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FORM	STATE OF HAWAII — DEPARTMENT OF TAXATION
N-11	Individual Income Tax Return

(Rev. 2011)	RESIDENT
	RESIDENT
	Calendar Year 2011
	OR

AMENDED Return

NOL Carryback

FOR OFFICE USE ONLY

Fiscal Year Beginning

and Ending

THIS

฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀ ฀

Do NOT Submit a Photocopy!!

Place an X in applicable box, if appropriate

First Time Filer

Address or Name Change

Your First Name

M.I. Your Last Name

Here
Here	Spouse’s First Name	M.I.	Spouse’s Last Name
Label	Spouse’s First Name	M.I.	Spouse’s Last Name
Label
Place	Care Of (See Instructions, page 7.)
	Care Of (See Instructions, page 7.)

Present mailing or home address (Number and street, including Rural Route)

City, town or post ofﬁce.	State	Postal/ZIP code

If Foreign address, enter Province and/or State		Country

SPACE

RESERVED

IMPORTANT — Complete this Section

Enter the ﬁrst four letters of your last name.

Use ALL CAPITAL letters

Your Social

Security Number

Enter the ﬁrst four letters

of your Spouse’s last name. Use ALL CAPITAL letters

Spouse's Social

Security Number

฀ ฀ ฀ ฀

(Place an X in only ONE box)

1Single

2Married ﬁling joint return (even if only one had income).

3Married ﬁling separate return. Enter spouse’s SSN and the ﬁrst four letters of last name above. Enter spouse’s full name here. _____________________________________

4Head of household (with qualifying person). If the qualifying person is a child but not your dependent, enter the child’s full

name. h __________________________________

5Qualifying widow(er) with dependent child. Enter the year

your spouse died

฀ ฀ ฀ ฀ ฀

CAUTION: If you can be claimed as a dependent on another person’s tax return (such as your parents’), DO NOT place an X on line 6a, but be sure to place an X above line 21.

6a	Yourself	Age 65 or over	Enter the number of Xs
6b	Spouse	Age 65 or over	} on 6a and 6b	฀
	If you placed an X on lines 3 and 6b above, see the Instructions on page 9 and if your spouse meets the qualifications, place an X here
6c	Enter the number of your dependent children (see page 9 of the Instructions)		6c	฀
6d	Enter the number of other dependents (see page 9 of the Instructions)		6d
6e	Total number of exemptions claimed.	Add numbers entered in boxes 6a thru 6d above	6e฀

FORM N-11

฀	฀	฀	฀	฀ ฀ ฀
	Your Social Security Number			Your Spouse’s SSN

Name(s) as shown on return

ROUND TO THE NEAREST DOLLAR

7	Federal adjusted gross income (AGI) (see page 11 of the Instructions)			7
8	Difference in state/federal wages due to COLA, ERS,
	etc. (see page 11 of the Instructions)		8
9	Interest on out-of-state bonds
	(including municipal bonds)		9
	Other Hawaii additions to federal AGI
	(see page 11 of the Instructions)		฀
11	Add lines 8 through 10	Total Hawaii additions to federal AGI		11
12	Add lines 7 and 11			12
13	..............Pensions taxed federally but not taxed by Hawaii		13
14	.................Social security beneﬁts taxed on federal return		14

15First $5,881 of military reserve or Hawaii national

guard duty pay	15
16 Payments to an individual housing account	16

17Exceptional trees deduction (attach afﬁdavit)

(see page 14 of the Instructions)

18Other Hawaii subtractions from federal AGI

(see page 14 of the Instructions)	18
19 Add lines 13 through 18
............................................ Total Hawaii subtractions from federal AGI		19
Line 12 minus line 19		Hawaii AGI ³	฀

CAUTION: If you can be claimed as a dependent on another person’s return, see the Instructions on page 15, and place an X here.

21If you do not itemize your deductions, go to line 23 below. Otherwise go to page 15 of the Instructions and enter your itemized deductions here.

21a Medical and dental expenses
(from Worksheet A-1)	21a

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

23If you checked ﬁling status box: 1 or 3 enter $2,000;

2 or 5 enter $4,000; 4 enter $2,920

Standard Deduction ³ 23

TOTAL ITEMIZED

DEDUCTIONS

22Add lines 21a through 21f. If your adjusted gross income is above a certain amount, you may not be able to deduct all of your itemized deductions. See the Instructions on page 21. Enter total here and go to line 24.

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

FORM N-11

฀	฀	฀	฀	฀ ฀ ฀
	Your Social Security Number			Your Spouse’s SSN

Name(s) as shown on return

25If line 20 is $89,981 or less, multiply $1,040 by the total number of exemptions claimed on line 6e. Otherwise, see page 21 of the Instructions. If you and/or your spouse are blind, deaf, or disabled, place an X in the applicable box(es), and see page 21 of the Instructions.

	Yourself	Spouse		25
26	Taxable Income. Line 24 minus line 25 (but not less than zero)			Taxable Income ³ 26
27	Tax. Place an X if from	Tax Table;	Tax Rate Schedule; or	Capital Gains Tax
	Worksheet on page 37 of the Instructions.

(Place an X 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

28	Refundable Food/Excise Tax Credit
	(attach Schedule X) DHS, etc. exemptions	.... 28
29	Credit for Low-Income Household
	Renters (attach Schedule X)	29
	Credit for Child and Dependent
	Care Expenses (attach Schedule X)

31Credit for Child Passenger Restraint

	System(s) (attach a copy of the invoice)	31
32	Total refundable tax credits from
	Schedule CR (attach Schedule CR)	32
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

37Hawaii State Income tax withheld (attach W-2s)

	(see page 26 of the Instructions for other attachments)	37
38	2011 estimated tax payments	38
39	Amount of estimated tax applied from 2010 return	39
	Amount paid with extension	฀
41	Add lines 37 through 40	Total Payments ³ 41

42	If line 41 is larger than line 36, enter the amount	(line 41 minus line 36) (see Instructions).. 42
43	Contributions to (see page 27 of the Instructions):	Yourself	Spouse
	43a Hawaii Schools Repairs and Maintenance Fund	$2	$2
	43b Hawaii Public Libraries Fund	$2	$2
	43c Domestic Violence / Child Abuse and Neglect Funds	$5	$5
44	Add the amounts of the Xs on lines 43a through 43c and enter the total here		44
	45 Line 42 minus line 44		45

FORM N-11

฀	฀	฀	฀	฀ ฀ ฀
	Your Social Security Number			Your Spouse’s SSN

Name(s) as shown on return

46Amount of line 45 to be applied to your

฀	฀	46
47a Amount to be REFUNDED TO YOU (line 45 minus line 46) If ﬁling late,
see page 27 of Instructions		47a

Place an X in this box if this refund will ultimately be deposited to a foreign (non-U.S.) bank. Do not complete lines 47 b, c, or d.

b Routing number

c Type:

Checking

Savings

dAccount number

48	฀	฀	(line 36 minus line 41). Send Form N-200V with your payment.
	Make check or money order payable to the “Hawaii State Tax Collector”			48

49Estimated tax penalty. (See page 28 of

Instructions.) Do not include on line 42 or 48. Place an X in

this box if Form N-210 is attached ³

฀AMENDED RETURN ONLY – Amount paid (overpaid) on original return. (See Instructions) (attach Sch. AMD).......

51	AMENDED RETURN ONLY – Balance due (refund) with amended return. (See Instructions) (attach Sch. AMD) ..... 51

52	Did you ﬁle a federal Schedule C?	Yes	No		If yes, enter Hawaii gross receipts
	your main business activity:			,
	your main business product:			, AND your HI Tax I.D. No. for this activity

53	Did you ﬁle a federal Schedule E				If yes, enter Hawaii gross rents received
	for any rental activity?	Yes	No
					AND your HI Tax I.D. No. for this activity
54	Did you ﬁle a federal Schedule F?	Yes	No		If yes, enter Hawaii gross receipts
	your main business activity:			,
	your main business product:		,		AND your HI Tax I.D. No. for this activity

DESIGNEE

If designating another person to discuss this return with the Hawaii Department of Taxation, complete the following. This is not a full power of attorney. See page 29 of the Instructions.

Designee’s name h

Phone no. h

Identiﬁcation number h

฀

CAMPAIGN FUND

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

Note: Placing an X in the “Yes” box will not increase your tax or reduce your refund.

PLEASE SIGN HERE

DECLARATION — I declare, under the penalties set forth in section 231-36, HRS, that this return (including accompanying schedules or statements) has been examined by me and, to the best of my knowledge and belief, is a true, correct, and complete return, made in good faith, for the taxable year stated, pursuant to the Hawaii Income Tax Law, Chapter 235, HRS.

Your signatureDateSpouse’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				Date	Check if	Preparer’s identiﬁcation number
		Preparer’s					Check if
		Signature					Self Employed h
Paid
Paid		Print	h
Preparer’s		Print					Federal E.I. No. h
Preparer’s		Preparer’s Name					Federal E.I. No. h
Information
		Firm’s name (or yours					Phone No. h
		if self-employed),	h				Phone No. h
		Address, and ZIP Code

FORM N-11

Question	Answer
Form Name	Hawaii Form N 11
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	HI N11 hawaii state tax forms

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