Form N-15 - Individual Income Tax Return - Hawaii Department Of Taxation - 2003 Page 2

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FORM N-15 (REV. 2003)

PAGE 2

34 Hawaii adjusted gross income from line 33, Column B.........................................................................................

35 Ratio of Hawaii AGI to Total AGI. Divide line 33, Column B, by line 33, Column A

35l

(Compute to 3 decimal places and round to 2 decimal places)

l and see Instructions.

CAUTION: If you can be claimed as a dependent on another person’s return, check here

36 If you do not itemize deductions, enter zero on line 36g and go to line 37a. Otherwise go to page 19 of the

Instructions and enter your Hawaii itemized deductions here.

36a Medical and dental expenses (from Worksheet NR-1 or PY-1) ....................................

36al

36b Taxes (from Worksheet NR-2 or PY-2) .......................................................................

36bl

36c Interest expense (from Worksheet NR-3 or PY-3) .......................................................

36cl

36d Contributions (from Worksheet NR-4 or PY-4) ............................................................

36dl

36e Casualty and theft losses (from Worksheet NR-5 or PY-5) ..........................................

36el

36f Miscellaneous deductions (from Worksheet NR-6 or PY-6) .........................................

36fl

36g If line 34 is more than $100,000 ($50,000 for married filing separately), see the worksheet on page 39 of the

Instructions. If not, add lines 36a through 36f. Enter total here and go to line 38.......Total Itemized Deductions ä

36g

[

]

37a If you checked filing status box:

1, enter $1,500

3, enter $950

2 or 5, enter $1,900

4, enter $1,650

.....

37a

37b Multiply line 37a by the ratio on line 35 .................................................................Prorated Standard Deduction ä

37bl

38 Line 34 minus line 36g or 37b, whichever applies. (This line MUST be filled in) ........................................................

38l

39a Multiply $1,040 by the total number of exemptions claimed on line 6e. If you and/or your spouse are blind,

deaf, or disabled, check applicable box(es) l

Yourself l

Spouse, and see page 24 of the Instructions 39a

39b Multiply line 39a by the ratio on line 35 ............................................................................Prorated Exemption(s) ä

39bl

40 Taxable Income. Line 38 minus line 39b (but not less than zero) .............................................Taxable Income ä

40l

41 Tax. Check if from

Tax Table;

Tax Rate Schedule;

Form N-168;

Form N-615; or

Capital Gains Tax Worksheet on

page 39 of the Instructions. Net capital gain from line 14 of Capital Gains Tax Worksheet l

Include separate tax from Forms N-2, N-103, N-152, N-312, N-318, N-405, N-586, or N-814) .............Tax ä

41l

42 Total nonrefundable tax credits (attach Schedule CR) ...............................................................................................

43 Line 41 minus line 42 (but not less than zero) ..........................................................................................Balance ä

44 Hawaii State Income tax withheld, and tax withheld on Forms N-2 or N-4 ....................

44l

45 2003 estimated tax payments on Forms N-1 _________ ; N-288A _________ ..........

45l

46 Amount of estimated tax applied from 2002 return ......................................................

46l

47 Amount paid with extension(s) ...................................................................................

47l

48 Low-Income Refundable Tax Credit (attach Schedule X) DHS, etc. exemptions l

48l

49 Credit for Low-Income Household Renters (attach Schedule X)...................................

49l

50 Credit for Child and Dependent Care Expenses (attach Schedule X) ...........................

50l

51 Credit for Child Passenger Restraint System(s) (attach a copy of the invoice) ......................

51l

52 Total refundable tax credits from Schedule CR (attach Schedule CR)..........................

53 Add lines 44 through 52 ............................................................................................Total Payments and Credits ä

53l

54 If line 53 is larger than line 43, enter the amount OVERPAID (line 53 minus line 43) ................................................

54l

55 Amount of line 54 to be applied to your 2004 ESTIMATED TAX.................................

55l

56 Line 54 minus line 55 ..................................................................................................................................................

56l

57 Contribution to Hawaii School-Level Minor Repairs and Maintenance Special Fund. (See Instructions)

Yourself

Spouse. (Enter $2 if one box is checked, or $4 if both boxes are checked) ........................

58 Amount to be REFUNDED TO YOU (line 56 minus line 57) If late filing, see page 29 of Instructions........................

59 AMOUNT YOU OWE (line 43 minus line 53). Send Form N-200V with your payment...............................................

59l

60 Estimated tax penalty. (See page 29 of Instructions.) Do not include this amount in

line 54 or 59. Check box if Form N-210 is attached ä

..........................................

60l

61 If you would like us to mail you a packet of forms for next year’s filing, please check this box ...................................

62 Proceeds from the sale of a qualified high technology business’ NOL l $

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 ä

Phone no. ä

Identification number ä

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 filing jointly, BOTH must sign)

Date

Preparer’s Signature

Preparer’s identification number

Check if

Paid

and date

self-employed

Print Preparer’s Name