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3083810521 Legal Aid of Nebraska GI 02:40:41 p.m. 10-05-2018 4/5 ■5131;44-544A- Nebraska Schedule I—Income Statement FORM Good Life.Great Service. • Attach this schedule to the 2018 Nebraska Homestead Exemption Application 458 or Certitication of Status,Form 458. - aThan•..rh • Red instructions arefully. Schedule I app � ��i�l ��lillfll - 0 / , T g_ncome Statement is sled for(select one on y : / Gt Applicant ❑Applicant&Spouse ❑ Spouse El Other Owner-Occupant Sp' .e'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 2017 income for both you and your spouse. Part I—For Applicants Who DID NOT FILE a 2017 Federal IncomeTax Return Complete Worksheet A on reverse side,as necessary. If you filed a 2017 federal income tax return,complete only Part IL Household Income:January 1 through December 31,2017 1 Wages and salaries 1 O 2 Social Security retirement income.If none,explain / /� 2 JloSC� CU 3 Tier I Railroad Retirement income 3 0 4 Total pensions and annuities 4a 0 4b Taxable amount 4b 0 5 IRA distributions 5a 0 5b Taxable amount Sb Q 6 Tax exempt interest and dividends(must include all state and local bond income) 6 0 7 Taxable interest and dividends 7 0 8 Other income or adjustments(from line G,Worksheet A on reverse side) 8 0 L�� f� 9 Total of Lines 1 through 8 9 J(U ' L ) Medical and Dental Expenses-Caution:Do not Include expenses reimbursed by insurance or paid by others. 10a Medical and dental expenses(see instructions) l0a (poop , p 0' lOb 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 11 Household income(line 9 minus line 10c) 11 IOW) Co Part II—For Applicants Who FILED a 2017 Federal Income Tax Return •If you did not file a 2017 federal Income tax return,complete only Part l and Worksheet A. Household Income:January 1 through December 31,2017 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) 2 3 Tier I Raiiroad Retirement income(see instructions) p f - �- 4 Nebraska adjustments increasing federal AGI (enter amount from Form 1040N, line 12) l az,. (, 5 Income from Nebraska obligations(enter amount from Form 1040N, line 2,Schedule I) on 0 5 2018 6 Total of lines 1 through 5 6 iMedical and Dental Expenses -Caution:Do not include expenses reimbursed by insuranl5il .pkiklitb}rlmtherf;, i �;i I 7a Medical and dental expenses(see instructions) 7a GRAND IS( r 'JI' L i „t St<A 7b Multiply fine 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'¢ minus line 7c) 8 er penalties flaw.f law. dear I I ha this schedule,and that it is,to the best of my knowledge and belief,correct and complete. sign / /// i here� toreoof Per soA W ncome is Shown O.Spouse's Signature it Income Included Date Dayli e Phone `—.) File 2018 Form 458 and all Schedules with your county assessor after February 1,2018 and by July 2,2018. Retain a copy for your records. Nebraska aeparrmenl of Revenue Foam No.96-296-2009 Rev.I-201e Supersedes 96-2962009 Rev.1-2017 Atfho,iaed by Web.Re..Slat.§§77-3510-14 and 77-3528