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ads— Nebraska Schedule I—Income Statement FORM NebfBSka Oepa6TCOr°` • Attach this schedule to the 2015 Nebraska Homestead Exemption Application 458 REVENUE • or Certification of Status,Form 458. linaanna • Read instructions carefully. Schedule I Applicant's Name on Form 458 Applicant's Social Security Number(SSN) c h 2 e. i b pci C I t cl<- 5- 0 1/0a-0759/ This Income Statement is filed for(select one only): ❑Applicant Applicant&Spouse ❑Spouse ❑Other Owner-Occupant Spouse's or Owner-Occupant's Name Spouse's or Owner-Occupant's SSN / 13�- , s—a, )P�- ) k.-1s g %d 5 Co -3601 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. Pqrit--,FOlt-iik5110410sWitio DID NOT FILE a 2014 Federal Income`tax Return Complete worksheet A on reverse side,as necessary. . 114trua a;2014 federal income tax-.return,complete only Part II. , Household Income:January 1 through December 31,2014 1 Wages and salaries 1 2 Social Security retirement income. If none, explain 2 c 3 Tier I Railroad Retirement income 3 4 Total pensions and annuities 4a 4b Taxable amount 4SL 1 3 !015 5 IRA distributions 5a 5b Taxable amount . Sb i, 6 Tax exempt interest and dividends (must include all state and local bond income) tj:t-, 4 `'''' 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 '_ 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) 106 10c Subtract line 10b from line 10a.If line 10b is more than line 10a enter-0- 10c 11 Household income line 9 minus line 10c) 11 g i - '� �- : , e,-. 1 m '�1 � r�i y }F�§C- Federal 5 �„ & E �`1�t !. ` %5` zc.' - - ' to .-~ably A ' . Household Income:January 1 through December 31,2014 1 Federal adjusted gross income (AGO: Federal Form 1040, line 37; s Federal Form 1040A, line 21;or Federal Form 1040EZ, line 4 1 /3 5 27 tom 1 2 Social Security retirement income (see instructions) 2 3 Tier I Railroad Retirement income (see instructions) 3 4 Nebraska adjustments increasing federal AGI (enter amount from Form 1040N, line 12) 4 5 Income from Nebraska obligations (enter amount from Form 1040N, line 46, Schedule I) 5 6 Total of lines 1 through 5 - 6 Medical and Dental Expenses —Caution:Do not include expenses reimbursed by insurance or paid by others. 7a Medical and dental expenses(see instructions) 7a 7b Multiply line 6, Part II, by 4%(.04) 7b 7c Subtract line 7b from line 7a. lin- 7b is more than line 7a enter-0- 7c 1 8 House, •Id I. ome 'ne 6 inus lin- 7c/ 8 / 3537 O d ` d-r.-Ities o 1w, •:-fi-that I hay—1:m a ed this schedule,and that It is,to the best of my knowledge and belief,correct and complete. sign I / . 7-13 - $ .386-4 32/ her gt - . of-=rs �G`3L'4r �'� . 'Spouse's Signature it 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 96-296-2009 Rev.1-2014 Authorized by Nab.Rev.Slat.§§77-3510 and 77-3528