07/28/2015 - Laserfiche WebLink

Home Browse Search

Nebraska Schedule I—Income Statement FORM Nebraska Department or • Attach this schedule to the 2015 Nebraska Homestead Exemption Application 458 REVENUE or Certification of Status,Font,458. • Read instructions carefully. Schedule I Applicant's Name on Form 458 Applicants Social Security Number(SSN) CONNIE OLIVO 506-26-0769 This Income Statement is filed for(select one only): U Applicant QApplicant&Spouse OSpouse QOtherOwner-Occupant Spouse's or Owner-Occupant's Name Spouse's or Owner-Occupant's SSN Note: Do not include the owner-occupant's income on the Income statement of the applicant/spouse listed above. Each owner-occupant's income must be reported on a separate Nebraska Schedule I—Income Statement. If married, you must report 2014 income for both you and your spouse. Part For Applicants Who DID NOT FILE a 2014 Federal Income Tax Return Complete Worksheet.A on reverse side,as necessary. If you filed a 2014 federal income tax return,complete only Part.IL Household Income: January 1 through December 31,2014 1 Wages and salaries 1 2 Social Security retirement income. If none, explain 2 12,936.00 3 Tier I Railroad Retirement income 3 4 Total pensions and annuities 4a 4b Taxable amount 4b 5 IRA distributions 5a 5b Taxable amount 5b 6 Tax exempt interest and dividends(must include all state and local bond income) 6 7 Taxable interest and dividends 7 8 Other income or adjustments (from line G,Worksheet A on reverse side) 8 9 Total of Lines 1 through 8 9 12,936:00 Medical and Dental Expenses-Caution:Do not include expenses reimbursed by insurance or paid by others. 10a Medical and dental expenses (see instructions) 10a 10b Multiply line 9 by 4% (.04) 10b 10c Subtract line 10b from line 10a. If line 10b is more than line 10a enter-0- 10c 1 11 Household income(line 9 minus line 10c) 11 • 12,936:00 AMU—For Applicants Who FLED a 2014 Federal Income Tax Return ell you did not Wee 2014 federal t tcomelax retar l,.complete only Part and worksheet A. Household Income:January 1 through December 31,2014 1 Federal adjusted gross income(AGO:Federal Form 1040, line 37; Federal Form 1040A, line 21;or Federal Form 1040EZ, line 4 1 2 Social Security retirement income (see instructions) i r 3 Tier I Railroad Retirement income (see instructions) 4 Nebraska adjustments increasing federal AGI (enter amount from Form 1040N, line 12) J 4 5 Income from Nebraska obligations (enter amount from Form 1040N, line 46, Schedule I). . . . . . 5 9 20/5 6 Total of lines 1 through 5 ' a• t8' Medical and Dental Expenses -Caution:Do not include expenses reimbursed by insurance or pa dtyi4lhprs., 7a Medical and dental expenses (see instructions) 7a "y>k 4 7b Multiply line 6,Part II,by 4%(.04) 7b 7c Subtract line 7b from line 7a. If line 7b is more than line 7a enter-0- 7c 8 Household income(line 6 minus line 7c) 8 r penalties of law,I declare that I h ye mjn r ed this schedule,and that it is,to the best of my knowledge and belief,correct and complete. hehere Cc '�?iccome/ire Signature of Person Whose Income is S o own Spouse's Signature if Income Included Date Daytime Phone File Form 458 and all Schedules with your county assessor after February 1 and by June 30. Nebraska Department of Revenue Retain a copy for your records. Form No.96-296-2009 Rev.1-2015 supersedes 98-296-2009 Rev.1-2014 Authorized by Neb.Rev.Slat.§§77-3510 and 763528