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���_ NEBRASKA SCHEDUL� I--Income Statement �o�M
<br /> Nebra�ka Oepartment of • Attach this schedule to Nebraska Homestead Exemption Appiication 458
<br /> REVENUE or Certification of Status,Form 458.
<br /> • Read instructions carefully_ _ SCh�dUl� I
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<br /> A licants Name as shown on�orm 458 Applicants Social ecurity Nurn er
<br /> JAYNE A D�CKER 5�8-60-6685
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<br /> This Income Statement is filed for(select one only):
<br /> � Applicant Applicant&Spouse Spouse �Owner-Occupant
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<br /> 5pouse's or Owner-�ccupanYs Name I Spouse s or Owner-Occupants aSN
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<br /> NOTE: Do not include owner-occupanYs incnme on the income statement of the applicanUspouse listed at�ove.
<br /> Each owner-occupanYs income must be re orted on a separate Nebraska Schedule I—Income Statement.____
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<br /> �pw �����E�� ��..�����.f»",a `xQ��,��d..a ���� {������ ���'i��`,/�� ���i ����`{�`JS..� �����.���� �"��x�-'�..a�m.,a�,?,�».
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<br /> RAR71----For'Applicants Wha [���D t�C�'� FfL.� a 2010 Fcderal IncomeTax Return
<br /> ��i+�st cvi�a�a1���'lk'or��h�e�A on r�wct`��sdd�.
<br /> •If you filed a 2D10 federal income tax return,complete only Part II.
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<br /> Household Income: January 1 through t]ecember 31,2010
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<br /> 1 Wages and salaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
<br /> 2 5ocial Security retirement income. If none, explain
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<br /> 3 Tier I railroad retirement income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
<br /> 4 Total pensions and annuities 4a _ _ _ 4b Taxable amount. . . . . . . . . . . 4b
<br /> 5 IRA distributions 5a ,_ __.,__._ 5b Taxable amount. . . . . . . . . . . 5b
<br /> 6 7ax exempt inter�st and dividends (must include all state and local bond income). . . . . . . . . . . . . . 6
<br /> 7 Taxable interest and dividends. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
<br /> 8 Other income or adjustments (from line G,Worksh�et A on reverse side) . . . . . . . . . . . . . . . . . . . . 8
<br /> 9 TOTAL O�LINES 1 THROUGH 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . `
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<br /> _ --Caution:Do not include ex enses reimbursed b insuranc � ; `
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<br /> 10a Medi ai and dental�xpe sesP(ee nstructions) . . . . . . . . . . . . . . . . . . . . 10a
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<br /> 10b Multiply L1C���by 4% (D4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10b _.__., ----- �U�..1._��—... ._
<br /> 10c Subtract line 10b from line 10a. If line 10b is mare than line 10a en�er-0-. . . . . . . . . . . . . . . . .��� 1 � . '
<br /> �Sr:;��:;.T'�
<br /> '11 H�USEH�LD INCOM� pine 9 minus Iine 10c) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ��.A �� l.AND, NEBF:�.,�;,.
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<br /> 'PAR711—F�r Applicants Wha �E��t�a 201Q �ederal IncomeTax l�eturn
<br /> •If you did not file a 2010 tederal income tax return,complete only Part i and Worksheet A.
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<br /> - Hausehold Incame:January 1 through December 31,2010
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<br /> 1 Federal adjusted grass income (AGI)from line 37, Federal Form 1040;
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<br /> line 21, Federal Form 1040A or line 4, Federal Form 1040EZ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 _�G� ..i��
<br /> 2 Social Security retirement income (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
<br /> 3 Tier I railroad retirement income (see instructions). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
<br /> 4 Nebraska adjustments increasing federal AGI (enter amount from line 12, Form 1040N� . . . . . . . . . 4
<br /> 5 Income from Nebraska obligaiions (enter amount from line 45b, Schedule I, Form 1040N) . . . . . . . 5 _.
<br /> 6 TOTAL OF LINES 1 THROUGH 5 . . . •_-_. . . . . . . . . . ._. . . . . . ._. . . . . . . . . . . .: :, . .__. . . . fi �`.._fi��r� G`�'
<br /> � MEDICAL ANQ DENTAL EXF'ENSES —�Caution:I]o nnt include expenses reimbursed by insurance or paid By other�
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<br /> 7a Medical and dental expenses (see instructions). . . . . . . . . . . . . . . . . 7a ,�� L7�_.�.
<br /> 7b Multiply 1 it�� 6,F��rt 11, by 4% (.04) . . . . . . . . . . . . . . . . . . . . . . . . . . . 7b�__ /.._�. 7 � —`�.z
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<br /> 7c Subtract lin�7b from line 7a. If line 7b is more than line 7a enter-0-. . . . . . . . . . . . . . . . . . . . . . . . . _7c ,/u^� ��1�-- ; .4.,
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<br /> S HOUSEHOLD INCOME line 6 minus line 7c) _ . . . . . ._T_. . . . . . . . . . . . . •_. ._• : . . . . . . . . . ._:_• . 8 �`' ��.,�_._.�1
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<br /> Under'penalties o1 law,I declare that I have examined this schedule,and that it is,to ihe best ot my knowledge and belief,correr..t and complete.
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<br /> here Signat`ure of rson Whose lncome is 51�wn Spous�ure i1 Incomc Included Daic; Uaytime Pnnne
<br /> � FII..E FQRM 458 AND7HIS SCHEDULE WITHYOUR C�UNTY AS5E5SOR AFT�R FEBRUARY 1 AND BY JL1NE 30.
<br /> RETAIN A COPY FORYOUR RECORDS.
<br /> Nebraska Oep2rtment of Fevenue
<br /> Fprm Nn.96�296-2009 ReV.1-2p1 Y Supersedes 96-2EF-2009 Authnrized Gy Nc6.Rev.Slat.§§77-351 p and 77-3528
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