TC-40A
Clear form
Income Tax Supplemental Schedule
40103
Rev. 12/11
Your last name
Your social security number
Part 1 - Additions to Income (write the code and amount of each addition to income, see page 12)
Code
Amount
Code
Code
51 Lump sum distribution
56 Child's income excluded from parent's return
.00
*
53 Medical Savings Account (MSA) addback
57 Municipal bond interest
.00
*
54 Utah Educational Savings Plan (UESP) addback
60 Untaxed income of a resident trust
*
61 Untaxed income of a nonresident trust
55 Reimbursed adoption expenses
.00
*
To the extent previously deducted
69 Equitable adjustments - attach explanation
.00
or credited on Utah return
.00
Total additions to income (add all additions to income and enter total here and on TC-40, line 5)
.00
Part 2 - Subtractions from Income (write the code and amount of each subtraction from income, see page 13)
Code
Code
Code
Amount
71 Interest from U. S. Government Obligations
78 Railroad retirement income
.00
77 Native American income
79 Equitable adjustments - attach explanation
Tribe
Your enrollment number
82 Nonresident active duty military pay
Code
.00
85 State tax refund distributed to beneficiary
.00
88 Nonresident military spouse income
Spouse's enrollment number
Code
.00
.00
Total subtractions from income (add all subtractions and enter total here and on TC-40, line 8)
.00
Part 3 - Apportionable Nonrefundable Credits (write the code and amount of each nonrefundable credit, see pages 14 - 15)
Code
Code
Amount
Code
04 Capital gain transactions credit
22 Medical Care Savings Account (MSA) credit
.00
18 Retirement tax credit (attach TC-40C)
23 Health benefit plan credit
20 Utah Educational Savings Plan (
UESP)
credit
24 Qualifying solar project credit
.00
.00
.00
.00
Total apportionable nonrefundable credits (add all credits and enter total here and on TC-40, line 23)
.00
Part 4 - Nonapportionable Nonrefundable Credits (write the code and amount of each nonrefundable credit, see pages 16 - 18)
Code
Code
Amount
Code
01 At-home parent credit
10 Recycling market dev. zone credit
.00
02 Qualified sheltered workshop credit
12 Research activities credit
13 Carryover of mach./equip. research credit
Name
.00
17 Tax paid to another state (attach TC-40S)
05 Clean fuel vehicle credit
.00
19 Live organ donation expenses credit
06 Historic preservation credit
21 Renewable residential energy systems credit
.00
07 Enterprise zone credit
25 Combat related death credit
08 Low-income housing credit
.00
Total nonapportionable nonrefundable credits (add all credits and enter total here and on TC-40, line 26)
.00
Submit this page ONLY if data entered
Attach completed schedule to your 2011 Utah Income Tax return