Attachment 5-J
FORM 1040 WORKSHEET-TO DETERMINE PROVIDER’S INCOME
Line on Form 1040 7. Wages, salaries, tips, etc. 8a. Taxable interest 8b. Tax-exempt interest 9. Dividend income 10. Taxable refunds, credits, or offset of state and local income taxes 11. Alimony received 12. Business income or (loss) 13. Capital gain or (loss) Instruction Face Value Face Value Disregard Face Value Disregard as this is considered a one-time only, lump sum payment Face Value Face Value if income, Disregard if loss Refer to Schedule C Disregard if loss or one-time only, lumpsum payment Refer to Schedule D Disregard if loss or one-time only, lumpsum payment, Refer to Form 4797 Face Value Disregard Face Value Disregard Disregard, if loss or one-time only, lumpsum payment Refer to Schedule E Face Value if income, disregard if loss Refer to Schedule F Face Value Face Value Disregard Face Value Add lines 7-21 Child support payments Welfare benefits (not food stamps) Add total 1040 income, child support, and welfare benefits Amount
0 0
14. Other gains or (losses) 15a. Total IRA distributions 15b. Taxable amount 16a. Total pensions and annuities 16b. Taxable amount 17. Rental real estate, royalties, partnerships, S corporation, trusts, etc. 18. Farm income or (loss)
0 0
19. Unemployment compensation 20a. Social security benefits 20b. Taxable amount 21. Other income 22. Total income from the 1040 form Disregard lines 23-31 on Form 1040 In addition to Total Income from Form 1040, include: Total Verified Income (CACFP)
0