Income Statement Form - Nebraska
This Income Statement is filed for (select one only):
Applicant Applicant & Spouse Spouse Other Owner-Occupant
Applicant’s Name on Form 458 Applicant’s Social Security Number (SSN)
458
Schedule I
FORM
Nebraska Department of Revenue
Form No. 96-296-2009 Rev. 1-2015 Supersedes 96-296-2009 Rev. 1-2014
Authorized by Neb. Rev. Stat. §§ 77-3510 and 77-3528
Part I — 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 II
.
If married, you must report 2014 income for both you and your spouse.
Household Income: January 1 through December 31, 2014
Part II — For Applicants Who FILED a 2014 Federal Income Tax Return
• If you did not file a 2014 federal income tax return, complete only Part I and Worksheet A.
Household Income: January 1 through December 31, 2014
Signature of Person Whose Income is Shown Spouse’s Signature if Income Included Date Daytime Phone
( )
Under penalties of law, I declare that I have examined this schedule, and that it is, to the best of my knowledge and belief, correct and complete.
Nebraska Schedule I — Income Statement
File Form 458 and all Schedules with your county assessor after February 1 and by June 30.
Retain a copy for your records.
• Attach this schedule to the 2015 Nebraska Homestead Exemption Application
or Certification of Status, Form 458.
• Read instructions carefully.
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.
sign
here
Spouse’s or Owner-Occupant’s Name Spouse’s or Owner-Occupant’s SSN
1 Federal adjusted gross income (AGI): 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 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
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. If line 7b is more than line 7a enter -0- . . . . . . . . . . . . . . . . . . . . . . . . .
7c
8 Household income (line 6 minus line 7c) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
1 Wages and salaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
2 Social Security retirement income. If none, explain
______________________________________________
________________________________________________________________________________________________
2
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
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
11 Household income (line 9 minus line 10c) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
Medical and Dental Expenses – Caution: Do not include expenses reimbursed by insurance or paid by others.
Medical and Dental Expenses
–
Caution: Do not include expenses reimbursed by insurance or paid by others.
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