INCOME AND ADJUSTMENTS INFORMATION (See Instruction 4.) 1. Wages, salaries, tips, etc. . . . . . . . . . . . . . . . . . . . . . . . .1.
2. Taxable interest income . . . . . . . . . . . . . . . . . . . . . . . . .2.
3. Dividend income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3.
4.Taxable refunds, credits or offsets of state and local
income taxes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4.
5. Alimony received . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5.
6. Business income or (loss) . . . . . . . . . . . . . . . . . . . . . . . .6.
7. Capital gain or (loss). . . . . . . . . . . . . . . . . . . . . . . . . . . .7.
8. Other gains or (losses) (from federal Form 4797) . . . . . . .8.
9.Taxable amount of pensions, IRA distributions,
and annuities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9.
10.Rents, royalties, partnerships, estates, trusts, etc.
(Circle appropriate item.) . . . . . . . . . . . . . . . . . . . . . . . 10.
11. Farm income or (loss). . . . . . . . . . . . . . . . . . . . . . . . . . 11.
12. Unemployment compensation. . . . . . . . . . . . . . . . . . . . . 12.
13.Taxable amount of Social Security and
Tier 1 Railroad Retirement benefits . . . . . . . . . . . . . . . . 13.
14.Other income (including lottery or other
gambling winnings). . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.
15. Total income (Add lines 1 through 14.). . . . . . . . . . . . . . 15.
16.Total adjustments to income from federal return
(IRA, alimony, etc.) . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.
17.Adjusted gross income (Subtract line 16 from 15.)
(Enter on page 2, in each appropriate column of line 1.) . 17.