Acom U.S.Individual

Acom U.S.Individual If total? is 310.000 or men, or it toldl Mono Horn interns. dive I-188 Income Tax Return "teliorc:17,,,'Imr"Ilign Is i ' .5 .;s1 eb; 1 Na we, use lust names aad middle initials ol toga our social security number 4. C one: . Sing, : 0 terniAt."" : 12, ".11,1.:a 0. r E a e :• •• Home address Musty shot or foul route) '7 -7e . ri :td:- AUg mesa s weal la income) O I.r._,11,,,isz Mint war, . K pj • S ib • • Id z S PI ___2] • Cdy, town or post office, Stets ad ZIP rade - 1 a Winn. enter her (his) mug ',Hurd number in gem 3 and give 6:3 ri me hear l/r. Enter below (If same as changing Is enter 1967 name and a--rest used your turn bove. write "Same.") If none tiled. give reason. If m separate to joint or joint to separate returns. ernes and addresses. Enter total wages, saki Forms W- 2. Copy 8. I Forms W-2 attach expl His, tips, etc. Enclose you,* p. not shown on enclosed nation. SpouSe's lo .e/ 14.(2 @Interest Yours * Spouse's * x..1 if ©Dividends: yours—before exclusion $ NW le • • If item 7 A 55.000 or more, compute tax A surcharge & pay (See instr.) Spouse's—before exclusion $ Aber P. item 10 in full with return. If under $5.000. IRS will compute tax if you omit items 8. 10 & 11 (but complete item 9). 7 Total income (add items S. 6a. and 6b) P. flip," for tax, see Instructions: pages 5-7 for regular tables, page 8 M 8 Tax S + b. Surcharge $ c. Total * -- 6 4 IM surcharge, page 4 for $5,000 or mole computatiyn. Total Federal Income tax withheld (from Forms W-2) IP BC/ aped y r U.S. Savings Bonds, Mond to: L. & excess refunded; or ..9/ Refund onl 0 If item 8c is larger than item 9, enter Balance doe le ..LQ UST YOUR EXEMPTIONS AND SIGN ON OTHER SIDE. II it item 9 is taro than item 8c, enter Refund 10* ji ;11777 ®EXEMPTIONS FOR YOURSELF—ANC. SPOUSE (only if all her (his) Income Is Included In this return, or she (he) had no income) Re r 65 or over Blind • O 0 Yourself . . 0 } er Ent number Spouse O O of boxes P ' —.t— boxes which apply ey checked oC ck First names of your dependent children who lived with you Enter * number ODEMENOIJITS OTIO4 THAN RINI CAMEO IN ITEM 13. (4 NAME P. Enter figure 1 in the Int sob (inn to right for each name listed (if more spas* Is needed. attach schedule) ON IbILSCHWhie NY Months lined in your home. II born or died dui ing year also write (4) Did depomfmt hem income el $600 or i were (o) Arnow' YOU fur. mats for depend. ant's support. II IOC% write "All" Hy Amount furnished by OTHERS Including dependent. See in. striatum le * * * S S 11. TOTAL EXEMPTIONS FROM ITEMS 12, 13, AND 14 ABOVE 1 / Your present employer and address wj j 9 "FAY e— lf you had an expense allowance or charged expenses to your employer, see instructions for "Reimbursed Expenses" and check here 0 if appropriate. Under penalties of perjury, i declare that to the best of my knowledge and belief this is a true, correct, and complete return. Sign Yow signature • — r . Data here • • - s..... Prawn (II Ming We*. !MTN arrir sile arm it Wilt me AM in 6 ii Tax Computation Schedule (Use only if total income, item 7 of Form 1040A is $5,000 or more) Fenn W-2 U.S. Treasury Department Internal Revenue Service WAGE AND TAX STATEMENT Keep this copy as part of your tax records. INCOME TAX INFORMATION Metal inceme tax Wages I paid subject to with withheld holding in 1968 5.70 122.40 Copy C—For employee's record 1968 SOCIAL SECURITY INFORMATION STATE OR MUNICIPAL INFORMATION Other nimpensation • F.I.C.A. employee Total F.I.C.A. wages New York State New York City paid in 1968 tax withheld • Paid In 1968 • Tax Withheld TeX Withheld • 0 II • 2.30 122.40 .20 .20 Type or print EMPLOYEE'S social security number, yarns and address bel Amu-dyne rry ss Tarr Be Kafka 1770 Surf avaoue Brooklyn, New York 5- Single M—If Mar- rled No. of OsPee- dents -- —12.4801032 'RICHTON BEACH "ATMS. IOC. SUITE 34OO TIDE AU) !Art WILDING ROCK/PC.1XE CENTER NEts YORK. N.Y. 1OO2O Type or Print E OYER'S rte tification nu er, name arc address • Includes tips reported by employee. Amount is before payroll deductions Or sick pay exclusion. • Add this item to wages in figuring the amount to be re- ported as wages and salaries on your income tax return. s the social security (F.I.C.A.) rate of 4.4% Includes .6% for Hospital Insurance Benefits and 3.8% for Old-age, survivors. and disability insurance. • Includes ties reports by employee. W. c'let lee E":(00Yee Tax on TIPS Form W-2 U.S. Treasury Department APP. IRS awes EFTA01145587