Form 1040ez - Income Tax Return For Single And Joint Filers With No Dependents (2015'0
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1
2Department of the Treasury—Internal Revenue Service
Income Tax Return for Single and
Form
2015
1040EZ
Joint Filers With No Dependents
(99)
OMB No. 1545-0074
Your first name and initial
Last name
Your social security number
Sample
Student
1 2 3 4 5 6 7 8 9
If a joint return, spouse’s first name and initial
Last name
Spouse’s social security number
Home address (number and street). If you have a P.O. box, see instructions.
Apt. no.
Make sure the SSN(s)
above are correct.
123 My Street
City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions).
Presidential Election Campaign
Check here if you, or your spouse if filing
My Town, ST 99999
jointly, want $3 to go to this fund. Checking
Foreign country name
Foreign province/state/county
Foreign postal code
a box below will not change your tax or
refund.
✔
You
Spouse
1
Wages, salaries, and tips. This should be shown in box 1 of your Form(s) W-2.
Income
Attach your Form(s) W-2.
1
13,164
00
Attach
Form(s) W-2
2
Taxable interest. If the total is over $1,500, you cannot use Form 1040EZ.
2
here.
131
64
Enclose, but do
3
3
Unemployment compensation and Alaska Permanent Fund dividends (see instructions).
not attach, any
payment.
4
Add lines 1, 2, and 3. This is your adjusted gross income.
4
13,295
64
5
If someone can claim you (or your spouse if a joint return) as a dependent, check
the applicable box(es) below and enter the amount from the worksheet on back.
✔
You
Spouse
If no one can claim you (or your spouse if a joint return), enter $10,300 if single;
$20,600 if married filing jointly. See back for explanation.
5
6,300
00
6
Subtract line 5 from line 4. If line 5 is larger than line 4, enter -0-.
This is your taxable income.
6
6,995
64
7
Federal income tax withheld from Form(s) W-2 and 1099.
7
921
48
Payments,
8a
Earned income credit (EIC) (see instructions)
8a
Credits,
b Nontaxable combat pay election.
8b
and Tax
9
9
Add lines 7 and 8a. These are your total payments and credits.
10
Tax. Use the amount on line 6 above to find your tax in the tax table in the
instructions. Then, enter the tax from the table on this line.
10
698
00
11
✔
11
Health care: individual responsibility (see instructions)
Full-year coverage
12
12
Add lines 10 and 11. This is your total tax.
698
00
13a
If line 9 is larger than line 12, subtract line 12 from line 9. This is your refund.
Refund
If Form 8888 is attached, check here
13a
223
48
Have it directly
deposited! See
b Routing number
c Type:
Checking
Savings
instructions and
fill in 13b, 13c,
and 13d, or
d Account number
Form 8888.
14
If line 12 is larger than line 9, subtract line 9 from line 12. This is
Amount
You Owe
the amount you owe. For details on how to pay, see instructions.
14
Do you want to allow another person to discuss this return with the IRS (see instructions)?
Yes. Complete below.
No
Third Party
Designee
Designee’s
Phone
Personal identification
name
no.
number (PIN)
Sign
Under penalties of perjury, I declare that I have examined this return and, to the best of my knowledge and belief, it is true, correct, and
accurately lists all amounts and sources of income I received during the tax year. Declaration of preparer (other than the taxpayer) is based
Here
on all information of which the preparer has any knowledge.
Daytime phone number
Your signature
Date
Your occupation
Joint return? See
4/15/16
555-123-4567
Sample Student
Student
instructions.
Spouse’s occupation
Spouse’s signature. If a joint return, both must sign.
Date
If the IRS sent you an Identity Protection
Keep a copy for
PIN, enter it
your records.
here (see inst.)
Print/Type preparer’s name
PTIN
Preparer’s signature
Date
Paid
Check
if
self-employed
Preparer
Firm’s name
Firm’s EIN
Use Only
Firm’s address
Phone no.
1040EZ
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see instructions.
Cat. No. 11329W
Form
(2015)
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