Form D-400 Fillable Individual Income Tax Return (no tax credits) -
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

D 400 and your name address and social security number on the payment If filing a joint return write both (Add Lines 46a 46b 46c 46d and 46e and enter on Line 46f ) 46f (Add Lines 47a 47b and 47c and enter on Line 47d ) 47d (Bailey settlement Important: See Line instructions on Page 14) (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (checkbox) Unchecked (combobox) (combobox) (FEIN SSN or PTIN) (From Form D 400TC Part 5) (MM DD YY) (MM DD YY) (See instructions on Page 13) (See instructions on Page 15) (See Line instructions and enter letter in box if applicable) (See Line Instructions beginning on Page 15 Note: Do not complete Lines 53 through 55 if you were a full year resident ) (See Line instructions on Page 15 for deduction limitations) (See Line instructions on Page 15 for explanation of qualifying severance wages) 45 (Staple original or copy of the original State (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (You must fill in appropriate circle See instructions on Pages 7 8 and 9) 10 Subtract Line 9 from Line 8 10 11 N C standard deduction OR N C itemized deductions 15 Enter amount from Line 14 15 16 Part year residents and nonresidents 17 North Carolina Taxable Income 18 North Carolina Income Tax If the amount on Line 17 is less than $68 000 use the Tax Table 19 Tax Credits (From Form D 400TC Part 4 Line 37 You must attach Form D 400TC 20 Subtract Line 19 from Line 18 20 21 Consumer Use Tax (See instructions on Page 10) 22 Add Lines 20 and 21 22 23 North Carolina Income Tax Withheld 24 Other Tax Payments 25 North Carolina Earned Income Tax Credit 26 Add Lines 23a through 25 and enter the total on Line 26 26 27 a Tax Due If Line 22 is more than Line 26 subtract and enter the result 28 Add Lines 27a 27b 27c and 27d and enter the total Pay This Amount 29 Overpayment If Line 22 is less than Line 26 subtract and enter the result 29 30 Amount of Line 29 to be applied to 2014 Estimated Income Tax 31 Contribution to the N C Nongame and Endangered Wildlife Fund 32 Add Lines 30 and 31 32 33 Subtract Line 32 from Line 29 and enter the Amount To Be Refunded 34 Interest income from obligations of states other than North Carolina 34 35 Adjustment for bonus depreciation (See instructions on Page 13) 35 36 Adjustment for section 179 expense deduction (See instructions on Page 13) 36 37 Adjustment for tuition and fees deduction Form 1040 Line 34 or Form 1040A Line 19 38 Other additions to federal adjusted gross income (Attach explanation or schedule) 38 39 Total additions Add Lines 34 through 38 (Enter the total here and on Line 7) 39 40 State or local income tax refund if included on Line 10 of Federal Form 1040 40 41 Interest income from obligations of the United States or United States possessions 41 42 Taxable portion of Social Security and Railroad Retirement Benefits 43 Retirement benefits received from vested N C State government 44 If you have retirement benefits not reported on Lines 42 or 43 complete the 45 Severance wages 46b 200946a 2008 46c 2010 46e 201246d 2011 47 Adjustment for section 179 expense deduction added back in 2010 2011 and 2012 (See Line instructions on Page 15) 47a 2010 47b 2011 47c 2012 48 Contributions to North Carolina s National College Savings Program (NC 529 Plan) 49 Adjustment for absorbed NOL added back in 2003 2004 2005 and 2006 51 Other deductions from federal adjusted gross income (Attach explanation or schedule 52 Total deductions Add Lines 40 through 51 (Enter the total here and on Line 9) 52 53 Enter the amount from Column B Line 34 of the Part Year 54 Enter the amount from Column A Line 34 of the Part Year 55 Divide Line 53 by Line 54 (Enter the result as a decimal amount here and on Line 16; round 6 Federal adjusted gross income(Form 1040 Line 37; Form 1040A Line 21; or Form1040EZ Line 4) (If negative see the Line instructions) 7 7 Additions to federal adjusted gross income(If applicable complete Lines 34 through 39 on Page 3and enter amount from Line 39) 8 Add Lines 6 and 7 8 9 9 Deductions from federal adjusted gross income(If applicable complete Lines 40 through 52 on Page 3and enter amount from Line 52) a 2013 Estimated Tax a Your tax withheld accurate and complete based on all information of which the preparer has any knowledge Additions to Federal Adjusted Gross Income (See Line Instructions beginning on Page 12 ) Adjustment for bonus depreciation added back in 2008 2009 2010 2011 Adjustment for net business income that is not considered passive income (See instructions on Page 15)50 50 All Pages of Amended Returns and 2012 (See Line instructions on Page 15) and ending (MM DD YY) are payable in U S dollars Please do not staple tape paper clip or otherwise attach your payment or voucher attach a copy of the NC K 1 b Paid with Extension b Penalties b Spouse s tax withheld Be sure to sign and date your return on Page 4 beginning on Page 22 of the instructions to determine your tax If the amount on Line 17 is $68 000 c Interest c Partnership Complete Lines 53 through 55 on Page 4 and enter Computation of North Carolina Taxable Income for Part Year Residents and Nonresidents corner of the return) D 400 D 400 Web Fill D 400 Web Fill D 400V Enclose the voucher with your return and payment and mail to the address listed above If you do not pay d Interest on the underpayment of estimated income tax d S Corporation Date residency began Date residency ended Deceased Taxpayer Information decimal amount from Line 55 Deductions from Federal Adjusted Gross Income(See Line Instructions beginning on Page 13 ) Do not include any deduction for retirement benefits on this line ) enter on Lines 53 and 54 below Enter the Number Enter Whole U S Dollars Only Exception tounderpaymentof estimated tax Filing Status Fill in one circle only (See instructions on Page 7) Fill in applicable circles Fill in circle if return is filed and signed by Executor Administrator or Court Appointed Personal Representative Fill in circle if you or your spouse were out of the country on April 15 and a U S citizen or resident Fill in circle(s) if you or your spouse moved into or out of North Carolina during the year and enter the dates of residency in the boxes Fill in circle(s) if you or your spouse were nonresidents of North Carolina for the entire year Fill in residency information and complete Lines 53 through 55 For calendar year 2013 or fiscal year beginning (MM DD YY) For direct deposit file electronically Go to www dornc com and click on efile Full year residents enter the amount from Line 15 Head of Household4 Home Telephone Number (Include area code ) I certify that to the best of my knowledge this return is If prepared by a person other than taxpayer this certification is If a Joint Return Spouse s First Name M I If No complete Lines 1 through 15 Then go to Page 4 of Form D 400 If REFUND mail If return is for a deceased taxpayer or deceased spouse enter date of death If you ARE NOT due a If you claim a partnership payment on Line 24c if you enter an amount on this line) IMPORTANT: Do not enter the amount from your federal return included on your federal return Individual Income Last Name (First 10 Characters) Tax Year Your Social Security Number Last Name (First 10 Characters) Your Social Security Number Mailing Address Apartment Number Married Filing Jointly2 Married Filing Separately3 N C DEPT OF REVENUE N C local government or federal government retirees N C personal exemption allowance (See instructions on Page 9)13 13 Name(Enter your spouse sfull name and Social North Carolina Department of Revenue not accept a check money order or cashier s check unless it is drawn on a U S (domestic) bank and the funds of Exemptionsclaimed on yourfederal income online or by payment voucher mail a check or money order with your return for the full amount due Please write Online You can pay your tax online by bank draft credit or debit card using Visa or MasterCard Go to or more use the Tax Rate Schedule on Page 30 to calculate your tax or S corporation payment on Line 24d you must Original Return Payment Options P O BOX 25000 P O BOX R Page 2 Page 3 Page 4 Paid Preparer s Signature Date Part year residents and nonresidents multiply amount on Line 15 by the decimal amount on Line 16 Part year residents and nonresidents must read the instructions on Page 15 and complete the worksheet on Page 16 to determine the amounts to Payment voucher If you do not pay your tax online go to www dornc com and generate a personalized Form Preparer s FEIN SSN or PTIN Preparer s Telephone Number (Include area code ) Qualifying Widow(er) with Dependent Child (Year spouse died: )5 RALEIGH NC 27634 0001 RALEIGH NC 27640 0640 refund mail return anypayment and D 400V to: Residency Status Resident/Nonresident Worksheet on Page 16 of the Instructions Retirement Benefits Worksheet on Page 14 and enter the result here return to: Security Number) See Form D 400X for the mailing address and payment options for amended returns Sign Here Single1 social security number(s) social security numbers on your payment in the order that they appear on the return Note: The Department will Spouse Spouse (MM DD YY)Taxpayer (MM DD YY) Spouse s Last Name Spouse s Signature (If filing joint return both must sign ) Spouse s Social Security Number Staple Staple W 2s Here Subtract Line 11 from Line 10 12 12 Subtract Line 13 from Line 1214 14 tax return Tax Return 2013 Tax Year to four decimal places ) to your return or to each other wage and tax statement(s) in lower left hand Was your spouse a resident for the entire year? Web Fill Were you a resident of N C for the entire year of 2013? www dornc com and click on Electronic Services for details Yes No You can pay online Go to www dornc com and click on Electronic Services for details You must enter your You Spouse Your Last Name Your First Name(USE CAPITAL LETTERS FOR YOUR NAME AND ADDRESS) M I Your Return Here Your Signature Date Your Social Security Number Zip Code Country (If not U S )City State County (Enter first five letters)