Form 1040 - U.s. Individual Income Tax Return - 2016
ADVERTISEMENT
1
2
31040
2016
(99)
F
Department of the Treasury—Internal Revenue Service
o
U.S. Individual Income Tax Return
r
OMB No. 1545-0074
IRS Use Only—Do not write or staple in this space.
m
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
Donnie
D
Sense
123-76-9876
If a joint return, spouse's first name and initial
Last name
Spouse's social security number
Spouse
D
Sense
234-76-9876
Home address (number and street). If you have a P.O. box, see instructions.
Apt. no.
Make sure the SSN(s) above
123 ABC Street
and on line 6c are correct.
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
Columbus
OH
43204
jointly, want $3 to go to this fund. Checking
a box below will not change your tax
Foreign country name
Foreign province/state/county
Foreign postal code
or refund
You
Spouse
Head of household (with qualifying person). (See instr.) If the
Single
1
4
Filing Status
qualifying person is a child but not your dependent, enter this
X
2
Married filing jointly (even if only one had income)
child's name here.
Married filing separately. Enter spouse's SSN above
Check only one
3
and full name here.
box.
5
Qualifying widow(er) with dependent child
Boxes checked
X
2
Exemptions
6a
Yourself. If someone can claim you as a dependent, do not check box 6a
. . . . . . .
on 6a and 6b
X
No. of children
b
Spouse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
on 6c who:
(4) X
•
c
Dependents:
if child under age 17
(2) Dependent's
(3) Dependent's
lived with you
qualifying for child tax credit
social security number
relationship to you
•
(1) First name
Last name
(see instructions)
did not live with
you due to divorce
or separation
If more than four
(see instructions)
dependents, see
Dependents on 6c
instructions and
not entered above
check here
2
Add numbers on
d Total number of exemptions claimed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
lines above
7
Wages, salaries, tips, etc. Attach Form(s) W-2 . . . . . . . . . . . . . . . . . . . . . . . . . .
48,000
Income
7
0
8a
8a Taxable interest. Attach Schedule B if required . . . . . . . . . . . . . . . . . . . . . . . . . .
0
b Tax-exempt interest. Do not include on line 8a . . . . . . . . . . . . . .
8b
Attach Form(s)
0
9a Ordinary dividends. Attach Schedule B if required . . . . . . . . . . . . . . . . . . . . . . . . .
9a
W-2 here. Also
0
b Qualified dividends . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9b
attach Forms
0
10
10
Taxable refunds, credits, or offsets of state and local income taxes . . . . . . . . . . . . . . . .
W-2G and
11
Alimony received . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
1099-R if tax
0
was withheld.
12
Business income or (loss). Attach Schedule C or C-EZ . . . . . . . . . . . . . . . . . . . . . .
12
0
13
Capital gain or (loss).
13
Attach Schedule D if required. If not required, check here
. . . . . . . . . . . . . . . . . .
14
If you did not
14
Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
get a W-2,
0
15b
15a IRA distributions . . . . . . . . . . . . . .
15a
b Taxable amount
. . .
see instructions.
0
16b
16a Pensions and annuities . . . . . . . . . . .
16a
b Taxable amount
. . .
17
17
Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E . . . . .
0
18
Farm income or (loss). Attach Schedule F . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
18
19
19
Unemployment compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
20b
20a Social security benefits
b Taxable amount
. . . . . . . .
20a
0
21
21
Other income. List type and amount _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
48,000
22
22
Combine the amounts in the far right column for lines 7 through 21. This is your total income
0
23
Educator expenses
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
23
Adjusted
24
Certain business expenses of reservists, performing artists, and
Gross
0
24
fee-basis government officials. Attach Form 2106 or 2106-EZ . . . . . . .
Income
0
25
25
Health savings account deduction. Attach Form 8889 . . . . . . . . . . .
0
26
26
Moving expenses. Attach Form 3903
. . . . . . . . . . . . . . . . . . .
0
27
27
Deductible part of self-employment tax. Attach Schedule SE
. . . . . . .
0
28
28
Self-employed SEP, SIMPLE, and qualified plans . . . . . . . . . . . . .
29
29
Self-employed health insurance deduction . . . . . . . . . . . . . . . . .
0
30
30
Penalty on early withdrawal of savings . . . . . . . . . . . . . . . . . . .
31a
31a Alimony paid
b Recipient's SSN
11,000
32
IRA deduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
32
33
33
Student loan interest deduction . . . . . . . . . . . . . . . . . . . . . .
34
34
Tuition and fees. Attach Form 8917 . . . . . . . . . . . . . . . . . . . .
0
35
35
Domestic production activities deduction. Attach Form 8903
. . . . . . .
11,000
36
Add lines 23 through 35 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
36
37,000
37
Subtract line 36 from line 22. This is your adjusted gross income . . . . . . . . . . . . . . . .
37
1040
KIA
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions.
Form
(2016)
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