Laserfiche WebLink
men_--e__ Nebraska Schedule I—Income Statement FORM <br /> Nebraska pevnnmem or 458 <br /> REVENUE or this schedule of Status,tus,the Form Nebraska Homestead Exemption Application <br /> ff77GG�r _ G or Read Instructions of Status,Form 458. <br /> • Read Instructions carefully. Schedule <br /> Applicant's Name on Form 458 Applicants Social Security Number(SSN) <br /> TY)ax—lire-- gut 1 eAt 5o 1 61,9, p W c9 c <br /> This Income Statement is filed for(select one only): <br /> This <br /> ❑Applicant&Spouse ❑ Spouse ❑Other Owner-Occupant <br /> Spouse's or Owner-Occupant's Name Spouse's or Owner-Occupant's SSN <br /> r <br /> Note: Do not include the owner-occupant's income on the income statement of the applicant/spouse listed above. <br /> Each owner-occupant's income must be reported on a separate Nebraska Schedule I—Income Statement. <br /> If married,you must report 2014 income for both you and your spouse. <br /> Part I.--For Applicants Who DID NOT FILE a 2014 Federal Income Tax Return' <br /> Complete Worksheet A on reverse side,as necessary. <br /> If you filed a:2014.federalincome tax return,complete only Part II. <br /> Household Income:January 1 through December 31,2014 <br /> 1 Wages and salaries 1 <br /> 2 Social Security retirement income. If none, explain rr p <br /> 2 Fg 1 ni <br /> 3 Tier I Railroad Retirement income .. 3 <br /> 4 Total pensions and annuities 4a 4b Taxable amount 413:' ? 4; } <br /> 5 IRA distributions 5a 5b Taxable amount J(4' 5b 'g 1 ,' <br /> 6 Tax exempt interest and dividends (must include all state and local bond income) /yAN ,. . €b', <br /> 7 Taxable interest and dividends 'c: -i' i ^7 <br /> 8 Other income or adjustments(from line G,Worksheet A on reverse side) <br /> 9 Total of Lines 1 through 8 9 <br /> I . <br /> I Medical and Dental Expenses-Caution:Do not include expenses reimbursed by insurance or paid by others. <br /> 10a Medical and dental expenses (see instructions) 10a 1 <br /> 10b Multiply line 9 by 4% (.04) 10b <br /> 10c Subtract line 10b from line 10a.If line lob is more than line 10a enter-0- 10c i. <br /> 11 Household income (line 9 minus line 10c) 11 ?`/ q77; <br /> Paittilf43 tiA141410291tS Who FILED =14 Federal Incon Taxaeturn: <br /> .:,1140 not fll - 14 federal iicomi taxisurn,icpmseti only.Nrt landWorkshee_t A. <br /> Household Income:January 1 through December 31,2014 <br /> 1 Federal adjusted gross income (AGI): Federal Form 1040, line 37; <br /> Federal Form 1040A, line 21;or Federal Form 1040EZ, line 4 1 <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 Form 1040N, line 12) 4 <br /> 5 Income from Nebraska obligations (enter amount from Form 1040N, line 46, Schedule I) 5 <br /> 6 Total of lines 1 through 5 6 <br /> Medical and Dental Expenses -Caution:Do not include expenses reimbursed by insurance or paid by others. <br /> 7a Medical and dental expenses(see instructions) 7a <br /> 7b Multiply line 6, Part II,by 4% (.04) 7b i <br /> 7c Subtract line 7b from line 7a. If line 7b is more than line 7a enter-0- 7c <br /> 8 Household income (line 6 minus line 7c) 8 <br /> Underrppeennaties of llaa .'/•- laathe •exa •i this schedu- :nd that it is,to the best of my knowledge and belief,correct and complete. ,/yy��,�T"" <br /> sign A lfe /' /1/1 1 /S <iF is�27v, (3cr3 �/ <br /> here at :.c� F =.ouses Signature if Income Included Date Daytime Phone <br /> ' - • .f'�"�3f7TT��jr////J'' <br /> File Form 458 a d all Sche• r, rs with your county assessor after February 1 and by June 30. <br /> Nebraska Departmental Revenue i- Retain a copy for your records. <br /> Form Na 96-296.2009 Rev.1-2015 Supersedes 96-296-2009 Rev.1-2614 Authorized by Neb.Rev.Stat.§§77-3510 and 77-3528 <br />