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Nebraska Schedule I—Income Statement FORM Nebraska Department of • Attach this schedule to the 2015 Nebraska Homestead Exemption Application 458 REVENUE • or Certification of Status,Form 458. • Read instructions carefully. Schedule I Applicant's Name r 4 Sod rity N S ta. QxtftnB � ` �1!b T Income Statement is filed for( ct one only): Applicant ❑ Applicant&Spouse ❑ Spouse ❑ Other Owner-Occupant S u 's or Owner-Occupant's Name Spouse's or Owner-Occupant's SSN 6 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 .7 rApp cantswho ID:NOT.FILE a2014 ederal eTax;R.eturn ' Complete WorksheetA on reeverse side as necessar :. If you flied,a?2014 federal Incest fax eturh;complete only Papt II. Household Income:January 1 through December 31,2014 1 Wages and salaries p +w § _1 2 Social Security retirement income. If none, explain E i 1. t J JUL 1 7 2015 2 - 3 Tier I Railroad Retirement income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 / / 0 y ; "I: . ",[35. - 4 Total pensions and annuities 4a 4b 19pRJ t' j oo, 4b 5 IRA distributions 5a 513 Taxable amount 5b 6 Tax exempt interest and dividends (must include all state and local bond income) -6 7 Taxable interest and dividends 7 j I 8 Other income or adjustments (from line G,Worksheet A on reverse side) 8 9 Total of Lines 1 through 8 9 // 0 ` i Ri 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 ;v 10c Subtract line 10b from line 10a. If line 10b is more than line 10a enter-0- 10e 11 Household income(line 9 minus line 10c) _ 11 // 0� q yy� .. . ..• :;°+f r rax a• '.- r.):1, r •t w a r, az =,1 . _-i 91. ,i x f-t li.ra ,.v_' - lz fe h< �'T, .. t , r Household Income:January 1 through December 31,2014 1 Federal adjusted gross income (AGI): Federal Form 1040, line 37; Federal Form 1040A, line 21;or Federal Form 1040EZ, line 4 _ 1 t 2 Social Security retirement income(see instructions) _ 2 3 Tier I Railroad Retirement income (see instructions) _ 3 j 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 I 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 . i 7c Subtract line 7b from line 7a. If line 7b is more than line 7a enter-0- 7e 8 Household income (line 6 minus line 7c) 8 Under penalties o law,I declare that I esami d }xsthedule,and that R is,to the best of my knowledge and belief,correct and complet o/K here � /%� - �'V' July )7 1. f'4, let a TSiett re of rson Whose Income is Shown ,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 96-2962009 Rev.1-2014 Authorized by Neb.Rev.Stet.§§77-3510 and 77-3528