Form Schedule ND-1SA Fillable Statutory Adjustments
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

81 03 01 1 06 Include on this line a (text) (text) (text) (text) 1 Renaissance zone income exemption (Attach Schedule RZ) (S7) 1 2 New or expanding business income exemption under N D C C ch 40 57 1 (NH) 2 3 Human organ donor expense deduction (NL) 3 4 Employee workforce recruitment exclusion (CA) 4 5 Total subtractions Add lines 1 through 4 Enter result on Form ND 1 line 16 5 actually provided and not when the amount of the exempt income see North Attach any required schedule (as indicated in parentheses) based on your employment enter on this being you may deduct up to $10 000 of business income exemption complete and attach it to Form ND 1 Complete and attach this schedule to Form ND 1 if any of the adjustments listed on this schedule apply to you Dakota Administrative Code did not deduct in calculating your donates part or all of a liver pancreas employer verifying that your employer Enter on this line qualified expenses exemption from a North Dakota expanding business income exemption expenses are billed or paid expenses for which you receive federal income tax purposes) that you federal taxable income Medical for transplantation into another human fringe benefit payment shown on the If the qualified expenses are incurred in If you have any of the adjustments If you operate a business as a sole If you or your dependent while living If you qualified for the business or If you receive a statement from your included in your 2013 federal taxable income Attach a copy of the statement income exemption incurred during the 2013 tax year incurred when the medical care is information on how to calculate the investment income exemption under the is eligible for the exemption For more kidney intestine lung or bone marrow Line 1 Renaissance zone Line 2 New or expanding Line 3 Organ donor deduction Line 4 Employee workforce line the amount of the signing bonus Lost wages not compensated for by Medical expenses (as defined for more than one tax year the expenses moving expense payment or non typical must be deducted in the tax year in which ND 1SA Statutory Adjustments 2013 new or expanding business income North Dakota renaissance zone plan or other source do not qualify for Please type or print in black or blue ink Attach to Form ND 1 portion of your net business income that program enter the amount from proprietorship and were granted a new or Purpose of schedule Qualified expenses means: qualified expenses related to the donation qualified for the North Dakota received from your employer recruitment exclusion reimbursement under an insurance Schedule K 1 Schedule North Dakota Office of State Tax Commissioner Schedule RZ Schedule RZ Part 7 line 1 Attach shown on Schedule ND 1SA you must sick pay Specific line instructions statement but only to the extent it is that you incurred during the tax year the deduction they are incurred Medical expenses are under N D C C ch 40 57 1 enter the workforce recruitment income tax credit Your name (First MI Last name) Your social security number