Form 1npr Draft - Nonresident & Part-Year Resident Wisconsin Income Tax - 2012 Page 9
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18Form
Department of the Treasury - Internal Revenue Service
2012
1040A
U.S. Individual Income Tax Return
(99)
IRS Use Only - D o not w rit e or st aple in t h is space.
OMB No. 1545- 0074
Mary N Sorrel
Your social security number
123 Anywhere Ave
400-00-5483
SINGLE PARENT
600-00-1002
Cataract, WI 54656
111 DESPERATE WAY
Spouse's social security number
NAPOLEAN, MI 49261
M ak e sure t h e SSN(s) ab ove
and on line 6c are correct .
Presidential Election Campaign
Ch eck h ere if y ou, or y our spouse if f iling
joint ly, w ant $3 t o go t o t h is f und . Ch ecking
Foreign count ry name
Foreign province/ st at e/ count y
Foreign post al cod e
a b ox b elow w ill not ch ange your t ax or
ref und .
You
Spouse
X
✔
1
Single
4
Head of household (with qualifying person). (See instructions.)
Filing
2
Married filing jointly (even if only one had income)
status
If t h e q ualif ying person is a ch ild b ut not your d epend ent , ent er t h is
3
ch ild 's name h ere.
M arried f iling separat ely . Ent er spouse's SSN ab ove & f ull name b elow .
Check only
one box.
5
Qualifying widow(er) with dependent child (see instructions)
✔
Exemptions
X
6a
Yourself.
If someone can claim you as a dependent, do not check box 6a.
B oxes
1
ch eck ed on
1
6a and 6b
Spouse
b
No. of ch ild ren
on 6c w h o:
(4)
if ch ild
c
Dependents:
(2) Dependent's social
(3) Dependent's
und er age 17
1
lived w it h
1
security number
relationship to you
q ualif ying f or
y ou
(1) First name
Last name
ch ild t ax cr.
(see inst r.)
d id not live
w it h you d ue
✔
400-00-5443
LIVEWITH PARENT
Sunny
Sorrel
600-00-1012 SON
daughter
X
t o d ivorce or
separat ion
If more
(see inst r)
than six
dependents,
see instructions.
D epend ent s
on 6c not
ent ered ab ove
Ad d numb ers
2
on lines
2
d
Total number of exemptions claimed.
ab ove
Income
20,000
20,000.
7
Wages, salaries, tips, etc. Attach Form(s) W- 2.
7
Attach
Form(s) W- 2
8a
Taxable interest. Attach Schedule B if required.
8a
here. Also
b
Tax- exempt interest. Do not include on line 8a.
8b
attach
9a
Ordinary dividends. Attach Schedule B if required.
9a
Form(s)
1099- R if tax
b
Qualified dividends (see instructions).
9b
was withheld.
10
Capital gain distributions (see instructions).
10
11a
IRA
11b
Taxable amount
If you d id not
get a W- 2, see
distributions.
11a
(see instructions).
11b
inst ruct ions.
12a
Pensions and
12b
Taxable amount
annuities.
12a
(see instructions).
12b
Enclose, b ut d o
not at t ach , any
pay ment . Also,
13
Unemployment compensation and Alaska Permanent Fund dividends.
13
please use
Form 1040- V.
14a
Social security
14b
Taxable amount
benefits.
14a
(see instructions).
14b
20,000
20,000.
15
Add lines 7 through 14b (far right column). This is your total income.
15
Adjusted
16
Reserved
16
gross
17
IRA deduction (see instructions).
17
income
18
Student loan interest deduction (see instructions).
18
19
Reserved
19
Add lines 16 through 19. These are your total adjustments.
20
20
20,000
20,000.
21
Subtract line 20 from line 15. This is your adjusted gross income.
21
KBA
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions.
Form 1040A (2012)
1040A (2012)
FD1040A- 1 (DRAFT FORM)
Form Sof t w are Copyrigh t 1996 - 2013 H RB Tax Group, Inc. 1.18- 15.2
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