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L Last Name Spouse Social Security Number Print Spouse's Name Mailing Address RESIDENCY STATUS City/Town State Zip Code RESIDENT MUST COMPLETE SCHEDULE F & G on PAGE 2 NONRESIDENT INCOME ATTACH 1. PART-YEAR RESIDENT From federal return Wages, salaries, tips, etc. Exclusions Total EXEMPTIONS from Page 2 Income subject to tax 1 COPY OF 2. Taxable interest and Ordinary dividends. FEDERAL 3. Alimony received. 00 (RESIDENTS & PART-YEAR RESIDENTS ONLY) 2 00 3 00 RETURN 4.

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