Form 1040xn - Amended Nebraska Individual Income Tax Return - 2015 Page 3

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FORM 1040XN

NEBRASKA SCHEDULE I — Nebraska Adjustments to Income

Schedules

NEBRASKA SCHEDULE II — Credit for Tax Paid to Another State

I, II, and III

NEBRASKA SCHEDULE III — Computation of Nebraska Tax

2015

Name on Form 1040XN

Social Security Number

Nebraska Schedule I — Nebraska Adjustments to Income

for Nebraska Residents, Partial-Year Residents, and Nonresidents

PART A — Adjustments Increasing Federal Adjusted Gross Income (AGI)

Correct Amount

1 Total adjustments increasing federal AGI (include interest from non-Nebraska state and local obligations).

Enter here and on line 12, Form 1040XN. See instructions, then list items being changed. _______________

______________________________________________________________________________________

PART B — Adjustments Decreasing Federal AGI

2 State income tax refund deduction .......................................................................................................................

3 Interest or dividend income from U.S. obligations ................................................................................................ 3

4 Benefits paid by the Railroad Retirement Board (RRB) included in federal AGI ..................................................

5 Special capital gains/extraordinary dividends deduction (see instructions) .........................................................

6 Nebraska College Savings Program ......................................................................................................................

7 Nebraska Long-Term Care Savings Plan

a Contributions: $ ________________ b Earnings: $ ________________

(Add amounts in a and b, and enter the result on line 7).......................................................................................

8 Other adjustments decreasing federal AGI (see instructions). List adjustments being changed and

attach documentation _____________________________________________________________________

9 Total adjustments decreasing federal AGI (add lines 2 through 8). Enter here and on line 13, Form 1040XN. .....

Nebraska Schedule II — Credit for Tax Paid to Another State for Full-Year Residents Only

• If line 2 or 3 is amended, a copy of the return filed with another state must be attached.

Correct Amount

1 Total Nebraska tax (line 17, Form 1040XN) ..........................................................................................................

2 AGI derived from another state (Do not enter the amount of taxable income from the other state. Use the

Conversion Chart on the Department’s website.) .................................................................................................

3 Ratio (Calculate to six decimal places, and round to five)

Line 2

From Form 1040XN, Line 5 + Line 12 – Line 13

4 Calculated Tax Credit. Line 1 multiplied by line 3 ratio ........................................................................................

5 Tax due and paid to another state (Do not enter the amount of income tax withheld for the other state. Use the

Conversion Chart on the Department’s website.) .................................................................................................

6 Allowable tax credit (line 1, 4, or 5, whichever is least). Enter amount here and on line 20, Form 1040XN .........

Nebraska Schedule III — Computation of Nebraska Tax

• Nonresidents and partial-year residents complete lines 1 through 13 below.

Correct Amount

1 Income derived from Nebraska sources ...............................................................................................................

2 Adjustments as applied to Nebraska income. Refer to Form 1040N instructions and list the items being

changed _______________________________________________________________________________

3 Nebraska AGI (line 1 minus line 2) .....................................................................................................................

4 Ratio – Nebraska’s share of the total income (Calculate to six decimal places, and round to five)

Line 3

From Form 1040XN, Line 5 + Line 12 - Line 13

5 Nebraska Taxable Income (from line 14, Form 1040XN) .....................................................................................

6 Nebraska total income tax (see instructions)

, minus credits: $

. Enter difference here ...............................................................

7 Enter personal exemption credit (if any) ...........................................................................................................

8 Tax after personal exemption credit (line 6 minus line 7) If less than zero, enter -0-. ...........................................

9 Nebraska share of line 8 (multiply line 8 by line 4 ratio). Enter here and on line 15, Form 1040XN .....................

10 Nebraska other tax (see instructions) .................................................................................................................. 10

11 Nebraska share of line 10. Subtract any unused personal exemption credit from line 7.

Multiply the result by the line 4 ratio. Enter here and on line 16, Form 1040XN ...................................................

12 Earned income credit (partial-year residents only).

Number of qualifying children

. Federal earned income credit

x .10 (10%) ...........

13 Partial-year residents, multiply line 12 by line 4 ratio. Enter here and on line 33, Form 1040XN ........................