Form Ia 1040a - Iowa Individual Income Tax - Short Form

IA 1040A

2001

Iowa Individual Income Tax Short Form

For full-year Iowa residents only.

STEP 1:

Fill in all spaces. You MUST fill in your Social Security Number.

•

Last name

Your first name/middle initial

Social Security Number

A .

•

Spouse’s last name

Spouse’s first name/middle initial

Social Security Number

Your Occupation

B .

Current mailing address (number and street, apartment, lot or suite number) or PO Box

Are your name,

•

Spouse’s Occupation

your spouse’s

name, if applic-

City, State, ZIP

able, and your

Residence on 12/31/01

address the same

•

County No.

Sch.Dist.No.

as on last year’s

return?

STEP 2: Filing Status: Mark one box only.

Y E S

N O

School District Name

sNONNO

Single: Were you claimed as a dependent on another person’s Iowa return?

YES

Married filing a joint return.

Head of household with qualifying person. If qualifying person is not claimed as a dependent on this return, enter the person’s name and

Qualifying widow(er) with dependent child.

SSN here. Name:

SSN:

STEP 3

4 0

a. Personal Credit: Enter 1 (Enter 2 if filing joint or head of household) ................... _______

X $ _________ = $ __________

YOU

2 0

(and spouse if

b. Enter 1 for each spouse who is 65 or older and/or 1 for each spouse who is blind

_______

X $ _________ = $ __________

Exemption

filing jointly)

4 0

Credits

c. Dependents: Enter 1 for each dependent ..................................................................... _______

X $ _________ = $ __________

d. Enter first names of dependents here: ____________________________________

e. TOTAL $ ______________

1. Total wages, salaries, tips and unemployment compensation. .................................................................. 1 .

__________________ .00

STEP 4

2. Taxable interest. If more than $400, complete Schedule B. ....................................................................... 2 .

__________________ .00

Figure

3. Taxable dividends. If more than $400, complete Schedule B. ................................................................... 3 .

__________________ .00

your

................................................................................................................. 4 . s __________________ .00

4. Net income. Add lines 1, 2, and 3.

income

5. Federal income tax refund received in 2001. Do NOT include your Federal Tax Rebate. ................. 5 . s __________________ .00

6. TOTAL. Add lines 4 and 5. ................................................................................................................................. 6 .

__________________ .00

a . s ___________ .00

7. Federal tax payment information.

(a) Federal tax withheld ...............................................

b. s ___________ .00 7 .

__________________ .00

(b) Additional paid in 2001 for 2000 and any prior year .

8. Income subject to tax. Subtract line 7 from line 6. If greater than $100,000 you must use IA 1040 long form. 8 .

__________________ .00

9. Tax from tables. See tax tables on pages 6-11, worksheets on page 5. .............................................. 9 . s __________________ .00

STEP 5

10. Total exemption credits from Step 3. ............................................................................................................. 1 0 .

__________________ .00

Figure

X .065) ............................................. 1 1 . s __________________ .00

11. Iowa Earned Income Credit. (Federal credit $

your

12. Total credits. Add lines 10 and 11. ................................................................................................................. 1 2 .

__________________ .00

tax,

13. BALANCE. Subtract line 12 from line 9. If less than zero, enter zero. .................................................. 1 3 . s __________________ .00

credits

and

14. School District Surtax/Emergency Medical Services Surtax, pages 12-13. ......................................... 1 4 . s __________________ .00

checkoff

15. Fish and Wildlife Fund Contribution. $1 or more supports the Wildlife Diversity Program. ............... 1 5 . s __________________ .00

contri-

16. State Fairgrounds Renovation Contribution. $1 or more helps renovate the fairgrounds. ................ 1 6 . s __________________ .00

butions

17. Keep Iowa Beautiful Contribution. $1 or more assists beautification efforts in Iowa. ......................... 1 7 . s __________________ .00

18. Total Tax and Contributions. Add lines 13 through 17. ............................................................................... 1 8 .

__________________ .00

19. Iowa income tax withheld from Box 18 of your W-2 form(s). ................................................................... 1 9 . s __________________ .00

20. If line 19 is more than line 18, subtract line 18 from line 19. This is your REFUND. .......................... 2 0 . s __________________ .00

STEP 6

Mail to Iowa Income Tax Refund Processing, Hoover State Office Bldg, Des Moines IA 50319-0120

Figure

21. If line 19 is less than line 18, subtract line 19 from line 18. This is the AMOUNT OF TAX YOU OWE. ..... 2 1 . s __________________ .00

your

22. Penalty. See back of payment voucher. ........................................................................................................ 2 2 . s __________________ .00

refund

23. Interest. See back of payment voucher. ....................................................................................................... 2 3 . s __________________ .00

amount

24. TOTAL AMOUNT DUE. Add lines 21, 22, and 23 and enter here. .......................................................... 2 4 . s __________________ .00

due

Write check to Treasurer, State of Iowa / Mail to Iowa Income Tax Processing, PO Box 9187, Des Moines IA 50306-9187

POLITICAL CHECKOFF.

SPOUSE

YOU

Next year, (check one)

This checkoff does not

$1.50 to Democratic Party

Would you like to receive a booklet?

$1.50 to Republican Party

increase the amount of tax you

This option is not available to

Yes

$1.50 to Green Party

electronic filers.

owe or decrease your refund.

$1.50 to Campaign Fund

I (We), the undersigned, declare under penalty of perjury that I (we) have examined this return, including all accompanying schedules and statements, and, to the best of my (our)

PLEASE

knowledge and belief, it is a true, correct, and complete return. Declaration of preparer (other than taxpayer) is based on all information of which the preparer has any knowledge.

SIGN HERE

Your Signature

Date

Preparer’s Signature

Date

SIGN HERE

Spouse’s Signature

Date

Address

•

Verify your Social

Security Number(s)