Form 40s - Oregon Individual Income Tax Return - 2001
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1
2Clear Form
Oregon
Form
2001
S
40
Individual
For office use only
Income Tax
Date received
FULL-YEAR
Return
RESIDENTS ONLY
SHORT FORM
Last name
First name and initial
Birth Year
For office
Social Security No. (SSN)
use only
1
Spouse’s last name if different and joint return
Spouse’s first name and initial if joint return
Spouse’s SSN, if joint return
Spouse’s
Birth Year
2
Current mailing address
Telephone number
(
)
City
State
ZIP Code
3
If you filed a return in 2000, and this
address is different, check here
•
1
Single
Exemptions
Severely
•
Filing
Total
Regular
disabled
Status
2
Married filing jointly
6a Yourself
6a
3
Married filing separately
6b Spouse
b
Check
(Spouse’s name)
only one
6c Dependents
•
c
box
(Spouse’s Social Security number)
(First names)
4
•
d
Head of household
6d Disabled
(Person who qualifies you)
children only
(First names)
•
6e
Total
5
Qualifying widow(er) with dependent child
•
•
7a
Check if: You were:
7b
7c
65 or older
Blind
Check if you filed
If someone else can claim you
Spouse was:
an extension
as a dependent, check here
65 or older
Blind
•
8 Wages, salaries, tips, commissions, and other pay for work
8
•
9 Interest: 9a
plus Dividends: 9b
9
•
10 Unemployment benefits. See instructions, page 10
10
11
11 Total income. Add lines 8 through 10
•
12 2001 federal tax liability. ($0 - $3,000, see instructions for the correct amount)
12
13 Standard deduction from the back of this form
13
14 Add lines 12 and 13
14
•
•
15 Oregon taxable income. Line 11 minus line 14.
If line 14 is more than line 11, fill in -0-
15
•
•
16 Tax from tables, pages 21 through 23
16
Staple
17
EXEMPTION CREDIT.
Multiply your total exemptions on line 6e by $142
17
W-2
•
18 Earned income credit. See instructions, page 10
wage
18
slips
•
19 Working family child care credit. See instructions, page 10
19
here
•
20 Child and dependent care credit. See instructions, page 11
20
•
21 Other credits (see instructions). Identify
21
22 Total credits. Add lines 17 through 21
22
•
•
23 Net income tax. Line 16 minus line 22. If line 22 is more than line 16, fill in -0-
23
•
24 Oregon tax withheld from income. Attach your Form(s) W-2 and 1099
24
•
•
25
REFUND. If line 24 is more than line 23, you have a refund. Line 24 minus line 23
REFUND
25
•
•
26
TAX-TO-PAY.
If line 23 is more than line 24, you have tax to pay. Line 23 minus 24
TAX-TO-PAY
26
•
$1,
$5,
$10,
Other $ ______
27 Oregon Nongame Wildlife
DONATIONS
27
•
$1,
$5,
$10,
Other $ ______
28 Child Abuse Prevention
28
I wish to
These will
•
$1,
$5,
$10,
Other $ ______
29 Alzheimer’s Disease Research
29
donate
reduce
part of my
•
$1,
$5,
$10,
Other $ ______
30 Stop Domestic & Sexual Violence
30
your refund
tax refund
•
$1,
$5,
$10,
Other $ ______
31 AIDS/HIV Education and Services
31
to the
following
•
•
$1,
$5,
$10,
Other $ ______
32 Other charity. Enter code ______
32
fund(s)
33 Total. Add lines 27 through 32. Total can’t be more than your refund on line 25
33
34
NET REFUND.
Line 25 minus line 33. This is your net refund
NET REFUND
34
•
DIRECT
35 For direct deposit of your refund, see the instructions on pages 4 and 12.
Type of account:
Checking
Savings
DEPOSIT
•
•
Routing No.
Account No.
Under penalties for false swearing, I declare that I have examined this return, including accompanying schedules
I authorize the Department of Revenue to discuss this
and statements. To the best of my knowledge and belief it is true, correct, and complete. If prepared by a person
Yes
No
return with this preparer or any member of his/her firm.
other than the taxpayer, this declaration is based on all information of which the preparer has any knowledge.
Your signature
Date
Signature of preparer other than taxpayer
License No.
X
X
SIGN
HERE
Spouse’s signature (If filing jointly, BOTH must sign)
Date
Address
Telephone No.
X
150-101-044 (Rev. 10-01) Web
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