2012 IA 1040 Schedule B
Interest and Dividend Income
www.iowa.gov/tax
Iowa Department of Revenue
PART I: INTEREST INCOME
Name(s) as shown on page 1 of the IA 1040
  Social Security Number
41-004b (09/17/12)
You must complete this part if you received more than $1,500 in interest in 2012. Interest income which should be reported includes
earnings from savings and loan associations, mutual savings banks, cooperative banks, credit unions, and bank deposits; state and
municipal bonds (see instructions for IA 1040, line 2, Taxable Interest Income), and interest from tax refunds. Report both exempt and
taxable interest.
Total Taxable Interest: 
If
 filing status 1, 2, 5, or 6 
– report total taxable interest on line 2, column A on the IA 1040; none should be
reported in column B. If
 filing status 3 
– the taxpayer will enter on line 2, column A on the IA 1040, the total taxable interest from
accounts owned by the taxpayer, plus 50% of any amount from a joint account. The spouse will enter in Column B on the IA 1040, the
total taxable interest from accounts owned by the spouse, plus 50% of any amount from a joint account. If
 filing status 4
 – the amount
entered on line 2, column A on the IA 1040 will be the total taxable interest from accounts owned by the taxpayer, plus 50% of any
amount from a joint account; nothing is reported in column B.
Account Ownership: 
For each payer, indicate the type of account ownership. If the interest was earned by you, check “Taxpayer.”
For interest earned by your spouse, check “Spouse.” If the interest was earned jointly, check “Joint.” Check only one for each payer.
PART II: DIVIDEND INCOME
You must complete this part if you received more than $1,500 in gross dividends in 2012. Report both exempt and taxable dividends.
Total Taxable Dividends: 
If
 filing status 1, 2, 5, or 6 
– report total taxable dividends on line 3, column A on the IA 1040; none should
be reported in column B. If
 filing status 3 
– the taxpayer will enter on line 3, column A on the IA 1040, the total taxable dividends from
accounts owned by the taxpayer, plus 50% of any amount from a joint account. The spouse will enter in Column B on the IA 1040, the
total taxable dividends from accounts owned by the spouse, plus 50% of any amount from a joint account. If
 filing status 4
 – the
amount entered on line 3, column A on the IA 1040 will be the total taxable dividends from accounts owned by the taxpayer, plus 50%
of any amount from a joint account; nothing is reported in column B.
Account Ownership: 
For each payer, indicate the type of account ownership. If the dividend was earned by you, check “Taxpayer.”
For dividends earned by your spouse, check “Spouse.” If the dividend was earned jointly, check “Joint.” Check only one for each
payer.
NOTE: 
You must report all taxable interest and dividends on IA 1040, even if you are not required to complete Schedule B.
Check one for each payer
(list names of all payers)                               
  TOTALS
(must equal the
total of Exempt &
Taxable Interest)
$
 $
$
  Taxpayer     Spouse       Joint
Iowa Tax
12345678901234567890123456789012
12345678901234567890123456789012
12345678901234567890123456789012
12345678901234567890123456789012
12345678901234567890123456789012
12345678901234567890123456789012
 Name of Payer                                                                      
Total Dividends
(list names of all payers)                               
  TOTALS
(must equal the
total of Exempt &
Taxable Dividends)
$
 $
$
  Taxpayer     Spouse       Joint
Iowa Tax
12345678901234567890123456789012
12345678901234567890123456789012
12345678901234567890123456789012
12345678901234567890123456789012
12345678901234567890123456789012
         Account Ownership
Check one for each payer
  
   
                                                                                                      
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Exempt from
      
Dividends
    
Dividends
         
Taxable
 Name of Payer
                                                                       
Total Interest
       
Interest
            
Taxable
                                                    
Exempt from
       
Interest
               
Account Ownership
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