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��_ N�BRASKA SCH�DUL� I—Income Statement �oRnn Nehraska Oepartment of • Attach this schedule to Nebraska Homestead Exemption Application q,58 REVENUE or Certification of Status,Form 458. SChedUlO I • Read instructions carefully. -- --- ' " Applicants Social Security Nwnber(SSN) A IicanYs Name as sho _—..--- - �,p wn on Form 458 WIL.LIAM D MORROW 506-30-3851 This Income Statem�t iAfded ant&Seousee pn1 Spouse Q O _ - -- _,. _ ( Y) � Applicant � pp p J _� wner-Dccupant _ ----... P... _ _ — _ - S ouse's or Owner-OccupanYs 5SN Spouse's or Owner-OccupanYs Name D�LORE5 M MORROW 340-�6-3052 --- _ _ _. . _ _.,.. � NOTE: Do nat include owner-occupant's income on the income statement of the applicant/spouse listed above. Each owner-occu anYs income must be repofted.on e separate Nebraska Schedule l_.-Income._Staicrnent. _--._ _ _�, �� h'.�� ,.��t�� {�;�� %�.�..�..� �a��«��4`�� i ��"t 1'Yr�� i''��p�R�:'"; �. a €:},.��,".°�. —.. - .. _. -- - - _ ---- PART I—For Applicants Wha L�1� 6�t�"� ��-� a 201� Federal IncameTax Return �I�[r�t cs�arspC��t�'ar�she°t�on rcv�rse sis��;. � . , P - y 2�10.. -- Y. _ _ .. , If you filed a �ncome: January.l through December 31, -- .-� ..� 2010 federai income tax return com lete onl Part Hausehold_ . . --- -. ..- -. .._ _... 1 Wages an. _ _..—----..... _.. _. - - d salaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 8ocial Security retirement income. If none, explain 2 --- 3 7ier I railroad retirement income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . �� _._ '.. �� 4 Total pensions and annuities 4a__. -- _ 4b Taxable amount. . . . . . . . . . . 4b _ . _— _ -- _...... 5 IRA distributions 5a 5b Taxable amount. . . . . . . �1.JL � �o�� _. _ _ 6 Tax exempt interest and dividends (must include all state and local bond income). . . . . .�A�� .� � ��50R ::__ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .��ANp.IS � ,NE6RA� 7 Taxable interest and dividends. . . . . . . . . . . . . . ---...•- 8 Other income or adjustments (from line G,Worksheet A on r�verse side) . . . . . . . . . . . . . . . . . . . . 8 __. .___ 9 TOTAL OF LIN�S 1 TWROUGH S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _ 9 __.. _ ..�__._. .._ _ _ ._ --- - L L AND D�NTAL EXPENSES—Caution:Do not include eXpenses reimbursed by insurance ar paid by_at ers. MEbICA -. -- � �,_ _ 10a M�diral and dental expenses (see instructions) . . . . . . . . . . . . . . . . . . . . 10a 10b Multiply �.1N�9 t�y 4% (.04). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Qb�.. .. _ 1Qc 5ubtract line 10b from line 10a. If line 10b is more than line 10a enter-0-. . . . . . . . . . . . . . . . . . . . 1Qc 11 HOUS�HOLD INCOME�ne 9 minus lin� 10c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 --.. �----• _ _ _ _._ - _ � PAR711—For Applicants Who �l�.�� a 2010 Federal Income ax e urn •If you did not file a 2D10 federal income 1ax return,completa only Part I and Worksheet A. _ � ---- -...... _ _. . -- -- _.— __ __ _... ---.,. Household Income: January 1 through December 31,2010 - ,. _..... _.. .. . . __ 1 Federal adjusted gross income (AGI)from line 37, Federal Form 1040; � - • �. line 21, Federal Form 1040A or line 4, Federal Form 1Q40EZ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 � _ � 2 Socia! Security retirement income (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 3 Tier I railroad retiremeni incnme (see instructions). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 4 Nebraska adjustments increasing federal AGI (enter amount from fine 12, Form 1040N) . . . . . . . . . .4 _:_ 5 Income from Nebraska obligations (enter amount from line 45b, Schedule I, Form 1040N) . . . . . . . ...5_, 6 7QTAL OF LINES 1 THROUGH 5 . . . . . . . . . . . . . ..: . . . . . .•'--. . . . . :.. . . . . . . . . . . . . . - •—. . . _y ��..� _.._ � _ . - --. . � MEDIGAL AN�b�NTAL EXPENSES — Caution: L7a not include expenses reimbuYSed by insurance or paid by others. . . _ 7a Medical and dental expenses (see instructions). . . . . . . . . . . . . . . . . . . 7a . . . . . . . . . . . . . . . . . . . . . . . . . 7b Multiply L11�E 6, �'�rt 91, by 4% (.04) . . . _.. _ _. _.. -. _-... 7b _ ' _.._ . . . . . . . . . . 7c _ - _..,_. - . . . . . . . . . . _. -_....�..r . . . . . . . . . . . . . . -_�.'--. . . . . . _ _ ._ 7c Subtract line 7b from line 7a. If line is more an ine a - -. . . . . . . . . . . . . 8 HOUSEHOL.D INCOME lin�6 minus line 7c) . . . . . . . . _ __ 8J.. ._ IJndcr penalties of law,I declare that I have examincd this schedule,and thal it is,to the best of my knowledge and beliet,correct and complele. S� n � ) �.... -- —.... ._ �`��'-� _. _ __ here�Si nature oi Person Whose Income is Shown Spouse's Signature if Income Included Oate f]aytimc Phone g -- FILE�ORM 458 AND7MIS SGHEDULE WI7MYOUR GOUN7Y AS5E550R AFT�R FEBRUARY 1 AND BY JUNE 3d. RETAIN A COPY FORYOUR RECORDS. Nebiaska bepa�lment of Revenue Form Na.96•296-2003 Rcv.1-2017 Supersedes 96-296-2009 Authorized hy Nc6.Fe�i,Stac yFj 77-351 p and 77-3G?f1