Form Ia 1040a - Iowa Individual Income Tax Short Form - 2012 Page 2
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2IA 1040A Schedule B
Iowa Department of Revenue
Interest and Dividend Income
Name(s) as shown on page 1 of the IA 1040A
Social Security Number
Note: You must report all taxable interest and dividends on IA 1040A, even if you are not required to complete Schedule B.
PART I: INTEREST INCOME
You must complete this part if you received more than $1,500 in interest in 2012. Interest income which should be reported includes
earnings from savings and loan associations, mutual savings banks, cooperative banks, credit unions, and bank deposits; state and
municipal bonds, and interest from tax refunds. Report both exempt and taxable interest.
Total Taxable Interest: Enter total on IA 1040A line 2.
Account Ownership: For each payer, indicate the type of account ownership. If the interest was earned by you, check “Taxpayer.”
For interest earned by your spouse, check “Spouse.” If the interest was earned jointly, check “Joint.” Check only one for each payer.
Name of Payer
Total Interest
Interest
Taxable
Account Ownership
Check one for each payer
(must equal the
(list names of all payers)
Exempt from
Interest
total of Exempt &
Iowa Tax
Taxable Interest)
Taxpayer
Spouse
Joint
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1
TOTALS
enter here and on IA 1040A, line 2
$
$
$
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1
PART II: DIVIDEND INCOME
You must complete this part if you received more than $1,500 in gross dividends in 2012. Report both exempt and taxable dividends,
such as from mutual funds that is attributable to federal securities.
Total Taxable Dividends: Enter total on IA 1040A line 3.
Account Ownership: For each payer, indicate the type of account ownership. If the dividend was earned by you, check “Taxpayer.” If
the dividend was earned by your spouse, check “Spouse.” If the dividend was earned jointly, check “Joint.” Check only one for each
payer.
Account Ownership
Name of Payer
Dividends
Taxable
Total Dividends
Check one for each payer
(must equal the
(list names of all payers)
Exempt from
Dividends
total of Exempt &
Iowa Tax
Taxable Dividends)
Taxpayer
Spouse
Joint
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2
TOTALS enter here and on IA 1040A line 3
$
$
$
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2
*1241080029999*
41-080b (09/20/12)
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