Publication 54 - Tax Guide For U.s. Citizens And Resident Aliens Abord - 2011 Page 24
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441040
2011
(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, 2011, or other tax year beginning
, 2011, ending
, 20
Your rst name and initial
Last name
Your social security number
James M.
Adams
111
00
1111
If a joint return, spouse’s rst name and initial
Last name
Spouse’s social security number
Judith E.
Adams
22
2222
222
Apt. no.
Home address (number and street). If you have a P.O. box, see instructions.
Make sure the SSN(s) above
21 Rue Reynaud
and on line 6c are correct.
City, town or post of ce, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions).
Presidential Election Campaign
City Y
Check here if you, or your spouse if ling
jointly, want $3 to go to this fund. Checking
Foreign country name
Foreign province/county
Foreign postal code
a box below will not change your tax or
Country Y
North Country
99999
refund.
You
Spouse
1
Single
4
Head of household (with qualifying person). (See instructions.) If
Filing Status
2
Married ling jointly (even if only one had income)
the qualifying person is a child but not your dependent, enter this
Check only one
3
Married ling separately. Enter spouse’s SSN above
child’s name here.
box.
5
and full name here.
Qualifying widow(er) with dependent child
}
Boxes checked
6a
Yourself. If someone can claim you as a dependent, do not check box 6a .
.
.
.
.
Exemptions
2
on 6a and 6b
b
Spouse
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No. of children
(4)
if child under age 17
on 6c who:
c
Dependents:
(2) Dependent’s
(3) Dependent’s
2
qualifying for child tax credit
• lived with you
social security number
relationship to you
(1) First name
Last name
(see instructions)
• did not live with
you due to divorce
Chris T. Adams
333 00
daughter
3333
or separation
If more than four
Stephen F. Adams
444 00
son
(see instructions)
4444
dependents, see
Dependents on 6c
instructions and
not entered above
check here
Add numbers on
4
d
Total number of exemptions claimed
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lines above
147,000
7
7
Wages, salaries, tips, etc. Attach Form(s) W-2
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Income
7,500
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
9b
Quali ed dividends
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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
12
Business income or (loss). Attach Schedule C or C-EZ .
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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
.
.
.
15b
see instructions.
16 a
16a
b Taxable amount
16b
Pensions and annuities
.
.
.
17
Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E
17
Enclose, but do
18
Farm income or (loss). Attach Schedule F .
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18
not attach, any
19
19
Unemployment compensation .
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payment. Also,
20 a
Social security bene ts
20a
b Taxable amount
.
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.
20b
please use
Form 1040-V.
Forms 2555 & 2555-EZ
(147,000)
21
Other income. List type and amount
21
7,500
22
Combine the amounts in the far right column for lines 7 through 21. This is your total income
22
23
23
Educator expenses
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Adjusted
24
Certain business expenses of reservists, performing artists, and
Gross
fee-basis government of cials. Attach Form 2106 or 2106-EZ
24
Income
25
25
Health savings account deduction. Attach Form 8889
.
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 quali ed plans
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28
29
29
Self-employed health insurance deduction
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30
Penalty on early withdrawal of savings .
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30
31 a
Alimony paid
b Recipient’s SSN
31a
32
32
IRA deduction .
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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
36
Add lines 23 through 35 .
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7,500
37
Subtract line 36 from line 22. This is your adjusted gross income
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37
1040
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions.
Form
(2011)
Cat. No. 11320B
Chapter 4 Foreign Earned Income and Housing: Exclusion – Deduction
Page 24
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