Form N 11 – Fill Out and Use This PDF

Your First Name

M.I.

Your Last Name

Spouse’s First Name

M.I.

Spouse’s Last Name

Care Of (See Instructions, page 7.)

City, town or post office.

State

Postal/ZIP code

If Foreign address, enter Province and/or State

Country

Enter the first four letters

!!!!

Use ALL CAPITAL letters

of your last name.

(Fill in only ONE oval)

1

= Single

4

= Head of household (with qualifying person). If the qualifying

2

= Married filing joint return (even if only one had income).

person is a child but not your dependent, enter the child’s full

3

= Married filing separate return. Enter spouse’s SSN and

name. h __________________________________

!

the first four letters of last name above. Enter spouse’s full

name here.

_____________________________________

5

= Qualifying widow(er) with dependent child. Enter the year

6a

= Yourself

= Age 65 or over

}

Enter the number of ovals

!

6b

= Spouse

= Age 65 or over

filled on 6a and 6b

..........

¶

If you filled ovals 3 and 6b above, see the Instructions on page 9 and if your spouse meets the qualifications, fill in this oval =

6c

!!

Dependents:

If more than 4 dependents

2. Dependent’s social

Enter number of

¶

and

1. First and last name

use attachment

security number

3. Relationship

your children listed

... 6c

6d

Enter number of

!!

¶

other dependents

6d

21b

Taxes (from Worksheet A-2)

21b

21c

Interest expense (from Worksheet A-3)

21c

21d

Contributions (from Worksheet A-4)

21d

21e

Casualty and theft losses (from Worksheet A-5)

21e

21f

Miscellaneous deductions (from Worksheet A-6)

21f

2 or 5 enter $4,400; 4 enter $3,212

Standard Deduction ³ 23

24 Line 20 minus line 22 or 23, whichever applies. (This line MUST be filled in)

24

= Yourself

= Spouse

25

26

Taxable Income. Line 24 minus line 25 (but not less than zero)

...................

Taxable Income ³ 26

27

Tax. Fill in oval if from = Tax Table; = Tax Rate Schedule; or

= Capital Gains Tax

Worksheet on page 39 of the Instructions.

( = Fill in oval if tax from Forms N-2, N-103, N-152, N-168, N-312, N-318, N-338,

N-344, N-405, N-586, N-615, or N-814 is included.)

Tax ³ 27

27a

If tax is from the Capital Gains Tax Worksheet, enter

the net capital gain from line 14 of that worksheet

27a

!!!,!!!,!!!.00

33

Add lines 28 through 32

Total Refundable Credits ³ 33

34

Line 27 minus line 33. If line 34 is zero or less, see Instructions.

.................................................. 34

35

Total nonrefundable tax credits (attach Schedule CR)

35

36

Line 34 minus line 35

Balance ³ 36

37

Hawaii State Income tax withheld (attach W-2s)

!!!,!!!,!!!.00

(see page 27 of the Instructions for other attachments)

37

38

2013 estimated tax payments

38

!!!,!!!,!!!.00

39

Amount of estimated tax applied from 2012 return

39

!!!,!!!,!!!.00

40

Amount paid with extension

40

!!!,!!!,!!!.00

42

If line 41 is larger than line 36, enter the amount OVERPAID (line 41 minus line 36) (see Instructions).. 42

43

Contributions to (see page 28 of the Instructions):

Yourself

Spouse

43a Hawaii Schools Repairs and Maintenance Fund

= $2

= $2

43b Hawaii Public Libraries Fund

= $2

= $2

43c Domestic and Sexual Violence / Child Abuse and Neglect Funds

= $5

= $5

44

Add the amounts of the filled ovals on lines 43a through 43c and enter the total here

................. 44

45 Line 42 minus line 44

45

50

AMENDED RETURN ONLY –

Amount paid (overpaid) on original return. (See Instructions) (attach Sch. AMD)

50

51

AMENDED RETURN ONLY –

Balance due (refund) with amended return. (See Instructions) (attach Sch. AMD)

51

Designee’s name h

Phone no. h

Identification number h

Do you want $3 to go to the Hawaii Election Campaign Fund?

=

Yes

=

No

If joint return, does your spouse want $3 to go to the fund?

=

Yes

=

No

Your signature

Date

Spouse’s signature (if filing jointly, BOTH must sign)

Date

h

h

Your Occupation

Daytime Phone Number

Your Spouse’s Occupation

Daytime Phone Number

Preparer’s

h

Date

Check if

Preparer’s identification number

h

Signature

self-employed

Paid

Print

h

Preparer’s

Federal E.I. No. h

Preparer’s Name

Information

Firm’s name (or yours

Phone No. h

if self-employed),

h

Address, and ZIP Code