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Show Page Schedule D.—CONTRIBUTIONS. Qsuction 11) Schedule -—_"'o_ 3 (See Instruction 12) mie 1. Name and Address of Organization Total. 2. Amount (Enteras item 11, pagel, subject to 15%limitation)_| Schedule F.—TAXES. $ Total. (See Instruction 13) 1. Nature Total. 1. To Whom Paid © Schedule 2. Amount (Enter as item 13, page 1) $ Schedule (Enter as item 12, page 1) $ ¥ G.—LOSSES AND OTHER DEDUCTIONS. 1. Item No. eS 2. Amount (See Instructions 14 and 16) 2. Explanation 3. Amount | H.—MEDICAL, DENTAL, ETC., EXPENSES. 1. Name and Address of Person to Whom Payments Were Made (See Instruction 15) . Approximate Date of Actual Payment I . Total medical, dental, etc., expenses actually paid during the year as shown in column 3, above 2 . Amount received during the year as compensation for such expenses 3 . Payment for medical care not compensated for during the year (line | less line 2) 4 . Total income in item 10, page | 5 . Total deductions claimed in items 11, 12, 13, 14, and 16, page | 6 . Net income before deduction for medical, dental, etc., expenses (line 4 less line 5) 7 . 5% of line 6_8 . Excess of line 3 over line 7. (Enter as item 15, page 1, subject to maximum limitation.) Schedule IL—PERSONAL (1) Personal EXEMPTION AND CREDIT FOR (See Instruction 15) DEPENDENTS. Exemption (2) Number of months during the year in each status Status (See Tax Computation Credit Instructions) for Dependents Number of months during the year Credit claimed Name of dependent and relationship Under 18 | years old 18 years Credit claimed (Head of a family may not claim credit for dependent used to qualify him as head of a family) Single, or married and not living with husband or wife, and not head of family Married and living with husband or wife Head of a family (explain below) Reason for support if 18 years a or over Schedule J.—COMPUTATION (1) If your net income is $3,000 or LESS, of schedule OF EARNED use only INCOME this part Net income (item 18, page 1) Earned income above) credit (10% of net (2) CREDIT. If your ‘ net (See Tax Computation income is MORE than of schedule Instructions) $3,000, use only this part Earned net income (not more than $14,000) Net income (item 18, page 1) Earned income credit (10% of earned net income or 10% of net income, above, whichever amount is smaller, but do not enter less than $300) income, QUESTIONS 1. Did you file a return for any prior year? If so, what was the latest year? To which Collector’s office was it sent? 5. Was the rate of your salary or wages increased or decreased during your taxable year? (Yes or No) 2. If you claimed credit for tax paid in line 21 (c), page 4, to which Collector’s 6. Did you receive during your taxable year any amount claimed to be non- office was your declaration sent? 3. If separate return was made for the current year, state: taxable (see General Instruction 1)? If so, attach schedule showing source, nature, and amount of such income. = (a) Name of husband or wife (b) Personal exemption, if any, claimed thereon (c) Collector’s office to which it was sent . Check whether this return was prepared on the cash [_] or accrual [] basis. 7. Did you at any time during your taxable year own directly or indirectly any stock of a foreign corporation, or a personal holding company as defined by section 501 of the Internal Revenue Code? If so, attach statement required by General Instruction L. 16—37129-1 |
