preparer’s
Check if
Signature
self-employed
Paid
Print
Preparer’s
Federal E.I. No.
Preparer’s Name
Information
Firm’s name (or yours
Phone No.
if self-employed),
Address, and ZIP Code
ID NO 99
FORM N-11

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