Form 1040 - U.s. Individual Income Tax Return - 2016 Page 2
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1
2
3Donnie
D Sense
123-76-9876
2
Form 1040 (2016)
Page
37,000
38
Amount from line 37 (adjusted gross income) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
38
Tax and
Blind.
You were born before January 2, 1952,
39a Check
Total boxes
Credits
0
checked
39a
if:
Spouse was born before January 2, 1952,
Blind.
39b
b If your spouse itemizes on a separate return or you were a dual-status alien, check here
Standard
12,600
Deduction
40
40
Itemized deductions (from Schedule A) or your standard deduction (see left margin)
. . . . . .
for—
24,400
41
41
Subtract line 40 from line 38
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• People who
8,100
check any
42
42
Exemptions. If line 38 is $155,650 or less, multiply $4,050 by the number on line 6d. Otherwise, see instructions
.
box on line
16,300
43
43
39a or 39b or
Taxable income. Subtract line 42 from line 41. If line 42 is more than line 41, enter -0-
. . . . . . . . . . . . . . .
who can be
1,633
44
44
Tax (see instructions). Check if any from:
a
Form(s) 8814
b
Form 4972
c
claimed as a
0
dependent,
45
45
Alternative minimum tax (see instructions). Attach Form 6251 . . . . . . . . . . . . . . . . . . . . . . . . . .
see
instructions.
46
Excess advance premium tax credit repayment. Attach Form 8962 . . . . . . . . . . . . . . . . .
46
1,633
• All others:
47
Add lines 44, 45, and 46 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
47
Single or
0
48
Foreign tax credit. Attach Form 1116 if required . . . . . . . . . . . . .
48
Married filing
separately,
49
49
Credit for child and dependent care expenses. Attach Form 2441 . . . .
$6,300
50
50
Education credits from Form 8863, line 19
. . . . . . . . . . . . . . .
Married filing
1,633
jointly or
51
51
Retirement savings contributions credit. Attach Form 8880 . . . . . . .
Qualifying
52
widow(er),
52
Child tax credit. Attach Schedule 8812, if required
. . . . . . . . . . .
$12,600
53
Residential energy credits. Attach Form 5695 . . . . . . . . . . . . . .
53
Head of
0
54
household,
54
a
b
c
Other credits from Form:
3800
8801
$9,300
1,633
55
55
Add lines 48 through 54. These are your total credits
. . . . . . . . . . . . . . . . . . . . . . .
0
56
Subtract line 55 from line 47. If line 55 is more than line 47, enter -0- . . . . . . . . . . . . . .
56
0
57
57
Self-employment tax. Attach Schedule SE
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other
0
58
a
4137
b
8919 . . . . . . . .
Taxes
58
Unreported social security and Medicare tax from Form:
0
59
59
Additional tax on IRAs, other qualified retirement plans, etc. Attach Form 5329 if required . . . . .
0
60a
60
a Household employment taxes from Schedule H . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
b First-time homebuyer credit repayment. Attach Form 5405 if required . . . . . . . . . . . . . . . .
60b
X
61
Health care: individual responsibility (see instructions)
Full-year coverage
. . . . . . . . . .
61
0
62
62
Taxes from:
a
b
c
I
Form 8959
Form 8960
nstructions; enter code(s)
0
63
63
Add lines 56 through 62. This is your total tax
. . . . . . . . . . . . . . . . . . . . . . . . .
0
64
64
Federal income tax withheld from Forms W-2 and 1099 . . . . . . . . .
Payments
0
65
2016 estimated tax payments and amount applied from 2015 return
. .
65
If you have a
66a
66a Earned income credit (EIC)
. . . . . . . . . . . . . . . . . . . . . .
qualifying
66b
b Nontaxable combat pay election . . . . .
child, attach
67
67
Additional child tax credit. Attach Schedule 8812
. . . . . . . . . . . .
Schedule EIC.
68
American opportunity credit from Form 8863, line 8
. . . . . . . . . . .
68
69
Net premium tax credit. Attach Form 8962 . . . . . . . . . . . . . . . .
69
70
Amount paid with request for extension to file . . . . . . . . . . . . . .
70
0
71
Excess social security and tier 1 RRTA tax withheld . . . . . . . . . . .
71
72
Credit for federal tax on fuels. Attach Form 4136
. . . . . . . . . . . .
72
73
Credits from Form:
0
b
c
8885
a
2439
d
Reserved
73
0
74
Add lines 64, 65, 66a, and 67 through 73. These are your total payments . . . . . . . . . . .
74
75
If line 74 is more than line 63, subtract line 63 from line 74. This is the amount you overpaid
. . .
75
Refund
76a Amount of line 75 you want refunded to you. If Form 8888 is attached, check here
. . . .
76a
Direct deposit?
XXXXXXXXX
b Routing number
c Type:
Checking
Savings
See
XXXXXXXXXXXXXXXXX
d Account number
instructions.
77
Amount of line 75 you want applied to your 2017 estimated tax
77
0
Amount
78
Amount you owe. Subtract line 74 from line 63. For details on how to pay, see instructions
. .
78
You Owe
79
Estimated tax penalty (see instructions) . . . . . . . . . . . . . . . . .
79
X
Do you want to allow another person to discuss this return with the IRS (see instructions)?
Third Party
Yes. Complete below
No
Designee's
Phone
Designee
Personal identification
name
no.
number (PIN)
Sign
Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct, and
accurately list all amounts and sources of income I received during the tax year. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Here
Your signature
Date
Your occupation
Daytime phone number
Accountant
614-874-2345
Joint return? See
instructions.
Spouse's signature. If a joint return, both must sign.
Date
Spouse's occupation
If the IRS sent you an Identity Protection
Keep a copy for
PIN, enter it
Zebra
your records.
here (see inst.)
Print/Type preparer's name
Preparer's signature
Date
PTIN
Paid
Check
if
self-employed
Preparer
Firm's EIN
Firm's name
Use Only
Firm's address
Phone no.
1040
KIA
Form
(2016)
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