Form Ia 1040a - Iowa Individual Income Tax - Short Form - 2004
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1IA 1040A 2004
Iowa Individual Income Tax Short Form
Click this button to reset the 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 12/31/04
address the same
•
•
County No.
Sch.Dist.No.
as on last year’s
return?
STEP 2: Filing Status: Mark one box only.
YES
NO
School District Name
1
Single: Were you claimed as a dependent on another person’s Iowa return?
YES
NO
NONNO
2
Married filing a joint return.
5
Head of household with qualifying person. If qualifying person is not claimed as a dependent on this return, enter the person’s name and
6
Qualifying widow(er) with dependent child.
SSN here. Name:
SSN:
STEP 3
40
a. Personal Credit: Enter 1 (Enter 2 if filing joint or head of household) ................... _______
X $ _________ = $ __________
YOU
20
(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)
40
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 $1,500, complete Schedule B. ...................................................................... 2 .
__________________ .00
Figure
3. Taxable dividends. If more than $1,500, complete Schedule B. .................................................................. 3 .
__________________ .00
your
4. Net income. Add lines 1, 2, and 3.
................................................................................................................... 4 .
__________________ .00
income
5. Federal income tax refund received in 2004. .................................................................................................... 5 .
__________________ .00
6. TOTAL. Add lines 4 and 5. ................................................................................................................................... 6 .
__________________ .00
7. Federal tax payment information.
a .
___________ .00
(a) Federal tax withheld ..............................................
b.
___________ .00 7 .
__________________ .00
(b) Additional paid in 2004 for 2003 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
STEP 5
9. Tax from tables. See IA 1040A tax tables at ............................................................. 9 .
__________________ .00
10. Total exemption credits from Step 3. ............................................................................................................... 1 0 .
__________________ .00
Figure
11. Iowa Earned Income Credit. (Federal credit $
X .065) ............................................... 11.
__________________ .00
your
12. Total credits. Add lines 10 and 11. .................................................................................................................. 1 2 .
__________________ .00
tax,
credits
13. BALANCE. Subtract line 12 from line 9. If less than zero, enter zero. ..................................................... 13.
__________________ .00
and
14. Multiply line 13 by your School District Surtax Rate. See 2004 School District Surtax List. ............... 14.
__________________ .00
checkoff
15. Fish and Wildlife Fund Contribution. $1 or more supports the Wildlife Diversity Program. ................. 15.
__________________ .00
contri-
butions
16. State Fairgrounds Renovation Contribution. $1 or more helps renovate the fairgrounds. ................... 16.
__________________ .00
17. Keep Iowa Beautiful Contribution. $1 or more assists beautification efforts in Iowa. ........................... 17.
__________________ .00
18. Volunteer Firefighter Preparedness Fund. $1 or more helps train volunteer firefighters in Iowa. ....... 18.
__________________ .00
19. Total Tax and Contributions. Add lines 13 through 18. ................................................................................ 1 9 .
__________________ .00
20. Iowa income tax withheld from Box 17 of your W-2 form(s). ...................................................................... 20.
__________________ .00
21. If line 20 is more than line 19, subtract line 19 from line 20. This is your REFUND. ............................ 21.
__________________ .00
STEP 6
Mail to Iowa Income Tax Refund Processing, Hoover State Office Bldg, Des Moines IA 50319-0120
Figure
your
22. If line 20 is less than line 19, subtract line 20 from line 19. This is the AMOUNT OF TAX YOU OWE. ...... 22.
__________________ .00
refund
23. Penalty. See back of the IA 1040V payment voucher. ................................................................................. 23.
__________________ .00
or
24. Interest. See back of the IA 1040V payment voucher. ................................................................................. 24.
__________________ .00
amount
due
25. TOTAL AMOUNT DUE. Add lines 22, 23, and 24 and enter here. ............................................................ 25.
__________________ .00
E-Pay at or write check to Treasurer, State of Iowa / Mail to Iowa Income Tax Processing, PO Box 9187, Des Moines IA 50306-9187
POLITICAL CHECKOFF.
Next year, (check one): Would you like to receive
SPOUSE
YOU
This checkoff does not increase
$1.50 to Republican Party
$1.50 to Republican Party
an IA 1040 booklet?
the amount of tax you owe or
$1.50 to Democratic Party
$1.50 to Democratic Party
This option is not available
0.
Yes
decrease your refund.
$1.50 to Campaign Fund
$1.50 to Campaign Fund
to electronic filers.
1.
No
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)
Daytime Telephone Number
Daytime Telephone Number
Identification Number
•
Recheck your math
S04
•
Attach all W-2s.
This return is due May 2, 2005.
41-080 (11/10/04)
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