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<br />usE Lest ~ame
<br />r Flrst n~me and ini6al
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<br />~ Soc1a1 Secu~ty number (SSN) Your Age
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<br />ABEL Pi i ~ i ~ .
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<br />L S~~.S ~st name if diHerent and'oint retum
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<br />Spouse's flrst ~ame and initial if jant retum
<br />Spouse's SSN, 'rf joint retum
<br />Spouse's Age
<br />Otherwise, Piace label here
<br />pleese Current mailing addr s
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<br />~ Telephone numbe n p~ G
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<br />" ZIP Cod~ y~
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<br />~ ~ J If you filed a retum in 1995 and this
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<br />1 ~ address is different, check here ~ ^
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<br />Stetus ~~ Single
<br />2~ Martied filing jointly
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<br />3^ Married filing separately Exemptions
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<br />6a YourseH qe9uiar ~~~ Tofal
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<br />Chet~c (gp~e's neme) 6b Spouse b
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<br />4^ Head of household (SPouse's Sodal Se~wiiry rn,mber) 6c Dependents .
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<br />(First nemes)
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<br />(Person who V~~~ f~+) '
<br />5^ Qualifying widow(er~ with dependent child
<br />6d Disabled
<br />children only • d
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<br />~~`~ "~'"eS~ Total • e
<br />7 Check if: ~ You were 65 or older ^ elind ~f someone else can claim you Extension For o~ice ~ 2 3
<br /> ^ Spouse was s5 or older ^ B-ind as a dependent, check here ~ Flled ^ use only
<br />8 Wages, salaries, tips, commissions, scholarships, and other pay for woiic .......... ~ 8
<br />9 Interest .............................................................. • 9
<br />10 Dividends ............................................................ • 10
<br />11 Unemployment compensatio~. See instn~ctions, page 15 . . . . . . . . . . . . . . . . . . . . . . . • 11
<br />12 Total income. Add lines 8 through 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
<br />13 1996 federai tax liability. ($0 -$3,000, see instructions for the correct amount) ....... • 13
<br />14 Standard deduction on the back of this foRn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
<br />15 Addlines 13 and 14 ..................................................... .....
<br />16 Oregon taxable income. Line 12 minus line 15. If line 15 is more than line 12, fill in -0- ~...
<br />17 Tax from tables, pages 12 through 14 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ~ . .
<br />18 EXEMPTION CREDIT. Mumpty your total exemptions on line 6e by $124 ........... 18
<br />19 Child and dependent care credit. See instructions, page 16 . . . . . . . . . . . . . . . . . . . . . . • 19
<br />20 Political contribution credit. See fimits, page 16 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • 20
<br />21 Other credits (see instructions). Identify ... • 21
<br />22 Total credits. Add lines 18 through 21 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
<br />23 Net income tax. Line 17 minus line 22. If line 22 is more than line 17, fill in -0- ....... ~...
<br />24 Oregon tax withheld from wages. Attach your W-2 wage slips . . . . . . . . . . . . . . . . . . • 24
<br />25 TAX-TO-PAY. If line 23 is more than line 24, you have tax to pay. Line 23 minus 24 ..!
<br />26 REFUND. If line 24 is more than line 23, you have a refund. Line 24 minus line 23 ...~
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<br />............ 22 1 3- AO
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<br />TAX-TO-PAY • 25
<br />... REFUND • 26 ~ ~"
<br />I wish to donate part of my tax refu~d to the following fund(s):
<br />27 Oregon Nongame Wildlife . . . . . . . . . ^ $1, ^ $5, ^ $10, ^ Other $ • 27
<br />28 Child Abuse Prevention ^$1, ^$5, ^$10, ^ Other $ • 28 These will
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<br />29 Alzheimer's Disease Research . . . . . .
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<br />^ $1,
<br />^ $5,
<br />^ $10, ^ Other $ ~ 29 reduce
<br />I 30 Stop DomesGc & Sexua) Violence . . . . . . ^ $1, ^ $5, ^ $10, ^ Other $ • 30 your refund
<br />; 31 AIDS/HIV Education and Services . . . ^ $1, ^ $5, ^ $10, ^ Other $ • 31
<br />32 Total donations. Add lines 27 through 31. Total can't be more than your refund on line 26 .............. 32 '
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<br />pder penalties for false swearing, I declare that I have examined this retum, including accompanying schedules and statements, and to the best oi my knowledge and
<br />~lief it Is true, correct and complete. If prepared by a person other than taxpayer, this declaration is based on all infortnation oi which the preparer has any knowledge.
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<br />~N ~ Your signature Date Signature oi preparer other lhan taxpayer L.icense No.
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<br />r ~ Spouse's signature (If filing jointly, BOTH must sign even H oNy one had income) AddfBSS
<br />lail tax-tapay returns to: Mail refund retums and no tax due returns to:
<br />regon Department of Revenue, PO Box 14555 Salem OR 97309-0940 REFUNO, PO Box 14700, Salem OR 97309-0930
<br />e check or money order payable to Oregon Department of Revenue. Write you~ Social Security number and "1996 Form 40S" o~ your payment.
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