Form Ia 1040 - Iowa Individual Income Tax Form - 2011
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1
22011 IA 1040
Iowa Individual Income Tax Form
or fiscal year beginning __/__ 2011 and ending __/__ /__
STEP 1: Fill in all spaces. You MUST fill in your Social Security Number (SSN).
Your last name
Your first name/middle initial
Spouse’s last name
Spouse’s first name/middle initial
Current mailing address (number and street, apartment, lot, or suite number) or PO Box
City, State, ZIP
•
•
•
Spouse SSN
Your SSN
Check this box if you or your spouse were 65 or older as of 12/31/11.
STEP 2 Filing Status: Mark one box only.
Residence on 12/31/11
•
•
County Number
School District Number
1
Single: Were you claimed as a dependent on another person’s Iowa return?
YES
NO
Dependent children for whom an exemption is claimed in Step 3
2
Married filing a joint return. (Two-income families may benefit by using status 3 or 4.)
•
How many have health care coverage?(including Medicaid or hawk-i)
•
3
Married filing separately on this combined return. Spouse use column B.
How many do not have health care coverage?
4
Married filing separate returns.
Spouse’s name:
SSN:
Income: $
5
Head of household with qualifying person. If qualifying person is not claimed as a dependent on this return, enter the person’s name and SSN below.
6
Qualifying widow(er) with dependent child.
Name:
SSN:
B. Spouse (Filing Status 3 ONLY)
A. You or Joint
STEP 3 Exemptions
a. Personal Credit:
Col. A: Enter 1 (enter 2 if filing status 2 or 5); Col. B: Enter 1 if filing status 3
X $ 40 = $
X $ 40 = $
b. Enter 1 for each person who is 65 or older and/or 1 for each person who is blind..............
X $ 20 = $
X $ 20 = $
c. Dependents: Enter 1 for each dependent ...................................................................
X $ 40 = $
X $ 40 = $
d. Enter first names of dependents here: ____________________________________
e. TOTAL $
$
B. Spouse/Status 3
A. You or Joint
B. Spouse/Status 3
A. You or Joint
1. Wages, salaries, tips, etc. ................................................................. 1. ______________ .00
______________ .00
STEP 4
Gross
2. Taxable interest income. If more than $1,500, complete Sch. B. ...... 2. ______________ .00
______________ .00
Income
3. Ordinary dividend income. If more than $1,500, complete Sch. B. ...... 3. ______________ .00
______________ .00
4. Alimony received .............................................................................. 4. ______________ .00
______________ .00
5. Business income/(loss) from federal Schedule C or C-EZ .............. 5. ______________ .00
______________ .00
NOTE: Use only
6. Capital gain/(loss) from federal Sch. D if required for federal purposes . 6. ______________ .00
______________ .00
blue or black ink,
7. Other gains/(losses) from federal form 4797 .................................... 7. ______________ .00
______________ .00
no pencils or red ink.
8. Taxable IRA distributions .................................................................. 8. ______________ .00
______________ .00
9. Taxable pensions and annuities ....................................................... 9. ______________ .00
______________ .00
10. Rents, royalties, partnerships, estates, etc. ..................................... 10. ______________ .00
______________ .00
11. Farm income/(loss) from federal Schedule F ................................... 11. ______________ .00
______________ .00
12. Unemployment compensation. See instructions. ............................. 12. ______________ .00
______________ .00
13. Taxable Social Security benefits ...................................................... 13. ______________ .00
______________ .00
14. Other income, gambling income, bonus depreciation/section 179 adjustment ... 14. ______________ .00
______________ .00
15. GROSS INCOME. ADD lines 1-14. ........................................................................................................................... 15. _______________ .00
_______________ .00
STEP 5
16. Payments to an IRA, Keogh, or SEP ............................................... 16. ______________ .00
______________ .00
Adjust-
17. Deductible part of self-employment tax ............................................ 17. ______________ .00
______________ .00
ments
18. Health insurance deduction .............................................................. 18. ______________ .00
______________ .00
to
19. Penalty on early withdrawal of savings ............................................ 19. ______________ .00
______________ .00
Income
20. Alimony paid ..................................................................................... 20. ______________ .00
______________ .00
21. Pension/retirement income exclusion .............................................. 21. ______________ .00
______________ .00
22. Moving expense deduction from federal form 3903 ......................... 22. ______________ .00
______________ .00
23. Iowa capital gain deduction
23. ______________ .00
______________ .00
certain asset sales ONLY (see instructions).
24. Other adjustments ............................................................................ 24. ______________ .00
______________ .00
25. Total adjustments. ADD lines 16-24. ........................................................................................................................ 25. _______________ .00
_______________ .00
26. NET INCOME. SUBTRACT line 25 from line 15. .................................................................................................... 26. _______________ .00
_______________ .00
STEP 6
27. Federal income tax refund / overpayment received in 2011 ............ 27. ______________ .00
______________ .00
Federal
28. Self-employment/household employment taxes .............................. 28. ______________ .00
______________ .00
Tax
29. Addition for federal taxes. ADD lines 27 and 28. ...................................................................................................... 29. _______________ .00
_______________ .00
Addition
30. Total. ADD lines 26 and 29. ...................................................................................................................................... 30. _______________ .00
_______________ .00
and
Deduc-
31. Federal tax withheld ......................................................................... 31. ______________ .00
______________ .00
tion
32. Federal estimated tax payments made in 2011 ............................... 32. ______________ .00
______________ .00
33. Additional federal tax paid in 2011 for 2010 and prior years ........... 33. ______________ .00
______________ .00
34. Deduction for federal taxes. ADD lines 31, 32, and 33. ............................................................................................ 34. _______________ .00
_______________ .00
35. BALANCE. SUBTRACT line 34 from line 30. Enter here and on line 36, side 2. .................................................... 35. _______________ .00
_______________ .00
41-001a (09/21/11)
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