Schedule X (Form N-11/n-13/n-15) - Tax Credits For Hawaii Residents - 2012

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SCHEDULE X

STATE OF HAWAII — DEPARTMENT OF TAXATION

TAX CREDITS FOR HAWAII RESIDENTS

(FORM N-11/N-13/N-15)

2012

(REV. 2012)

Attach to Form N-11, N-13, or N-15

Caution: Please read the Instructions for Schedule X in your tax return

instruction booklet carefully before completing this schedule.

YCF121

Name(s) as shown on Form N-11, N-13, or N-15

Your social security number

PART I: REFUNDABLE FOOD/EXCISE TAX CREDIT

1 Is your federal adjusted gross income less than $50,000? (See the Instructions) If “Yes”, go to line 2. If “No”, STOP. You CANNOT claim this credit.

However, you may claim the credit for a minor child receiving support from the Department of Human Services, etc. In this situation, only complete lines 3, 9, and 10.

2 List YOURSELF, YOUR SPOUSE, AND YOUR DEPENDENTS that meet all of the following: a) Resident of Hawaii, b) Present in Hawaii for more than 9

months in 2012, c) Not in prison, youth correctional facility, or jail for entire taxable year, AND d) Cannot be claimed as a dependent by another taxpayer.

DO NOT list minor children receiving more than half of their support from public agencies even though you may claim them as a dependent. List these minor children on line 3.

Name

Relationship

Name

Relationship

Self

Spouse

Enter the number of qualified persons listed above ................................................................................................................................

3 List MINOR CHILDREN RECEIVING MORE THAN HALF OF THEIR SUPPORT FROM PUBLIC AGENCIES, such as the Department of Human

Services, who meet all the following requirements and are NOT listed above on line 2: a) Resident of Hawaii, b) Present in Hawaii for more than 9 months in 2012,

c) Not in prison, youth correctional facility, or jail for entire taxable year, d) More than half of support from public agency, AND e) Cannot be claimed as a dependent by another taxpayer.

Caution: DO NOT list any children already listed on line 2 above.

Name

Social Security Number

Relationship

Name

Social Security Number

Relationship

Enter the number of minor children receiving more than half of their support from public agencies. Also enter this number in the

space provided on Form N-11, line 28; Form N-13, line 18; or Form N-15, line 44 ................................................................................

4 Enter the amount of your federal adjusted gross income (See the Instructions) ........................................................

5 If you are married filing a separate return, enter your spouse’s federal adjusted gross income .................................

6 Add lines 4 and 5. Enter the total here and in the space provided on Form N-13, line 18; or Form N-15, line 44 .................................

7 Enter on line 7 the amount of the tax credit that applies to the amount on line 6. (See the Instructions) ....................

8 Multiply line 2 by the amount of the tax credit on line 7. Enter the total here ...............................................................

9 Multiply line 3 by $85. Enter the total here ...................................................................................................................

10 Add lines 8 and 9. Enter the result here and on Form N-11, line 28; Form N-13, line 18; or Form N-15, line 44.

This is your refundable food/excise tax credit. (Whole dollars only) ............................................................................

PART II: CREDIT FOR LOW-INCOME HOUSEHOLD RENTERS

1 Is your adjusted gross income (Form N-11, line 20; Form N-13, line 11; or Form N-15, line 35, Column A) less than $30,000?

If “No”, STOP. You cannot claim this credit. If “Yes”, go to Question 2.

2 Are you a resident who was present in Hawaii more than nine months of the taxable year? If “No”, STOP. You cannot claim this credit. If “Yes”, go to Question 3.

3 Can you be claimed as a dependent by another taxpayer? If “Yes”, STOP. You cannot claim this credit. If “No”, proceed to line 4.

4 Enter required information for each rental unit that was fully subject to real property tax. DO NOT list rental units that were wholly or partially exempt from real property tax. If you occupied

more than one qualified unit, submit the required information for each additional unit on a separate sheet. If you shared the unit with others, enter only YOUR SHARE of the rent.

Address (give Apt. No., if any)

Occupied From

, 2012, To

, 2012. Total rent paid for this period. $ ______________

month

W __ __ __ __ __ __ __ __ - __ __

Owned by (or agent for owner)

name

address

(Hawaii Tax I.D. Number)

5 Add up YOUR SHARE of rent paid during the taxable year for all the units you have listed. .......................................

6 Enter the amount of your exclusions