Publication 517 - Social Security And Other Information For Members Of The Clergy And Religious Workers - 2011 Page 15

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1040
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
Your social security number
Last name
John E.
White
011
00
2222
If a joint return, spouse’s rst name and initial
Last name
Spouse’s social security number
Susan R.
White
011
00
1111
Home address (number and street). If you have a P.O. box, see instructions.
Apt. no.
Make sure the SSN(s) above
1040 Main Street
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
Hometown, TX 77099
Check here if you, or your spouse if ling
jointly, want $3 to go to this fund. Checking
Foreign country name
Foreign postal code
Foreign province/county
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 ling jointly (even if only one had income)
the qualifying person is a child but not your dependent, enter this
Check only one
3
child’s name here.
Married ling separately. Enter spouse’s SSN above
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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.
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.
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.
.
.
No. of children
(4)
on 6c who:
if child under age 17
Dependents:
c
(2) Dependent’s
(3) Dependent’s
1
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
Jennifer White
111 00 1113
daughter
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
Excess allowance $240
34,640
7
Wages, salaries, tips, etc. Attach Form(s) W-2
.
.
.
.
.
.
.
.
.
.
.
.
7
Income
8a
Taxable interest. Attach Schedule B if required .
.
.
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.
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.
.
.
.
.
8a
b
Tax-exempt interest. Do not include on line 8a .
8b
.
.
Attach Form(s)
9 a
9a
Ordinary dividends. Attach Schedule B if required
.
.
.
.
.
.
.
.
.
.
.
W-2 here. Also
b
9b
Quali ed dividends
.
.
.
.
.
.
.
.
.
.
.
attach Forms
10
10
W-2G and
Taxable refunds, credits, or offsets of state and local income taxes
.
.
.
.
.
.
1099-R if tax
11
Alimony received .
.
.
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.
.
11
was withheld.
3,732
12
Business income or (loss). Attach Schedule C or C-EZ .
.
.
.
.
.
.
.
.
.
12
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 .
.
.
.
.
.
.
.
.
.
.
.
.
.
14
get a W-2,
15 a
IRA distributions
.
15a
b Taxable amount
.
.
.
15b
see instructions.
16 a
Pensions and annuities
16a
b Taxable amount
.
.
.
16b
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
Unemployment compensation .
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.
19
payment. Also,
20 a
20a
b Taxable amount
20b
Social security bene ts
.
.
.
please use
Form 1040-V.
21
21
Other income. List type and amount
38,372
22
Combine the amounts in the far right column for lines 7 through 21. This is your total income
22
23
Educator expenses
.
.
.
.
.
.
.
.
.
.
23
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
Health savings account deduction. Attach Form 8889
.
25
26
Moving expenses. Attach Form 3903 .
.
.
.
.
.
26
3,090
27
Deductible part of self-employment tax. Attach Schedule SE .
27
28
Self-employed SEP, SIMPLE, and quali ed plans
.
.
28
29
Self-employed health insurance deduction
.
.
.
.
29
30
Penalty on early withdrawal of savings .
.
.
.
.
.
30
31 a
b Recipient’s SSN
31a
Alimony paid
32
32
IRA deduction .
.
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.
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.
.
33
33
Student loan interest deduction .
.
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.
.
.
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.
34
34
Tuition and fees. Attach Form 8917 .
.
.
.
.
.
.
35
Domestic production activities deduction. Attach Form 8903
35
3,090
36
Add lines 23 through 35 .
.
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.
36
35,282
37
Subtract line 36 from line 22. This is your adjusted gross income
.
.
.
.
.
37
1040
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions.
Form
(2011)
Cat. No. 11320B
Publication 517 (2011)
Page 15

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