Department of the Treasury—Internal Revenue Service
Income Tax Return for Single and
Joint Filers With No Dependents
OMB No. 1545-0074
Your first name and initial
Your social security number
1 2 3 4 5 6 7 8 9
If a joint return, spouse’s first name and initial
Spouse’s social security number
Home address (number and street). If you have a P.O. box, see instructions.
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 postal code
a box below will not change your tax or
Wages, salaries, and tips. This should be shown in box 1 of your Form(s) W-2.
Attach your Form(s) W-2.
Taxable interest. If the total is over $1,500, you cannot use Form 1040EZ.
Enclose, but do
Unemployment compensation and Alaska Permanent Fund dividends (see instructions).
not attach, any
Add lines 1, 2, and 3. This is your adjusted gross income.
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.
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.
Subtract line 5 from line 4. If line 5 is larger than line 4, enter -0-.
This is your taxable income.
Federal income tax withheld from Form(s) W-2 and 1099.
Earned income credit (EIC) (see instructions)
b Nontaxable combat pay election.
Add lines 7 and 8a. These are your total payments and credits.
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.
Health care: individual responsibility (see instructions)
Add lines 10 and 11. This is your total tax.
If line 9 is larger than line 12, subtract line 12 from line 9. This is your refund.
If Form 8888 is attached, check here
Have it directly
b Routing number
fill in 13b, 13c,
and 13d, or
d Account number
If line 12 is larger than line 9, subtract line 9 from line 12. This is
the amount you owe. For details on how to pay, see instructions.
Do you want to allow another person to discuss this return with the IRS (see instructions)?
Yes. Complete below.
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
on all information of which the preparer has any knowledge.
Daytime phone number
Joint return? See
Spouse’s signature. If a joint return, both must sign.
If the IRS sent you an Identity Protection
Keep a copy for
PIN, enter it
here (see inst.)
Print/Type preparer’s name
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see instructions.
Cat. No. 11329W