Form 1040-Ss - U.s. Self-Employment Tax Return (Including The Additional Child Tax Credit For Bona Fide Residents Of Puerto Rico) - 2012

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1040-SS
U.S. Self-Employment Tax Return (Including the Additional Child Tax
OMB No. 1545-0090
Form
Credit for Bona Fide Residents of Puerto Rico)
2012
U.S. Virgin Islands, Guam, American Samoa, the Commonwealth of the Northern Mariana Islands, or Puerto Rico.
, 2012, and ending
, 20
.
For the year Jan. 1–Dec. 31, 2012, or other tax year beginning
Department of the Treasury
Internal Revenue Service
For information about Form 1040-SS and its instructions go to
Your first name and initial
Last name
Your social security number
If a joint return, spouse’s first name and initial
Last name
Spouse’s social security number
Present home address (number, street, and apt. no., or rural route)
City, town or post office, commonwealth or territory, and ZIP code
Foreign country name
Foreign postal code
Foreign province/state/county
Part I
Total Tax and Credits
1 Filing status. Check the box for your filing status (see instructions).
Single
Married filing jointly
Married filing separately. Enter spouse's social security no. above and full name here.
2 Qualifying children. Complete only if you are a bona fide resident of Puerto Rico and you are claiming the additional child
tax credit (see instructions).
(b) Child’s
(c) Child’s
(a) First name
Last name
social security number
relationship to you
3
Self-employment tax from Part V, line 12.
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3
4
Household employment taxes (see instructions). Attach Schedule H (Form 1040)
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4
5
Total tax. Add lines 3 and 4 (see instructions) .
5
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6
2012 estimated tax payments (see instructions)
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6
7
Excess social security tax withheld (see instructions).
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8
Additional child tax credit from Part II, line 3
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8
9
Health coverage tax credit. Attach Form 8885 .
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9
10
Total payments and credits (see instructions)
10
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11
If line 10 is more than line 5, subtract line 5 from line 10. This is the amount you overpaid .
11
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12 a Amount of line 11 you want refunded to you. If Form 8888 is attached, check here
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12a
b Routing Number
c Type:
Checking
Savings
d Account Number
13
Amount of line 11 you want applied to 2013 estimated tax .
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13
Amount you owe. If line 5 is more than line 10, subtract line 10 from line 5. For details on how
14
to pay, see instructions
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14
Do you want to allow another person to discuss this return with the IRS (see instructions)?
Yes. Complete the following.
No
Third Party
Designee
Personal Identification
Designee's
Phone
Number (PIN)
name
no.
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 complete. Declaration of preparer (other than the taxpayer) is based on all information of which the preparer has
Here
any knowledge.
Daytime phone number
Your signature
Date
Joint Return?
See instructions.
Keep a copy
Spouse’s signature. If a joint return, both must sign.
Date
for your
records.
Print/Type preparer’s name
Preparer's signature
Date
PTIN
Paid
Check
if
self-employed
Preparer
Firm’s name
Firm's EIN
Use Only
Firm's address
Phone no.
1040-SS
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see instructions.
Cat. No. 17184B
Form
(2012)

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