Income Calculation Worksheet - South Dakota Department Of Revenue & Regulation - 2005

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For Office Use Only
Tax Year
Type
Total Income
Batch Number
Refund
2004
Personal Information
First Name
Social Security Number
Last Name
County
Telephone
Mailing Address
State
Date of Birth (Month/Day/Year)
City
Zip Code
Income Calculation
Please list your income and its source in the area provided below.
Remember: July 1, 2005 is the deadline for filing.
Attach a copy of your complete 2004 federal income tax return.
Federal Adjusted Gross Income
$
Support Payments
$
Wages, salaries, tips, other employee
$
Cash public assistance and relief
$
compensation
Interest
$
Title 19
$
Capital gains excluded from
Dividends
$
adjusted gross income
$
Self-employment (explain)
$
Other income
$
Social Security (attach a copy of each
TOTAL INCOME
$
household member’s SSA-1099)
$
Medicare premiums
$
Deductions
SSI
$
For Home Owners
A portion of your real estate taxes will be deducted
Veteran’s benefits
$
from your income. List 2004 real estate taxes due
$
and payable in 2005.
Railroad retirement benefits
$
For Renters
A portion of your rent will be deducted from your
Other pensions and annuities
$
income. List the total rent that you alone have paid
$
in 2004.
Excluded interest and dividends
$
Alimony payments not yet listed
$

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