Form 1040 - U.s. Individual Income Tax Return - 2016

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Itemized Filer HBB
1040
2016
(99)
Department of the Treasury—Internal Revenue Service
U.S. Individual Income Tax Return
OMB No. 1545-0074
IRS Use Only—Do not write or staple in this space.
See separate instructions.
For the year Jan. 1–Dec. 31, 2016, or other tax year beginning
, 2016, ending
, 20
Your first name and initial
Last name
Your social security number
1 1 1 2 2 3 3 3 3
Jack A.
Sample
If a joint return, spouse’s first name and initial
Last name
Spouse’s social security number
4 4 4 5 5 6 6 6 6
Jill
Sample
Home address (number and street). If you have a P.O. box, see instructions.
Apt. no.
Make sure the SSN(s) above
and on line 6c are correct.
134 Anyplace Ln.
Myhometown
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
Myhometown, US 11111
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
Single
4
Head of household (with qualifying person). (See instructions.) If
Filing Status
2
Married filing jointly (even if only one had income)
the qualifying person is a child but not your dependent, enter this
Check only one
child’s name here.
3
Married filing separately. Enter spouse’s SSN above
box.
and full name here.
5
Qualifying widow(er) with dependent child
}
Boxes checked
6a
Yourself. If someone can claim you as a dependent, do not check box 6a .
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Exemptions
on 6a and 6b
2
b
Spouse
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No. of children
(4) ✓ if child under age 17
on 6c who:
Dependents:
c
(2) Dependent’s
(3) Dependent’s
• lived with you
qualifying for child tax credit
1
social security number
relationship to you
(1) First name
Last name
(see instructions)
• did not live with
you due to divorce
7 7 7 8 8 9 9 9 9 Child
Jerico Sample
or separation
If more than four
(see instructions)
dependents, see
Dependents on 6c
instructions and
not entered above
check here
Add numbers on
3
d
Total number of exemptions claimed
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lines above
7
Wages, salaries, tips, etc. Attach Form(s) W-2
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7
Income
65000
00
8a
Taxable interest. Attach Schedule B if required .
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8a
b
Tax-exempt interest. Do not include on line 8a .
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8b
Attach Form(s)
9 a
Ordinary dividends. Attach Schedule B if required
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9a
W-2 here. Also
b
Qualified dividends
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9b
attach Forms
W-2G and
10
Taxable refunds, credits, or offsets of state and local income taxes
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10
1099-R if tax
11
Alimony received .
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11
was withheld.
12
Business income or (loss). Attach Schedule C or C-EZ .
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12
(22000
00)
13
Capital gain or (loss). Attach Schedule D if required. If not required, check here
13
If you did not
14
Other gains or (losses). Attach Form 4797 .
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14
get a W-2,
15 a
IRA distributions .
15a
b Taxable amount
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15b
see instructions.
16 a
Pensions and annuities
16a
b Taxable amount
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16b
17
Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E
17
18
Farm income or (loss). Attach Schedule F .
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18
19
Unemployment compensation .
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19
20 a
Social security benefits
20a
b Taxable amount
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20b
21
Other income. List type and amount
21
22
Combine the amounts in the far right column for lines 7 through 21. This is your total income
22
43000
00
23
Educator expenses
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23
Adjusted
24
Certain business expenses of reservists, performing artists, and
Gross
fee-basis government officials. Attach Form 2106 or 2106-EZ
24
Income
25
Health savings account deduction. Attach Form 8889
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25
26
Moving expenses. Attach Form 3903 .
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26
27
Deductible part of self-employment tax. Attach Schedule SE .
27
28
Self-employed SEP, SIMPLE, and qualified plans
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28
29
Self-employed health insurance deduction
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29
30
Penalty on early withdrawal of savings .
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30
31 a
Alimony paid
b Recipient’s SSN
31a
32
IRA deduction .
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32
33
Student loan interest deduction .
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33
34
Tuition and fees. Attach Form 8917 .
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34
35
Domestic production activities deduction. Attach Form 8903
35
36
Add lines 23 through 35 .
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36
37
Subtract line 36 from line 22. This is your adjusted gross income
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37
43000
00
1040
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions.
Form
(2016)
Cat. No. 11320B

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