DS9 Document EFTA01222546

Form 1040A Vow first name and rubel Last name OMB No. 1545-0074 Your social security number If a mint return. spouse's first name and initial Last name Spouse's social security number Home address (number and skeet). If you have a P.O. box. see instructions. Apt no- Make are the SSN(s) above a and on line 6c we correct. City. town or post office. state. and LP code. If you have a foreign address. also complete spaces below (see instruct's:en). Presidential Election Campaign Check here d you. or your sparse II filin baeobng a t want 33 to go to bas MI notNohs fund gpinny. t rge y2uf tax Of wend. D you El Spouse Feign country name Foreign province/state/county Fang' postal code Filing status Check only one box. Department of the Treasury—Internal Revenue Service U.S. Individual Income Tax Return (99) 2017 IRS Use Only—Do not write or staple in this space. Exemptions If may than six dependents, see mstructions. 1 K Single 4 K Head of household (with qualifying person). (see Indrucbons.) 2 O Married filing jointly (even if only one had income) If the qualifying person is a child but not your dependent, 3 O Married filing separately. Enter spouse's SSN above and enter this child's name here. lo full name here. lio 5 O Qualifying widow(er) (see instructions) 6a U Yourself. If someone can claim you as a dependent, do not check box 6a. b O Spouse c Dependents: (1) First name Last name 121 Dependent's social security number (3) Dependent's relationship to you (4)1 if chid wider age 17 qualifying for chid tax credit (see nstructions) I ■ d Total number of exemptions claimed. Boxes checked on 6a and 6b No. of children on 6c who: • kved with you • did not live with you due to divorce or separation (see instructions) Dependents on 6c not entered above Add numbers ri on lines above e Income Attach Form(s) W-2 here. Also attach Form(s) 1099-R if tax was withheld. If you did not get a W-2. see instructions. 7 Wages, salaries, tips, etc. Attach Form(s) W-2. 8a Taxable interest. Attach Schedule B if required. b Tax-exempt interest. Do not include on line 8a. 8b 9a Ordinary dividends. Attach Schedule B if required. b Qualified dividends (see instructions). 9b 10 Capital gain distributions (see instructions). 11a IRA distributions. 12a Pensions and annuities. 7 8a 9a 10 11b Taxable amount 11a (see instructions). 11b 12b Taxable amount 12a (see instructions). 12b 13 Unemployment compensation and Alaska Permanent Fund dividends. 13 14a Social security 14b Taxable amount benefits. 14a (see instructions). 14b 15 Add lines 7 through 14b (far right column). This is your total income. P. 15 Adjusted gross 16 Educator expenses (see instructions). 16 income 17 IRA deduction (see instructions). 17 18 Student loan interest deduction (see instructions). 18 19 Tuition and fees. Attach Form 8917. 19 20 Add lines 16 through 19. These are your total adjustments. 20 21 Subtract line 20 from line 15. This is your adjusted gross income. ► 21 For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Form 1040A (2017) EFTA01222546 Form 1040A (2017) Tax, credits, 22 and 23a payments b Standard Deduction for — • People who check any box on line 23a or 23b or who can be claimed as a dependent, see instructions. • All others: Single or Married filing separately, $6.350 Married filing pntly or Qualifying widow(er). $12,706 Heed of $9. household, 350 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 If you have a qualifying child attaah Schedule EIC. 42a b 43 44 45 46 47 Refund Direct deposit? See instructions and fill In 48b, 48c, and 48d or Form 8888. Page 2 Enter the amount from line 21 (adjusted gross income). 22 Check I 0 You were born before January 2, 1953, 0 Blind iTotal if: OSpouse was bom before January 2,1953, OBlind 1r:tweeted boxes lo 23a ■ If you are married filing separately and your spouse itemizes deductions, check here ► 23b 0 Enter your standard deduction. 24 Subtract line 24 from line 22. If line 24 is more than line 22, enter -0-. 25 Exemptions. Multiply $4,050 by the number on line 6d. 26 Subtract line 26 from line 25. If line 26 is more than line 25, enter -0-. This is your taxable income. P. 27 Tax, including any alternative minimum tax (see instructions). 28 30 Excess advance premium tax credit repayment. Attach Form 8962. 29 Add lines 28 and 29. Credit for child and dependent care expenses. Attach Form 2441. 31 36 Credit for the elderly or the disabled. Attach Schedule R. 32 Education credits from Form 8863, line 19. 33 Retirement savings contributions credit. Attach Form 8880. 34 Child tax credit. Attach Schedule 8812, if required. 35 Add lines 31 through 35. These are your total credits. Subtract line 36 from line 30. If line 36 is more than line 30, enter -0-. 37 Health care: individual responsibility (see instructions). Full-year coverage 0 38 Add line 37 and line 38. This is your total tax. 39 Federal income tax withheld from Forms W-2 and 1099. 40 46 2017 estimated tax payments and amount applied from 2016 retum. 41 Earned income credit (EIC). 42a Nontaxable combat Dav election. 42b Additional child tax credit. Attach Schedule 8812. 43 American opportunity credit from Form 8863, line 8. 44 Net premium tax credit. Attach Form 8962. 45 Add lines 40, 41, 42a, 43, 44, and 45. These are your total payments. ► If line 46 is more than line 39, subtract line 39 from line 46. This is the amount you overpaid. 47 48a Amount of line 47 you want refunded to you. If Form 8888 is attached, check here ► 0 48a op. b Routing ► c Type: 0 Checking 0 Savings number op. d Account number 49 Amount of line 47 you want applied to your 2018 estimated tax. 49 50 Amount you owe. Subtract line 46 from line 39. For details on how to pay, see instructions. ► 50 51 Estimated tax penalty (see instructions). 51 Amount you owe Third party designee Do you want to allow another person to discuss this return with the IRS (see Instructions)? El Yes. Complete the following. 0 No Designee's Phone Personal identification name P. no. IP. number (PIN) ► Under penalties of perjury. I declare that I have exarnmed this return and accompanyng schedules and statements. and to the best of my knowledge and be they are true. correct. and accurately list all amounts and sources of income I received during the tax year. Declaration of prepare' (other than the taxpayer) is based on all information of which the preparer has any knowledge. Your signature Date Your occupation Daytime phone number Sign here Joint return? See instructions. Keep a copy for your records. Paid preparer use only Print/Type preparer 's name Preparer s signature Date Check If self-employed PTIN Firm's name le Arm's EIN ► Firm's address e Phone no. Spouse's signature. If a pint return. both must sign. Date Spouse's occupation tithe IRS sent you en Identity Protection PIN. enter it here(see inst.) Go to wwwits.govIForm1040A for instructions and the latest information. Form 1040A (2017) EFTA01222547