Form Schedule S Individual Income Tax Supplemental Schedule

B14 Penaltyonearlywithdrawalofsavings B15 Alimonypaid B16 Movingexpenses B17 Otherfederaladjustments B19 Kansassourceincomeafterfederaladjustments(SubtractlineB18fromlineB12) B2 Interestanddividendincome B20 NetmodificationsapplicabletoKansassourceincome(Seeinstructions) B21 ModifiedKansassourceincome(LineB19plusorminuslineB20) B22 Kansasadjustedgrossincome(Fromline3 FormK 40) B3 Refundsofstateandlocalincometaxes B4 Alimonyreceived B5 Businessincomeorloss B6 Farmincomeorloss B7 Capitalgainorloss B8 Othergainsorlosses B9 Pensions IRAdistributions andannuities Enter on line 2 Form K 40 If negative shade minus ( ) in box (Rev 7/12) 00 00 00 00 00 00 00 00 00 00 114312 114412 A1 State and municipal bond interest not specifically exempt from Kansas income tax (Reducedbyrelatedexpenses) A2 Contributions to all KPERS (Kansas Public Employee's Retirement Systems) (See instructions) A3 Federalnetoperatinglosscarryforward A4 ContributionstoaRegionalFoundation(Seeinstructions) A5 Kansas expensing recapture (See instructions and enclose applicable schedules) A6 Other additions to Federal adjusted gross income (See instructions and enclose list) A7 Total additions to Federal adjusted gross income (Add lines A1 through A6) A10 Interest on U S Government obligations (Reduced by related expenses) A11 Stateorlocalincometaxrefund(Ifincludedonline1ofFormK 40) A12 Kansasnetoperatinglosscarryforward A13 Retirement benefits specifically exempt from Kansas income tax (Do not include Social Security A21 Net modifications to Federal adjusted gross income (subtract line A20 from line A7) A8 SocialSecuritybenefits(Seeinstructions) A9 KPERS lump sumdistributions exempt from Kansas income tax(See instructions) ADDITIONS TO FEDERAL ADJUSTED GROSS INCOME: ADJUSTMENTS AND MODIFICATIONS TO KANSAS SOURCE INCOME: B1 Wages salaries tips etc B10 Rentalrealestate royalties partnerships Scorporations estates trusts etc B11 Unemploymentcompensation taxable SocialSecuritybenefits &otherincome B12 Total incomefromKansas sources (AddlinesB1throughB11) B13 IRARetirementDeductions B18 TotalfederaladjustmentstoKansassourceincome(AddlinesB13throughB17) B23 Nonresidentallocationpercentage(DividelineB21bylineB22androundtothefourthdecimal place;nottoexceed100 0000) Enterresulthereandonline9ofFormK 40 benefitsorKPERSlumpsumdistributions) A14 Military Compensation of a Nonresident Servicemember (Nonresidents only; see instructions) A15 Qualified Long Term Care (LTC)insurance premiums(See instructions) A16 Contributions to Learning Quest or other states' qualified tuition programs (See instructions) A17 ArmedForcesRecruitment Sign up orRetentionBonus A18 Kansas expensing deduction (See instructions and enclose applicable schedules) A19 Other subtractions from Federal adjusted gross income (See instructions and enclose list) A20 Total subtractions from Federal adjusted grossincome (Add lines A8 through A19) Enter the first four letters of your last name Use ALL CAPITAL letters Enter the first four letters of your spouse'slast name Use ALL CAPITAL letters If amount is negative shade minus ( ) in box Example: Ifamountisnegative shadetheminus( )inbox Example: INCOME: KANSAS SUPPLEMENTAL SCHEDULE NET MODIFICATIONS: PART A MODIFICATIONS TO FEDERAL ADJUSTED GROSS INCOME (See instructions) PART B INCOME ALLOCATION FOR NONRESIDENTS and PART YEAR RESIDENTS SCHEDULE S 2012 Spouse's Social Security number SUBTRACTIONS FROM FEDERAL ADJUSTED GROSS INCOME: Total From Federal Return: Amount From Kansas Sources: Your Social Security number