Form 40n - Oregon Individual Income Tax Return For Nonresidents - 2011
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1
2Clear Form
OREGON
Amended Return
Form
40N
2011
Individual Income Tax Return
For office use only
FOR NONRESIDENTS
Fiscal year ending
Oregon resident:
mm
dd
yyyy
mm
dd
yyyy
K
F
P
J
From
To
Last name
First name and initial
Date of birth
(mm/dd/yyyy)
Social Security No. (SSN)
–
–
Deceased
Spouse’s/RDP’s last name if joint return
Spouse’s/RDP’s first name and initial if joint return
Spouse’s/RDP’s SSN if joint return
Date of birth
(mm/dd/yyyy)
–
–
Deceased
Current mailing address
Telephone number
(
)
City
State
ZIP code
Country
If you filed a return last year, and your
name or address is different, check here
•
Filing
1
Single
Exemptions
Status
•
•
2a
Married filing jointly
Total
2b
Registered domestic partners (RDP) filing jointly
Check
6a
6a
Yourself ...........
Regular
...... Severely disabled
....
only
3a
Married filing separately:
one
6b
b
Spouse/RDP ...
Regular
...... Severely disabled
......
Spouse’s name _____________________________ Spouse’s SSN ___________________
box
•
3b
Registered domestic partner filing separately:
6c
c
All dependents
First names __________________________________
Partner’s name _____________________________ Partner’s SSN ___________________
•
6d
d
Disabled
First names __________________________________
4
Head of household:
Person who qualifies you ________________________________
children only
•
Total
6e
5
Qualifying widow(er) with dependent child
(see instructions)
•
•
•
•
•
Check
7a
7b
You
7c
You have
7d
7e
If there is a kicker refund,
You filed
all that
You were:
65 or older
Blind
filed an
federal
I want to donate mine to the
Oregon
apply
➛
Spouse/RDP was:
65 or older
Blind
extension
Form 8886
State School Fund
Form 24
Federal column (F)
Oregon column (S)
•
.00
.00
8 Wages, salaries, and other pay for work. Include all Forms W-2 ........................ 8F
8S
INCOME
•
.00
.00
9 Taxable interest income from federal Form 1040, line 8a ...................................... 9F
9S
•
.00
.00
10 Dividend income from federal Form 1040, line 9a ................................................. 10F
10S
•
.00
.00
11 State and local income tax refunds from federal Form 1040, line 10 .................... 11F
11S
•
.00
.00
12 Alimony received from federal Form 1040, line 11 ................................................ 12F
12S
•
.00
.00
Include proof
13 Business income or loss from federal Form 1040, line 12 ..................................... 13F
13S
of withholding
•
.00
.00
14 Capital gain or loss from federal Form 1040, line 13 ............................................. 14F
14S
(W-2s, 1099s),
•
.00
.00
15 Other gains or losses from federal Form 1040, line 14 .......................................... 15F
15S
payment,
•
.00
.00
and
16 IRA distributions from federal Form 1040, line 15b ............................................... 16F
16S
payment
•
.00
.00
17 Pensions and annuities from federal Form 1040, line 16b ..................................... 17F
17S
voucher
•
.00
.00
18 Rents, royalties, partnerships, etc., from federal Form 1040, line 17 .................... 18F
18S
•
.00
.00
19 Farm income or loss from federal Form 1040, line 18 ........................................... 19F
19S
•
.00
.00
20 Unemployment and other income from federal Form 1040, lines 19 through 21 ... 20F
20S
•
•
.00
.00
21 Total income. Add lines 8 through 20 .................................................................
21F
21S
•
.00
.00
22 IRA or SEP and SIMPLE contributions, federal Form 1040, lines 28 and 32 ......... 22F
22S
ADJUSTMENTS
•
.00
.00
TO INCOME
23 Education deductions from federal Form 1040, lines 23, 33, and 34 .................... 23F
23S
.00
•
.00
24 Moving expenses from federal Form 1040, line 26 ................................................ 24F
24S
.00
•
.00
25 Deduction for self-employment tax from federal Form 1040, line 27 .................... 25F
25S
.00
•
.00
26 Self-employed health insurance deduction from federal Form 1040, line 29 ........ 26F
26S
.00
•
.00
27 Alimony paid from federal Form 1040, line 31a ..................................................... 27F
27S
•
.00
•
.00
•
•
28y $
28 Other adjustments to income. Identify:
28x
28z
28F
28S
Schedule
•
.00
•
.00
29 Total adjustments to income. Add lines 22 through 28 ......................................
29F
29S
•
.00
•
.00
30 Income after adjustments. Line 21 minus line 29 ...............................................
30F
30S
•
.00
•
.00
31 Interest on state and local government bonds outside of Oregon .....................
31F
31S
ADDITIONS
•
.00
•
.00
32 Federal election on interest and dividends of a minor child ...............................
32F
32S
•
.00
•
.00
•
•
33y $
33 Other additions. Identify:
33x
33z
......
33F
33S
Schedule included
•
.00
•
.00
34 Total additions. Add lines 31 through 33 ............................................................
34F
34S
•
.00
•
.00
35 Income after additions. Add lines 30 and 34 ......................................................
35F
35S
•
.00
36 Social Security and tier 1 Railroad Retirement Board benefits included on line 20F ...
36F
SUBTRACTIONS
•
.00
•
.00
•
•
37y $
37 Other subtractions. Identify:
37x
37z
37F
37S
Schedule included
•
.00
•
.00
38F
38 Income after subtractions. Line 35 minus lines 36 and 37 .................................
38S
•
.
Carry this
__ __ __
__ %
39 Oregon percentage. Line 38S ÷ line 38F (not more than 100.0%)
39
amount to line 40
➛
NOW GO TO THE BACK OF THE FORM
150-101-048 (Rev. 12-11)
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