Nebraska Department of Revenue
Form No. 96-296-2009 Rev. 1-2022 Supersedes 96-296-2009 Rev. 1-2021
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Nebraska Schedule I — Income Statement |
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FORM |
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• Attach this schedule to the 2022 Nebraska Homestead Exemption Application, Form 458. |
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458 |
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• Read instructions carefully. |
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• FILE WITH YOUR COUNTY ASSESSOR’S OFFICE. |
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Schedule I |
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Applicant’s Name on Form 458 |
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Applicant’s Social Security Number (SSN) |
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This Income Statement is filed for (select one only): |
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Applicant (filing status single) |
Applicant and Spouse (married filing jointly) |
Applicant (married filing separately) |
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Spouse (married filing separately) |
Other Owner-Occupant |
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Spouse’s or Owner-Occupant’s Name |
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Spouse’s or Owner-Occupant’s SSN |
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Note: Do not include the owner-occupant’s income on the income statement of the applicant/spouse listed above. Each owner-occupant’s income must be reported on a separate Nebraska Schedule I — Income Statement.
Part I — For Applicants Who FILED a 2021 Federal Income Tax Return
• If you did not file a 2021 federal income tax return, complete only Part II and Worksheet A. (as necessary)
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Household Income: January 1 through December 31, 2021 |
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1 |
Federal adjusted gross income (AGI): Federal Form 1040, line 11 |
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1 |
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2 |
Social Security or railroad retirement income (non-taxable portion): Federal Form 1040, subtract |
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line 6b from line 6a (see instr.) |
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2 |
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3 |
Nebraska adjustments increasing federal AGI (enter amount from Form 1040N, line 12; |
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Nebraska tax return). . . . . . . . . . . . . . . . . . 對 . . . |
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3 |
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Income from Nebraska obligations (enter amount from Form 1040N, line 2, Schedule I; |
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Nebraska tax return) |
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4 |
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5 |
Total of lines 1 through 4 |
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5 |
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Medical and Dental Expenses – Caution: Do not include expenses reimbursed by insurance or paid by others. |
6a |
2021 Medical and dental expenses (see instructions) |
6a |
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6b |
Multiply line 5, Part I, by 4% (.04) |
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6b |
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6c |
Subtract line 6b from line 6a. If line 6b is more than line 6a enter -0-. . . . |
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6c |
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Household income (subtract line 6c from line 5). . . . . . . . . . . . . . . . . 對 . . |
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7 |
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If married, you must report 2021 income for both you and your spouse.
Part I I — For Applicants Who DID NOT FILE a 2021 Federal Income Tax Return
Complete Worksheet A on reverse side, as necessary.
If you filed a 2021 federal income tax return, complete only Part I.
Household Income: January 1 through December 31, 2021
1 |
Wages and salaries |
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2 |
Social Security retirement income. If none, explain _______________________________________________ |
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_ ________________________________________________________________________________________________ |
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Tier I Railroad Retirement income |
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Tier II Railroad Retirement income |
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Total taxable distributions (including 1099-R distributions and pensions paid out) |
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Tax exempt interest and dividends (must include all state and local bond income) |
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Taxable interest and dividends |
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Other income or adjustments (from line G, Worksheet A on reverse side) |
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Total of lines 1 through 8 |
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Medical and Dental Expenses – Caution: Do not include expenses reimbursed by insurance or paid by others.
10a |
2021 Medical and dental expenses (see instructions) |
10a |
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10b |
Multiply line 9 by 4% (.04). . . . . . . . . . . . . . . . . . 對 . |
10b |
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10c |
Subtract line 10b from line 10a. If line 10b is more than line 10a enter -0- . |
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10c |
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Household income (subtract line 10c from line 9) |
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Under penalties of law, I declare that I have examined this schedule, and that it is, to the best of my knowledge and belief, correct and complete.
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Signature of Person Whose Income is Shown |
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Spouse’s Signature if Income Included |
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Daytime Phone (required) |
Email Address
File 2022 Form 458 and all Schedules with your county assessor after February 1, 2022 and on or before June 30, 2022.
Retain a copy for your records.
Authorized by Neb. Rev. Stat. §§ 77-3510 – 3514 and 77-3528
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Worksheet A — Part II |
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FORM 458 |
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Line 8, Other Income or Adjustments |
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Schedule I |
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Worksheet A |
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.........................................................A Net business income including rental, or farm income, or (loss) |
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B Capital gain or (loss) |
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C Other gain or (loss) |
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D Unemployment compensation |
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E Any other income or adjustments reducing income. Explain: |
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E |
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F Penalty on early withdrawal of savings |
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G Total of lines A through E, minus line F (enter this amount here and on Part II, line 8) |
G |
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Retain a copy for your records. |
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Instructions |
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Who Must File. This Form 458 Schedule I must be filed by persons applying for a homestead exemption, who are not filing as a veteran drawing compensation from the Department of Veteran’s Affairs (DVA) or as a paraplegic veteran or multiple amputee whose home was substantially contributed to by the DVA. This form is to be attached to and filed with the Nebraska Homestead Exemption Application or Certification of Status, Form 458. (See Form 458 Instructions). If you filed, or would have filed as married for Nebraska individual income tax purposes for 2021, you must include income for both you and your spouse, even if you filed as “married, filing separately.” Each additional owner who occupied the homestead during any part of 2021 must also report their income on a separate schedule.
When and Where to File. Schedule I must be attached to the Form 458 and FILED WITH YOUR COUNTY ASSESSOR, after February 1, 2022 and on or before June 30, 2022.
Specific Instructions
Note – Do NOT include the following on the income statement:
•Department of Veterans Affairs disability compensation;
•Supplemental Security Disability Income (SSDI);
•Worker’s Compensation Act payments;
•Child support payments;
•Aid to Dependent Children (ADC); and
•Nebraska Department of Health and Human Services aid.
Exclude Social Security payments based on disability for applicants and spouses under their full retirement age (generally age 66) EXCEPT for any portion of the benefits included in federal adjusted gross income (AGI). Disability benefits automatically convert to retirement benefits at full retirement age and must be reported. See SSA Publication No. 05-10035.
Part I
Line 1, Federal AGI. Include income as reported for federal income tax purposes on line 11, Federal Form 1040 for tax year 2021.
Line 2, Social Security Retirement Income and/or Railroad Retirement Income. Enter retirement benefits minus any portion included as taxable in AGI (Line 6b, Federal Form 1040, minus any amount reported on line 6a, Federal Form 1040). Do NOT subtract Medicare premiums or any other adjustments from the amount in Box 6.
Line 3, Nebraska Adjustments Increasing federal AGI. Report the total amount of Nebraska adjustments increasing federal AGI as shown on line 12, Nebraska Form 1040N. Do not reduce this amount. Amounts on line 13 of the Form 1040N are not allowed.
Line 4, Income From Nebraska Obligations. Include the total amount of interest income from Nebraska obligations as shown on line 2, Schedule I, Nebraska Form 1040N.
Line 5, Total of Lines 1 Through 4. Add all amounts listed in lines 1 though 4. Put the total amount on line 5. Line 6a-6c, Medical and Dental Expenses. See medical expenses instructions below.
Line 7. Household Income. This amount represents your household income. Household income table can be located at revenue.nebraska.gov/PAD/homestead-exemption.
Part II
Line 1, Wages and Salaries. Include any wages, salaries, fees, commissions, tips, bonuses, etc. received in 2021, even if you do not have a Federal Form W-2. If you have a Federal Form W-2, this information is shown in Box 1.
Line 2, Social Security Retirement Income. Report net benefits received in 2021, as shown in Box 5, Federal Form SSA‑1099. Do NOT subtract Medicare premiums or any other adjustments from the amount in Box 5.
Line 3, Tier I Railroad Retirement Income. Include Tier I net Social Security equivalent benefit received in 2021, as shown in Box 5, Federal Form RRB-1099.
Line 4, Tier II Railroad Retirement Income. Include Tier II Railroad retirement income received in 2021, as shown in Box 7, Federal Form RRB-1099-R.
Line 5, Total Taxable Distributions. On line 5, report the taxable amount from Box 2(a), Form 1099‑R. Report any taxable portion of any pensions received. Do not report any amount from a qualified IRA rollover. See Federal Form 1099-R and IRS Publication 590.
Line 6, Tax Exempt Interest and Dividends. Report the total interest received in 2021 on tax exempt obligations as shown in:
1.Box 8, Federal Form 1099-INT (Interest Income) or similar statement;
2.Box 11, Federal Form 1099-OID; and
3.Box 11, Federal Form 1099-DIV.
State and local bond income from both Nebraska and out-of-state obligations must be included. Include any exempt interest from a mutual fund or other regulated investment company. Do not include interest earned on your IRA, or excludable interest on series EE bonds. (see Federal Form 8815).
Line 7, Taxable Interest and Dividends. Include your total interest and dividends received in 2021, as shown in:
1.Box 1 and Box 3, Federal Form 1099-INT (Interest Income) or similar statement;
2.Box 1 and Box 2, Federal Form 1099-OID; and
3.Box 1a and Box 2a, Federal Form 1099-DIV.
Interest and dividends from all U.S. government obligations must be included.
Line 8, Other Income or Adjustments. Complete Worksheet A and enter the amount from line G. Line 9, Total of Lines 1 Through 8. Add all amounts listed in lines 1 through 8. Put total amount on line 9. Line 10a-10c, Medical and Dental Expenses. See medical expenses specific instructions on next page.
Line 11. Household Income. This amount represents your household income. Household income table can be located at revenue.nebraska.gov/PAD/homestead-exemption.
Medical Expenses Instructions
Part I, Line 6a or Part II, Line 10a
“Medical expenses paid” includes all 2021 medical expenses incurred for and paid by the applicant, spouse, or owner-occupant.
In general, medical expenses include any payments you made that would qualify for the income tax medical expenses deduction on Federal Form 1040, Schedule A, line 1; except payments for the treatment of a dependent who is not an owner-occupant of the homestead. Include all amounts that were paid during 2021, regardless of when the care was received. If your insurance company paid the service provider directly for part of your expenses, and you paid only the amount that remained, include ONLY the amount you paid. Do not include amounts paid on your behalf directly to the service provider by any other person or governmental unit. IRS Publication 502 contains more information on medical and dental expenses.
Reimbursements. Do not include any amounts you paid that have been or will be reimbursed by insurance. Doctors, Dentists, Hospitals. Include amounts paid for medical services such as:
1.Payments to doctors, dentists, osteopaths, nurses, chiropractors, and other licensed medical practitioners;
2.Payments to hospitals or licensed nursing care facilities; and
3.Payments for purchases of medical equipment, crutches, hearing aids, eyeglasses, contact lenses, dentures, etc.
Do not include funeral, burial, or cremation costs.
Prescription Medicines. Include payments for prescription medicines and insulin. Prescription medicines are only those drugs and medicines that cannot be purchased without a prescription.
Do not include any medicine that can be purchased over-the-counter without a prescription, whether or not they have been prescribed by a doctor. For example, aspirin, vitamins, and cough drops are not prescription medicines.
Health Insurance Premiums. Include insurance premiums paid for medical insurance for the applicant, spouse, or owner-occupant. Medical insurance includes Medicare Part B, Medicare Supplemental, Part D Medicare prescription drug coverage, or insurance for licensed nursing care. Part B Medicare withheld from Social Security payments should be included as insurance premiums paid.
Do not include: Medicare Part A deductions withheld from wages; self-employed health insurance that reduced total income; the medical payments portion of a car insurance policy; an accident or health insurance policy where the benefits do not specifically cover medical care; life insurance or income protection policies; employer-sponsored health insurance plans; and flexible spending accounts. These are not deductible medical insurance premiums.
Worksheet A — Part I
Note: Retain a copy for your records.
Line A, Net Business Income Including Rental, or Farm Income, or (Loss). Report your 2021 net
income. For information on computing the income, refer to the following federal schedules and instructions:
1.For business income, see Schedule C, Federal Form 1040, or Schedule C-EZ, Federal Form 1040;
2.For income from rental real estate, royalties, partnerships, S corporations, trusts, REMICs, etc., see Schedule E, Federal Form 1040; and
3.For farm income, see Schedule F, Federal Form 1040.
Line B, Capital Gains or (Loss). Include all income or loss resulting from the sale of stock, bonds, or real estate from Federal Forms 1099-B, 1099-S, 1099-DIV, or equivalents. See Schedule D, Federal Form 1040.
Line C, Other Gains or (Loss). Report all other gains or losses on tangible or intangible property not included on line A or line B. See Federal Form 4797.
Line D, Unemployment Compensation. Include all unemployment compensation received for 2021 from Box 1, Federal Form 1099-G.
Line E, Any Other Income or (Adjustments Reducing Income). Report all other taxable income from Federal Form 1099‑MISC and taxable state income tax refunds reported on Federal Form 1099-G. Report any adjustments reducing income such as moving expenses, IRA deductions, student loan interest, tuition and fees, self-employment tax and self-employment health insurance, SEP, SIMPLE, and other qualified retirement plans, and alimony paid. Refer to the instructions for Federal Form 1040. Health expenses and health insurance premiums other than self-employment health insurance should be entered on line 10a.
Subtract the calculated adjustments from the calculated “other income” and enter the net income or loss on line E.
Line F, Penalty on Early Withdrawal of Savings. Report your total amount of penalties for early withdrawal of savings from Box 2, Federal Form 1099-INT.
Note: A homestead exemption percentage is subject to change based upon the review by the Tax Commissioner of any information necessary to determine whether an application is in compliance with Neb. Rev. Stat. §§ 77‑3501 to 77-3529. Action by the Tax Commissioner shall be taken within three years after December 31 of the year in which the homestead exemption was claimed.
For more information, contact your local county assessor’s office, or
visit revenue.nebraska.gov/PAD/homestead-exemption, or call 888‑475‑5101
