Hawaii Individual Income Tax Return Form
In the case of an individual who is residing in the State of Hawaii wanting to report his/her individual earnings to the State, the following form has to be completed and submitted.
DownloadExtracted Text for Proper Search
Your First Name M.I. Your Last Name
Spouse’s First Name M.I. Spouse’s Last Name
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
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FORM STATE OF HAWAII � DEPARTMENT OF TAXATION
N-11 Individual Income Tax Return
(Rev. 2012) RESIDENT
Calendar Year 20 12
OR
Fiscal YearBeginning and Ending
fi AMENDED Return
FOR OFFICE USE ONLY
Please Print In Black Ink. Enter One Letter Or Number In Each Box. Fill In Ovals Completely. Do NOT Submit a Photocopy!!
Fill in applicable oval, if appropriate
fi First Time Filer fi Address or Name Change
THIS
SP
RESER
00D0 Place Label Here
00D0
M M D D Y Y M M D D Y Y
CAUTION: If you can be claimed as a dependent on another person�s tax return (such as your parents�), DO NOT ll in oval 6a, but be sure to ll in the oval above line 21.
6a \037 Yourself ............................................ \036 \037 Age 65 or over ........................................................
6b \037 Spouse ............................................. \036 \037 Age 65 or over ........................................................ }
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 \037
6c Enter the number of your dependent children (see page 9 of the Instructions) ........................................................................\
....... 6c 00B6\037 \037\037
6d Enter the number of other dependents (see page 9 of the Instructions) ........................................................................\
.................. 6d 00B6 \037\037
6e Total number of exemptions claimed. Add numbers entered in boxes 6a thru 6d above .............................................................. 6e\03700B6 \037\037
008B IMPOR 008B Enter the first four letters of your last name. Use ALL CAPIT letters \037\037\037\037
Your Social Security Number \037\037\037\036\037\037\036\037\037\037\037 Enter the first four letters of your Spouse’s last name. Use ALL CAPIT letters \037\037\037\037
Spouse's Social Security Number \037\037\037\036\037\037\036\037\037\037\037
\(Fill in onl
1 \037 Single
2 \037 Married filing joint return (even if only one had income).
3 \037 Married filing separate return. Enter spouse’s SSN and
the first four letters of last name above. Enter spouse’s full
name here. _____________________________________
4 \037 Head of household (with qualifying person). If the qualifying
person is a child but not your dependent, enter the child’s full
name. 0068 __________________________________ \036\037
5 \037 Qualifying widow(er) with dependent child. Enter the year
your spouse died \037\037\037\037
Enter the number of ovals filled on 6a and 6b ........ 00B6\037 \037
0073000000210000 007300000021
0026002F0032002D0000002E000D00110011
\037 NOL Carr
If amount is negative (loss), shade the minus (-) in the box. Example:
ROUND TO THE NEAREST DOLLAR
7 Federal adjusted gross income (AGI) (see page 11 of the Instructions) ....................................... 7 !!! ,!!! ,!!! .00 8 Difference in state/federal wages due to COLA, ERS,
etc. (see page 11 of the Instructions) .................................. 8 !!! ,!!! ,!!! .00 9 Interest on out-of-state bonds
(including municipal bonds) ................................................. 9 !!! ,!!! ,!!! .00 10 Other Hawaii additions to federal AGI
(see page 11 of the Instructions) ...................................... 10 !!! ,!!! ,!!! .00
11 Add lines 8 through 10 .................. Total Hawaii additions to federal AGI 11 !!! ,!!! ,!!! .00
12 Add lines 7 and 11 ........................................................................\
................................................. 12 !!! ,!!! ,!!! .00
13 Pensions taxed federally but not taxed by Hawaii .............. 13 !!! ,!!! ,!!! .00
14 Social security benefits taxed on federal return ................. 14 !!! ,!!! ,!!! .00 15 First $5,975 of military reserve or Hawaii national
guard duty pay ................................................................... 15 !!! ,!!! ,!!! .00
16 Payments to an individual housing account ...................... 16 !!! ,!!! ,!!! .00 17 Exceptional trees deduction (attach affidavit)
(see page 14 of the Instructions) ....................................... 17 !!! ,!!! ,!!! .00 18 Other Hawaii subtractions from federal AGI
(see page 14 of the Instructions) ....................................... 18 !!! ,!!! ,!!! .00 19 Add lines 13 through 18
............................................ Total Hawaii subtractions from federal AGI 19 !!! ,!!! ,!!! .00
20 Line 12 minus line 19 ........................................................................\
.................... Hawaii AGI ä 20 !!! ,!!! ,!!! .00
CAUTION : If you can be claimed as a dependent on another person’s return, see the Instructions on page 16, and fill in this oval. =
21 If you do not itemize your deductions, go to line 23 below. Otherwise go to page 16 of the Instructions
and enter your itemized deductions here.
21a Medical and dental expenses
(from Worksheet A-1) ...................................................... 21a !!! ,!!! ,!!! .00
21b Taxes (from Worksheet A-2) ............................................ 21b !!! ,!!! ,!!! .00
21c Interest expense (from Worksheet A-3) ........................... 21c !!! ,!!! ,!!! .00
21d Contributions (from Worksheet A-4) ................................ 21d !!! ,!!! ,!!! .00
21e Casualty and theft losses (from Worksheet A-5) ............. 21e !!! ,!!! ,!!! .00
21f Miscellaneous deductions (from Worksheet A-6) ............. 21f !!! ,!!! ,!!! .00 !!! ,!!! ,!!! .00
23 If you checked filing status box: 1 or 3 enter $2,000;
2 or 5 enter $4,000; 4 enter $2,920 ........................................................ Standard Deduction ä 23 !!! ,!!! ,!!! .00
24 Line 20 minus line 22 or 23, whichever applies. (This line MUST be filled in) .................. 24 !!! ,!!! ,!!! .00
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Form N-11 (Rev. 2012) Page 2 of 4
Your Social Security Number Your Spouse’s SSN
!!! !! !!!! !!! !! !!!!
Name(s) as shown on return ___________________________________________________
FORM N-11
22 Add 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 20. Enter total here and go to line 24.
TOTAL ITEMIZED
DEDUCTIONS
25 If 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, fill in the applicable oval(s), and see page 21 of the Instructions.
= Yourself = Spouse ........................................................................\
....................... 25 !!! ,!!! ,!!! .00
26 Taxable Income. Line 24 minus line 25 (but not less than zero) ................... Taxable Income ä 26 !!! ,!!! ,!!! .00 27 Tax. Fill in oval if from = Tax Table; = Tax Rate Schedule; or = Capital Gains Tax
Worksheet on page 37 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.) .......................................................... Ta x ä 27 !!! ,!!! ,!!! .00 27a If tax is from the Capital Gains Tax Worksheet, enter
the net capital gain from line 14 of that worksheet .......... 27a !!! ,!!! ,!!! .00
28 Refundable Food/Excise Tax Credit
(attach Schedule X) DHS, etc. exemptions !! .... 28 !!! ,!!! ,!!! .00 29 Credit for Low-Income Household
Renters (attach Schedule X) ............................................. 29 !!! ,!!! ,!!! .00 30 Credit for Child and Dependent
Care Expenses (attach Schedule X) ................................. 30 !!! ,!!! ,!!! .00 31 Credit for Child Passenger Restraint
System(s) (attach a copy of the invoice) ............................ 31 !!! ,!!! ,!!! .00 32 Total refundable tax credits from
Schedule CR (attach Schedule CR) .................................. 32 !!! ,!!! ,!!! .00
33 Add lines 28 through 32 ................................................................. Total Refundable Credits ä 33 !!! ,!!! ,!!! .00
34 Line 27 minus line 33. If line 34 is zero or less, see Instructions. .................................................. 34 !!! ,!!! ,!!! .00
35 Total nonrefundable tax credits (attach Schedule CR) .................................................................. 35 !!! ,!!! ,!!! .00
36 Line 34 minus line 35 ........................................................................\
......................... Balance ä 36 !!! ,!!! ,!!! .00 37 Hawaii State Income tax withheld (attach W-2s)
(see page 26 of the Instructions for other attachments) .................. 37 !!! ,!!! ,!!! .00
38 2012 estimated tax payments ............................................ 38 !!! ,!!! ,!!! .00
39 Amount of estimated tax applied from 2011 return ........... 39 !!! ,!!! ,!!! .00
40 Amount paid with extension ............................................... 40 !!! ,!!! ,!!! .00
41 Add lines 37 through 40 ........................................................................\
......... Total Payments ä 41 !!! ,!!! ,!!! .00
42 If line 41 is larger than line 36, enter the amount OVERPAID (line 41 minus line 36) (see Instructions) .. 42 !!! ,!!! ,!!! .00 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 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 !! .00
45 Line 42 minus line 44 ........................................................................\
................................ 45 !!! ,!!! ,!!! .00
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Form N-11 (Rev. 2012) Page 3 of 4
Your Social Security Number Your Spouse�s SSN
!!! !! !!!! !!! !! !!!!
Name(s) as shown on return ___________________________________________________
FORM N-11
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DESIGNEE
PLEASE
SIGN HERE
Note: Filling in the “Yes” oval will not increase your tax or reduce your refund.
Preparer’s Date Check if Preparer’s identification number
Signature † self-employed † o
Print Preparer’s Name † Federal E.I. No. †
Firm’s name (or yours if self-employed), † Phone No. † Address, and ZIP Code
Paid Preparer’s Information
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Form N-11 (Rev. 2012) Page 4 of 4
Your Social Security Number Your Spouse�s SSN
!!! !! !!!! !!! !! !!!!
Name(s) as shown on return ___________________________________________________
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FORM N-11
46 Amount of line 45 to be applied to your
2013 ESTIMATED TAX ..................................................... 46 !!! ,!!! ,!!! .00 47a Amount to be REFUNDED TO YOU (line 45 minus line 46) If ling late,
see page 27 of Instructions ........................................................................\
................................... 47a !!! ,!!! ,!!! .00
Fill in this oval 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 \037\037\037\037\037\037\037\037\037 c Type: Checking Savings
d Account number \037\037\037\037\037\037\037\037\037\037\037\037\037\037\037\037\037 48 AMOUNT YOU OWE (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 !!! ,!!! ,!!! .00 49 Estimated tax penalty. (See page 28 of
Instructions.) Do not include on line 42 or 48. Fill in
this oval if Form N-210 is attached � ................... 49 !!! ,!!! ,!!! .00
50 AMENDED RETURN ONL Amount paid (overpaid) on original return. (See Instructions) (attach Sch. AMD) ....... 50 !!! ,!!! ,!!! .00
51 AMENDED RETURN ONL Balance due (refund) with amended return. (See Instructions) (attach Sch. AMD) ..... 51 !!! ,!!! ,!!! .00
52 Did you le a federal Schedule C? Yes No If yes, enter Hawaii gross receipts !!! ,!!! ,!!! .00 your main business activity: ,
your main business product: , AND your HI Tax I.D. No. for this activity W \037\037\037\037\037\037\037\037 � \037\037
53 Did you le a federal Schedule E If yes, enter Hawaii gross rents received !!! ,!!! ,!!! .00 for any rental activity ? Ye s No
AND your HI Tax I.D. No. for this activity W \037\037\037\037\037\037\037\037 � \037\037
54 Did you le a federal Schedule F? Ye s No If yes, enter Hawaii gross receipts !!! ,!!! ,!!! .00 your main business activity: ,
your main business product: , AND your HI Tax I.D. No. for this activity W \037\037\037\037\037\037\037\037 � \037\037
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 Identi cation number h
HAWAII ELECTION Do you want $3 to go to the Hawaii Election Campaign Fund? Yes No
CAMPAIGN FUND � If joint return, does your spouse want $3 to go to the fund? Yes No 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 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
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