Sample Format for Computing IRS Form 1040 Series Adjusted ...



|Name: | |

| | |SUBTOTAL |

| |FAMILY MEMBER |(ADD A-D) |

| |A. |B. |C. |D. |E. |

|WAGES, SALARIES, TIPS | | | | | |

|TAXABLE INTEREST | | | | | |

|DIVIDEND INCOME | | | | | |

|TAXABLE REFUNDS/ CREDITS/OFFSETS OF | | | | | |

|STATE/ LOCAL INCOME TAXES | | | | | |

|ALIMONY RECEIVED | | | | | |

|BUSINESS INCOME (OR LOSS) | | | | | |

|CAPITAL GAIN (PR LOSS) | | | | | |

|OTHER GAINS (OR LOSSES) | | | | | |

|TAXABLE AMOUNT OF IRA DISTRIBUTIONS | | | | | |

|TAXABLE AMOUNT OF PENSIONS AND ANNUITIES | | | | | |

|RENTAL REAL ESTATE, ROYALTIES, | | | | | |

|PARTNERSHIPS, TRUSTS, ETC. | | | | | |

|UNEMPLOYMENT COMPENSATION | | | | | |

|TAXABLE AMOUNT OF SOCIAL SECURITY | | | | | |

|BENEFITS | | | | | |

|OTHER INCOME | | | | | |

|SUBTOTAL (LINES 1-15) | | | | | |

|IRA DEDUCTION | | | | | |

|MEDICAL SAVINGS ACCOUNT DEDUCTION | | | | | |

|MOVING EXPENSES | | | | | |

|ONE-HALF OF SELF-EMPLOYMENT TAX | | | | | |

|SELF-EMPLOYED HEALTH INSURANCE DEDUCTION | | | | | |

|KEOGH AND SELF-EMPLOYED SEP AND SIMPLE PLANS | | | | | |

|PENALTY ON EARLY WITHDRAWAL OF SAVINGS | | | | | |

|PAID ALIMONY | | | | | |

|SUBTOTAL (LINES 17-24) | | | | | |

|SUBTRACT LINE 24 FROM LINE 16. THIS IS | | | | | |

|ADJUSTED GROSS INCOME…………… | | | | | |

DATA PRIVACY

RAMSEY COUNTY WARRANTS COMPLIANCE WITH APPLICABLE DATA PRIVACY LAWS AND REGULATIONS INCLUDING THE MINNESOTA GOVERNMENT DATA PRACTICES ACT WHICH SETS POLICIES ON INFORMATION THAT CAN BE OBTAINED, STORED AND/OR RELEASED IN CONNECTION WITH PUBLIC PROGRAMS.

Income information on individuals or households collected and maintained by the subrecipient agency to determine eligibility may be disclosed to the county or to the U.S. Department of Housing and Urban Development.

I understand that Ramsey County Energy Efficiency Rehab Program receives funds from Ramsey County that require income verification. I agree that the information I provide may be reviewed by Ramsey County and/or the U.S. Department of Housing and Urban Development or their agents. I agree that the income information provided by me may be verified by Ramsey County.

Buyer _________________________________________________________

Buyer _________________________________________________________

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