Form N-15 - Individual Income Tax Return Nonresident And Part-Year Resident - 2015 Page 4
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4Form N-15 (Rev. 2015)
Page 4 of 4
Your Social Security Number
Your Spouse’s SSN
Name(s) as shown on return
JCF154
52
52
Total nonrefundable tax credits (attach Schedule CR) ..................................................................
If negative number, place a minus sign (-)
-
53
Line 51 minus line 52 ................................................................................................. Balance
† 53
54
Hawaii State Income tax withheld (attach W-2s)
54
(see page 32 of the Instructions for other attachments) ...
55
2015 estimated tax payments on
55
TOTAL
Forms N-1 _____________ ; N-288A _____________ ..
PAYMENTS
58 Add lines 54 through 57.
56
56
Amount of estimated tax applied from 2014 return .................
57
57
Amount paid with extension...............................................
59
If line 58 is larger than line 53, enter the amount OVERPAID
59
(line 58 minus line 53) (see Instructions) .......................................................................................
60
Contributions to (see page 32 of the Instructions): ........................
Yourself
Spouse
ID NO 01
60a Hawaii Schools Repairs and Maintenance Fund .....................
$2
$2
60b Hawaii Public Libraries Fund ...................................................
$2
$2
60c Domestic and Sexual Violence / Child Abuse and Neglect Funds .............
$5
$5
61
61
Add the amounts of the Xs on lines 60a through 60c and enter the total here .............................
62
62
Line 59 minus line 61 ....................................................................................................................
63
Amount of line 62 to be applied to
your 2016 ESTIMATED TAX..............................................
63
64a
Amount to be REFUNDED TO YOU (line 62 minus line 63) If filing late, see page 33 of Instructions. Place an X here
if this refund will
ultimately be deposited to a foreign (non-U.S.) bank. Do not complete lines 64b, 64c, or 64d.
64b
64c Type:
Routing number
Checking
Savings
64d
64a
Account number
.................................
65
AMOUNT YOU OWE (line 53 minus line 58). Send Form N-200V with your payment.
65
Make check or money order payable to the “Hawaii State Tax Collector” ......................................
66
Estimated tax penalty. (See page 34 of Instr.) Do not include this amount in line
59 or 65. Place an X in this box if Form N-210 is attached
†
66
...
If negative number, place a minus sign (-)
-
67
AMENDED RETURN ONLY - Amount paid (overpaid) on original return. (See Instructions) (attach Sch. AMD) .........
67
If negative number, place a minus sign (-)
-
68
AMENDED RETURN ONLY - Balance due (refund) with amended return. (See Instructions) (attach Sch. AMD) ......
68
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 34 of the Instructions.
†
†
†
Designee’s name
Phone no.
Identification number
HAWAII ELECTION
Â
Note: Placing an X in the “Yes”
Do you want $3 to go to the Hawaii Election Campaign Fund?
Yes
No
CAMPAIGN FUND
box will not increase your tax
If joint return, does your spouse want $3 to go to the fund?
Yes
No
or reduce your refund.
(See page 35 of the Instructions)
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.
Spouse’s signature (if filing jointly, BOTH must sign)
Your signature
Date
Date
†
†
Your Occupation
Daytime Phone Number
Your Spouse’s Occupation
Daytime Phone Number
Date
Preparer’s identification number
Paid
Preparer’s
Check if
†
o
†
Preparer’s
Signature
self-employed
Information
Print
†
†
Federal E.I. No.
Preparer’s Name
Firm’s name (or yours
†
†
Phone No.
if self-employed),
Address, and ZIP Code
FORM N-15
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