FL-140
ATTORNEY C» PARTY WITHOUT ATTORNEY INtmt. »•<»
««I SlMlOSS):
Phong H. Nguyen(SUN 280611)
Nguyen & l.imon, 1.1.P
1625 't he Aliimeda. Suite 200. San Jose. CA 95126
TELEPHONENO (408)4 13-(l8()()
FAX NO : (408)419-1862
E-MAIL ADDRESS
ATTORNEY FOR W.m.) |<()C Pjj-j'LRINI
SUPERIOR COURT OF CALIFORNIA, COUNTY OF Santa Clara
STREETAOORESS 201 N. I'irsl SlFecl
MAUNGAOORESS. 191 N. I'lrsl SlTCCt
CITY ANO ZIP CODE Son JllSC. CA 95113
BRAHCHNAME I'amilv Justice Center
PETITIONERJOANNA PIFf-iiRINI
RESPONDENTiROC Pil l liRINI
OTHER PARENT/PARTY:
CASE NUMBER
DECLARATION OF DISCLOSURE
1
1 Petitioner's
1 X 1 Respondent's
I81T.003353
j X j Preliminary
[
j Final
DO NOT RLE DECLARATIONS OF DISCLOSURE OR FINANCIAL ATTACHMENTS WITH THE COURT
In a dissolulion, legal separation, or nullity eclion, both a preliminary and a final declaration of disclosure must be served on the other
party with certain exceptions. Neither disclosure is filed with the court. Instead, a declaration staling that service of disclosure
documents was completed or waived must be filed with the court(see form FL-141).
• In summary dissolution cases, each spouse or domestic partner must exchange preliminary disclosures as described in Summary
Dissolution Information (form FL-810). Final disclosures are not required(see Family Code section 2109).
• In a defaultjudgment case that is not a stipulatedjudgment or a Judgment based on a marital settlement agreement, only the
petitioner is required to complete end serve a preliminary declaration of disclosure. A final disclosure is not required of eitherparly
(see Family Code section 2110).
• Samoa ofpreliminary declarations of disclosure may not be waived by an agreement between the parties.
• Parties who agree to waive final declarations of disclosure must file their written agreement with the court(see form FL-144).
The petitioner must serve a preliminary declaration of disclosure at the same lime as the Petition or within 60 days offiling the Petition.
The respondent must serve a preliminary declaration of disclosure at the same time as the Response or within 60 days offiling the
Response. The lime periods may be extended by written agreement of the parties or by court order(see Family Code section 2104(f)).
Attached are the following:
1, I X I A completed Schedule of Assets and Debts(form FL-142) or I
I
2, I
I Community and Quasi-Community Property
j
I A Properly Declaration (form FL-160}for (specify):
j Separate Property.
IA completed Income and Expense Declaration (form FL-150).
3, I X I All tax returns filed by the party in the two years before the date that the party served the disclosure documents.
4.[n A statement of all material facts and information regarding valuation of all assets that are community property or in which the
community has an Interest (not a form).
Respondent is not yet fully aware of valuation of all assets that are community properly.
5. 1X1 A statement of all material facts and information regarding obligations for which the community is liable (not a form).
Respondent is not yet fully aware of alt obligations for which the community is liable.
6. I X I An accurate and complete written disclosure of any investment opportunity, business opportunity, or other income-producing
opportunity presented since the date of separation that results from any investment, significant business, or other incomeproducing opportunity from the dale of marriage to the date of separation {not a form).
Respondent is not yet fully aware of any investment, business, or other income-producing opportunities,
I declare under penalty of perjury under the laws of the State of Califor^pldmat th
ing is true and correct.
Dale; S
ROC PIFFERINI
SIGNATURE
(TYPE OR PRINT NAUE)
Pagel of 1
Form Adopted(c Wondotory Um
Judool Counol of Cotifomn
a-140[Rey July t,20l9)
DECLARATION OF DISCLOSURE
(Family Law)
r«mlrC(>4e.$f2102.21O4.
2105.2106.2112
rtWW COJTfS CS POV
FL-iSO
AnOfWEVra PARTY WIIHOWr AnOflNEY ptiai*.SMSanuater.tnfMttntf-
fORCOCMrtlMONlY
_ Phong H.Nguyen(SBN:280611)
Nguyen & Limon,LLP
1625 The Alameda,Suite 200
San Jose,CA 95126
TcupfeNcin:(408)4I3>0800
Electronically filed
by Superior Court of CA,
Counfy of Santa Clara,
eAtwiAccReaswptoKiQ
ATTOANEYroRiwuKT ROC PIFFERINI
suPEiuoR COURT OF CAUFORNtA.COUNTY OF Santa Clara
STREET AMMESS; 201 N. FlTSt SttCCt
HMUNaAOIWESS: 191 N. FifSt StTCCt
on 5/8/2019 10:09 AM
Reviewed By:J. Viramontes
cfTYANoapcooE: San Josc,CA 95113
aRAwcMHAiiE. Family Justlcc Ccntcr
Case #18FL003353
Env #2857242
PETITIONEnPLAlNTIFF: JOANNA PIFFERINI
RESPONOENT/OEFENOANT: ROC PIFFERINI
OTHER PARENT/CIAIMANT:
CASEKUiaeR
INCOME AND EXPENSE DECIARATION
I8FL003353
1. Employment(Ghre InUtrmaUon on yourcumnlfiA or.ifyouVo unemployed, your most recentJott.f
a.
b.
a
d.
e.
Attach copies
of your pay
stubs for last
tiMO months
(blade cut
social
Employer Ci^ ofSan Jose
Employer's address:201 West Mission Street,San Jose, CA 95110
Employer's phone number (408)277-4631
Occupation; Police Oflicer
Date|ob started: 7/1/2006
f. if unemployed,date Job ended: N/A
secuiity
numbers).
g. Iwoiltabout
40 hours per week.
h. i gel paid S 10,625 gross(before taxes) I " I pemTonth I
I perwook I
I per hour.
(If you have more than ono Jolr,attach an 8)Miy-114nch shoot of paper and Uat thesame infUrmatlon aa abovefor your other
Jobs. Writs"Question l-^XftorJotTS"atthe top.)
2. Age and education
a. My age Is fspudiyj: 50
b. i have comptatsdh^h school or the eguivalenl: LjU Yes I—I No
c Number of yeareolcoItegecompteledfApediyj.- 2
If no.higheslgreito completed (^Mcf(K).-
LU Degree(8)obtained ftpedftij: Multidisciplinaiy Stuti.
d. Number of years of graduate school completed(specify}:
l_J Oegreefs)obtained (speedy/-'
e. 1 have: \-i-l professlonaVoccupaHonai iloense(s)(spedljf): Police Officer
I
I vocational training(apecdyj:
3. Tax Information
a.
I last filed taxes for tax year(apecfly year): 2018
b. My tax(Hing status Is ' t single I 'head of household i
i marrted.filing separately
'^ t married. CBng jolnUywRh(speedy narrte): Joanna Pifierini
c. I file state tax returns In I
I California L—I other(spnciiystafe/.-
d. I claiffl the following number of exemptions(inctuding myselQ on my taxes fspeedy): 3
4. other party's Income. I esUmate the gross monthly Income(before taxes)of the ether party In this case at(speedy):S
This estimate Is based on (expfaen):
(If you nood more epaco to ansvrar any questions on thisform,attach an 8K-by-11*inch shootof paper and wrtto the
question number Irafore your answer.) Number of pages attached:
I dectare under penally of perjury underthe laws of the Slate of Can
any attachfflents to true and correct
the Infomiallon conlabiad on all pages of tids form and
Date: ^
ROC PIFFERINI
rcmiAifatreSbrWtiXiroiYU**
JtiOdW CoooftofCrVbrIb
rut90|Rw.Jmay tIMI)
V
INCOME AND EXPBISE DECLARATION
Btail^
F«ngYC0O>,HE0)0-in2,
]ieo4its.SS91:saioosM.
4S90-4tTA43SO-«aO
mMMoaeVbLCipsr
PETITtONEIVPlAINTIFF: JOANNA PIFFERINI
CASertUUBIR:
.RESPONDENTrOEFENOANT: ROC PIFFERINI
I8FL003353
OTHER RARENT/ClAtMANT:
Attach coplos of your pay stubs for tha lasttwo months and proof ofany othor Income. Take a copy of your latestfMeral
tax return to the court hoarino.(Blaek out yoursoelatseeari^mimbercn th9paystub and tax rafumj
Income(Forevaraga monthly, add up aB die Inoomo you moeived In each categoryIn tha last 12 months
and dMde tha total by 12.)
Last month
Aver
menu
a. Salary or wages(gross, before taxes)
5 I0.62S
\0.6i
b. Overtime(gross, before taxes)
^ Varies
Varies
Commissions or bonuses
siL
Public assistance(for example:TANF,SSI,6A/GR) I—I ounently receiving
$2.
Spousal support I •r i from Oils marriage 1
$0_
i from a different marriage
Partner support I I from Oils domestic partnership I i from a differentdomeslic partnership $2PensionfreUrement fiind payments
$2Sodal security retlremenl(not SSI)
—
s2_
Oisebaity: l_J Sodal security(not SSI) I I State dlsabiiay(SDI) I 1 Private Insurance.s2J. Unemployment compensation
6.
$2.
k.
Workers'compensation
$2-
I.
OOier(military BAG,royally payments,etc.)
S:
Investmont Income(AHach a schedula ahowbtg gross receiptstoss cash expensestor each place otproparto.)
a. OlvidendsfinteiesL
$2
b. Rental property income
$2—
c. Tnnllneome
s2—
d. Other(spec/fy):
$2
7. Income from self-ompleyment,after business expanses for all tMislnesses
I am the 1 1 ownerfSole proprietor I I business partner I
Number of years In this business(tpeciiy):
0
JT
22
I other(fpecayj;
Name of buslnass(specfy):
Type of business(to>aeOy):
Attach a prolK and loss statemontfor the last two years ora Schedule C from your last federal lax return. Black out your
social security number. If you have more than one buslrtess, provide the Information above for each of your businesses.
8. I
I Addlttonal Income.I received one^e money(lolletyrmnrrings.inhetilanoe.etc)In the last 12 months
source and
anrnunt):
9. I
I Change In Income. My financial situation has changed ^nUieanlly over the last 12 months because(speetiy);
I.ast month
10. Oeductlons
a. Reriuired union dues.
b. Required rotiremenl payments(not social security,PICA.401(k),orIRA)
$2
c. Medical, hospital,dental,and other health insurance premiums(total monthly amount).
d. Child support that I pay(or children from other relationshbis
$203
e. Spousal support that I pay by court order from a diflerentmamage
sfi
S;
f. Parltter support that I pay by court order from a different domestic partnership
$!
g. Necessary JotMalated expenses not reimbursed by my employer(altscfi explanation lattetod "Question lOgT).
11. Assets
Total
a. Cash and checking accounts,savings,credit union,money maricei and other deposit accounts
$^4:22-
b. Stocks,bonds,and other assets t could easily seP
S' ^|_
c. All other property, 1 *' 1 real and 1
FUiaO(lUv.JMMiy 1.2C01)
1 persrmal (esSmato tat matlmt value minus the detds you owe).... 8
INCOME AND E}(PENSE DECLARATION
^
FL-lfiO
PETinONER/PUINTIfF: JOANNA PIFFBRINl
-RESPONOENT/OEFENDANT: ROC PIFFERINI
CASBNUUOSft
18FL0033S3
OTHER PARENT/CLAIMANT;
12. The following people live wtlh me:
How the person Is
That person's gross
r^ed to me?(ax:son) monthly Income
Age
Name
□
□
!!□
□
□□
a.
b.
c.
d.
e.
13. Average monlhly expenses
a.
I * I Estimated expenses I
Home:
(1) I
h.
I Rent Of CZZl
S
522
I Actual expenses I
Yes
Yes
Yes
Yes
Yes
□
□
CZl
CD
CD
No
No
No
No
No
I Proposed needs
30
Laundiy and cleaning
Clothes...
$.
Education
Ifmoitoaga;
(a) average pfintipal: $.203
Entertainment, gifts, and vacation
(b) average Interest: $ 318
(2) Real property taxes
Auto expenses and transportation
(4) Malnlenanoe and repair
m.
100
s TBD
b. Health care costs not paid by Insurance... $ 9.
S ^92
e. Ealing out
Ullfilles (gas, electric, water, trash)
$ 50
s 750
g. Telephone, ceil phone, and e-man
$ 250
n 737
Insurance (life, accidenL etc; do not
Include auto, home, or health insurance)... S 260
a
Savings and Investments
s0
o.
CharHabte contributions
$ 175
P-
Monthly payments listed In Item 14
c. Chadcare
d. Groceries and household supplies
—
finsurance, gas, repairs, bus, etc.)
$68
(3) Honwownei^ or rentei's Insurance
01 not Included above)
f.
Pays some of the
household expenses?
(Sembe batowtnJ4 aitd ^sfulfolalhep).. $ Varies
TOTAL EXPENSES (a-g) (do not odd In
the emounts In a(1)(B} and (b))
s.
4.277
Amount of exponsos paid by others
14. Installment payments and debts not Bsted strove
Paid to
For
Amount
Be la TOG
Date of test payment
AAdvantage Mastercard 9120
Credit Card
$700
$4,076
4/2019
$
$
$
$
$
$
$
$
$
$
15. Attomoy foes (This Is mquliod If eitherparty is requasdng Bttvmey fees.);
a. To date, I have paid my attorney this amount for fees and costs (spedfy): $
b. The source of this money was (i^pecfly);
& I slill owe the following fees and costs to my attorney (apedfy total awed): S
d. My attoms/s hourly rate Is (ppecfiy).' S
I confinn this fee arrangement.
istoNATune or ATTommi)
(nrre on FKMT NAME OF ATIOfWeV)
ruiUISM. JUMiy t.Moq
INCOME AND EXPENSE DECLARATION
ng»lof4
FL.1fiO
CASfiNUUfiCfl
PETITtONEiVPLAlNTIFF: JOANNA PIPPERINI
-RESPONDENTrOEFENOANT ROC PIPPERINI
I8FL0033S3
OTHER PARENTrClAIMANT:
CHILD SUPPORTINFORMATION
(NOTE:Fin outthis pase only If your case Involvas cliDd support.)
16. Number of chlldran
& tham(sfiedfynmAei):
ddtdren under the «ge of18 Mitt)iheelhsrparenMnUds case,
b. The diSdren spend
percenloflhelrtimewilhnieand
percent ofthelrlbnewilh the other parent
ff/youVe ffofsure atourpercsiilape or A hesnotbean egmed on,pfease doseribe yourpatenting selteduie tiem.)
17. Chtldren's heatth-care expenses
a. I
I I do
I
I i do not
have health insurance avaOabte to me for the children through my Job.
b. Name ofInsurance company;
c. Address of insurance company:
d. The monthly coal fra the children's health Insurance is or would be fapectty/'S
(Do not bttbtde On anwunl yourenfployerpaiys.}
16. Additional expenses for the chltdron In this case
0. Child core so t can v/oik or gel Job training
Amount per month
S
b. Chtldren'B health care not covered by Insurance
R
c. Travel expenses for vtsUatton
d. Chttdrenls educational or other spectel needs(apeedybeftiwj;
$
$
19. Special hardships. I ask the court to considerIhe following special financial tircumslsnoes
(attach doeumentaOott ofanyItam Sitedlnm,tttelatSogeomtoidets):
Amount per month
For how many monUis?
a. Extraordinary hesllh expenses not biciuded In IS).
sO
0
b. Major losses not covered by Insurance(examptes:lire, theft, other
Insured loss)
^
6^2
6 (1) Expenses(or my minor Children who are from other relationships and
are living with me
.
Sz
(2) Names and ages ofthose children (speeSir):
(3) Child support I receive(orthose children
The expenses listed In a.b,and ccreate an extreme financial hardship because(explain):
20. Other Information I wantthe courtto know concerning supportIn my case(ipacOy):
Fl'iseIRW.j«a«r 1.MO)]
INCOME AND EXPENSE DECLARATION
ngtotro
SCHEDULE SE
c^i*
(Form 1040)
T^v
OUB No. 1545-0074
ombno.isas-oota
Self-Employment Tax
Oepartmer,of.he Treasury
@0)17
!®17
m^Jrs.gov/ScheduleSE for instntctions and the latest information.
Attachment
►Attach to Form 1040 or Form 1040NR.
internal Revenue SeivBO (9?)
Sequence
Sequence No.
No. 17
17
Name of person with seif-em^oyment income (as shown on Form 1040 orFonn toaONR)
Social securjty number of person
ROC M PIFFERINI
with self-employment income ►
551-53-5651
Before you begin: To determine if you must file Schedule SE, see the instructions.
May I Use Short Schedule SE or Must 1 Use Long Schedule SE?
Note: Use this flowchart only If you must file Schedule SE. If unsure, see Who Must File Schedule SB In the Instructions.
!
' ' "
Did you racelve wages or tips in 2017?
j
Are you a minister, member of a religious order, or Christian
Science practilioner who received IRS approval not to be taxed
Was the total of your wages and tips subject to social security yes
on earnings from these sources, but you owe self-employment
self-employment more than SI 27,2007
or railroad retirement (tier 1j tax plus your net earnings from
tax on other earnings?
Are you using one of the optional meOiods to figure your net
Did you receive tips subject to social security or Medicare tax
that you didn't report to your employer?
y^,
earnings ftee instructions)?
Old you receive church employee Income (see Instructions) [Ves
reported en Form W-2 of $108.28 or more?
Yes
No I Old you report any wages on Form 8916, Uncollecied Social Yes
r~
You must use LJing Schedule SE on page 2
You may use Short Schedule SE below
Section A—Short Schedule SE. Caution: Read above to see If you can use Short Schedule SE,
la
Net farm profit or (loss) from Schedule F, line 34, and farm partnerships, Schedule K-1 (Form
1065), box 14, code A
b If you received social security retirement or disability benefits, enter the amount of Conservation Reserve
Program payments included on St^edule F. line 4b, or listed on Schedule K-1 (Form 1055), box 20, code Z
2
Net profit or (loss) from Schedule C, line 31; Schedule C-E2, line 3; Schedule K-1 (Form 1065),
box 14. code A (other than farming); and Schedule K-1 (Foim 1065-B), box 9, code J1.
Ministers and members of religious orders, see instructions for types of income to report on
3
4
21.120
21.120
this line. See Instructions for other Income to report
Combine lines la, lb, and 2
Multiply line 3 by 92.35% (0.9235). If less than $400, you don't owe self-employment tax; don't
19,504
file this schedule unless you have an amount on line 1b
^
Note; If line 4 is less than $400 due to Conservation Reserve Program payments on line lb.
see instructions.
5
Self-employment tax. If the amount on line 4 Is;
• $127,200 or less, multiply line 4 by 15.3% (0.153). Enter the result here and on form 1040, line
57. or Form1040NR, line 55
• More than $127,200, multiply llne-1 by 2.9% (0.029). TTien, add $15,772.80 to the result.
Enter the total here and on Form 1040, line 57, or Form 1040NR, line 55
6
Deduction for one-half of seff-employment tax.
Multiply line 5 by 50% (0.50). Enter the result here and on Form
1040, line 27, or Form 1040NR, line 27
For Paperwork Reduction Act Notice, see your tax retum instructions.
I
E
6
1, 4 92^
Cat. No. 11353Z
Schedule SE ^orm 1040) 2017
0MB No. 154&-O074
Employee Business Expenses
Oepartmsnl ot e Treasury
imemal Revenue Service |9S)
1017
^ Attach to Form 1040 or Form 1040NR.
Attachment
^ Qo to www.lrs.gev/Fom2l06 tor instructions and the latest Information.
I
Sequence No. 129
Occupation in which you incurred expenses Social security numtier
Your name
ROC M PIFFERINI
POLICE OFFICER
551-|53-56|51
Employee Business Expenses and Reimbursements
Column B
Column A
Step 1 Enter Your Expenses
Other Than Meals
Meals and
and Entertainment
Entertainment
Vehicle expense from tine 22 or line 29. fRural mail carriers; See
instructions.)
1,198
Parking fees, tolis, and transportation, including train, bus, etc.. that
didn't involve overnight travel or commuting to and from work . .
Travel expense while away from home overnight, including lodging,
airplane, car rental, etc. Don't include meals and entertanment. .
Business expenses not included on lines 1 through 3. Don't include
meals and entertainment
5 Meals and entertainment expenses(see instructions)
6 Total expenses. In Column A, add lines 1 through 4 and enter the
result. In Column B, enter the amount from line 5
6
1,198
Note: If you weren't reimbursed for any expenses in Step 1. skip line 7 and enter the amount from line 6 on line 8.
step 2 Enter Reimbursements Received From Your Employer for Expenses Listed in Step 1
7 Enter reimbursements received from your employer that weren't
reported to you in box 1 of Form W-2. Include any reimbursements
reported under code "L" In box 12 of your Form W-2(see
instructions)
Step 3 Rgure Expenses To Deduct on Schedule A(Form 1040 or Form 1040NR)
8 Subtract line 7 from line 6. If zero or less, enter -0-. However, if line 7
is greater than line 6 in Column A. report the excess as income on
Form 1040, line 7(or on Form 1040NR, line 8)
0
1,198
Note: If both columns of line 8 are zero, you can't deduct
employee business expenses. Stop here and attach Form 2106 to
your return.
9 In Column A. enter the amount from line 8. In Column B, multiply line
8 by 50% (0.50).(Employees subject to Department of Transportation
(DOT)hours of service limits: MuKlply meal expenses incurred while
away from home on business by 80% (0.80) instead of 50%. For
details, see instructions.)
_9
^
10 Add the amounts on line 9 of both columns and enter the total here. AJso, enter the total on
Schedule A (Form 1040), line 21 (or on Schedule A (Form 1040NR), line 7).(Armed Forces
reservists, qualified performing artists, foe-basis state or local government officials, and
Individuals with disabilities; See the Instructions for special rules on where to enter the total.) .
For Paperwork Reduction Act Notice, see your tax return instructions.
Cat. Nu. 11 7oon
1,198
Fomi2106(2017)
Page 2
Form?106(?017)
Vehicle Expenses
Section A—General {nformation (You must complete this section if you
are claiming vehicle expenses.)
11
12
13
14
15
(b) Vehicle 2
(a) Vehicle 1
Enter the date the vehicle was placed in service
Totai miles the vehicle was driven during 2017
Business miies inciuded on line 12
Percent of business use. Divide line 13 by line 12
Average daiiy roundtrip commuting distance
11 01 ^01 /2017
_12
15, OOOmiles
_13
2.24 0mlles
J[4
14.93 %
_16
miies
>
/
16
Commuting miles included on line 12
_16
miles
17
Other miles. Add lines 13 and 16 and subtract the total from line 12 . .
_17
12,760miles
18
Was your vehicle available for personal use during off-duty hours?
□ Yes
IX No
19
20
Do you (or your spouse) have another vehicle available for persona! use?
Do you have evidence to support your deduction?
□ Yes
X Yes
X No
□ No
"""Uss
nilles
%
niiles
niiles
miles
21
If "Yes," is the evidence written?
X Yes □ No
Section 8—Standard Mileage Rate (See the instructions for Part II to find out whether to complete this section or Section C.)
1.198
a) Vehide 1
Section C—Actual Expenses
Vehicle 2
Gasoline, oil, repairs, vehicle
insurance, etc
Vehicle rentals
Inclusion amount (see Inslructicns)
.
Subtract line 24b from line 24a
Value of employer-provided
vehicle (applies only if 100% of
annual lease value was included
on Form W-2—see instructions)
Add lines 23, 24c, and 25.
.
.
Multiply line 26 by the percentage
on line 14
Depreciation (see instructions) .
Add lines 27 and 2B. Enter total
here and on line 1
Section D—Depreciation of Vehicies (Use this section only if you owned the vehicle and are completing Section C for the vehicle,
1
WVehicie 1
I
(b) Vdiicle 2
30
Enter cost or other basis (see
instructions)
31
Enter section 179 deduction and
special allowance (see instructions) I 31
Multiply line 30 by line 14 (see
Instructions if you claimed the
section 179 deduction or special
allowance)
Enter depreciation method and
percentage (see instructions)
.
Multiply line 32 by the percentage
on line 33 (see instructions) . .
Add lines 31 and 34
.
.
.
.
Enter the applicable limit explained
in the line 36 instructions .
.
.
Multiply line 36 by the percentage
on line 14
Enter the smaller of line 35 or line
37. If you skipped lines 36 and 37,
enter the amount from line 35.
Also enter this amount on line 26
above
4562
inigna Rgvenuo S(i«v« (99) [
&
Attachment
► Go to www.irs.gov/Form4Se2 for instructions and the latest information.
Name(a) shown on return
M
i§i7
►Attach to your tax return,
Depe™.«.,oMh«T,^
ROC
OUB No. 1545-0172
Depreciation and Amortization
(Including Information on Listed Property)
Sequence No. 179
Business or activity to wnich this form relates
JOANNA
L
Identifying number
PIFFERINI
551-53-5651
Eieirtion To Expense Certain Property Under Section 179
Note: If you have any listed property, complete Part V before you complete Part i.
1
J_l
Maximum amount (see instructions)
2 Total cost of section 179 property placed in service (see instructions)
3 Threshold cost of section 179 property before reduction in limitation (see instructions)
510.000
2
3 I 2,030.000
4 Reduction in limitation. Subtract line 3 from line 2. If zero or less, enter -0-
5 Dollar limitation for tax year. Subtract line 4 from line 1. If zero or less, enter -0-. If married filing
separately, see instructions
6
(a) Description ot property
I (b) Cost (l>uslnea» use only) I
7 Listed property. Enter the amount from line 29
510.000
(o) 0sctecl cost
| 7 |
8 Total elected cost of section 179 property. Add amounts in column (c), lines 6 and 7
9 Tentative deduction. Enter the smaller of line 5 or line 8
10 Carryover of disallowed deduction from line 13 of your 2016 Form 4562
11 Business income limitation. Enter the smaller of business Income (not less than zero) or line 5 (see instructions)
12 Section 179 expense deduction. Add lines 9 and 10, but don't enter more than line 11
13 Carryover of disallowed deduction to 2018. Add linesSand 10, less line 12 ►
510.000
| 13 I
Note: Don't use Part II or Part ill below for listed property. Instead, use Part V.
Special Depreciation Allowance and Other Depreciation (Don't include listed property.) (See Instructions.
14 Special depreciation allowance for qualified property (other than listed property) placed in service
during the tax year (see instructions)
15 Property subject to section I68(f)(1j election
_
16 Other depreciation (includinq ACRS)
Part lil
MACRS Depreciation (Don't include listed property.) (See instructions.
Section A
17 MACRS deductions for assets placed in service in tax years beginning before 2017
18 If you are electing to group any assets placed in service during the tax year into one or more general
asset accounts, check here
^ □
Section B—Assets Placed in Service During 2017 Tax Year Using the General Depreciation System
Id) Bscovery
(«) Classification ot property
b
3-vear propei
S-year propei
c
7-year propei
19a
m Method
Convention
period
(s) OwreciaCondeduetlon
f 20-year pro
25-vear pro
25 vrs.
h Residential rental 06/2017
property
07/2017
189.008 27.5 vrs.
MM
14.
14. 904
9041 27.5
27.5 yrs.
vrs.
i Nonresidential real
I
MM
S/L
S/L
^
3.723
1
248"
39 vrs.
property
Section C—Assets Placed in Service During 2017 Tax Year Using the Alternative Depreciation System
20a Class life
b 12-vear
c 40-vear
Summary (See instructions.)
I
1
12 yrs.
40 yrs.
I
1
I
I
MM
S/L
S/L
S/L
21 Listed property. Enter amount from line 28
22 Total. Add amounts from line 12, lines 14 through 17, lines 19 and 20 in column (g), and line 21. Enter
here and on the appropriate lines of your return. Partnerships and 3 corporations—see instructions
23 For assets shown above and placed in service during the current year, enter the
portion of the basis attributable to section 263A costs
For Paperwork Reduction Act Notice, see separate instructions.
21
22
IWy
23
Cat. No. 12906N
3, 971
-• V;.-
1 '
Form-ase? gOlT]
Page 2
QSQ Listed Property (Include automobiles, certain other vehicles, certain aircraft, certain computers, and property
used for entertainment, recreation, or amusement.)
Note: For any vehicle for which you are using the standard mileage rate or deducting lease expense, complete only 24a,
24b. columns(a)through (c) of S^tion A. all of Section S, and Section C if applicable.
Section A—Depreciation and Other information (Caution: See the instructions for limits for passenger automobiles.
24a Do you have evidence to support the business/investment use claimed? G Yes Si No 24b IfYes," is the evidence written? G Yes □ No
M
(b)
Type of property (i>sl Date placeO
vehicles first)
(g)
Method/
Convention
in service
(h)
□epraciaticn
Elected section 179
deduction
cost
25 Special depreciation allowance for qualified listed property placed in service during
the tax year and used more than 50% in a qualified business use (see instructions) .
26
Prooerty used more than 50% in a Qualified business use:
27
Property used 50% or less In a qualified business use:
5/LS/L-
!ss»g3Sf
5/L-
28 Add amounts in column (h), lines 25 through 27. Enter here and on line 21, page 1
| 28 |
29 Add amounts in column (1), line 26, Enter here and on line 7, page t
29
Section B—Information on Use of Vehicles
Complete this section f(»' vehicles used by a sole proprietor, partner, or other "more than 5% owner.' or related person, If you provided vehicles
to your employees, first answer the questions in Section C to see if you meet an exception to completing this section for those vehicles.
30 Total business/investment miles driven during
(a|
(b)
|c>
Id}
(e)
(fi
Vehiclsl
Vehicles
Vehicles
Vehicle 4
Vehicles
Vehicle 6
vehicle i
the year (don't include commuting miles)
31 Total commuting miles driven during the year
32 Total other personal
(noncommuting)
miles driven
33 Total miles driven during the year. Add
lines 30 through 32
34 Was the vehicle available for persona!
use during off-duty hours?
35 Was the vehicle used primarily by a more
than 5% owner or related person? . .
36
Yes
Is another vehicle available for personal use?
Section C—Questions for Employers Who Provide Vehicles for Use by Their Employees
Answer these questions to determine if you meet an exception to completing Section B for vehicles used by employees who aren't
more than 5% owners or related persons (see instructions).
37 Do you maintain a written poiicy statement that prohibits aii personal use of vehicles, including commuting, by
Yes
your employees?
38 Do you maintain a written policy statement that prohibits personal use of vehicles, except commuting, by your
employees? See the instructions for vehicles used by corporate officers, directors, or 1 % or more ownere .
.
39 Do you treat aii use of vehicles by employees as personal use?
40 Do you provide more than five vehicles to your employees, obtain information from your employees about the
use of the vehicles, and ret^n the information received?
41
Do you meet the requirements concerning qualified automobile demonstration use? (See instructions.)
Note: If your answer to 37.38, 39. 40. or 41 is "Yes," don't complete Section B for the covered vehicles.
Part VI
.
.
.
SSfH
Amortization
M
Oescriplion of costs
(b)
Dale amonizalion
begins
(•)
ic)
(d)
Amortizable amount
Code section
AmoftizaUon
period or
Amortization for this year
percentage
42 Amortization of costs that m ins during vour 2017 tax year (see instructions
VA
FEE
106-01-20171
8,712 r
43 Amortization of costs that began before your 2017 tax year
44 Total. Add amounts in column (f). See the instructions for where to report
339
Form 4562 (2017)
8283
Noncash Charitable Contributions
iRev Decen-cef 2014)
0MB No. 1S45-0908
Attach to your tax return H you claimed a total deduction
Depertmeni of the Treasury I
Anachmenl
^'O'' con^birted property.
Internal Revenue Service | ► infonnation about Form 8283 and Its separate instructions Is at www.lrs.gov/form8283.
Name(s) shown on your income tax return
ROC
K
&
JOANNA
L
Sequence No. 155
IdentHylng number
551535651
PIFFERINI
Note. Figure the amount of your contribution deduction before completing this form. See your tax return instructions.
Section A. Donated Property of $5,000 or Less and Publicly Traded Securities—List in this section only Items (or
groups of similar items) for which you claimed a deduction of $5,000 or less. Also list publicly traded
Part I
securities even if the deduction is more than $5,000 (see instructions).
Information on Donated Property—If you need more space, attach a statement.
(b) if donated property is a vehicle (see instructions),
(a) Name and address of trte
donea organization
check the box. Aiso enter the vehicle identificetion
number (unless Form tOS8-C is attached).
(c) Description of Oonaled property
(For a vehicle, enter the year, maice. rrtodel, std
mileage. For securities, enter the company name and
the number of sharee.)
QODWILL
125 SOUTH GRANT
Note. If the amount you claimed as a deduction for an Item is $500 or less, you do not have to complete columns (e), (f), and (g).
Id) Dale of the
contribution
(a) Date acqured
by donor (mo., yr.]
(f) How acquired
tjy donor
(q) Donor'ecosl
or adjusted basis
Qi) Fair market viJue
(see inshuctiofts)
(i) Metixid used to determine
the fair market value
eSObARAGE GALE VALUE
9-24-2017
Partial Interests and Restricted Use Property—Complete lines 2a through 2e if you gave less than an
entire interest in a property listed in Part I. Complete lines 3a through 3c if conditions were placed on a
2a
contribution listed in Part 1; also attach the required statement (see instructions).
Enter the letter from Part I that Identifies the property for which you gave less than an entire interest ►
If Part II applies to more than one property, attach a separate statement.
b Total amount claimed as a deduction for the property listed in Part I; (1)
(2)
c
For this tax year
►
For any prior tax years
►
Name and address of each organization to which any such contribution was made in a prior year (complete only if di^erent
from the donee organization atjcve):
Name of charltabis crganlzation (donee)
AdOresa (number, street, and room or eulio no.)
Crtyor town, state, and ZIP code
d
e
3a
For tangible property, enter the place where the property is located or kept ►
Name of any person, other than the donee organization, having actual possession of the property ►
Is there a restfictlon, either temporary or permanent, on the donee's right to use or dispose of the donated
Yes I No
property?
b
Did you give to anyone (other than the donee organization or another organization participating with the donee
organization In cooperative fundraistng) the right to the income from the donated property or to the possession of sS
the property, including the right to vote donated securities, to acquire the property by purchase or otherwise, or to
designate the person having such Income, possession, or right to acquire?
c
Is there a restriction limiting the donated property for a particular use?
For Paperwork Reduction Act Notice, see separate instructions.
Cat. No. &2299J
Form 8283 (Rev. 12-2014)
02g'|
Department of the Treasury
Internal Revenue Service (99)
Alternative Minimum Tax—Individuals
^
0MB No. 1545-0074
www.lrs.gov/Forni62S1 for InstrucUons and the latest information.
Altachm«fit
► Attach to Form 1040 or Form 1040N R.
Saguence No.32
Nama(s) shown on Form 1040 or Form 104ONR
Your social BBCurlty number
ROC M & JOANNA L PIFFERINI
551-53-5651
Alternative Minimum Taxable Income (See instructions for how to complete each line.)
1 If filing Schedule A (Form 1040), enter the amount from Form 1040, line 41, and go to line 2. Otherwise,
enter the amount from Form 1040, line 38, and go to line 7. pf less than zero, enter as a negative amount.)
2 Reserved for future use
1 ____^201^4^
2
3 Taxes from Schedule A(FoiTn 1040), line S
_3
4 Enter the home mortgage interest adjustment, If any, from line 6 of the worksheet in the instaictions for this Ijne
5 Miscellaneous deductions from Schedule A (Form 1040), line 27
_4
_5
6 If Form 1040, line 38, is SI 56,900 or less, enter -0-. Otherwise, see instructions
7 Tax refund from Form 1040, line 10 or line 21
6 (
7 (
8 Investment interest expense (difference between regular tax and AMT)
9 Depletion (difference between regular tax and AMT)
10 Net operating loss deduction from Form 1040, line 21. Enter as a positive amount
^
1 > 671
_§
_9
_10
11 Alternative tax net operating loss deduction
12
13
14
16
16
17
18
19
20
21
22
22 , 582
11 (
Interest from specified private activity bonds exempt from the regular tax
Qualified small business stock, see Instructions
Exercise of incentive stock options (excess of AMT Income over regular tax income)
Estates and trusts (amount from Schedule K-1 (Form 1041), box 12, code A)
Electing large partnerships (amount from Schedule K-1 (Form 1065-B), box 6)
Disposition of property (difference between AMT and regular tax gain or loss)
Depreciation on assets placed In service after 1986 (difference between regular tax and AMT)
Passive activities (difference between AMT and regular tax Income or loss)
Loss limitations (difference between AMT and regular tax income or loss)
Circulation costs (difference between regular tax and AMTj
Long-term contracts (difference between AMT and regulartax income)
.
.
.
.
)_
_12
_13
_14
Jl5
_16
17 __________
_Jfi
_1j!
_20
_21
_22
23 Mining costs (difference between regular tax and AMT)
24 Research and experimental costs (difference between regular tax and AMT)
_24
25 Income from certain installment sales before January 1.1967
26 (
26 Intangible drilling costs preference
27 Other adjustments, including income-based related adjustments
^
)_
_26
_27
28 Alternative minimum taxable income. Combine lines 1 through 27. (If married filing separately and line
28 Is more than $249,450, see instructions.)
28
222 > 404
. . I 29
69.124
Alternative Minimum Tax (AMT)
29 Exemption. (If you were under age 24 at the end of 2017, see Instructions.)
IF your filing status is...
AND line 28 is not over... THEN enter on line 29...
Single or head of household . . . .
Married filing jointly or qualifying widow(er)
$120,700
160,900
$54,300
84,500
60,450
42,250
Married filing separately
If line 28 Is over the amount shown above for your filing status, see instructions.
30 Subtract line 29 from line 28. if more tha-n zero, go to line 31. If zero or less, enter -0- here and on lines 31, 33,
and 35. and go to line 34
153,280
31 • If you are filing Form 2556 or 2555-EZ, see instmctions for the amount to enter.
• If you reported capital gain disthbutions directly on Form 1040, line 13; you reported qualified dividends
on Fot-m 1040. line 9b; or you had a gain on both lines 15 and 16 of Schedule D (Form 1040) (as
39,853
refigured for the AMT, if necessary), complete Part lit on the back and enter the amount from line 64 here.
• All others; It line 30 Is $187,800 or less ($93,900 or less if married filing separately), multiply lino
30 by 26% (0.26). Otherwise, multiply line 30 by 28% (0.28) and subtract $3,756 ($1,878 U
married filing separately) from the result.
32 /yiemative minimum tax foreign tax credit (see instructions)
32
33 Tentative minimum tax. Subtract line 32 from line 31
33
39r 853
34
39,901
34 Add Form 1040, line 44 (minus any tax from Form 4972), and Form 1040. line 46. Subtract from the result any
foreign tax credit from Form 1Q40, line 49, If you used Schedule J to figure your lax on Form 1040, line 44,
refigure that tax without using Schedule J before completing this line (see instructions)
35 AMT. Subtract line 34 from line 33. If zero or lass, enter -0-. Enter here and on Form 1040, line 45
For Paperwork Reduction Act Notice, see your tax return instructions.
Cat. No. 13600G
Form 8251 (2017)
Form
ORIIO
OMB No. 154S-1D08
Passive Activity Loss Limitations
►See separate instructions.
Department of the Treasury
1017
►Attach to Form 1040 or Form 1041.
Internal Revenue Service (99)
M
&
JOANNA
Sequence No. 88
Id
'< entHylng number
Nama(s| shown on return
ROC
Attachment
► Go to www./fs.gov/Form858g for Instructions and the latest Information.
Internal Revenue Service (OT)
L
551-53-5651
PIFFERINI
2017 Passive Activity Loss
Caution: Complete Worksheets 1.2, and 3 before completing Part I.
Rental Real Estate Activities With Active Participation (For the definition of active participation, see
Special Allowance for Rental Real Estate Activities in the instructions.)
la Activities with net income (enter the amount from Worksheet 1,
column (a))
_1a
b
Activities with net loss (enter the amount from Worksheet 1. column
(b))
c
_1^(
1
1c |(
]
2a (
)
Prior years' unallowed losses (enter the amount from Woritsheet 1,
column (c))
d Combine lines la. lb, and 1c
Commercial Revltallzadon Deductions From Rental Real Estate Activities
2a Commercial revitalization deductions from Worksheet 2, column (a).
b
Prior year unallowed commercial revitalization deductions from
Worksheet 2, column (b)
c
2b (
Add lines 2a and 2b
All Other Passive Activities
3a
Activities with net income (enter the amount from Worksheet 3,
*
column (a)}
b
Activities with net loss (enter the amount from Worksheet 3, column
(b))
c
3b 1(
12, 017 )
Prior years' unallowed losses (enter the amount from Worksheet 3,
t'l-r
column (c))
iJi'
d Combine lines 3a, 3b, and 3c
4
. •
I 3d I
-12, 017
4 |
-12, 017
Combine lines id, 2c, and 3d. If this line is zero or more, stop here and include this form with
your return; ait losses are allowed, Including any prior year unallowed losses entered on line 1c,
2b, or 3c. Report the tosses on the forms and schedules normally used
If line 4 is a loss and;
• Line 1 d is a loss, go to Part II.
• Line 2c is a loss (and line Id is zero or more), skip Part 11 and goto Part ill.
• Line 3d is a loss (and lines 1d and 2c are zero or more), skip Parts ii and ill and go to line 15.
Caution: If your filing status is married filing separately and you lived with your spouse at any time during the year, do not complete
Part Ii or Part 111. Instead, go to line 15.
Special Allowance for Rental Real Estate Activities With Active Participation
5
6
7
Note: Enter all numbers in Part il as positive amounts. See instructions for an example.
Enter the smaller of the loss on line Id or the loss on line 4
Enter $150,000. If married filing separately, see insttuctions . .
_6
Enter modified adjusted gross income, but not less than zero (see instructions)
7
Note: If line 7 is greater than or equal to line 6, skip lines 8 and 9,
I 5
■m
enter -0- on line 10. Otherwise, go to line 6.
8
Subtract line 7 from line 6
9
Multiply line 8 by 50% (0.50). Do not enter more than $25,000. If married filing separately, see instructions |_9
10
I 8
■a i
Enter the smaller of line 5 orline 9
If line 2c is a loss, go to Part lil. Otherwise, go to line 15.
Special Allowance for Commercial Revitalization Deductions From Rental Real Estate Activities
Note: Enter all numbers in Part III as positive amounts. See the example for Part II in the instructions.
11
Enter $25,000 reduced by the amount, if any, on line 10. If married filing separately, see instructions
11 I
12
Enter the loss from line 4
12
13
Reduce line 12 by the amount on line 10
13
14
Enlerthe smallest of line 2c (treated as a positive amount), line 11, or line 13
Part IVI Total Losses Allowed
15
Add the income, if any, on lines la and 3a and enlerthe total
16 Total losses allowed from all passive activities for 2017. Add lines 10. 14, and 15. See
instructions to find out how to raoorl the tosses on your fax return
For Paperwork Reduction Act Notice, see Instructions.
14
16
Cat. No. a37D4F
Form 8582 (2017)
0MB No. 1545-0074
Additional Medicare Tax
8959
^ tr any line does not apply to you, leave It blank. See separate instructions.
► Attach to Form 1040,1040NR, 1040-PR, or 1040-SS.
^ Go to Mww.lrs.govlFom8X9 for instructions and the latest information.
D^H/tment of ine Treasury
Internal Revenue Service
Part \
1
JOANNA L
PIFFERINI
5!
551-53-5651
Additional Medicare Tax on Medicare Wages
Medicare wages and tips from Form W-2, box 5. If you have
more than one Form W-2, enter the total of the amounts
from box 5
_1
2
Unreported tips from Form 4137, line 6
_2
3
Wages from Form 8919, line 6
_3
5
Enter the following amount for your filing status:
4 Add lines 1 through 3
Married filing jointly
Manied filing separately
_4
ra|
256. 575 ^
256.
256, 575
575{!^
$250,000
$125,000
M
H
Single, Head of household, or Qualifying widow(er) $200,000 __5
250.0001
250.
OOP BS
6
Subtract line 5 from line 4. If zero or less, enter -0-
7
Additional Medicare Tax on Medicare wages. Multiply line 6 by 0.9% (0.009). Enter here and
go to Part II
PartJI
8
Sequence No. 71
Yourcoclal Mcurity number
Narne{s) shown on relum
ROC M &
1®17
Anachment
7
Additional Medicare Tax on Setf-Empioyment income
Self-employment income from Schedule SE (Form 1040),
Section A, line 4, or Section B, line 6. If you had a loss, enter
-0- (Form 1040-PR and Form 1040-SS filers, see instructions.) _8
9
Enter the following amount for your filing status:
Married filing jointly
Married filing separately
19, 504
$250,000
$125,000
10
Single, Head of household, or Qualifying widow(er) $200,000 _9
Enter the amount from line 4
_10
11
Subtract line 10 from line 9. If zero or less, enter-0- .
12
Subtract line 11 from line 8. If zero or less, enter -0-
13
Additional Medicare Tax on self-employment Income. Multiply line 12 by 0.9% (0.009). Enter
.
.
250. OOP
250.000
256. 575
256,575
_11
19,504
here and go to Part III
Part III
14
13
Additional Medicare Tax on Railroad Retirement Tax Act (RRTA) Compensation
Railroad retirement (RRTA) compensation and tips from
Form(s) W-2, box 14 (see instructions)
15
_14
Enter the following amount for your filing status:
Married filing jointly
Manied filing separately
$250,000
$125,000
Single. Head of household, or Qualifying widow(er) $200,000
_15
16
Subtract line 15 from line 14. If zero or less, enter -0-
17
Additional Medicare Tax on railroad retirement (RRTA) compensation. Multiply line 16 by
0.9% (0.009). Enter here and go to Part IV
^ .
iPartlVl
Total Additional Medicare Tax
18
Add lines 7, 13, and 17. Also include this amount on Fotm 1040, line 62, (Form 1040NR.
1040-PR, and 1040-SS filers, see instructions) and go to Part V
PartV
Withholding Reconoiliation
19
Medicare tax withheld from Form W-2, box 6. If you have
more than one Form W-2, enter the total of the amounts
from box 6
20 Enter the amount from line 1
P|H
_19
BB
4.23 0|B
20
2 5 6 . 5 / bjffP
_21
3,72 0^^
21
Multiply line 20 by 1.45% (0.0145). This is your regular
22
Subtract line 21 from line 19. If zero or less, enter -0-. This is your Additional Medicare Tax sm
withholding on Medicare wages
Additional Medicare Tax withholding on railroad retirement (RRTA) compensation from Form
23
Medicare tax withholding on Medicare wages
W-2, box 14 (see Instructions)
24
Total Additional Medicare Tax withholding. Add lines 22 and 23. Also include this amount
with federal Income tax withholding on Form 1040, line 64 (Form 1040NR. 1040-PR, and
1040-SS filers, see instructions)
For Paperwork Reduction Act Notice, see your tax return instructions.
24
Cat. No. SS47SX
510
Form 8959 (2017)
Schedule A Supporting Statements
GIFTS TO CHARITY BY CASH OR CHECK
ELKS
PAAF
375
130
FEDERAL TOTAL
505
STATE TOTAL
505
MISCELLANEOUS DEDUCTIONS SUBJECT TO 2% AGI LIMIT - JOB RELATED (Line 21)
Form 2106
1,198
All other union dues
900
Job supplies
425
UNIFORMS
450
CELL BUS USE 50
200
UNIFORM CLEANING
240
LINE 21 TOTAL
3.413
551-53-5651
ROC M & JOANNA L PIFFERINI
SCHEDULE E - OTHER RENTAL EXPENSES STATEMENT # 1
RENTAL 13506 27TH AVE NE Seattle WA 98125
A
Air Travel
375
TOTAL OTHER EXPENSES
375
□ CORRECTED (if checked)
PAYER'S tume, street address, dty or town, state or province, country, ZIP
or foreign postal code, and telepfione no.
1 Rents
First Alarm Security & Patrol, Inc
0MB Mo. 1545K)US
$
1731 Technology Drive
Miscellaneous
Income
2017
2 Royalties
Suite 800
San lose, CA 95110
Form 1099-MlSC
$
4 Federal Income tax withheld
3 Ottier oicome
Phone:
PAYSfS federal Identincadon number
(408) 364-1110
$
REaPlENTS Identificatian number
77-0237870
Copy B
FOr Recipient
$
5 Hsfiing boat proceeds
6 Medical and heaSti care payments
$
$
7 Nonempioyee compensation
BSubstitute payments In lieu of
551-53-5651
REdPlENTS name
This is important tax
dividends or interest
Roc Miller Ptfferlnl
information and is
being furnished to
Street address (Indudtng apt na)
$
21,120.00
9 Payer made direct sales of
201W. Mission Street
(recbjient) fOr resale P LJ
$
12
11
San lose, CA 95110
Service. If you are
required to file a
return, a negligence
penalty or other
sanction may be
imposed on you If
10 Crop insurance proceeds
$5,000 or more of consumer
products to a buyer .
•
City or town, state or province, country, and ZIP or foreign postal code
the Internal Revenue
$
this income is
taxable and the IRS
Account number (see Instructions}
13 Excess golden parachute
FATCA filing
requirement
3152
lSaSeetian<«»Aderenals
payments
□
ISb Section 409A Income
$
$
Fbmi 1099-MlSC
(keep for your records.)
1 i=(i 111=1111 in 11 n=! M n
III
16 State tax withheld
17 State/Payer's state no.
$
$
$
DepaitmentaftheTreasuiy-Jntenial Revalue Service
n I M=iii 11=11 n 1=111 i 1=11 M 1=11111 =11111=11111 =11111=11111 mill
'
im
' < ngn. iijiT'
>11111—11111
i^n=nzns:r
:n=nCn=nZn=n^n=n
ii:n=nZn=n:rn = n~n=p
nii=niit=ti
f=n—nrn-nzn-nzn-nrr
ni-nil
I-It
I"
~ 11
in-nin-nni-tfiif
siiTrrsri 111 i =1
in=iiin=itin=iiiii=ii
=n=n
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• ai—11 n <
OMBNft. 154S0008
7 social naaay tr*
1 wagn, tpx. cow coarcnHMi
FatmW-2 Wage, and Tax Statement
e ERVMyai naiM. aMtns, CM ZIP oods
CITY OP SAN JOSE
FINANCE -PAYROLL
200 EAST SANTA CLARA. STREET
SAN JOSE CA 95113-1905
c fciripiiawx nsffw, wwm^ nd o^ooda
217841.59
a/wceaiodops
a scciii tdcuoiy mon
a vanncaiion codo
0 Moddtra vagaand Hp*
11 NonHuttOod plaia
0 EnpiaTW moietoon lutew (tnq
Mcnw
94-6000419
40375:35
4 8oclil*aaiitr ln«OMid'
'
256575.22
10 Oop^idom c*re_Mratia.
a rediiii wcomeiuxweniwd
.
e MMwata OK wniMid''
4229.52
S 1 13000.00
DD r 19^53.90
W-2
Type
T/S
4,230
19,065
19,065
SWT
4,230
Local
■ T/OCPAYER TOTALS'
MedWH
'SPOUSE TOTALS'
•• COMBINED TOTALS'
88 WH
19,065
SDI
40,375
40,375
40,375
FWT
217,842
217,842
217,842
GroBs
WAGE STATEMENT LISTING
4,230
CITY OF SAN JOSE
CA 94.6000419
Employer / State / EIN
ROC M & JOAMNA L PIFFERINI
Tips
256,575
256,575
256,575
88 Wages/ Med Wages Txbl 1099R
Txbl IRA
No
Pension
551.53.565
[17116]
FORM
TAXABLE YEAR
Caiifornia Resident
2017
540
Income Tax Return
ATTACH FEDERAL RETURN
APE
A
551-53-5651
ROC
JOANNA
17
PIFF
564-89-5273
M
PIFFERINI
L
PIFFERINI
R
RP
PO BOX 1495
TWAIN
11-30-1968
01
06
07
08
09
10
11
12
13
14
16
17
18
19
31
32
33
34
35
40
43
44
CA
HARTE
95383
09-12-1971
2
0
2
228
0
0
0
0
01
353
581
217842
239141
1671
0
237470
18583
218887
15070
581
14489
0
14489
0
0
0
45
46
47
48
61
62
63
64
71
72
73
74
75
76
91
92
93
94
95
96
97
400
401
403
0
0
0
14489
0
0
0
14489
19065
0
0
0
0
19065
0
19065
0
4576
0
4576
0
0
0
0
405
406
407
408
410
413
422
423
424
425
430
431
432
433
434
435
436
437
438
439
440
110
111
112
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
113
0
115
4576
116
4576
117
0
APE
0
3800
0
3803
0
SCHGl
0
5870A
0
5805 5805F
0
DESIGNEE
1
TPIDP 00073913
FN
CCF
3805P
NQDC
3540
3554
3805Z
3807
3808
3809
IRC453A
IRC1341
JOEPIFFER0HOTMAIL.COM
(480) 233-5857
ROC
PIFFERINI
524-97-2698 SON
CT
^B
:z. ^
^(73
0
0
0
0
0
0
0
0
0
0
0
DDRl
121137522
8000810591
1
4 I I Head of tiousehold (v/ith qualifying person). See instructions.
1 I I Single
2 I X I Married/RDP filing jointly. See inst
5 I I Qualifying widow(er) with dependent child. Enter year spouse/ROP died
3 I I Married/RDP filing separately. Enter spouse's/ROP's SSN or ITIN above and full name here
If your California filing status is different from your federal filing status, check the box here
6 If someone can claim you (or your spouse/RDP) as a dependent, check the box here. See inst..
090 I
3101176
O
6
□
□
Form 540 2017 Sidel
[17116]
Your name:
PIFFERINI
551-53-5651
YourSSN orlTlN:
k- For line 7, line 8, line 9, and line 10: Multiply the amount you enter In the box by the pre-printed dollar amount for that line.
7 Personal: If you checked box 1,3, or 4 above, enter 1 in the box. If you checked
box 2 or 5. enter 2, in the box. If you checked the box on line 6, see instructions, (i) 7
X S114 = ®S
8 Blind: If you (or your spouse/RDP)are \nsually impaired, enter 1;
if both are visually impaired, enter 2
®8
X S114 = ® $
9 Senior: If you (or your spouse/ROP) are 65 or older, enter 1;
if both are 65 or older, enter 2
</)
tr
o 9
228
X S114 = ® $
10 Dependents: Do not Include yourself or your spouse/RDP.
DapendenI1
D.
m
□
□
Whole dollars only
Dependent 2
Dependent 3
First Name
P
®
ROC
®
®
®
PIFFERINI
®
®
9
524-97-2698
9
Last Name
UJ
SSN
Dependent't
relationship
to you
® SON
■
■—.I
1
—
1
..
■ — — —
®
9
®
9 10 Q
I ±J X $353= ® $
Total dependent exemptions
11 Exemption amount: Add line 7 through line 10. Transfer this amount to line 32
12 State wages from your Form(s)W-2, box 16
9 12
® 11
S
353
581
217, 842 IJoq
® 13
39,141
14 California adjustments - subtractions. Enter the amount from Schedule OA (540), line 37, column B . . . 9 14
1.671
13 Enter federal adjusted gross income from Form 1040, line 37; 1D40A, line 21; or 1040EZ, line 4
15 Subtract line 14 from line 13. If less than zero, enter the result in parentheses. See instructions
15
237.470
o
U
c
^
16 California adjustments - additions. Enter the amount from Schedule CA (540), line 37, column C
9 16
17 California adjusted gross income. Combine line 15 and line 16
9 17
237,470
. 9 18
18,583
® 19
218.887
18 Enter the
larger of:
Your California Itemized deductions from Schedule CA (540), line 44; DR
Your California standard deduction shown below for your filing status:
• Single or Married/RDP filing separately
$4,236
• Married/RDP filing jointly. Head of household, or Qualifying widow(er)
$8,472
If Married/RDP filing separately or the box on line 6 is checked, STOP. See instructions. .
19 Subtract line 18 from line 17. This is your taxable Income. If less than zero, enter -0-
31 Tax. Check the box if from:
□ Tax Table
[Kl Tax Rate Schedule
9 n FTB3800 9 D FrB3803
,y
,y
9 31
15.070 m
® 32
581
33 Subtract line 32 from line 31. If less than zero, enter -0-
® 33
14,489
34 Tax. See instructions. Check the box if from: 9 dl Schedule G-1 O CH FTB5870A
9 34
35 Add line 33 and line 34
® 35
32 Exemption credits. Enter the amount from line 11. If your federal AGI is more than Si 87,203
see instructions
Side 2 Form 540 2017
090 I
3102176
14,489
m
QQ
[17116]
Your name: IpIFFERINI
Your SSN or ITIN:
551-53-5651
40 Nonrefundable Child and Dependent Care Expenses Credit. See instructions
• 40
QQ
u
43 Enter credit name i
code•
and amount,
•43
44 Enter credit name
code•
and amount.
•44
ij")
O
"
45 To claim more than two credits, see instructions. Attach Schedule P (540)
•45
46 Nonrefundable renter's credit. See instructions
•46
47 Add line 40 and line 43 through line 46. These are your total credits
® 47
48 Subtract line 47 from line 35. If less than zero, enter -0-
® 48
61 Alternative minimum tax. Attach Schedule P (540)
•61
.b
® 62
.b
.2
O
o
a.
£/)
14.489
(/}
O
62 fWental Health Services Tax. See instructions
o
n
63 Other taxes and credit recapture. See Instructions
•63
64 Add line 48, line 61, line 62, and line 63. This is your total tax
•64
14.489 QQ
71 California income tax withheld. See instructions
• 71
19.065
72 2017 CA estimated tax and other payments. See instructions
• 72
73 Withholding (Form 592-B and/or 593). See Instructions
• 73
74 Excess SDI (or VPDI) withheld. See instructions
• 74
75 Earned Income Tax Credit (EITC)
.• 75
QQ
c
0)
£
(C
o.
® 76
19,065 QQ
92 Payments balance. If line 76 is more than line 91, subtract line 91 from line 76
® 92
19,065
93 Use Tax balance. If line 91 is more than line 76, subtract line 76 from line 91.
® 93
76 Add lines 71 through 75. These are your total payments. See instructions
91 Use Tax. Do not leave blank. See instructions
X
1^
•91
If line 91 is zero, check if: I X I No use tax is owed.
o
0)
3
□ You paid your use tax obligation directly to CDTFA.
~ Q 94 Overpaid tax. If line 92 is more than line 64, subtract line 64 from line 92
k.
® 94
4,576
nj
O H
95 Amount of line 94 you want applied to your 2018 estimated tax
• 95
96 Overpaid tax available this year. Subtract line 95 from line 94
• 96
97 Tax due. If line 92 is less than line 64, subtract line 92 from line 64
® 97
•b
.b
O
090 1
3103176
4.576
Form 540 2017 Side 3
.b
.y
[17116;
Your name: IpIFFERINI
YourSSNorlTlN:
551-53-5651
Coda
California Seniors Special Fund. See instructions
•400
Alzheimer's Disease/Related Disorders Fund
•401
Rare and Endangered Species Preservation Voluntary Tax Contribution Program
*403
Calttornia Breast Cancer Research Voluntary Tax Contribution Fund
California Firefighters' Memorial Fund
Emergency Food for Families Voluntary Tax Contribution Fund
#407
California Peace Officer Memorial Foundation Fund
#408
California Sea Otter Fund
•410
California Cancer Research Voluntary Tax Contribution Fund
•413
School Supplies for Homeless Children Fund
•422
State Parks Protection Fund/Parks Pass Purchase.
.• 423
Protect Our Coast and Oceans Voluntary Tax Contribution Fund
,
•424
Keep Arts In Schools Voluntary Tax Contribution Fund.
State Children's Trust Fund for the Prevention of Child Abuse
*430
Prevention of Animal Homelessness and Cruelty Fund
*431
Revive the Salton Sea Fund
•432
California Domestic Violence Victims Fund
•433
Special Olympics Fund.
.• 434
Type 1 Diabetes Research Fund
California YMCA Youth and Government Voluntary Tax Contribution Fund.
Habitat for Humanity Voluntary Tax Contribution Fund.
CaliforniaSenior Citizen Advocacy Voluntary Tax Contribution Fund
Native California Wildlife Rehabilitation Voluntary Tax Contribution Fund
Rape Backlog Kit Voluntary Tax Contribution Fund.
110 Add code 400 through code 440. This is your total contribution
•ASS
Amount
[17116]
PIFFERINI
Your name:
YourSSN or iTIN:
551-53-5651
111 AMOUNT YOU OWE. It you do not Oave an amount on line 96, add line 93. line 97, and line 110. See instructions. Do not send cash.
Mail to: FRANCHISE TAX BOARD
PO BOX 942867
II
Ill
SACRAMENTO CA94267-D001
Pay online - Go to ttb.ca.gov/pay for more information.
^ v; 112 Interest, late return penalties, and late payment penalties
i:' n 113 Underpayment of estimated tax. Check the box:
M
112
FT6 5B05 attached •
□
FTB SBOSF attached. .*113
114 Total amount due. See instructions Enclose, but do not staple, any payment
114
QD
115 REFUND OR NO AMOUNT DUE. Subtract the sum of line 110, line 112 and line 113 from line 95. See instructions.
Mail to:
FRANCHISE TAX BOARD
POBOX 942840
SACRAMENTO CA 94240-0001
O
iT
D
4,576
• 115
.U
Fill In the Information to authorize direct deposit of your refund into oneor h.vo accounts. Do not attach a voided check or a deposit slip. See instructions.
Have you verllled the routing and account numbers? Use vrhcie dollars only.
All or the following amourrt of my refund (line 115) is authorized for direct deposit into the account shown below;
• Type
o
Zi
Routing number
5
S Checking ♦ Account number
• 116 Direct deposit amount
•c
o
□
121137522
"t5
c
Savings
4.576 J2Qi
8000310M1
The remaining amount of my refund (line 115) is authorized for direct deposit into the account shown below:
• Type
n Checking
• Routing number
117 Direct deposit amount
Account number
IMPORTANT: See the irstructiorrs to tmd out il you sbO'.ild aiiaeh a copy ot your compleie federal lax reiurn.
To learn aboul your pnvacy rights, how we may use your information, ar)d the consequences tor not providing the requested intormallon. go to
ftb.ca.gov/rorms and search (or 1131. To request this notice by mail, call 800.652.57i 1. Under penalties of perjury, i declare that 1 have examined this
tax return, including accompanying schedules and statements, artd to the best of my knowledge and belief, it Is true, correct, and complete.
Vbur signature
Spouto's/RDh 8 signaiuro (it a joint lax reiurn. both must sign)
Date
®Pfclorred phone number
(^Youi email address Enter only one email address.
Sign
Here
iigratuic [declaration of preparar is trased on all Intonation of which preparsr has any loiowledga)
It is unlawful
to forge a
spouse's/R tip's
signature.
Firm s name (or yo'rs, if self-employed)
DONALD
PTIN
■7^
P00073913
BYFIELD
Joint tax return?
(See Ihslruclions)
• FEIN
Rrm's addresa
1960
FRUITDALE AVE
JOSE
CA
95128
Oo you want to allow another person to discuss this tax reiurn with us? See ihslruclions.
□ No
Telephone Number
Print Third Party Dasigneo's Name
DONALD
Yes
408-295-0777
BYFIELD
090 I
3105175
Form 540 2017 Side 5
[17116]
SCHEDULE
TAXABLE YEAR
2017
California Adjustments — Residents
CA (5401
Important: Attach this schedule behind Form 540, Side 5 as a supportins California schedule.
SSN or ITIN
Names|s)as shown on lax relurn
551-53-5651
|o51-
ROC M & JOANNA L PIFFERINI
Partl Income Adiuslment Schedule
IB SuMftdlMi
See Hstiuclisns
A
Section A-Income
7
B
9
10
11
JUdllleai
B
See iisUuciiiiiii
Wages, salaries, tips. etc. See instructions betore making an entry In column B or C — 7 ® 217,8 42. ®
Taxable Interest(b)
— 8(8)®
®
Ordinary dividenfls. See instructions,(h)
9(3) ®
®
Taxable refunds, credits, offsets of state and focal Income taxes
10 ® 1,671.®
Alimony received
11®
il.
12®
®
13 Capital gain or (loss). See instructions
14 Other gains or (losses)
15 IRA distributions. See instructions,(a)
12 Business income or (loss)
13 ®
14 ®
15(b) ®
®
®
®
16
17
18
19
16(b) ®
®
^
®
®
Pensions and annuities. Sea Instructions.(a)__
Rental real estate, royalties, partnerships, S corporations, trusts, etc
Farm income or (loss)
Unemployment compensation
Social security benefits(a)(g
17 ®
18®
19 ®
.20(b)®
■
Other income.
e NOL from FTB 380SZ,
a California lottery winnings
b Disaster loss deduction from FTB 3805V
c Federal NOL (Form 1040. line 21)
d NOL deduction from FTB 3805V
3808,3807, or 3809
t Other (describe):
®
22 Total. Combine line 7 through line 21 in column A, Add line 7 through line 21f in
column B and column C. Go to Section B
1,671.1®
22 ® 240,633.1®
Section B -Adjustmenisto income
23 Educator expenses
23 ®
24 Certain business expanses of reservists, performing artists, and fee-basis
25
26
27
28
29
30
31a
government officials
24 ®
Health savings account deduction
Moving expenses
Deductible part ol self-employment tax
Sell-employed SEP, SIMPLE,and qualified plans
Self-employed health insurance deduction
Penalty on early v/ithdrawal of savings
Alimony paid,(b) Recipient's: SSN®
25 ®
26 ®
27 ®
28 ®
29 ®
30 ®
Last name ®
. • 31a ®
— 32®
32 IRA deduction
33 Student loan interest deduction
34 Tuition and lees
33 ®
34 ®
35 Domestic production activities deduction
35 ®
36 Add line 23 through line 3l3 and line 32 through line 35 in columns A, B, and 0.
See instructions
37 Total. Subtract line 36 from line 22 in columns A, B, ana C. See instructions
For Privacy Notlco.gM FTB 1131 ENC/SP.
36l®
®_
1,492.
.
1.492.1®
37l® 239,141.[®
1,671.1®
Schedule CA (540) 2D17fnEV02-l8) SIdel
[17116]
Part II Adjustments to Federal Itemized Deductions
Federal itemized deductions. Enter the amount from federal Schedule A (Form 1040), lines 4.9,15, 19,20,27, and 28
®38
Enter total of federal Schedule A (Form 1040), line 5(State Disability Insurance, and state and local Income tax. or
General Sales Tax) and line 8 (foreign Income taxes only). See Instructions
37,648.
19.065.
18.583.
40
41
18,583.
42
43 is your federal AG!(Form 540, line 13) more than the amount shown below for your filing status?
Single or marrled/RDP lilino separately
$187,203
Head of household
$280,808
Marrled/RDP filing jointly or qualifying wldow(6r)
$374,411
No. Transfer the amount on line 42 to iine 43.
18,583.
Yes. Complete the Itemized Deductions Worksheet In the instructions for Schedule OA (540), line 43
44 Enter the larger of the amount on line 43 or your standard deduction listed below
Single or marrled/RDP filing separately. See instructions
Marrled/RDP filing jointly, head of household, or qualifying vvldow(er)
®44
Transfer the amount on line 44 to Form 540, line 18.
Side 2 Schedule CA (540) 2017
090 1
$4,236
$8,472
7732173
18,583.
TAXABLE YEAR
2017
■
Altematlve MmimUlll TOX aHCJ
California schedule
Credit Limitations — Residents
P(540)
Attach this schedule to Form 540.
Name(s)as sliown on Form 540
Your SSN or ITIN
ROC M
551-53-5651
&
JOANNA L PIFFERINI
Part I Altemallve Minimum Taxable Income (AMTI) Importaiit: See Instructions (or inlormation regarding Calitornla/federa! differences
1 If you itemized deductions, go to line 2. If you did not itemize deductions, enter your standard
deduction from Form 540, line 18, and go to line 6
1
Z Medical and dental expense. Enter the smaller of Schedule A (Form 1040). line 4. or 2V4% (.025) of Form 1040, line 37 ..(5) 2
3
4
5
6
Personal property taxes and real property taxes. See instructions
Certain interest on a home mortgage not used to buy. build, or improve your home. See Instructions
Miscellaneous itemized deductions. See instructions
Refund of personal property taxes and real property taxes. See Instructions
Do not include your state income tax refund on this line.
7 Investment interest expense adjustment. See instructions
(g) 3
(•) 4
(•) 5
(•) 6(
.
M
3.517 GO
00
lOO
lOO)
{
(g) 7
8 Post-1986 depreciation. See instructions
(g) 8
9 Adjusted gain or loss. See instructions
® 9
!00
10 Incentive stock options and California qualified stock options(CQSOs). See instructions
®1Q
[OO
11 Passive activities adjustment. See instructions
®11
iOO
12 Beneflclarlesofestatesandtrusts. Enter the amount from Schedule K-1 (541), line 12a
®12
ioO
13 Other adjustment and preferences. Enter the amount, if any, for each Item, a through I, and enter the total on line 13. See Instructions,
a
b
c
d
e
f
Circulation expenditures.. ®
Depletion
®
Installment sales
®
Intangible drilling costs... ®
Long-term contracts
®
Loss limitations
®
LQ3. g iMining costs
®
[OS. h Patron's adjustment
®
[fiO.
|Pollution control facilities .. ®
l92 j Research and experimental. ®
192 k Tax shelter farm activities .. ®
[92-|Related adjustments
®
LSfi.
iSS
[92,
122
[92
-92
®13
00
14 Total Adjustments and Preferences. Combine line 1 through line 13
® 14
3.517 00
15 Enter taxable income from Form 540, line 19. See instructions
®15
218.887 00
16 Net operating loss (NOL) deductions from Schedule CA (540), line 21b, line 21d, and line 21 e. column B. Enter as
a positive amount
17 AMTI exclusion. See instructions
®16
®17(
00
100)
18 If your federal adjusted gross income (AGI) is less than the amount for your filing status (listed below), skip this line and go
i
to line 19. If you itemized deductions and your federal AGI Is more than the amount for your filing status, see instructions. ®18(
Single or married/RDP filing separately
Married/RDP filing jointly or qualifying wldow(er)
$187,203
S374,411
Head of household
5280,808
19 Combine line 14 through line 18
20 Alternative minimum tax NOL deduction. See instructions
® 19
®20
00)
222,404 00
00
21 Allematlve Minimum Taiable income. Subtract line 20 from line 19 (if married/ROP filing separately and line 21
>
is more than $355,690,see instructions)
®21
222,404!oo
®22
91.793 00
23
130,611 00
® 24
® 25
9,143 00
15.070 00
Part II AHematlve Minimum Tax (AIWT)
22 Exemption Amount.(If this schedule is for a certain child under age 24, see instructions.)
If your filing status is;
And line 21 is not over
Enter on line 22:
Single or head of household
3258,168
$68,846
Married/RDP filing jointly or qualifying widovv(er)
$344,225
Married/ROP filing separately
3172,110
$91,793
$45,895
\
I
j
If Part I, line 21 is more than the amount shown above for your filing status, see Instructions.
23 Subtract line 22 from line 21. If zero or less, enter -0-
24 Tentative Minimum Tax. Multiply line 23 by 7.0% (.07)
25 Regular tax before credits from Form 540,line 31
26 Alternative Minimum Tax. Subtract line 25 from line 24. If zero or less, enter -0- here and on Form 540, line 61. If more
than zero, enter here and on Form 540, line 61. If you make estimated tax payments for taxable year 2018, enter amount from
line 26 on the 2018 Form 540-ES, Estimated Tax Worksheet, line 16.(Exception: If you have carryover credit for solar
energy or commercial solar energy, first enter the result on Side 2, Part III, Section C, line 22 or 23)
For Privacy Notice,get FTB1131 ENG/SP.
090
| 7971174 |
® 26
Sctiedule P (540) 2017 SltJC 1
|
[OO,
[17116] ROC M & JOANNA L PIFFERINI
Part 111 Credits that Reduce Tax
551-53-5651
Note: 8e sure to attach your credit forms to Form 540.
14.489
1 Enter ihe amount from Form 540, line 35
2 Enterihe tentative minimum tax from Side 1, Part II, line 24
9,143
ID)
(d|
Credit used
Ciedd
carryover
thU year
Section A - Credits that reduce excess tax.
3 Subtract line 2 from line 1. II zero or less enter -0- and see instructions.
This Is vour excess tax which mav be offset bv credits
3
A1 Credits that reduce excess tax and tiave no carryover provisions.
4 Code: 162 Prisonmmate labor credit (FT8 3507)
4
5 Code- 232 Child and deoenderl care expenses credit (FIB 35G6)
5
A2 Credits that reduce excess tax and have carryover provisions. See instructions.
6
7
8
9
Code:®_
Code:®_
Cod6;®_
Code:®_.
, Credit Name:_
, Credit Name:_
, Credit Name:_
, Credit Name:
Section B - Credits that may reduce tax below tentative minimum tax.
11 It Part Mi. line 3 is zero, enter the amount from line 1. if line 3 is more liian
zero, enter the total ol ime 2 and the last entry m column (c)
11
81 Credits that reduce net tax and have no carryovar provislens.
12 Code: 170 Credit lor loint custody head ol household
12
13 Code: 173 Credit lor dependent parent
13
14 Code: 163 Credit for senior head of household
15 Nonrefundabie renter's credit
B2 Credits that reduce net lax and have carryover provisions. See Instructions.
14
IS
16 Code;®
17 Code:®
18 Code:®.,
Credit Name;
Credit Name:
Credit Name:
IB
17
18
19 Code:®
Credit Name:
19
83 Other stale lax credit.
20 Code: 187 Other Slate tax credit
20
Section C - Credils that may reduce aileraative minimum tax.
21 Enieryour alternative minimum taxtrom Side 1. Part li, Iine26.
22 Code. ISOSoiareneroy credit carryoverfrom Section 82. column (d)
21
22
23 Code;1B1 CQmmercialsoiareneroycrediIcarryoverfromSectionB2,coiumn(d).. 23
24 Adjusted AMT. Enter the balance from line 23, column (c) here
n Form 540, line 61
Siile2 Schedule P (540) 2017
7972174
5,346.
[17116]
TAXABLE YEAR
2017
CW-IFORNIAFORU
Passive Activity Loss Limitations
3801
Attach to Form 540, Long Form 540NR,Form 541, or Form 100S(S Corporations).
Naine(s) as shown an ta< lOturn
SSN. ITIN. FEIN, ot CA. co»potalion no.
ROC M
& JOANNA L PIFFERINI
551-53-5651
Part I
2017 Passive Activity Loss
See the inslructions for Worksheol 1 and Worksheet 3 for federal Form 858? before comoietins Part I. Be sure to use California amounts.
Rental Real Estate Acttviltes with Acllue Participation
la Activities with net Income from Worksheet 1. column (a).
lb Activities with net loss from Worksheet 1, column (b)
lit
1c Prior year unallowed losses from Worksheet 1, column (c)
1c
)\ OQ
Id Combinelinela. linBlb,and line lc
I Id
All Otfier Passive Activltias
2a Activities with net income from Worksheet 2, column (a)
2b Activities witft net loss from Worksheet 2. column (b)
_23_
2b
). 00
2c Prior year unallowed losses from Worksheet 2, column (c)..
2d Combine line 2a. line 2b. and line 2c
2tf
-12,017i qq
I 3 I
-12,017| qq
3 Combine line Id and line 2d. If the result is net Inco.me or zero, seethe Instructions for line 3. It line 3 and
line Id are losses, oo to line 4. Olhorwlse. enter -Q- on line 9 and go to line 10. See instructions
Part II Special Allowance for Rental Real Estate with Active Participation
Enter all numbers In Part II as positive amounts. See instructions.
4
Enter the smaller of losses from line Id or line 3.
5 Enter $150,000. If married/ROP filing a separate tax return, see instructions..
6 Enter federal modilled adlusted gross income, but not less than zero.
See Instructions.
If line 6 is equal to or more than line 5, skip line 7 and line 8. enter -0-
on line 9. and then go to line 10. Oifierwise. go to ime 7
_6__
7 Subtract line 6 from line 5.
8 Multiply line 7 by 50% (.50). Do not enter more than $25,000.
9 Enter the smaller of tine 4 or line 8
Part III Total Losses Allowed
10 Add the income, If any, from line 1 a and line 2a and enter the total
JL
11 Total losses allowed from all passive activities lor 2017. Add line 9 and line 10
LiL
Sec the inslructions on Page 2 to find cut how to report the losses on your tax return.
ForPrivacyNollce.gelFTBIISlENG^P.
090
FTB3801 2017
SIdel
FORM 3801 WORKSHEETS
Worksheet 2 - For Form 3801, Lines 2a, 2b, and 2c
Curre nt vear
Name of activity
a. Net income
Prior years
b. Net loss
RENTAL #1 RENTAL
c. Unald. loss
Overall cain or loss
d. Gain
e. Loss
12,017
Total. Enter on Form 3601 lines 2a,2b and 2c
12,017
12,017
Worksheet 4- Allocation of Unallowed Losses
Name of activity
RENTAL #1 RENTAL
Form or schedule
to be reported on
SCHEDULE E PART 1
a. Loss
Total
c. Unallowed
loss
b. Ratio
12.017
1.000000
12,017
12,017
1.00
12,017
Worksheet 5 - Allowed Losses
Name of activity
RENTAL #1 RENTAL
Total
Form or schedule
to be reported on
SCHEDULE E PART 1
c. Unallowed
loss
a. Loss
12,017
12,017
12,017
12,017
c. Allowed
loss
TAXABLE YEAR
2017
California Explanation of
Amended Return Changes
CALIFORNIA SCHEDULE
Attach this schedule to amended Form 540. Form 540 2E2. or Long or Short Form 540NR
Name(s)as shown on amended lax relurn
Your SSN Of ITIN
ROC M & JOANNA L PIFFERINI
551-53-5651
Part I Financial Adjustments - Reconciliation
1 Enter the amount you owe, as shown on the amended tax return
® 1.
M
2 Overpaid tax, If any, as shown on original tax return or as previously adjusted by the FTB. See instructions
® 2.
4>929 M
3 Add line 1 and line 2
® 3.
4,929 M
4 Enter the refund, as shown on the amended tax return. See instructions
® 4.
4,576 00
5 Tax paid with original tax return plus additional tax paid after it was filed. Do not include penalties and interest .. ® 5.
6 Add line 4 and line 5
®6.
4,576
7 AMOUNT YOU OWE. If line 3 is more than line 6, subtract line 6 from line 3. See instructions
® 7.
353 00
8 Penalties/Interest. See instructions: Penalties 8a
Interest Bb
9 REFUNO. If line 6 is more than line 3, subtract line 3 from line 6. See instructions
® Be.
® 9.
flO
Part II Reason(s)for Amending
1 Check all that apply:
®
®
®
®
®
a
b
c
d
e
□
□
□
□
□
Protective claim for refund
Reservation source income adjustments
Pass-through entity adjustments
Federal audit and/or adjustments
FTB audit contact
@
®
®
®
®
I
g
h
i
j
□ NOL carryback
□ Error on original return
□ Credit adjustment
® k □ Military HR 100
® I □ Informal claim
® m B) Dther
□ Earned income tax credit
□ Disaster Loss
2 If you checked boxes a, b, c, d, m or multiple boxes, provide further explanation of reason(s) for amending below. If needed, attach a separate sheet
that includes your name and SSN or ITIN.
DAUGHTER CLAIMED
HERSELF
For Privacy Notice, get FTB 1131 ENG/SP.
090 1
8531174
Schedule X (Nev/ 2017)
[1711^6],
Voucher at bottom of page.
DO NOT MAIL A PAPER COPY OF YOUR TAX RETURN WITH THE PAYMENT VOUCHER.
If amount of payment is zero,do not mail this voucher.
WHERE TO FILE:
Using black or blue ink, make your check or money order payable
to the "Franchise Tax Board." Write the taxpayer's social security
number(SSN)or individual taxpayer identification number (ITIN)
and "2017 FTB 3582X" on the check or money order. Detach
the voucher below. Enclose, but do not staple, payment with the
voucher and mail to:
FRANCHISE TAX BOARD
PO BOX 942867
SACRAMENTO CA 94267-0008
Make all checks or money orders payable in U.S. dollars and drawn against a
U.S.financial institution.
WHEN TO FILE:
Calendar Year- File and pay by April 17,2018.
When the due date falls on a weekend or holiday, the deadline to file and pay without
penalty is extended to the next business day.
Due to the federal Emancipation Day holiday on April 16, 2018, tax returns filed and
payments mailed or submitted on April 17,2018, will be considered timely.
ONLINE SERVICES: Use Web Pay and enjoy the ease of our free online payment service.
Go to ftb.ca.gov/pay for more information.
Do not mall this voucher If you use Web Pay.
IF NO PAYMENT IS DUE, DO NOT MAIL THIS VOUCHER
.DETACH HERE.
IaUtiinON:You may be required to pay electronically. See instructions.
TAXABLE YEAR Paymeiit Voucher for
DETACH HERE.
CALIFORNIA FORM
3582X (e-flle)
2017
551-53-5651
PIFF
ROC
M
PIFFERINI
564-89-5273
JOANNA
L
PIFFERINI
17
PO BOX 1495
TWAIN
HARTE
CA
95383
Amount of Pavment
Far Privacy NoUce,get FTB 1131 ENG/SP.
090
1301176
353.
FTB 3582X (NEW 2017)
V
DONALD BYFIELD EA
^
1960 FRUITDALE AVE
SAN JOSE CA 95128
Dear ROC M & JOANNA L PIFFERINI
We appreciate the opportunity we have had of serving you this year. Enclosed are your federal and
state tax returns for 2018.
You must pay a federal balance due of $1,823. Make your check payable to the UNITED STATES
TREASURY.
You have indicated that you and all persons on your return had full-year health care coverage. There is
no Affordable Care Act shared responsibility payment.
Yau will receive a state refund of $3,716.
Very truly yours,
DONALD BYFIELD EA
2018 PRIOR YEAR COMPARISON
INCOME
Salaries & Wages
2017
2018
CHANGE
217,842
174,214
-43,628
1,671
4,576
2,905
27,105
27,105
205,895
-21,120
-34,738
Taxable Interest
Tax-exempt Interest
Dividend Income
State tax refund
Alimony received
Business income or loss
Capital gain/losss
Form 4797 gains/losses
IRA distributions (taxable)
Pensions (taxable)
Rents, ptnr, estates
Farm income or loss
Unemployment comp.
Soc. sec. benefits (taxable)
Other income
21,120
240,633
TOTAL INCOME
ADJUSTMENTS TO INCOME
2017
Educator expenses
Certain business expenses
Health savings account deduction
Moving Expenses
Deductible part of SE tax
SE SEP, SIMPLE and qualified plans
Self-emp health Insurance ded
Penalty on early savings withdrawal
Alimony paid
2018
CHANGE
1,492
363
-1,129
1,492
239,141
363
205,532
-1,129
-33,609
IRA deducUon
Student loan interest deduction
Tuition and fees deduction
Other adjustments
TOTAL ADJUSTMENTS
ADJUSTED GROSS INCOME
ITEMIZED DEDUCTIONS
2017
CHANGE
2018
Allowed medical & dental
22,582
13,911
1,155
10,000
14,222
-12,582
760
-395
STANDARD DEDUCTION
37,648
12,700
24,982
24,000
-12,666
11,300
Total exemptions
12,150
-12,150
Exemptions phased out
Exemptions allowed
12,150
-12,150
Total tax deductions
Total Interest deductions
Total gifts to charity
Casualty & theft deductions
311
Misc. ded. sub to 2% AGI
Misc. ded. not sub to 2%
Itemized deduction limitation
TOTAL ITEMIZED DEDUCTIONS
TAXABLE INCOME
189,343
175,202
-14,141
Continued on next page...
2018 PRIOR YEAR COMPARISON
ADDITIONAL INFORMATION - Continued...
Regular tax
39.901
30.627
-9.274
39,901
30,627
-9,274
Additional taxes(4972 & 8814)
Alternative minimum tax
Excess advance PTC repayment
INCOME TAX+ AMT
CREDITS
2017
2018
CHANGE
Foreign tax credit
Child care credit
Education credits
Retirement savings credit
Child tax credit
500
500
500
500
30,127
-9,774
Residential energy credits
Elderly/Disabled credit
General business credit
8396.8801,8839,8910
TOTAL CREDITS
TOTAL TAX LESS CREDITS
39,901
OTHER TAXES
2017
Seir-employment tax
Unreported soc. sec. & Medicare tax
2018
2.984
CHANGE
726
-2.258
Tax on an IRA
Household employment taxes
Repayment of homebuyer credit
Health Care - individual Responsibility
Additional medicare tax
235
-235
Net Investment income tax
Other taxes(4255,4970 & 8828)
TOTAL TAX
43,120
PAYMENTS
Federal income tax withheld
2017
30.853
2018
-12.267
CHANGE
40.885
29,030
-11,855
40.885
29,030
-11.855
Estimate payments
Eamed income credit
Additional child tax credit
American opportunity credit
Net Premium tax credit
Paid with extension
Excess FICA & RRTA tax
Fuels tax credit
Form(s)2439, 8839, 8801 and 8885
TOTAL PAYMENTS
REFUND OR BALANCE DUE
2017
2018
CHANGE
Amount overpaid
Amount to be refunded
Amt applied to estimates
Balance due
2,235
1.823
-412
Form 2210 penalty
Continued on next page...
ROC IVI & JOANNA L PIFFERINI
XXX-XX-56S1
2018 PRIOR YEAR COMPARISON
ADOmONAL INFORMATION - Continued..
OTHER DATA
Estimate option # used
State tax refund carryover
NOL carryover
Short cap. ioss carryover
Long cap. ioss carryover
Contribution carryover
Investment int. cr. carryover
Passive activity loss carryover
2017 FILING STATUS:Married Joint
2018 FILING STATUS:Married Joint
2017
2018
CHANGE
4,576
982
-3,594
12,017
35,945
23,928
[18160]
OMBNo. 1S4S-0074
Form 8879
Department of the Treasury
IRS e-file Signature Authorization
^ Go to www.lrs.gov/Fom8879 for the latest Information.
Internal Revenue Service
Submission Identification Number
(SID) ^
Taxpayer's name
ROC
M
>®18
>■ Return completed Form 8879 to your ERO. (Don't send to the IRS.)
Social security number
PIFFERINI
551-53-5651
Spouse's name
Spouse's sodal security number
JOANNA L PIFFERINI
564-89-5273
Parti
Tax Return Information — Tax Year Ending December 31,2018 (Whole dollars onl
1
2
3
Adjusted gross income (Form 1040, line 7; Form 1040NR, line 35)
Total tax (Form 1040, lire 15; Form 1040NR, line 61)
Federal Income tax withheld from Forms W-2 and 1099 (Form 1040, line 16; Form 1040NR, line 62a).
4
Refund (Form 1040, line 20a; Form 1040-88, Part I, line 13a; Form 1040NR, line 73a)
5
Amount you owe (Form 1040, line 22; Form 1040NR, line 75)
Part 11
205.532
30.853
29, 030
| 5
1. 823
Taxpayer Declaration and Signature Authorization (Be sure you get and keep a copy of your return)
Under penalties of perjury. I declare that I have exarrlned a copy of my electronic individual Income tax return and accompanying schedules and statements
for the tax year ending December 31, 2018. and to the best of my knowledge and belief, they are true, correct, and complete, I further declare that the amounts
In Part I above are the amounts from my electronic income tax return. I consent to allow my Intermediate service provider, transmitter, or electronic return
originator (ERO) to send my return to the IRS and to receive from the IRS (a) an acknowledgement of receipt or reason tor rejection of the transmission, (b) the
reason for any delay in processing the return or refund, and (c) the date of any refund. If applicable, I authorize the U.S. Treasury and Its designated Financial
Agent to Initiate an ACH electronic funds withdrawal (direct debit) entry to the financial Institution account indicated in the tax preparation software for payment
of my federal taxes owed on this return and/or a payment of estimated tax, and the financial institution to debit the entry to this account. This authorization Is to
remain In full force and effect until I notify the U.S. Treasury Financial Agent to terminate the authortzalion. To revoke (cancel) a payment, I must contact the U.S.
Treasury Financial Agent at 1-S88-353-4537. Payment cancellation requests must he received no later than 2 business days prior to the payment (settlement)
date. I also authorize the financial institutions involved in the processing of the electronic payment of taxes to recwe confidential Information necessary to
answer inquiries and resolve Issues related to the payment. I further acknowledge that the personal identification number (PIN) below is my signature for my
eiectronic income tax return and, if applicable, my Hectronic Funds Withdrawal Consent.
Taxpayer's PIN: check one box only
i—i—i—i—i—
IS I authorize DONALD D BYFIELD
ERO firm name
as my signature on my tax
D I will enter my PIN as
to enter or generate my PIN I 5 I 5 I 3 I 5 I 5
Enter
Enter five
five digits,
digits, but
but
don't enter all zeros
S electronically filed income tax return.
"*"0®
on my tax year 2018 electronically filed income tax return. Check this box only if you are
entering your owo^^lm^our r^m is filed using the Practitioner PIN method. The ERO must complete Part III below.
Your signature ►
Date ► 03-26-2019
Spouse's PIN: checl^ie box only
i—i—i—i—i—
iS I authorize DONALD D BYFIELD
to enter or generate my PIN I 7 | 8 I 9 I 5 I 5
ERO firm nams
Enter five
five dl^ts,
dltfts, but
hut
Enter
dont enter all zeros
as my signature on my tax year 2018 electronically filed income tax return.
D I will enter my PIN as my signature on my tax year 2018 electronically filed income tax return. Check this box only if you are
entering your own PIN and your retum is filed using the Praclitfoner PIN method. The ERO must complete Part III below.
Spouse's signature ►
Date^
03-26-2019
Practitioner PIN Method Returns Only—continue below
Certification and Authentication — Practitioner PiN Method Only
7 I ll418 I 0 I
ERO's EFiN/PIN. Enter your six-digit EFIN followed by your five-digit self-selected PIN.
Don't enter all zeros
I certify that the above numericentryls my PIN, which is my ^qnature for the tax year 2018 electronically filed income tax retum for
the taxpayer(s) indicated abov^^conflmi that I am submrtting^is return in accordance with the requirements of the Practitioner PIN
method and Pub. 1345, Handb^'^o'' Whoriz^RS e-Tile Providers of Individual Income Tax Returns.
ERO's signatured
Dated
03-26-2019
ERO Must Retain This Form — See instructions
Don't Submit This Form to the IRS Unless Requested To Do So
For Paperwork Reduction Act Notice, see your tax retum instructions.
Cat. No. 3277BX
Form 8879 (2018)
090
[18160]
Date Accepted
DO NOT MAIL THIS FORM TO THE FTB
TAXABLE YEAR
2018
FORM
California e-file Return Authorization for Individuals
Your Hrst name and Initial
Last name
Suffix
Last name
Sufflx
8453
YourSSNorlTIN
ROC M PIFFERINI
XXX-XX-5651
If joint return, spouse's/RDP's first name and Initial
Spouse's/RDP's SSN or ITIN
JOANNA L PIFFERINI
XXX-XX-5273
Street address(number and street) or PO box
Apt. no.late. no.
PMByprivato mailbox
Daytime telephone number
201 W MISSION STREET
(480) 233-5857
City
State
SAN JOSE
ZIP code
95110
CA
Foroign country name
Foreign province/state/county
Foreign postal code
Part I Tax Return Intortnallon (whole dollars only)
1 California adjusted gross income. See instructions.
1
200.956.
2 Refund or no amount due. See instructions
2
3.716.
3 Amount you owe. See instructions
.3
Partll Settle Your Account Electronically tor Taxable Year 2018(Payment due 4/15/20191
4 □ Direct deposit of refund S □ Electronic funds withdrawai 5a Amount.
5b Withdrawal date (mm/dd/Vyyy).
Part III Mafre Estimated Tax Payments for Taxable Year 2019 These are NOT installment payments for the current amount you owe.
First Payment Due 4/15/2019
Second Payment Due 6/17/2019
Third Payment Due 9/16/2019
Fourth Payment Due 1/15/2020
6 Amount
7 Withdrawal date
Part IV Banking Information (Have you verified your banking Information?)
8 Amount of refund to be directly deposited to account below_
9 Routing number
12 The remaining amount of my refund for direct deposit.
13 Routing number
10 Account number
14 Account number
11 Type of account: □ Checking
□ Savings
Part V Declaration of Taxpayer(s)
15 Type of account: □ Checking
□ Savings
I authorize my account to be settled as designated in Part 11. If I check Part II, Box 4,1 declare that the direct deposit refund Information in Part IV agrees with the authorization
stated on my return. If I check Part II, Box 5,1 authorize an electronic funds withdrawal for the amount listed on line 5a and any estimated payment amounts listed on line 6
from the bank account listed on lines 9,10, and 11. If I have filed a joint return, this is an irrevocable appointment of the other spouse/RDP as an agent to receive the refund
or authorize an electronic funds withdravral.
Under penalties of perjury, I declare that the information I provided to my electronic return originator (ERO), transmitter, or intermediate service provider, including my
name.adc'
"
'
..
u,,.....
,
^
amounts!
filing r
all applicable interest and penalties. I auth^e I
service provider. If the processing offprfffliffri
delay or the dale when the refund <
return and accompanying schedules and statements be transmitted to the FTB by my ERO, transmitter, or Intermediate
refund is delayer!, I authorize the FTB to disclose to my ERO or Intermediate service provider the reason(s) for the
Sign
03/26/19 1^
Here
signatu
03/26/19
Spouse's/RDP's signature. II liiingjointly, I>o0i must sign.
D ate
It Is unlatvful to forge a spouse's^DP^ signature.
Date
Part VI Declaration of Electronic Return Originator (ERO) and Paid Preparer. See Instructions.
I declare that I have reviev/ed the above taxpayer's return and that the entries on form FTB 8453 are complete and correct to the best of my knowledge. (If I am only an intermediate
service provider, I understand that I am not responsible for reviewing the taxpayer's return. I declare, however, that form FTB 8453 accurately reflects the data on the return.) I have
obtained the taxpayer's signature on form FTB 8453 before transmitting this return to the FTB; I have provided the taxpayer with a copy of all forms and Information that I will file with
the RB, and I have followed all other requirements described in RB Pub. 1345,2018 Handbook for Authorized e4ile Providers. I will keep form RB 8453 on file for four years from
the due date of the retum or four years from the date the return Is filed, whichever is later, and I will make a copy available to the RB upon request. If I am also the paid preparer,
under penalties of perjury, I declare tbatl^re examined the above taxpayer's retum and accompanying schedules and statements, and to the best of my knowledge and belief, they
are true, correct, and complete. I
this deration based on all information of which I have knowledge.
•1
ERO
Must
Sign
XA
ERO's- ^ \ ^
signature
Cliecklf
03/26/19
also paid
preoarer Bi
Check
It self-
SAN JOSE CA
P00073913
FEIN
1960 FRUITDAlX AVE
^
ERO's PTIN
emploved BI
DONALB D BYPIELD
Firm's name (or yours
If self-employed)
and address
Date
ZIP code 95128
^
belief, they are true, correct, and complete. I make this declaration based on all information of which I have knowledge.
Dale
Paid
'
preparer's
Must
Firm's name (or yours^
allin
II seii-eiiipiuyeu;
Preparer signature W
"
and address
For Privacy Notice, get FTB 1131 ENG/SP.
Check
If self-
Paid preparer's PTIN
employed □
FEIN
ZIP code
FTB 8453 2018
[18160]
OepartmenlofttaeTreasuiy—intemolRevenueSefvice
(99]
■ O 0MB No.1545-D074 I IRSUseOnly'Dono^mrtdorstaf^olnth^spsco.
'
£ w*fU U.S. Individual Income Tax Return
Filing status: Q Single
Kl Manied filing jolnlfy Q Married fifing separately [~~1 Head ot hous^cJd l~) Qualifying wldow<er)
Your first name atMf initial
Last name
ROC M
Your sodal security number
PIFFERINI
Your standard deduction:
I I Someone can claim you as a dependent
If joint return, spouse's first name and Initial
D Youareblind
Last name
JOANNA L
Spouse's social security number
XXXlXXl5273
Full-year health care coverage
PIFFERINI
Spouse standard deduction: Q Someone can claim your spouse as a dependent
l~l Spouse Is blind
XXX|XX|5651
I 1 You were bom before January 2,1954
O Spouse was bom before January 2,1954
O Spouse Itemizes on a separate return or you were dual-status alien
or exempt (see inst.)
Home address (number and street}. If you haveaP.O, box, see Instructions,
Apt. no,
i
Apt.
(see^) □you □spouse
201 W MISSION STREET
City, town or post office, slate, and 2SP code. If you have a foreign address, attach Schedule 6,
If more trian four dependents,
SAN JOSE OA 95110
Dependents (see instnictfons):
(1) First name
Presidential Bection Campaign
x—
(2) Sodal security number
(3) Relatwi^lp to you
see InsL and ✓ here ►
(4) / if qualifies for (see Inst.):
Child tax credit
Chi
last name
ROC M PIFFERINI
□
XXX-lXXf2698 SON
Credit for other dependents
^
1
□
□
Sign
Here
Under penalties of perjury, I dedBS that I have examined B<is return and accompanying schedules and statements, and la tha best ol my knowledge and befief, they are (rue,
correct, and complete. Derdaralion of preparer yber than tanpayed is based on all Mormatlon of which pr^jarer haa any knowledge.
PIN, enter it
POLICE
See instnictiorts.
(return, tfodi must sign. | Dale
Keep a copy for
Preparer
Use Only
For Disclosure,
OFFICER
tiere (see Inst)
II ttie IRS sent you an Identity Protection
Spouse's oocupallon
PIN, enter It
your records.
Paid
It the IRS sent you an Identity Protection
Your occupadon
Your signature
Joint return?
Sme
DONALD BYFIELD EA
Pj|(MJ^r'ysigr\a,ture^
I
HOUSEWIFE
j
\ ^
PTIN
Firm's
hare (see Inst)
P0Q073913
Phone no, 408~295
Firm's name ► DONALD BYFIELD '
408~295"— 0777
Firm'saddresse-1960 FRUITDALE AVE SAN JOSE CA 95128
Privacy Act, and Paperwork Reduction Act Notice, see separate instnictlons.
Ver.
03/21/19
CaL No. 11320B
IX] Srd Ferty Oesignee
Sslf'employed
Foon 1040 (2018)
Page 2
174,214
Form 1040(2018)
Wages, salaries, tips, etc. Attach Form(s) W'2
Tax-exempt interest.
AnachFonn(i}
W-2.Also attach
FoiTn(4W-2Qand
3a
lO^RIftaxvias
withheltl.
^
^
.
_2a
.
3a
IRAs, penaons, and anniitles ,
4a
Social security benefits .
5a I
Qualified dividends ,
.
b Taxable interest
.
.
b Ordinary dividends.
b Taxable amount
|
Tolalinconie.Addl(nes1through5.AddanyamoumlromSdiedule1,lne22
b Taxable amount
.
.
.
31# 68 1
205.895
Adjusted gross income, tf you have no adjustments to income, enter the amount from line 6; otherwise,
Standsnl
205.532
24.982
subtract Schedule 1, line 36, from line 6
1
Oaduction Tor—
•Singlo or marnod
8
Standard deduction or Itemized deductions (from Schedule A)
filing separalBly.
®
Qualified business inccxne deduction (see instructions)
$12,000
5, 348
175.202
Taxable Income, Subtract lines S and 9 from line 7. If zero or less, enter -0-
•Mailed filing
jointly or Qualifying 11
aTax (see inst)
widow(er},
$24,000
b Add any amount from Schedule 2 and check here
)
► IZI
a Child tax credit/credit for other dependents
'3
Subtract line 12 from line 11, If zero or less, enter-0-
14
OlJier taxes. Attach Schedule 4
IS
Total tax. Add lines I3and 14
30.853
Federal income lax withheld from Forms W-2 and 1099
29,030
household,
• If you checked
any box under
Standard
deduction,
see Instruclione,
500 b Add any amount from Schedule 3 and check here ► !ZI
30.627
500
^3
• Head of
$18,000
30, 627 (check II any from: 1 I I FormfslSSK 2 I I Form 4972 3 D
Refundatile credits: a EIC (see Inst.)
30.127
726
b Sch 8812
c Form 8863
886:
Add any amount frofii Schedule 5
29,030
Add lines 18 and 17. These are your total payments
II line 18 Is more than linelS, subtract line 15 from line 18. This is the amount you overpaid
Refund
Amountofline19youwantrefundedtovou. tf Form 68B8 Is attached, check here
Direct deposit?
^
I,
>■
a
See instiuctlons.
Routing number
Account number
I
|
I
|
I
|
I
I
I
I
I
I
I
I
I
I
I
I
22
.
I ►cType: Q Checking
I I I I I I I
Amount of lire 19vouwantapDliedtovour2019estimafedtax .
Amount You Owe
.
, ►
21 |
Amount you owe. Subtract line 18 from line 15. For details on how to pay, seelnstnjctlohs
Estimated tax penalty (see Instructions)
Go to www.lrs.gov/Form 1040 for Instructions and the latest information.
n Savings
1. 823
I 23 I
FofTR 1040 (2018)
Additional Income and Adjustments to Income
Depailniert of the Treasury
^„.
1©18
^Attach to Fonn 1040.
^
for instructions and tiie latest informatfon.
^ Go to www.lrs.gov/Form1040
www.ln
Inteniai fleveiue Servfce
OMB No. 1545-0074
Attachment
Sequence No.01
Your social security number
Name(s)shown on Form 1040
XXX-XX-5651
ROC M & JOANNA L PIFFERINI
Additional
Reserved
. . . .
Income
Taxable refunds, credits, or offsets of state and local Income taxes
4,376
Taxable refunds, credits
Alimony received
Business Income or (loss). Attach Schedule C or C-EZ
27,105
Capital gain or (loss). Attach Schedule 0 if required. If not required, check here > □
Other gains or (losses). Attach Form 4797
Reserved
Reserved
Rental real estate, royalties, partnerships. S corporations, trusts, etc. Attach Schedule E
Farm income or (loss). Attach Schedule F
Unemployment compensation
Reserved
Other income.
Combine the amounts in the far right column. If you don't have any adjustments to
income, enter here and Include on Form 1040. line 6. Otherwise, go to line 23 .
Educator expenses
_23
Certain business expenses of reservists, performing artists,
and fee-basis govemment officials. Attach Form 2106 . . _24
Health savings account deduction. Attach Form 8889 .
31.681
f\4ovlng expenses for members of the Armed Forces.
Attach Form 3903
_26
Deductible part of self-employment tax. Attach Schedule SE _27
Self-employed SEP, SIMPLE, and qualified plans
Self-employed health Insurance deduction . .
Penalty on early withdrawal of savings
Alimony paid b Recipient's SSN ►
IRA deduction
,
Student loan Interest deduction
Reserved
Reserved
.
.
.
.
361:
_28
_29
31a
_32
_33
_34
I 35 I
.
'
.
-
Add lines 23 through 35
For Paperwork Reduction Act Notice, see your tax retum Instructions.
Cat. N0.71479F
Schedule 1 [Fonti 1040) 2016
SCHEDULE 4
(Form 1040)
CMS No. 1545-0074
Other Taxes
i®i8
P-Attach to Form 1040.
Department ol the Treasuiy
Attachment
P^Go to ivww./rs.gov/Fomi1040for Instructions and the latest Information.
Internal Revenue Service
Sequence No.04
Your social security number
Name(s)shown on Form 1040
ROC M & JOANNA L PIFFERINI
Other
Taxes
XXX-XX-5651
57
Self-employment tax. Attach Schedule SE
^ Unreported social security and Medicare tax from: Form a □ 4137 b □ 8919
726
58
59
Additional tax on IRAs, other qualified retirement plans, and other tax-favored
accounts. Attach Form 5329 if required
60a Household employment taxes. Attach Schedule H
b Repayment of first-time homebuyer credit from Form 5405. Attach Form 5405 if
required
61
Health care; Individual responsibility (see Instructions)
62
Taxes from: a □ Form 8959 b □ Form 8960
59
60a
60b
61
cD Instructions; enter code(s)
63
, j
Section 965 net tax liability Installment from Form
965-A
64
62
'
1 63 1
1
• ■
'
•
.
1
1
Add the amounts In the far right column. These are your total other taxes. Enter
here and on Form 1040, line 14
For Paperwork Reduction Act Notice, see your tax return Instructions.
64
Cat. No. 71481R
726
Schedule 4 (Fonn 1040) 2018
Foreign Address and Third Party Designee
SCHEDULE6
(Form 1040)
Oepaitment of the Treasury
Intmal Revenue Service
1@18
► Attach to Form 1040.
► Go to www.lr8.gov/Form1040 for instructions and the latest information.
Name(s) shown on Form 104Q
ROC M
&
Foreign
JOANNA L
0MB No. 15454)074
Attachment
Sequence No. U5A
Your social security number
XXX-XX-5651
PIFFERINI
Foreign country name
Foreign province/county
Foreign postal code
Address
Third Party
Designee
Do you want to allow another person to discuss this return with the IRS (see Instructions)? S] Yes. Complete below.
□ No
Deslgnee's
Phone
Personal Identification number
name ►DONALD BYFIELD EA
no. ► 408-295-0777
(PIN) ► 80148
For Paperwork Reduction Act Notice, see your tax return instructions.
Cat. No. 71483N
Schedule 6 (Form 1040) 2018
Itemized Deductions
ir«iin iw-rw^
Department of the Treasury
Internal Revenue Service (99)
OMB No. 1S45-0074
►Go to ivmv./ra.gov/Scftedo/eA for instructions and the latest Informalion.
►Attach to Form 1040.
Caution: If you are claiming a net qualified disasterloss on Form 4684, see the instructions for line 16.
Na/nefs) shown on Form 1040
ROC
M
&
JOANNA L
Medical
Sequence No. 07
Your social security number
PIFFERINI
XXX-XX-5651
Caution: Do not include expenses reimbursed or paid by others.
and
1 Medical and dental expenses (see instructions)
Dental
2 Enter amount from Form 1040, line 7 |2|
Expenses
3 Multiply line 2 by 7.5% (0.075)
_1
205, 532
[_3l
4 Subtract line 3 from line 1. If line 3 is more than line 1. enter -0- .
Taxes You
Paid
^{fi)18
Attachment
5
15,415
.
State and local taxes.
a State and local income taxes or general sales taxes. You may
include either income taxes or general sales taxes on line 5a,
but not both, if you elect to include general sales taxes instead
of income taxes, check this box
► □ 5a
b State and local real estate taxes (see instructions)
5b
15.654
3, 637
c State and local personal property taxes
d Add lines 5a through 5c
e Enter the smaller of line 5d or $10,000 ($5,000 if married filing
5c
5d
19,632
^
10,000
separately)
341
6 Other taxes. List type and amount ►
10.000
Add tines 5e and 6
Interest You 8 Home mortgage interest and points. If you didn't use all of your
Paid
home mortgage )oan(s) to buy, build, or improve your home,
CauUon: Your
see instructions and check this box
mortgage interest
deduction may be
►IS
a Home mortgage interest and points reported to you on Form
limited (see
-rioo
Instructions).
12,7841
lUytS
bHome mortgage interest not repotted to you on Form 1098. If
paid to the person from whom you bought the home, see
instructions and stiow that person's name, identifying no., and
address ►
J83|
c Points not reported to you on Form 1098. See instructions for
special fules
8c
d Reserved
8d
eAdd lines 8a through 8c
8e_
9 Investment interest.
Attach
Form
4952
if required.
Gifts to
Charity
If you made a
gift and got a
benefit for II,
see Instructions.
[_9
14,222
Add lines 8e and 9
11 Gifts by cash or check. If you made any gift of $250 or more,
see instructions SEE STATEMEN'T
JJ
1S_
12 Other than by cash or check. If any gift of $250 or more, see
instructions. You must attach Form 8283 if over $500 . . . ^
13 Carryover from prior year
14 Add lines 11 through 13
Casualty and
14 , 222| "
See
Instructions .
10
455l
[13
.
Theft Losses
15 Casualty and theft loss(es) from a federally declared disaster (other than net qualified
disaster losses). Attach Form 4684 and enter the amount from line 18 of that form. See
Other
16 ether—from list in instructions. List type and amount ►
instructions
Itemized
Deductions
Total
Itemized
17 Add the amounts in the far right column for lines 4 through 16. Also, enter this amount on
24. 982
Form 1040, lines
Deductions 18 If you elect to Itemize deductions even though they are less than your standard
deduction, check here
For Paperwork Reduction Act Notice, see the Instructions for Form 1040.
• • • ►
Cat. No. 171450
D
Schedule A ^orm 1040) 2018
SCHEDULE0
(Form 1040)
Oepartmsnt of the Treasuiy
Internal Revenue Service(99)
OMB No. 1545-0074
Profit or Loss From Business
(Sole Proprietorship)
P Go to wwwJrs.gov/ScheduleC for instructions and the latest information.
P-Attach to Form 1040,1040NR,or 1041; partnerships generally must file Form 1065.
Name of proprietor
Sequence No.09
Social security number(SSN)
ROC M PIFFERINI
A
1018
Attachment
XXX-XX-5651
Principal business or profession, including product or service(see instructions)
B Enter code from Instructions
►I5l6lll6l0l0
SECURITY
C
Business name. If no separate business name, leave blank.
D Employer ID number (EIN) (see instr.)
1
FIRST ALARM SECURITY
Business address (including suite or room no.) ► 4160 JADE ST
City, town or post office, state, and ZIP code
CAPITOLA CA
(2) Q Accrual
1
1
Accounting method:
G
Did you "materially participate" in the operation of this business during 2018? if "No," see instructions for limit on losses
H
I
If you started or acquired this business during 2018, check here
Did you make any payments in 2018 that would require you to file Foim(s) 1099? (see instnictions)
1
. HYes
QYes
►□
6
Other income, including federal and state gasoline or fuel tax credit or refund (see instructions) .
7
Gross income. Add lines 5 and 6 .
Part II
.
.
Advertising
.
6
►
7
22
Office expense (see instructions)
Pension and profit-sharing plans
Rent or lease (see instructions):
Vehicles, machinery, and equipment
Other business property . . .
Repairs and maintenance . . .
Supplies (not included in Part ill) .
23
Taxes and licenses
18
8
19
Car and truck expenses (see
instructions)
3.701
20
10
a
11
11
b
Mortgage (paid to banks, etc.)
Other
12
13
21
32.175
14
16b
20a
20b
21
22
23
Travel
24a
b
Deductible meals (see
instructions)
24b
25
25
Utilities
26
Wages (less employment credits).
Other expenses (from line 48). .
27a
Reserved for future use .
27b
27a
b
Legal and professional services
28
Total expenses before expenses for business use of home. Add lines 8 through 27a
29
Tentative profit or (loss). Subtract line 28 from line 7
17
19
a
15
16a
18
Travel and meals:
24
17
30
.
Expenses. Enter expenses for business use of your home only on line 30
Contract labor (see instnictions)
Depletion
Depreciation and section 179
expense deduction (not
Included in Part ill) (see
instructions)
Employee benefit programs
(other than on line 19). .
insurance (other than health)
interest (see instructions):
16
32.175
5
Commissions and fees
15
32.175
_4_
10
14
QNo
32.175
3
Subtract line 2 from line 1
13
QNo
2
Returns and allowances
Cost of goods sold (from line 42)
Gross profit Subtract line 4 from line 3
12
1
Gross receipts or sales. See instructions for line 1 and check the box if this income was reported to you on
3
9
1
Income
4
5
8
1
^ GSI
OY^
Form W-2 and the "Statutory employee" box on that form was checked
2
1
(3) Q Other (specify)
If "Yes." did you or will you file required Forms 1099?
Part I
1
95010
F
J
(1) Xl^ash
1
65
.
.
^
26
1.369
28
5.070
29
27.105
Expenses for business use of your home. Do not report these expenses elsewhere. Attach Form 8829
unless using the simplified method (see instructions).
Simplified method fliers only: enter the total square footage of: (a) your home:
and (b) the part of your home used for business:
31
■ Use the Simplified
30
Method Worksheet In the Instructions to figure the amount to enter on line 30
Net profit or (ioss). Subtract line 30 from line 29.
• If a profit, enter on both Schedule 1 (Form 1040), line 12 (or Form ia40NR, line 13) and on Schedule SE,
line 2. (If you checked the box on line 1, see instructions). Estates and trusts, enter on Form 1041, line 3.
27.105
31
• If a loss, you must go to line 32.
32
If you have a loss, check the box that describes your investment In this activity (see instructions).
• If you checked 32a, enter the loss on both Schedule 1 (Form 1040), line 12 (or Form 1040NR,
line 13) and on Schedule SE, line 2. (If you checked the box on line 1, see the line 31 Instructions).
Estates and trusts, enter on Form 1041, line 3.
» If you checked 32b, you must attach Form 6198. Your loss may be limited.
For Paperwork Reduction Act Notice, see the separate Instructions.
32a G All Investment Is at risk.
32b G Some Investment is not
at risk.
Cat.No. 11334P
Schedule C (Form 1040) 2018
ROC M PIFFERINI
XXX-XX-5651
Schedule C(Form 1040)2018
Part III
33
Method(s) used to
value closing inventory:
34
Page 2
Cost of Goods Sold (see Instructions)
a K) Cost
b □ Lxiwer of cost or market
c □ Other (attach explanatbn)
Was there any change in determining quantities, costs, or valuations between opening and closing inventory?
If "Yes," attach explanation
35
Inventory at beginning of year. If different from last year's closing inventory, attach explanation
35
36
Purchases less cost of items withdrawn for personal use
36
37
Cost of labor. Do not include any amounts paid to yourself
37
38
Materials and supplies
39
Other costs
39
40
Add lines 35 through 39
40
41
Inventory at end of year
41
42
Cost of goods sold. Subtract line 41 from line 40. Enter the result here and on line 4 .
Part IV
.
.
Q Yes
|X) No
42
Information on Your Vehicle. Complete this part only if you are claiming car or truck expenses on line 9
and are not required to file Form 4562 for this business. See the instructions for line 13 to find out If you must
file Form 4562.
43
When did you place your vehicle In service for business purposes? (month, day, year)
44
Of the total number of miles you drove your vehicle during 2018, enter the number of miles you used your vehicle for.
a
Business
b Commuting (see Instructions)
►
/
/
c Other
45
Was your vehicle available for personal use during off-duty hours?
CI
D
46
Do you (or your spouse) have another vehicle available for personal use?
Q Yes
Q No
Cl Yos
Q No
□ Yes
Q No
47a Do you have evidence to support your deduction?
b If "Yes," is the evidence written?
Part V
^
^
Other Expenses. List below business expenses not included on lines 8-26 or line 30.
UNIFORM CLEANING
384
UNIFORMS
385
CELL
600
48
Total other expenses. Enter here and on line 27a
I 48
1.369
Schedule C (Form 1040) 2018
LEE
Supplemental Income and Loss
40)
ombno.1545-0074
(From rental real estate, royalties, partnerships,S corporations, estates,trusts, REMICs,etc.}
► Attach to Form 1040,1040NR.
'
' or Form 1041.
Deparlrnem of the
Treasury
theTreasury
InterraJ Revenue
le Service
Service(M)
(M)
AttachmenI
► Go to www.irs.gov/ScheduleE for instructions and the latest information.
Sequence No. 13
Your social security number
Name(s)shown
m on return
ROC M &
JOA^
JOANNA L
4Q
PIFFERINI
XXX-XX-5651
Income or Loss From Rental Real Estate and Royalties
Note: If you are In the business of renting personal property, use
Schedule C or C-EZ (see instructions), if you are an Indlvldu^, report farm rental Income or loss from Form 4835 on page 2, line 40.
A Did you make any payments in 2018that would requireyouto file Fonn(s) 1099? (seeinstnjctions)
□ Yes
B If "Yes," did you or will you file required Forms 1099?
D Yes
la I Physical address of each property (street, city, state, ZIP code
113506 27TH AVE
Seattle WA 98125
Type of Property
For each rental real estate property listed
Fair Rental
Personal Use
(from list below)
above, report the number of fair rental and
Days
Days
personal use days. Check the QJV box
i
only if you meet the requirements to file as
a qualitied joint venture. See instructions.
Type of Property:
1 Single Family Residence
3 Vacation/Short-Term Rental 5 Land
2 Multi-Family Residence
4 Commercial
Income:
3 Rents received .
7 Self-Rental
6 Royalties
ProperHes: (
. ! ! ! ! ! ! ! ! i !
3
8 Other (describe)
A
I
B
B
3,000
Royalties received
Expenses:
5
Advertising
_5
6
Auto and travel (see instructions)
_6
7
Cleaning and maintenance
_7
8
Commissions
_§
9
Insurance
_9
600
10
11
12
Legal and other professional fees
Management fees
Mortgage interest paid to banks, etc. (see instructions)
_10
_11
_12
200
1, 800
10 , 355
13
Other interest
_13
14
Repairs
_14
15
Supplies
_15
16
Taxes
_16
17
Utilities
_12
18
19
Depreciation expense or depletion
Other (list) ► OTHER EXPENSE STMT # 1
_18
J9
7, 995
^
20
Total expenses. Add lines 5 through 19
_20
26, 928
21
Subtract line 20 from line 3 (rents) and/or 4 (royalties). If
_21
-23, 928
1, 886
900
2,842
result is a (loss), see instructions to find out If you must
file Form 6198
22
Deductible rental real estate loss after limitation, if any,
on Form 8582 (see instructions)
22 |(
23a Total of all amounts reported on line 3 for all rental properties
b Total of all amounts reported on line 4 for all royalty properties
)(
. . . .
23a
.
23b
.
.
.
c Total of all amounts reported on line 12 for all properties
23c
d Total of all amounts reported on line 18 for all properties
23d
e Total of all amounts reported on line 20 for all properties
23e
3_£
10,
355
^ 995'
26,
928;
24
Income. Add positive amounts shown on line 21. Do not include any losses
24
25
Losses. Add royalty losses from line 21 and rental real estate losses from line 22. Enter total losses here .
25 (
26
Total rental real estate and royalty income or (loss). Combine lines 24 and 25. Enter the result
here. If Parts II, III, IV, and line 40 on page 2 do not apply to you, also enter this amount on
Schedule 1 (Form 1040), line 17. or Form 1040NR. line 18. Otherwise, Include this amount in the
total on line 41 on page 2
For Paperwork Reductlan Act Notice, see the separate instructions.
Cat. No. 113<ML
Schedule E (Form 1040)2018
Schedule E(Form 1040)2018
AHachmenl Sequence No. 13
Name(s)shown on return. Do not enter name and social security number if shown on other side.
Page 2
Your social security number
ROC M & JOANNA L PIFFERINI
XXX-XX-5651
Caution: The IRS compares amounts reported on your tax return with amounts shown on Schedulefs) K-1.
ligUii
Income or Loss From Partnerships and S Corporations - Note: if you report a loss, receive a distribution, dispose of
stock, or receive a loan repayment from an S corporation, you must check the box In column (e) on line 28 and attach the required basis
computation, if you report a loss from an at-risk activity for which any amount is not at risk, you must check the box In column (f) on
line 28 and attach Form 6198(see Instructions).
27
Are you reporting any loss not allowed In a prior year due to the at-risk, excess farm loss, or basis limitations, a prior year
unallowed loss from a passive activity (if that loss was not reported on Form 8582), or unreimbursed partnership expenses? If
you answered "Yes," see instructions before completing this section
(o) Name
D Yes (X No
(b) Enter P for
(c) Check if
(d) Employer
(e) Check if
(f) Check If
partnership: S
for S corporation
foreign
partnership
Identification
number
basis computation
any amount is
Is required
not at risk
Nonpasslve income and Loss
Passive income and Loss
(g) Passive loss allowed
(attach Form SS82 If required)
(h) Passive income
(i) Nonpassiva loss
(k) Nonpassiva income
from Schedule K-1
from Schedule K-1
from Schedule K-1
^
DI
29a Totals
b
30
31
32
•
^
- • .
Totals
Add columns(h) and (k) of line 29a
Add columns (g), (i), and (j) of line 29b
Total partnership and S corporation Income or (loss). Combine lines 30 and 31
Income or Loss From Estates and Trusts
(b) Employer
la) Name
Identlllcnllon number
Nonpasslve Income and Loss
Passive Income and Loss
(c)Pas»ve deduction or loss allowed
(d)Passive income
(a) Deduction or loss
(f)other Income from
(attach Form SS82 if required)
from Schedule K-1
from Schedule K-1
Schedule K-1
Totals
I'
Totals
I
I
!
Add columns(d) and (f) of line 34a
Add columns(c) and (e) of line 34b
35
36
Total estate and trust income or (loss). Combine lines 35 and 36 . .
37
Income or Loss From Real Estate Mortgage Investment Conduits(REMICs)—Residual Holder
(a) Name
Employer Idcntlficalion
number
(c) Excess Inclusion from
Schedules Q,line 2c
(see Instructions)
(d)Taxable Income (net loss)
|e)Income bom
from Schedules Q,line 1b
Schedules Q,line 3b
Combine columns(d)and (e) only. Enter the result here and Include In the total on line 41 below |
39
Party
Summary
Net farm rental income or(loss)from Form 4835. Also, complete line 42 below
Toli Income or (loss). Combine fines 26,3?,37,39,and <0. &itef Iheresdl hge and on Schedule 1 (Fcrni 1040), Bne 17. or Form 1040NR.line I8> I 41
Reconciliation of farming and fishing income. Enter your gross
farming and fishing Income reported on Form 4835, line 7; Schedule K-1
(Form 1085), box 14, codeB; Schedule K-1 (Form 11205), box 17, code
AC; and Schedule K-1 (Form 1041), box 14, code F (see Instructions) .
^
Reconciliation for real estate professionals. If you were a real estate
professional (see instructions), enter the net Income or (loss) you reported
anywhere on Form 1040 or Form 1040NR from all rental real estate activities
In vrfiichvou materially participated under the passive activity loss njles . .
43
SCHEDULE SE
^
(Form 1040)
Department of the Treasury
Internal Revenue Service (99)
■
xv
cmb No. 1545-0074
0MB No. 1545-0074
Self-Emproyment Tax
;@18
Att'f
h^fNo. 17
Sequence No.
17
Sequence
^ ®o to <^.irs.govlScheduteSE
for instructioas and the latest InformaUon.
►Attach to Form 1040 or Form 1040NR.
Attachment
Name of person with self-employment income (as shown on Form 1040 or Form 1D40NR)
Social security number of person
ROC M PIFFERINI
with self-employment income ►
XXX-XX-5651
Before you begin: To determine if you must file Schedule SE, see the instructions.
May I Use Short Schedule SE or Must I Use Long Schedule SE?
Note: Use this flowchart only ft you must file Schedule SE. If unsure, see Who Must File Schedule SE in the instructions.
Did you reoehre wages or tips in 2018?
Are you a minister, m^ber of a religious order, or Christian
Science practitioner who received IRS approval not to be taxed
on earnings from these sources, but you owe self-employment
Was the total of your wages and tips subject to social security yes
or railroad retirement (tier 1) tax plus your net earnings from '
self-employment more than $128,400?
tax on other earnings?
Did you receive tips subject to social security or Medicare tax
Are you using one of the optional methods to figure your net
Did you receive church employee Income (sea instructions) |Yes
Yes
that you didn't report to your employer?
earnings (see Instructions)?
No
reported on Form W-2 of $108.28 or more?
Did you report any wages on Form 8919, Uncolfected Social jYes
Security arid Medicare Tax on Wages?
You must use Long Scliedule SE on page 2
You may use Short Schedule SE below
Section A—Short Schedule SE. Caution: Read above to see if you can use Short Schedule SE.
1a Net farm profit or (loss) from Schedule F, line 34, and farm partnerships, Schedule K-1 (Form
1065), box 14, code A
b if you received social security retirement or disability benefits, enter the amount of Conservation Reserve
Program payments included on Schedule F, line 4b, or listed on Schedule K-1 (Form 1065), box 20, code AH
2
Net profit or (loss) from Schedule C, line 31; Schedule C-EZ, line 3; Schedule K-1 (Form 1065),
box 14, code A (other than farming); and Schedule K-1 (Form 1065-B), box 9, code J1.
Ministers and members of religious orders, see instructions for types of income to report on
this line. See instructions for other income to report
3
4
Combine lines la, lb, and 2
Multiply line 3 by 92.35% (0.9235). if less than $400, you don't owe seif-empioyment tax; don't
file this schedule unless you have an amount on line lb
►
Note: if line 4 is less than $400 due to Conservation Reserve Program payments on line lb,
see instructions.
5
Self-employment tax. if the amount on line 4 is:
•$128,400 or less, multiply line 4 by 15.3% (0.153). Enter the result here and on Schedule 4 (Form
1040), line 57, or Form 1040NR, line 55
• More than $128,400, multiply line 4 by 2.9% (0.029). Then, add $15,921.60 to the result.
Enter the total here and on Schedule 4 (Form 1040), line 57, or Form 1040NR, line 55 .
6
.
Deduction for one-half of self-employment tax.
Multiply line 5 by 50% (0.50). Enter the result here and on
Schedule 1 (Form 1040), line 27, or Form 1040NR, line 27 .
For Paperwork Reduction Act Notice, see your tax retum instructions.
g
CaLNo. 11358Z
Schedule SE (Form 1040) 2018
Schedule SE(Form 1040)2018
Attachment Sequence No. 17
Name of person with self-employment income(as shown on Form 1040 or Form 1040NR)
Social security number of person
Page 2
ROC M PIFFERINI
with self-employment income^
XXX-XX-5651
Section B—Long Schedule SE
Part 1
Self-Employment Tax
Note: If your only income subject to self-employment tax is church employee income,see instructions. Also see Instructions for the
definition of church employee income.
A
if you are a minister, member of a religious order, or Christian Science practitioner and you filed Form 4361, but you
had $400 or more of other net eamlngs from self-employment, check here and continue with Part I
1a
Net farm profit or(ioss)from Schedule F, line 34, and farm partnerships, Scheduie K-1 (Form 1065),
box 14, code A Note:Skip iines 1 a and 1 b if you use the farm optional method (see instmctions)
If you received sociai security retirement or disability benefits, enter the amount of Conservation Reserve
Program payments included on Schedule F, line 4b, or iisted on Schedule K-1 (Form 1065), box 20,code AH
^ D
la
lb
Net profit or doss)from Schedule 0,line 31; Schedule C-EZ, line 3; Schedule K-1 (Form 1065),
box 14, code A (other than farming); and Schedule K-1 (Form 1065-B), box 9, code J1.
Ministers and members of religious orders, see instructions for types of income to report on
this line. See instructions for other income to report. Note: Skip this line if you use the nonfarm
optionai method (see instructions)
3
4a
If line 3 is more than zero, muitiply iine 3 by 92.35% (0.9235). Otherwise, enter amount from line 3
4a
b
4b
c
Note: If line 4a is less than $400 due to Conservation Resenre Program payments on line lb,see instructions.
If you elect one or both of the optional methods, enter the total of lines 15 and 17 here . .
Combine lines 4a and 4b. If less than $400, stop; you don't owe self-employment tax.
5a
Exception: If less than $400 and you had church employee income,enter -0- and continue >
Enter your church employee income from Form W-2.See
instructions for definition of church employee income . . .
6
27.105
27.105
25.031
Combine lines la, lb, and 2
25.031
4c
I Sa I
Multiply iine 5a by 92.35% (0.9235). If less than $100, enter -0-
5b
Add lines 4c and 5b
6
25,031
7
Maximum amount of combined wages and self-employment earnings subject to social security
tax or the 6.2% portion of the 7.65% railroad retirement (tier 1)tax for 2018
8a Total sociai security wages and tips (total of boxes 3 and 7 on
Form(s) W-2)and railroad retirement (tier 1) compensation.
8a
128.400
If $128,400 or more, skip lines 8b through 10, and go to line 11
8b
b Unreported tips subject to social security tax (from Form 4137,line 10)
8c
c Wages subject to social security tax (from Form 8919, iine 10)
d Add lines 8a,8b,and 8c
9 Subtract iine 8d from line 7. If zero or less, enter -0- here and on line 10 and go to iine 11
128,400
8d
.►
10
Multipiy the smaller of line 6 or line 9 by 12.4% (0.124)
10
11
Multipiy line 6 by 2.9% (0.029)
11
726
12
Seif-employment tax. Add iines 10 and 11. Enter here and on Schedule 4 (Form 1040), line
12
726
13
57, orFoiTn1040NR, Iine55
Deduction for one-half of self-employment tax.
Multipiy line 12 by 50% (0.50). Enter the result here and on
-
Schedule 1 (Form 1040), line 27, or Form 1040NR, line27 .
I 13 |
■
363
Optional Methods To Figure Net Earnings (see instructions)
Farm Optional Method. You may use this method only If (a) your gross farm income^ wasn't more
than $7,920, or (b) your net farm profits' were less than $5,717.
Part II
14
15
5,280
14
Maximum Income for optional methods
Enter the smaller of: two-thirds C/a) of gross farm Income' (not less than zero) or $5,280. Also
15
include this amount on line 4b above
Nonfarm Optional Method. You may use this method only if (a) your net nonfarm profits'were less than $5,717
and also less than 72.189% of your gross nonfarm Income,' and (b) you had net earnings from self-employment
of at least $400 in 2 of the prior 3 years. Caution: You may use this method no more than five times.
16
16
Subtract iine 15 from line 14
17
Enter the smaller of: two-thirds p/a) of gross nonfarm income' (not less than zero) or the
amount on line 16. Also include this amount on line 4b above
' From Sch. F, line 9, and Sch. K-1 (Form 1065), box 14, code B
box 14,
14,code/
From Sch. F, line 34, and Sch. K-1 (Form 1065),1, box
code A—minus the
amount you would have entered on line 1 b had)you not used the optional
method.
17
' From Sch. C, line 31; Sch. C-EZ, line 3; Sch. K-1 (Form 1C6S), box 14, code
A; and Sch. K-1 (Fomi 106S-B), box 9, code J1.
'From Sch. C. line 7; Sch. C-EZ, line 1; Sch. K-1 (Form 1065), box 14. code
C: and Sch. K-1 (Form 1065-B). box 9, code J2.
Schedule SE (Form 1040) 2018
Electing out of special allowance — not deducting 50 percent
^4562 I
Dopanmen.o« .he Troaaury
Internal neverue Sefvica (99||
Depreciation
and Amortization
{including Information on Listed Property)
1®18
Attach to yoiit tax return.
Attachment
► Go to www.irs.gov/Fonn4562 for instructions and the latest Information.
Name(s) shown on return
ROC M &
OMB No. 1S«&-0172
Business or activity to which this form relates
Sequence No. 179
identtfylng number
JOANNA L PIFFERINI
XXX-XX-5651
Election To Expense Certain Property Under Section 179
Note: If you have any listed property, complete Part V before you complete Part I.
1 Maximum amount (see instructions)
2 Total cost of section 179 property placed in sen/ice (see instructions)
3 Threshold cost of section 179 property before reduction in limitation (see instructions)
1.000,000
2,500,000
4 Reduction in limitation. Subtract line 3 from line 2. If zero or less, enter -0-
5 Dollar limitation for tax year. Subtract line 4 from line 1. If zero or less, enter -0-. If married filing
separately, see instructions
6
5 I 1,000,000
(a)
7 Listed property. Enter the amount from line 29
| 7
"i"....
8 Total elected cost of section 179 property. Add amounts in column (c), lines 6 and 7
9 Tentative deduction. Enter the smaller of line 5 or line 8
_8
9
10 Carryover of disallowed deduction from line 13 of your 2017 Form 4562
_10
11 Business income limitation. Enter the smaller of business Income (not less than zero) or line 5. See instructions.
11
12 Section 179 expense deduction. Add lines 9 and 10. but don't enter more than line 11
12
13 Canyover of disallowed deduction to 2019. Add lines 9 and 10, less line 12 ►
1, 00
QQ 0,000
13
Note: Don't use Part II or Part III below for listed property, instead, use Part V.
Special Depreciation Allowance and Other Depreciation (Don't include listed property. See Instructions.
14 Special depreciation allowance for qualified property (other than listed property) placed in sen/ice
during the tax year. See instructions
14
15 Property subject to section 168(f)(1) election
15
16 Other depreciation (includinq ACRS)
16
liaami MACRS Depreciation (Don't include listed property. See Instructions.)
Section A
17 MACRS deductions for assets placed In service In tax years beginning before 2018
17 [
18 If you are electing to group any assets placed in service during the tax year into one or more general
asset accounts, check here
r
^ □
Section B—Assets Placed In Service During 2018 Tax Year Using the General Depreciation System
(b) Monthandyear
(e| Basts for depieciaiian
placed in
(busk«ss4iYestmenl use
only-see instructions)
service
(d) Recovery
period
(Q Method
(e) Convention
(g) Depreciation deduction
d 1 Q-year prope
e 15-year prope
SHmfi
h Residential rental
property
i Nonresidential real
25 vrs.
27.5 vrs.
27.5 vrs.
39 vrs.
property
Section C—Assets Placed in Service During 2018 Tax Year Using the Altemative Depreciation System
20a Class life
b 12-year
c 30-year
d 40-year
12yrs.
30 yrs.
40 yrs.
Summary (See Instructions.)
21 Listed property. Enter amount from line 28
22 Total. Add amounts from line 12, lines 14 through 17, lines 19 and 20 in column (g). and line 21. Enter
here and on the appropriate lines of your return. Partnerships and S coiporations—see instructions .
23 For assets shown above and placed in service during the current year, enter the
portion of the basis attributable to section 263A costs
For Paperwork Reduction Act Notice, see separate Instructions.
22
7.414
23
Cat. No. izeoeN
Form
Forr 4562(2018)
Page 2
Form 4562(2018)
Part V
Listed Property (Include automobiles, certain other vehicles, certain aircraft, and property used for
entertainment, recreation, or amusement.)
Note: For any vehicle for which you are using the standard mileage rate or deducting lease expense, complete only 24a,
24b, columns(a)through (c) of Section A, all of Section B, and Section C if applicable.
Section A—Depreciation and Other Information (Caution: See the instructions for limits for passenger automobiles.)
24a Do you have evidence to support the business/investment use claimed? □ Yes S No
(c)
(a)
(b)
Business/
Type of property (list Date placed
investment use
In service
vehicles first)
(d)
Cost or other basis
percentage
(a)
Basis for depreciation
(business/investment
use only)
24b If "Yes," is the evidence written? □ Yes □ No
(f)
Recovery
period
(g)
Method/
(W
Depreciation
Elected section 179
Convention
deduction
cost
25 Special depredation allowance for qualified listed property placed In service during
the tax year and used more than 50% in a qualified business use. See instructions .
(0
25
26 Property used more than 50% In a qualified business use:
27
Property used 50% or less in a qualified business use:
S/L-
%
%
S/L-
%
S/L-
28 Add amounts In column (h), lines 25 through 27. Enter here and on line 21, page 1
29 Add amounts in column (i), line 26. Enter here and on line 7, page 1 . . . .
t• '
28
"
.
.
.
.
■ !
.
i
29
Section B—Information on Use of Vehicles
Complete this section for vehicles used by a sole proprietor, partner, or other "more than 5% owner," or related person. If you provided vehicles
to your employees, first answer the questions In Section C to see if you meet an exception to completing this section for those vehicles.
30 Total business/investment miles driven during
the year (don't include commuting miles) .
(a)
(b)
(0
(d)
(e)
(f)
Vehicle 1
Vehicle 2
Vehicles
Vehicle 4
Vehicle 5
Vehicle 6
10,250
31 Total commuting miles driven during the year
32 Total other personal (noncommuting)
miles driven
9,750
33 Total miles driven during the year. Add
lines 30 through 32
34 Was the vehicle available for personal
use during off-duty hours?
35 Was the vehicle used primarily by a more
than 5% owner or related person? . .
20,000
Yes
No
Yes
No
Yes
No
Yes
No
No
Yes
Yes
No
X
X
X
Section C—Questions for Employers Who Provide Vehicles for Use by Their Employees
36 Is another vehicle available for personal use?
Answer these questions to determine if you meet an exception to completing Section B for vehicles used by employees who aren't
more than 5% owners or related persons. See instructions.
Yes
No
37 Do you maintain a written policy statement that prohibits all personal use of vehicles, including commuting, by
your employees?
38
Do you maintain a written policy statement that prohibits personal use of vehicles, except commuting, by your
employees? See the Instructions for vehicles used by corporate officers, directors, or 1 % or more owners . .
39
Do you treat all use of vehicles by employees as personal use?
40
Do you provide more than five vehicles to your employees, obtain information from your employees about the
use of the vehicles, and retain the information received?
41
Do you meet the requirements concerning qualified automobile demonstration use? See instructions
Note: If your answer to 37,38,39.40. or 41 Is "Yes," don't complete Section B for the covered vehicles.
(a)
Description of costs
(a)
(bJ
Date amortization
begins
(c)
(d)
Amortization
Amortizable amount
Code section
period or
(f)
Amortization for this year
percentage
42 Amortization of costs that begins during your 2018 tax year (see instructions):
43 Amortization of costs that began before your 2018 tax year
43
44 Total. Add amounts in column (f). See the instructions for where to report
44
581
581
Date in
5
291.824
291,824
291.824
291,824
Totals
R. rental
R. rental
\mortizati
R. rental
79.200
189.008
8.712
7.388
Basis
Fed.
Totals For - Sch E 1
Cost
7.51S
37-01-2017
37-01-2017
R. rental
Amortizati
R. rental
36-01-2017
4.00 3EWER LINE 50%
5.00 ROOF 50%
^on Deor A
St. Method
4,310
4.310
339
123
128
3.723
0
Fed.
Prior
ROC PIFFERINI
79.200
189.008
8.712
7.388
7.51S
Fed. Method
Non Dear A
R. rental
Service
31-03-2017
36-01-2017
Asset Description
1.00 /VA LAND 50%
2.00 3LDG 50%
3.00 i/AFEE
^sset No.
Tax Code: Schedule E# 1
ID NO. XXX-XX-5651
Report Date: 03-26-2019
TAX CODE DIVISIONS
7,995
7.995
581
268
273
0
6.873
Depr.
Fed.
0
c
0
0
0
0
0
3ecL 179i
Mlowance
291,824
291.824
7.519
7.388
8.712
79.200
189.008
state
Basis
4,310
4.31 C
D=
128
3.723
339
123
0
Pr
File Name: PIFRO
Prior
0
0 3ch E 1
0 3chE1
0 3ch E 1
0 3chE1
0 3ch E 1
&
12-31-2018
7,995
0
Disposed, Q = Quarter Worksheet
7.995
273
268
581
C
6.873
Depr. 179/Allow
State
Fiscal Year End
FomtoSoZ
Department of the Treasury
tntaital Revenue Servica(99)I
;©18
^Attach to Form 1040 or Form 1041.
► Go to www.iTS.goif/Fonn8S62 for Instructions and the latest information.
Name(s) shown on relum
ROC M &
0MB No. 1545-1008
Passive^Activity
Loss Limitations
See separate instructions.
Attachment
Sequence No.88
Identf^ng number
number
IdentiVng
JOANNA L PIFFERINI
2018 Passive Activity Loss
XXX-XX-5fiS1
XXX-XX-5651
Caution; Complete Worksheets 1, 2, and 3 before completing Part I.
Rental Real Estate Activities With Active Participation (For the definition of active participation, see
Special Allowance for Rental Real Estate Actlvfties in the instructions.)
la Activities with net income (enter the amount from Worksheet 1,
b
column (a))
Activities with net loss (enter the amount from Worksheet 1. column
(b))
c
la
_1^(
Prior years' unallowed losses (enter the amount from Worksheet 1,
column (c))
d
ic (
Combine lines la, lb, and 1c
Commercial Revltalizatlon Deductions From Rental Real Estate Activities
2a Commercial revrtallzation deductions from Worksheet 2, column (a).
b
Prior year unallowed commercial revitalization deductions from
c
Add lines 2a and 2b
2a (
Worksheet 2. column (b)
2b (
All Other Passive Activities
3a
Activities with net income (enter the amount from Worksheet 3,
b
Activities with net loss (enter the amount from Worksheet 3, column
column (a))
_3a
(b))
c
d
4
_3^ (
23,928)
3c |(
12,017
12,017
Prior years' unallowed losses (enter the amount from Worksheet 3,
column(c))
Combine lines 3a, 3b, and 3c
Combine lines Id, 2c, and 3d. If this line Is zero or more, stop here and Include this form with
your return; ail losses are allowed, including any prior year unallowed losses entered on line Ic,
2b, or 3c. Report the losses on the forms and schedules normally used
If line 4 is a loss and;
4 |
-35, 945
• Line 1 d is a loss, go to Part II.
• Line2c is a loss (and line Id is zero or more), skip Part II and goto Part ill.
• Line 3d is a loss (and lines 1 d and 2c are zero or more), skip Parts II and IIII and go to line 15.
Caution: If your filing status is married filing separately and you lived with your spouse at any time during the year, do not complete
Part II or Part III. Instead, go to line 15.
Special Ailowance for Rental Real Estate Activities With Active Participation
Note: Enter all numbers in Part II as positive amounts. See instructions for an example.
5
6
Enter the smaller of the loss on line 1 d or the loss on line 4
Enter $150,000. if married filing separately, see instructions
7
Enter modified adjusted gross income, but not less than zero (see Instructions)
8
Note: If line 7 is greater than or equal to line 6, skip lines 6 and 9,
enter -0- on line 10. Otherwise, go to line 8.
Subtract tine 7 from line 6
_8
9
Multiply line 8 by 50% (0.50). Do not enter more than $25,000. If married filing separately, see instructions
10
_5
.
.
_6
_7
Enter the smaller of line 5 or line 9
If line 2c is a loss, go to Part III. Otherwise, goto line 15.
_9
10
Special Ailowance for Commercial Revitalization Deductions From Rental Real Estate Activities
Note: Enter all numbers in Part III as positive amounts. See the example for Part II in the Instructions.
11
Enter $25,000 reduced by the amount, if any, on line 10. If married filing separately, see instructions I 11
12
Enter the loss from line 4
13
Reduce line 12 by the amount on line 10
14
Enter the smallest of line 2g (treated as a positive amount), line 11, or line 13
PartlVl Total Losses Allowed
15
Add the Income, if any, on lines la and 3a and enter the total
16
Total losses allowed from all passive activities for 2018. Add lines 10, 14, and 15. See
instructions to find out how to reoorl the losses on your tax retum
For Paperwork Reduction Act Notice, see Instructions.
Cat No. 63704F
Form
Form 8582
8582 (2018)
(2018)
Form
8959
Department of the Treasury
Internal Revenue Service
Additional Medicare Tax
0MB No. 154S-0074
>■ If any line does not apply to you, leave it blank. See separate Instructions.
Name(s) shown on return
ROC M
Part I
1
&
JOANNA L
1®18
► Attach to Form 1040,1040NR, 1040-PR, or 1040-SS.
> Go to Mn«w./rs.0Ov/Form8959 for instructions and the latest Information.
Attachment
Sequence No. 71
Your social security number
PIFFERINI
XXX-XX-5651
Additional Medicare Tax on Medicare Wages
Medicare wages and tips from Form W-2, box 5. If you have
more than one Form W-2, enter the total of the amounts
216,422
from box 5
2
3
4
5
Unreported tips from Form 4137, line 6
Wages from Form 8919, line 6
Add lines 1 through 3
Enter the following amount for your filing status:
Married filing jointly
Mam'ed filing separately
216,422
$250,000
$125,000
Single, Head of household, or Qualifying widow(er) $200,000
6
7
250,00 0
Subtract line 5 from line 4. If zero or less, enter -0Additional Medicare Tax on Medicare wages. Multiply line 6 by 0.9% (0.009). Enter here and
go to Part 11
Part 11
8
Additional Medicare Tax on Seif-Empioyment Income
Self-employment income from Schedule SE (Form 1040),
Section A, line 4, or Section B, line 6. If you had a loss, enter
-0- (Form 1040-PR and Form 1040-SS filers, see instructions.)
Enter the following amount for your filing status:
Married filing jointly
$250,000
8
25,031
Married filing separately
$125,000
Single, Head of household, or Qualifying widow(er) $200,000
9
10
Enter the amount from line 4
10
250,00 0
216,42 2
11
Subtract line 10 from line 9. if zero or less, enter -0- .
11
33^57 8
12
Subtract line 11 from line 8. if zero or less, enter -0-
13
Additional Medicare Tax on self-employment income. Multiply line 12 by 0.9% (0.009). Enter
9
.
.
12
here and go to Part ill
Part ill
14
15
13
Additional Medicare Tax on Railroad Retirement Tax Act (RRTA) Compensa ion
Railroad retirement (RRTA) compensation and tips from
Fonm(s) W-2, box 14 (see instructions)
Enter the following amount for your filing status:
Married filing jointly
$250,000
Mam'ed filing separately
$125,000
Single, Head of household, or Qualifying widow(er) $200,000
14
15
16
Subtract line 15 from line 14. If zero or less, enter -0-
16
17
Additional Medicare Tax on railroad retirement (RRT^ compensation. Multiply line 16 by
0.9% (0.009). Enter here and go to Part iV
17
Part iV
Total Additional Medicare Tax
Add lines 7,13, and 17. Also include this amount on Schedule 4 (Form 1040), line 62 (check
box a) (Form 1040NR. 1040-PR. and 1040-SS filers, see instructions), and go to Part V
liEBKl Withholding Reconciliation
18
19
18
Medicare tax withheld from Form W-2, box 6. If you have
mere than one Form W-2, enter the total of the amounts
3,286
216,422
from box 6
19
20
Enter the amount from line 1
20
21
Multiply line 20 by 1.45% (0.0145). This is your regular
22
21
3.138
Medicare tax withholding on Medicare wages
Subtract line 21 from line 19. if zero or less, enter -0-. This is your Additional Medicare Tax
"22
withholding on Medicare wages
23
Additional Medicare Tax withholding on railroad retirement (RRTA) compensation from Form
24
W-2, box 14 (see instructions)
Total Additional Medicare Tax withholding. Add lines 22 and 23. Also include this amount
148
23
with federal income tax withholding on Form 1040, line 16 (Form 1040NR, 1040-PR, and
1040-SS filers, see instructions)
For Paperwork Reduction Act Notice, see your tax return instructions.
24
Cat. No. 53475X
148
Form 8959 (2018)
Form VW ■
Paid Preparer's Due Diligence Checklist
0MB No. 1545-0074
Earned Income Credit0C), American Oppoflunity Tax Credit(AOTC), Child Tax Credit ^TC)(including tha Additional
1018
Child Tax Oedit(ACTC)and Cfsdit(or Other Dependents {ODCj), and Head ol Household fHOffl Filing Status
Department of theTreasuty
^To be completed by preparer and filed wfth Form 1040,1040NR,1040SS, or1040PR.
► Go to vfww.irs.gov/Fdrm8867 tor instructions and the latest information.
Internal Revenue Service
Attachment
Taxpayer name<s) shown on return
Sequence No. 70
Taxpayer idenUflcatlon number
ROC M &
XXX-XX-5651
JOANNA L PIFFERINI
Enter pr^arer's name and PTIN
DONALD
BYFIELD
ligiilM
Due Diligence Requirements
EA
P00073913
CTC/
AOTC
Please check the appropriate box for the credit(s) and/or HOH filing status claimed on
this return and complete the related Parts l-V for the benefitfs), and/or HOH filing
ACTC/ODC
status claimed (check all that apply].
Si
1
Did you complete the return based on information for tax year 2018 provided
by the taxpayer or reasonably obtained by you?
2
If credits are claimed on the retum, did you complete the applicable EIC and/
SI Yes
DNo
la Yes
□ No
or CTC/ACTC/ODC worksheets found in the Form 1040,1040SS, 1040PR, or
1040NR instructions, and/or the AOTC worksheet found in the Form 8863
instructions, or your own worksheet(s) that provides the same information,
and all related forms and schedules for each credit claimed?
3
□ N/A
Old you satisfy the knowledge requirement? To meet the knowledge
requirement, you must do both of the following.
• Interview the taxpayer, ask questions, and document the taxpayer's
responses to determine that the taxpayer is eligible to claim the credlt(s)
and/or HOH filing status.
• Review Information to determine that the taxpayer is eligible to claim the
credlt(s) and/or HOH filing status and the amount of any credlt(s) claimed.
4 Did any information provided by the taxpayer or a third party for use In
preparing the return, or information reasonably known to you, appear to be
incorrect. Incomplete, or inconsistent? (If "Yes," answer questions 4a and 4b.
If "No," go to question 5.)
a Did you make reasonable inquiries to determine tho correct, complete, and
SI Yes
□ Yes
□ Yes
consistent information?
b Did you document your inquiries? (Documentation should include the
questions you asked, whom you asked, when you asked, the information that
was provided, and the impact the Information had on your preparation of the
retum.)
5
□ Yes
Did you satisfy the record retention requirement? To meet the record
retention requirement, you must keep a copy of your documentation
referenced In 4b, a copy of this Form 8867, a copy of any applicable
worksheet(s), a record of how, when, and from whom the information used to
prepare Form 8867 and any applicable worksheet(s) was obtained, and a
copy of any documenf(s) provided by the taxpayer that you relied on to
determine eligibility for the credlt(s) and/or HOH filing status or to compute
[a Yes
the amount of the credit(s)
DNo
Ust those documents, if any, that you relied on.
Did you ask the taxpayer whether he/she could provide documentation to
substantiate eligibility for the credit(s) and/or HOH filing status and the
amount of any credit(s) claimed on the retum if his/her retum Is selected for
BiYes
audit?
Did you ask the taxpayer if any of these credits were disallowed or reduced in
a previous year?
(If credits were disallowed or reduced, go to question 7a; if not, go to question 8.)
Did you complete the required recertlflcatlon Form 8862?
If the taxpayer is reporting self-employment income, did you ask questions to
prepare a complete and correct Form 1040, Schedule C?
For Paperwork Reduction Act Notice, see separate Instructions.
□Yes
□ No
□ No
83 Yes
□ No
KlYes
Cat. No. 26142H
□N/A
□N/A
□ N/A
Form 8867 (2018)
[18160] ROC M & JOANNA L PIFFERINI
XXX-XX-5651
Form 8867(2018)
Part II
Due Diligence Questions Tor Returns Claiming EIC (If the return does not claim EIC, go to Part
CTC/
ACTC/ODC
AOTC
9a Have you determined that this taxpayer is, in fact, eligible to claim the EIC for
the number of children for whom the EIC Is claimed, or to claim the EIC if the
taxpayer has no qualifying child? (Skip 9b and 9c if the taxpayer is claiming
the EIC and does not have a qualifying child.)
b Did you ask the taxpayer if the child lived with the taxpayer for over half of
the year, even if the taxpayer has supported the child the entire year? . . .
c Did you explain to the taxpayer the rules about claiming the EIC when a child
is the qualifying child of more than one person (tiebreaker rules)? ■ ■ • ■
tfievm
□ Yes □ No
□VesnNo
G Yes D No
G N/A
Due Diligence Questions for Returns Claiming CTC/ACTC/ODC Of the retum does not claim CTC, ACTC, or ODC, go
to Part IV.)
CTC/
ACTC/ODC
Have you determined that each qualifying person for the CTC/ACTC/ODC is the
taxpayer's dependent who is a citizen, national, or resident of ttie United States?
HYesDNo
Did you explain to the taxpayer that he/she may not claim the CTC/ACTC if
the taxpayer has not lived with the child for over half of the year, even if the
taxpayer has supported the child, unless the child's custodial parent has
KlYesGNo
released a claim to exemption for the child?
GN/A
AOTC
Did you explain to the taxpayer the rules about claiming the CTC/ACTC/ODC for
a child of divorced or separated parents (or parents who live apart), including
KlYesGNo
any requirement to attach a Form 8332 or similar statement to the retum?
GN/A
Part IV
.
^
Due Diligence Questions for Returns Claiming AOTC (If the retum does not claim AOTC, go to Part V
ACTC/ODC
AOTC
Did the taxpayer provide the required substantiation for the credit, Including
a Form 1098-T and/or receipts for the qualified tuition and related expenses
for the claimed AOTC?
Part V-
QYesDNo
Due Diligence Questions for Claiming HOH (If the return does not claim HOH filirig stalus, gu to Part Vi.)
actoodcI
Have you determined that the taxpayer was unmarried or considered
unmarried on the last day of the tax year and provided more than half of the
cost of keepinq up a home for the year for a qualifying person?
GYesGNo
[Part VI
Eligibility Certification
>■ You will have complied with ail due diligence requirements for claiming the applicable creditfs) and/or HOH riling
status on the retum of the taxpayer identified above if you:
A. Interview the taxpayer, ask adequate questions, document the taxpayer's responses on the retum or in your notes, review
adequate information to determine if the taxpayer is eligible to claim the credit(s) and/or HOH filing status and to determine
the amount of the credit(s) claimed;
B. Complete this Form 8867 truthfully and accurately and complete the actions described in this checklist for any applicable
credit(s) claimed and HOH filing status, if claimed;
C. Submit Form 8867 in the manner required; and
D. Keep all five of the following records for 3 years from the latest of the dates specified in the Form 8867 instructions under
Document Retention.
1. A copy of Form 6867;
2. The applicable worksheetfs) or your own worksheet(s) for any credtf(s) claimed;
3. Copies of any documents provided by the taxpayer on which you relied to determine eligibility for the credit(s) and/or HOH
filing status;
4. A record of how, when, and from whom the information used to prepare this form and the applicable worksheet(s) was
obtained; and
5. A record of any additional questions you may have asked to determine eligibility to claim the credit(s), and/or HOH filing
status and the amount(s) of any credit(s) claimed and the taxpayer's answers.
^ If you have not complied with all due diligence requirements, you may have to pay a $520 penalty for each failure to
comply related to a claim of an applicable credit or HOH filing status.
Do you certify that all of the answers on this Form 8867 are, to the best of
your knowledge, true, correct, and complete?
K1 Yes
D No
Form 8867 (2018)
[18160]
Due Diligence 2018
Name(s)shown on return
Social SBCurily number
XXX-XX-5651
ROC M & JOANNA L PIFFERINI
01 Business Subslanliation Questions
A. What month and year did (he business start?
01-2018
B. Does the taxpayer maintain different credit card and/or banking
accounts to differentiate between business and personai transactions?
If "No', how does the taxpayer track between business and personal transactions?
LOG
C. Who is responsible for tracking and malrlaining business records?
TAXPAYER
02 Documents or Other Information that Substantiate There Is a Real Business
A. Business license
B.
Forms 1099
C. Records of gross receipts provided by largtayer
0. Taxpayer summary of income
E. Records of expenses provided by taxpayer
F. Taxpayer summary of expenses
G. Bank statements
H. Reconstruction of income and expenses
1.
outer(Specify)
J.
Did not rely on any documents, but made notes In file
K, Did not rely on any documents
03 Business Expense Quesllcms
A. Are typical expenses for this type of business missing?
B. Do the business expense amounts seem unreasonable (too highilow)?
C. Other Information about business expenses (if explanation is needed};
04 Explain Schedule C with no expenses used to claim credit
Prepared by DONALD BYFIELD EA on 03-26-2019
from information provided by ROC M & JOANNA L PIFFERINI.
Taxpayer's signature
Spouse's signature
Date
Schedule A Supporting Statements
GIFTS TO CHARITY BY CASH OR CHECK
Church
330
ELKS
300
PAAF
130
FEDERAL TOTAL
760
STATE TOTAL
760
MISCELLANEOUS DEDUCTIONS SUBJECT TO 2% AGI LIMIT - JOB RELATED (Line 21)
All other union dues
LINE 21 TOTAL
900
900
ROC M & JOANNA L PIFFERINI
XXX-XX-S651
SCHEDULE E - OTHER RENTAL EXPENSES STATEMENT # 1
RENTAL 13506 27TH AVE NE Seattle WA 98125
A
Air Travel
350
TOTAL OTHER EXPENSES
350
XXX-XX-5651
ROC M & JOANNA L PIFFERINI
2018 SCHEDULE OF 1099-MISC INCOME
TAXPAYER SCHEDULE C - FIRST ALARM SECURITY
PAYER
FIRST ALARM SECURITY
TOTAL
INCOME
32,175
32,175
[18160] ROC M & JOANNA L PIFFERINI
XXX-XX-5651
State and Local Income Tax Refund Worksheet—Schedule 1, Line 10
Keep for Your Records
Before you begin: ^Be sure you have read the Exception in the instructions for this line to see if you can use this worksheet instead of
Pub.525 to figure ifany of your refund is taxable.
1.
2.
Enter the income tax refund from Fornifs) 1099-G (or similar statement). But don't enter more than the amount
of your state and local income taxes shown on your 2017 Schedule A,line 5
Enter your total itemized deductions from your 2017 Schedule A,line 29
1.
4,576
2. 37,648
Note.Ifthe filing status on your 2017 Form 1040 was married filing separately and your spouse
itemized deductions in 2017,skip lines 3 through 5, enter the amount from line 2 on line 6, and
go to line 7.
3.
Enter the amount shown below for the filing status claimed on your
2017 Form 1040.
• Single or married filing separately—^36,350
• Married filing jointly or qualifying widow(er)—^512,700
• Head of household—59,350
4.
3. 12,700
Did you fill in line 39a on your 2017 Form 1040?
K1 No. Enter-0-.
I I
Multiply the number in the box on line 39a of your 2017
Form 1040 by 51,250(51,550 if your 2017 filing status
was single or head of household).
5.
Add lines 3 and4
6.
Is the amount on line 5 less than the amount on line 2?
□ No.
ISTOPI
5. 12,700
None of your refund is taxable.
IS Yes. Subtract line 5 from line 2
6. 24, 948
Taxable part of your refund. Enter tlie smaller of line 1 or line 6 here and on Schedule 1, line 10
7.
4,576
FORM 8582 WORKSHEETS
Worksheet 3 - For Form 8582, Lines 3a, 3b, and 3c
Name of activity
Current Year
a. Net Income
RENTAL #1 RENTAL
Total. Enter on Form 8582 lines 3a, 3b, and 3c
Prior Year
b. Net loss
23,928
23,928
c. Unald. loss
Overall aaln or loss
d. Gain
e. Loss
35,945
12.017
12,017
Worksheet 5 - Allocation of Unallowed Losses
Name of activity
RENTAL #1 RENTAL
Form or schedule to
be reoorted on
SCHEDULE E PART 1
Total
c. Unald.
a. Loss
35,945
35,945
b. Ratio
loss
1.000000
35,945
1.00
35,945
Worksheet 6 - Allowed Losses
Name of activity
RENTAL #1 RENTAL
Total
Form or schedule to
be reoorted on
SCHEDULE E PART 1
a. Loss
35,945
35,945
b. Unald. Loss
35,945
35,945
c. Allowed
loss
2018 Form 1040—Line 9
[18160] ROC M & JOANNA L PIFFERINI
2018 Qualified Business Income Deduction—Simplified
Keep for Your Records
Worksheet
Before you begin: This worksheet is for taxpayers who:
>/Have qualified business income.
^Are not a patron in a spceified agricultural or horticultural cooperative.
Have taxable income less than $157,500($315,000 if married filing jointly).
(a)
(b)
Trade or business name
Employer
identification number
FIRST ALARM SECURITY
(c)
Qualified business income or
(loss)
26,742
551-53-5651
2.
Total qualified business income or (loss). Add the amounts in column I(c)
2.
26,742
3.
Note. Ifreporting qualified business income or (loss)from more thanfour
trades or businesses, see the instructionsfor line 2 ofthis worksheet.
Qualified business loss carryforward from the prior year. Enter as a negative number
3.
4.
Total qualified business income. Combine lines 2 and 3. Ifzero or less, enter -0-
4.
26,742
5.
Qualified business income component. Multiply line 4 by 20%(0.20)
5.
5,348
6.
Qualified REIT dividends and FTP income or(loss)
7.
Qualified REIT and FTP loss carryfonvard from the prior year. Enter as a negative number
6.
7.(
8. Total qualified REIT and FTP income. Add lines 6 and 7. Ifzero or less, enter -0-
g.
9.
9.
Multiply line 8 by 20%(0.20)
10.
Qualified business income deduction before the income limitation. Add lines 5 and 9
11.
Income before qualified business income deduction
11.
12.
Net capital gains(see instructions)
12.
13.
Subtract line 12 from line 11. Ifzero or less, enter -0-
13.
)
10,
5,348
14. Income limitation. Multiply line 13 by 20%(0.20)
14.
36,110
15.
15.
5,348
180,550
180,550
Qualified business income deduction. Enter the smaller ofline 10 or line 14
16. Total qualified business lo.ss carryforward. Add lines 2 and 3. If more than zero, enter -0-
16.(
)
17. Total qualified REIT income and FTP loss carryforward. Add lines 6 and 7. If more than zero,
enter-0-
^7.(
)
ROC M & JOANNA L PIFFERINI
XXX~XX-5651
OVERFLOW SCHEDULE
Schedule A - Home Mortgage Interest 1
Description
50 PERCENT OF WASHINGTON LOAN
Amount
10.355
2,871
CABIN LOAN
STATE DEDUCTION
-442
total***
12,784
Schedule E - Mortgage Interest
Description
AMERICAN PACIFC
Amount
8,634
12,076
-10,355
10,355
SELENE FINANCE
50 PERCENT RENTAL
*** TOTAL***
Schedule E - Taxes
Description
FIRST STATEMENT
SECOND INSTALLMENT
50 PERCENT RENTAL
*** TOTAL***
Amount
2,842
2,842
-2,842
2,842
[18160]
TAXABLE YEAR
FORM
California Resident
income Tax Return
2018
540
ATTACH FEDERAL RETURN
APE
XXX-XX-5651
ROC
JOANNA
PIFF
XXX-XX-5273
PIFFERINI
L
PIFFERINI
201 W MISSION STREET
SAN JOSE
CA
11-30-1968
01
06
07
08
09
10
11
12
13
14
16
17
18
19
31
32
33
34
35
40
43
44
18
M
95110
09-12-1971
2
0
2
236
0
0
0
0
01
367
603
174214
205532
4576
0
200956
19402
181554
11391
603
10788
0
10788
0
0
0
45
46
47
48
61
62
63
64
71
72
73
74
75
76
91
92
93
94
95
96
97
400
401
403
405
0
0
0
10788
0
0
0
10788
14504
0
0
0
0
14504
0
14504
0
3716
0
3716
0
0
0
0
0
406
407
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
408
410
413
422
423
424
425
430
431
432
433
434
435
436
437
438
439
440
441
442
443
110
111
112
113
0
115
3716
116
0
117
0
APE
0
3800
0
3803
0
SCHGl
0
5870A
0
5805 5805F
0
DESIGNEE
1
TPIDP 00073913
FN
CCF
0
3805P
0
NQDC
0
3540
0
3554
0
3805Z
0
3807
0
3808
0
0
3809
IRC453A
0
IRC1341
(480) 233-51
PIFFERINI
ROC
524-97-2698 SON
JOEPIFFER@HOTMAIL.COM
-jy
If your California filing status is different from your federal filing status, clieck tlie box here ...
□
- □ Single
» □ Head of household (with qualifying person). See instructions
2 0 Married/RDP filing jointly. See inst. 5 Q Qualifying widow(er). See instr. Enter year spouse/ROP died
See instructions.
Married/ROP filing separately. Enter spouse's/RDP's SSN or ITIN above and full name here
090 I
3101186
r
Form 540 2018 Side1
[18160]
Your name: PIFFERINI
YourSSN or ITIN:
XXX-XX-5651
.«□
6 If someone can claim you (or your spouse/RDP)as a dependent,check the box here. See inst..
^ For line 7, line 8, line 9, and line 10: Multiply the amount you enter in the box by the pre-printed dollar amount for that line.
7 Personal: If you checked box 1,3, or 4 above, enter 1 1n the box. If you checked
box 2 or 5, enter 2, in the box. If you checked the box on line 6, see instructions. ® 7
8 Blind: If you (or your spouse/RDP) are visually impaired, enter 1;
if both are visually impaired, enter 2
® 8
9 Senior: If you (or your spouse/RDP) are 65 or older, enter 1;
if both are 65 or older, enter 2
'D
C
O
• 9
E]
□
□
X $118 = ®$
Whole dollars only
236
X $118 = ®$
X $118 = ®$
10 Dependents: Do not Include yourself or your spouse/RDP.
Dependent 2
Dependent 1
Dependent 3
First Hams
® ROC
®
®
®
®
®
®
Last Name
LU
®
PIFFERINI
SSH
• 524-97-2698
Oependanl's
retail onship
tavou
® SON
Total dependent exemptions
• 10
□
X $367 = ® $
367
® 11
603
11 Exemption amount: Add line 7 through line 10. Transfer this amount to line 32
12 State vtfages from your Form(s) W-2, box 16
• 12
$
174, 214 |.|oq
13 Enter federal adjusted gross Income from Form 1040, line 7
® 13
14 California adjustments - subtractions. Enter the amount from Schedule OA (540), line 37, column B . . . • 14
15 Subtract line 14 from line 13. If less than zero, enter the result in parentheses. See instructions
IS
205,532
4,5761.
200,956m
O
o
n
to
16 California adjustments - additions. Enter the amount from Schedule CA (540), line 37, column C
• 16
17 California adjusted gross income. Combine line 15 and line 16
Your California Itemized deductions from Schedule CA (540),Part II, line 30; DR
18 Enter the
• 17
200,956
18
19.402
larger of:
Your California standard deduction shown below for your filing status:
• Single or Married/RDP filing separately
$4,401
• Married/RDP filing jointly. Head of household, or Qualifying widow(er)
S8,802
If Married/RDP filing separately or the box on line 6 is checked, STOP. See instructions
19 Subtract line 18 from line 17. This is your taxable Income. If less than zero, enter-031 Tax. Check the box if from:
[ZI Tax Table
S Tax Rate Schedule
• □ FTB3800 • n FTB3803
® 19
• 31
32 Exemption credits. Enter the amount from line 11. If your federal AGI is more than SI 94,504
181, 554 . ^
11,391
iQDl
® 32
603 Lion
33 Subtract line 32 from line 31. If less than zero, enter -0-
® 33
10, 788m
34 Tax. See instructions. Check the box if from: • CD Schedule G-1 • CD FTB5870A
*34
^.y
35 Add line 33 and line 34
® 35
10,788m
see instructions
Side 2 Form 540 2018
090 I
3102186
r
[18160]
YourSSNorlTlN:
Your name: jPIFFERINI
XXX-XX-5651
40 Nonrefundable Child and Dependent Care Expenses Credit. See instructions
3
• 40
43 Enter credit name
code•
and amount.
•43
44 Enter credit name
code <
and amount.
•44
45 To claim more than two credits, see instructions. Attach Schedule P(540)
•45
46 Nonretundabie renter's credit. See instructions
•46
47 Add line 40 through line 46. These are your total credits
® 47
48 Subtract line 47 from line 35. if less than zero, enter -0-
® 48
61 Alternative minimum tax. Attach Schedule P(540)
•61
62 Mental Health Services Tax. See instructions.
•62
63 Other taxes and credit recapture. See instructions.
•63
64 Add line 48, line 61, line 62, and line 63. This is your total tax.
•64
.1^
10.788 £
71 California income tax withheld. See instructions
• 71
14.504
72 2018 CA estimated tax and other payments. See instructions
•72
73 Withholding (Form 592-B and/or 593). See instructions
• 73
74 Excess SDI (or VPDI) withheld. See instructions
• 74
75 Earned Income Tax Credit (EITC)
.• 75
o
5
Kj
(.V
ioQ
76 Add lines 71 through 75. These are your total payments. See instructions
.# 91
91 Use Tax. Do not leave blank. See instructions.
If line 91 is zero, check if:
® 76
10.788
lU
.£
£
ly
14.504
y
I X I No use tax is owed.
I I You paid your use tax obligation directly to CDTFA.
92 Payments balance. If line 76 is more than line 91, subtract line 91 from line 76
® 92
93 Use Tax balance. If line 91 is more than line 76, subtract line 76 from line 91.
® 93
14,504|.y
® 94
.y
3,716.y
95 Amount of line 94 you want applied to your 2019 estimated tax
•95
.bi
96 Overpaid tax available this year. Subtract line 95 from line 94
•96
3.716 .Iqq
® 97
y
~ o 94 Overpaid tax. If line 92 is more than line 64,subtract line 64 from line 92.
.fC
>
o
97 Tax due. If line 92 Is less than line 64,subtract line 92 from line 64.
090 I
3103186
Form 540 2018 Side 3
[18160]
Your name: iPIFFERINI
YourSSNorlTIN;
XXX-XX-5651
Code
California Seniors Special Fund. See instructions
•400
Alzheimer's Disease and Related Dementia Voluntary Tax Contribution Fund
•401
Rare and Endangered Species Preservation Voluntary Tax Contribution Program
•403
California Breast Cancer Research Voluntary Tax Contribution Fund
•405
California Rrefighters' Memorial Fund
.• 406
Emergency Food for Families Voluntary Tax Contribution Fund
•AO?
California Peace Officer Memorial Foundation Fund.
California Sea Otter Fund
California Cancer Research Voluntary Tax Contribution Fund.
School Supplies for Homeless Children Fund
.• 413
•422
State Parks Protection Fund/Parks Pass Purchase.
Protect Our Coast and Oceans Voluntary Tax Contribution Fund
Keep Arts in Schools Voluntary Tax Contribution Fund
•425
State Children's Trust Fund for the Prevention of Child Abuse
•430
Prevention of Animal Homelessness and Cruelty Fund.
Revive the Salton Sea Fund
California Domestic Violence Victims Fund
Special Olympics Fund
•434
Type 1 Diabetes Research Fund
California VMCA Youth and Government Voluntary Tax Contribution Fund.
.• 436
Habitat for Humanity Voluntary Tax Contribution Fund
•437
California Senior Citizen Advocacy Voluntary Tax Contribution Fund
Native California Wildlife Rehabilitation Voluntary Tax Contribution Fund
Rape Backlog Kit Voluntary Tax Contribution Fund.
Organ and Tissue Donor Registry Voluntary Tax Contribution Fund.
National Alliance on Mental Illness California Voluntary Tax Contribution Fund
•442
Schools Not Prisons Voluntary Tax Contribution Fund
•443
110 Add code 400 through code 443. This is your total conthbution
Side 4 Form 540 2018
3104186
•HO
Amount
[18160]
Your name; IpIFFERINI
YourSSNorlTIN:
XXX-XX-5651
Ill AMOUNT YOU OWE. If you do not have an amount on line 96, add line 93, line 97, and line 110. See instructions. Oo not send cash.
$
O
Mail to: FRANCHISE TAX BOARD
PO BOX 942867
SACRAMENTO OA 94267-0001
.1^
#111
Pay online - Go to nb.ca.gov/pay for more information.
V.
01 112 interest, late return penalties, and late payment penalties
lU
u
112
Q (0
? c 113 Underpayment of estimated lax. Check the box:
.□
FTB 5805 attached
.□
FTB 580SF attached. .*113
114 Total amount due. See instructions. Enclose, but do not staple, any payment
114
115 REFUND OR NO AMOUNT DUE. Subtract the sum of line 110, line 112 and line 113 from line 96. See instructions.
Mail to:
FRANCHISE TAX BOARD
PO BOX 942840
SACRAMENTO CA 94240-0001
V5
o
o
a
i.y
Fill In the information to authorize direct deposit of your refund into one or two accounts. Do not attach a voided check or a deposit slip. See instructions.
Have you verified the routing and account numbers? Use whole dollars only.
All or the following amount of my refund (line 115) is authorized for direct deposit into the account shown below:
• Type
o
• Routing number
D Checking • Account number
c
1^3
'5
3.716
•IIS
• 116 Direct deposit amount
.1^
Q Savings
The remaining amount of my refund (line 115) is authorized for direct deposit into the account shown below:
Type
mi Checking • Account number
• Routing number
• 117 Direct deposit amount
IMPORTANT: See the instrucllons to find out if you should attach a copy of your complete federal tax return.
To learn about your privacy rights, how we may use your information, and the consequences for not providing the requested information, go to
ftb.ca.gov/form8 and search for 1131. To request thimnotice by mail, call 800.852.5711. Under penaiUes of perjury, I declare that i have examined this
tax return, including accompanying schedu^al^§^ements, and to the best of my knowledge and belief, it is true, correct, and complete.
Your signature
Spousa's/RDP's signature (if a joint tax return, lioth must sign)
(% Preferred plione number
address. Enter only one email address.
Patd pr
s signature (declarption of pneparer Is based on all information of v/hlch preparer has any knovrfedge)
it is unlawful
to forge a
spouse's/RDP's
signature.
Firm's name (or yours,Yr self-employed)
• PTIN
DONALD
P00073913
BYFIELD
EA
Joint tax return?
(See instructions)
• FEIN
Firm's address
1960
FRUITDALE AVE
SAN
JOSE CA
95128
Do you want to allow another person to discuss this tax return with us? See instructions. . . ..•a Yes □ No
Print Third Party Designee's Name
Telephone Number
408-295-0777
DONALD BYFIELD EA
090 I
3105186
Form 540 2018 Side 5
[18160]
SCHEDULE
TAXABLE YEAR
2018
California Adjustments — Residents
CA(5401
Important; Attach this schedule behind Form 540, Side 5 as a supporting California schedule.
Names(s)as shown on lax return
ROC M &
SSN or ITIN
XXX-XX-5651
JOANNA L PIFFERINI
A
Part 1 Income Adjustment Schedule
Federal Amaiints
ft (taxable ameunls Irom
^ur led erallax return)
Section A-Income from federal Form 1040
p Subtractions
p Additions
D See instructions
Ij See instructions
®
®
®
®
1 Wages, salaries, tips, etc. See instructions before making an entry in column B or C — 1 ®174,214. ®
®
2 Taxable interest(a)(•)
2(bl ®
®
3 Ordinary dividends. See instructions,(a)(•)
3(b) ®
4 IRAs, pensions, and annuities. See instructions,(a)(ft
5 Social .security benefits.(a)(ft
4(h) ®
S(b) ®
®
®
10 ®
11 ®
4,576. ®
12 ®
13 ®
14 ®
15(b)
16(h)
17 ®
18 ®
19 ®
27,105. ®
®
®
®
®
®
®
®
®
Section B -Additional Income from federal Schedule 1 (Form 1040)
10 Taxable refunds, credits, or offsets of state and local income taxes
11 Alimony received
12
13
14
15a
16a
17
18
19
Business income or (loss)
Capital gain or (loss). See instructions
Other gains or(losses)
Reserved
Reserved
Rental real estate, royalties, partnerships, S corporations, trusts, etc
Farm income or (loss)
Unemployment compensation
20a Reserved
21
4,576.
®
®
®
20(b)
Other Income.
a California lottery winnings
e NOL from RB 3805Z,
b Disaster loss deduction from FTB 3805V
c Federal NOL
3806,3807, or 3809
21
'Other (describe):
(federal Schedule 1 (Form 1040), line 21)
®
(ft
d NOL deduction from FTB 3805V
a®
b®
a
c
c®
1
1
d®
e®
1 ®
b
d
e
f ®
22 Total. Combine line 1 through line 21 in column A. Add line 1 through line 21f in
column B and column C. Go to Section C
22
®205,895. ®
23
®
®
®
®
26 ®
27 ®
28 ®
29 ®
30 ®
®
®
4,576. ®
Section C-Adjustments to Income from federal Schedule 1 (Form 1040)
23
Educator expenses
24 Certain business expenses of reservists, performing artists, and fee-basis
government officials
25 Health savings account deduction
26 Moving expenses. Attach federal Form 3903. See instructions
27 Deductible part of self-employment tax
28 Self-employed SEP, SIMPLE, and qualified plans
29 Self-employed health insurance deduction
30 Penalty on early withdrawal of savings
31a Alimony paid,(b)Recipient's:
24
25
®
363.
SSN®_
Last name ®
32
IRA deduction
33
Student loan interest deduction
®
. 32 ®
. 33 ®
34
Reserved
. 34
35
Reserved
. 35
36
®
®
.31a
®
Add line 23 through line 31a and line 32 through line 35 in columns A,0,and 0.
See instructions
37 Total. Subtract line 36 from line 22 in columns A, B, and C. See instructions.
For Privacy NoUco,get FTB1131 EN6/SP.
090 I
7731184
36
®
363. ®
®
37
®205,532. ®
4.576. ®
Schedule CA (540) 2018 SIdel
[18160]
A FodcrsI Aniaunli
Part II Adfustmenls to Federal lletnlzed Deduclions
n (from (tdcral Sdicduld A
Check the box if vou did NOT itemize for federal but will itemize for California
n SnbUicOant
p Additioai
D S«9 liutruclions
O See Instnictlons
(Fotm 1040))
® 1—1
Medical and Denial Expenses
1 Medical and dental expenses
2 Enter amount from federal Form 1040,line 7(i)
S)
205,532
3 Multiply line 2 by 7.5%(0 075)
4
(i)
1
2
15,415.3
Subtract line 3from line 1. if line 3 is more than line 1. enter 0
4
Taxes You Paid
5a State and local income tax or general sales taxes
5a
15,654. ® 15,654.
Sb State and local real estate taxes
5h
3.637.
5c State and local personal property taxes
5c
5d Add lines Sa through 5c
5d
®
341.
® 19,632.
Se Enter the smaller of line 5d or $10,000($5,000 if married filing separately) in column A.
Enter the amount from line 5a,column B In line 5e,column B
Enter the difference from line 5d and line 5e,column A in line 5e,column C
G Other taxes. List type(S)
7
Add lines 5e and 6
® 10,000. ® 15,654. ®
6 ®
®
7 ® 10,000. ® 15,654. ®
5e
9,632.
9,632.
Interest You Paid
flb
® 12,784.
983.
®
8c
®
Home mortgage interest and points reported to you on Form 1098
Home mortgage interest not reported to you on Form 1098
Points not reported to you on Form 1098
8a
8d
Reserved
8d
8e
Add lines 8a through 8c
8e
8a
8b
8c
9
Investment interest
in
Arid lines Re and 9
9
10
455.
® 14,222.
®
®
® 14,222. ®
®
®
®
442.
®
®
®
442.
442.
Gifts to Cbaiitv
11
12 Other than by cash or check
13 Carryover from prior year
14
®
12 ®
13 ®
14 ®
®
®
760. ®
@
®
®
®
15
®
®
®
®
®
®
® 24,982. ® 15,654. ® 10,074.
11
Gifts by casii or check
Add lines 11 throuoh 13
760. @
Casualty and Theft Losses
15 Casualty or theft loss(es)(other than net qualified disaster losses). Attach federal
Form 4684. See instructions
Other Itemized Deductions
16
Other—from list in federal instructions
16
17
Add lines 4.7.10.14.15. and 16 in columns A. B. and C
17
18 Total Adjustmenis to Federal llemlzed Deductions. Combine line 17 column A less column B plus column C...
Side2 ScheduleCA(540) 2018
090 1
7732184
®t8
19,402.
[18160]
Job Expenses and Certain Miscellaneous Deductions
19
900.
150.
20
21
1,050.
22
23
24 Multiply line 23 by 2%(0.02). If less than zero, enter 0
0.
®
24
®24
4.111.
25
Subtract line 24 from line 22. If line 24 is more than line 22, enter 0
0.
®25
26
Total Itemized Deductions. Add line 18 and line 25
25.
®26
19,402.
®.
27 Other adjustments. See instructions. Specify. ®
®27
28
®28
19,402.
®29
19,402.
®30
19,402.
Combine line 26 and line 27
29 Is your federal AGI(Form 540, line 13) more than the amount shown below for your filing status?
Single or married/R DP filing separately
$194,504
Head of household
$291,760
Married/RDP filing jointly or qualifying widow(er)
$389,013
No. Transfer the amount on line 28 to line 29.
Yes. Complete the Itemized Deductions Worksheet in the Instructions for Schedule CA (540), line 29.
30 Enter the larger of the amount on line 29 or your standard deduction listed below
Single or married/ROP filing separately. See Instructions
Married/RDP filing jointly, head of household, or qualifying widow(er)
Transfer the amount on line 30 to Form 540, line 18.
090 I
7733184
$4,401
$8,802
Schedule CA (540) 2018 Side 3
[18160]
CALIFORNIA FOF!M
TAXABLE YEAR
2018
Passive Activity Loss Limitations
3801
Attach to Form 540,Long Form 540NR,Form 541, or Form IOCS(S Corporations).
Name(s)as shown on tax return
SSN,ITIN, FEIN,or OA corporation no.
ROC M &
XXX-XX-5651
Part I
JOANNA L PIFFERINI
2018 Passive Activity Loss
See the instructions for Worksheet 1 and Worksheet 3 for federal Form 8582 before complelino Part I. Be sure to use CalHornia amounts.
la Activities with net income from Worksheet 1,column (a)
la
lb Activities with net loss from Worksheet 1,column (b)
lb (
) 00
1c Prior year unallowed losses from Worksheet 1, column (c)
1c (
) 00
GO
Id Combine line la. line lb. and line 1c
Id
00
All Other Passive Activities
2a Activities with net income from Worksheet 2, column (a)
2a
2b Activities with net loss from Worksheet 2, column (b)
2b
(
23,928)
00
2c Prior year unallowed losses from Worksheet 2. column (c)
2c
(
12,017)
00
00
2d Combine line 2a. line 2b. and line 2c
2d
-35,945
00
3 Combine line 1 d and line 2d. If the result is net income or zero, see the instructions for line 3. If line 3 and
line Id are losses, oo to line 4. Otherwise, enter -0- on line 9 and oo to line 10. See instructions
3
-35,945
00
Part II Special Allowance for Rental Real Estate with Active Participation
Enter all numbers in Part II as positive amounts. See instructions.
00
4 Enter the smaller of losses from line Id or line 3.
5 Enter $150,000. if married/ROP filing a separate tax return, see instructions..
00
6 Enter federal modified adjusted gross income, but not less than zero.
See instructions.
If line 6 is equal to or more than line 5, skip line 7 and line 8, enter -0on line 9, and then go to line 10. Otherwise, go to line 7
00
00
7 Subtract line 6 from line 5.
8
00
9
00
10 Add the income, if any,from line la and line 2a and enter the total
10
00
11 Total losses allowed from all passive activities for 2018. Add line 9 and line 10
11
00
8
Muitiolv line 7 bv 50% f.50). Do not enter more than S25,000
9
Enter the smaller of line 4 or line 8
®
Part III Total Losses Allowed
See the instructions on Page 2 to find out how to report the losses on your tax return.
For Privacy NcUce,gel FTB1131 ENG/SP.
090 I
7451184
FTB 3801 2018
SIdel
FORM 3801 WORKSHEETS
Worksheet 2 - For Form 3801, Lines 2a, 2b, and 2c
Current vear
Name of activity
a. Net Income
Prior vears
b. Net loss
RENTAL #1 RENTAL
Total. Enter on Form 3801 lines 2a,2b and 2c
c. Unald. toss
23,928
12,017
23,928
12,017
Overall oaln or loss
d. Gain
e. Loss
35,945
Worksheet 4 - Allocation of Unallowed Losses
Name of activity
RENTAL #1 RENTAL
Form or schedule
to be reported on
SCHEDULE E PART 1
a. Loss
c. Unallowed
loss
b. Ratio
35,945
1.000000
35,945
35,945
1.00
35,945
Total
Worksheet 5 - Allowed Losses
Name of activity
RENTAL #1 RENTAL
Total
Form or schedule
to be reported on
SCHEDULE E PART 1
c. Unallowed
loss
a. Loss
35,945
35,945
35,945
35,945
0. Allowed
loss
THIS FORM SHOULD NOT BE FILED WITH THE COURT
TajEPHCNEMO: (408)413*0800
Nguyen & Limon, LLP.
162S The Alameda,Suite 200
PIFFKRINI
SUPERIOR COURT OF CALIFORNIA,COUNTY OF
PETITIONER: JOANNA PIFFERINl
RESPONDENT: ROC PiFFERINI
CAStNUMUA
SCHEDULE OF ASSETS AND DEBTS
1
1 Petitloner'a 1 X 1 Reepondenfa
I8FL0033S3
— INSTRUCTIONS
—
List all your known community and separata assets or debts. Include assets even if they are in the possession of another person,
including your^se.If you contend an asset or debt is separate, put P(for Petittoner)or R (for Respondent)in the first column
(separate priqjerty)to Indicale to whom you contend it btiongs.
AO values should be as of the date of signing the declaration unless you specHy a different valuation date with the description. For
additional space, use e continuation sheet nunfiwred to show whidi item is being continued.
SEP.
DATE
PROP ACQUIRED
ITEM
NO.
ASSETS DESCRIPTION
1. REAL ESTATE(Gh/e straei addrasses end attach copies of
deeds with togaldoseripSens andlatesttomfei'sstatement)
22657'iainuruck Road,1*wain Marie,CA 94383
CURRENT GROSS AMOUNT OF MONEY
FAIR MARKET
OWED OR
VALUE
ENCUMBRANCE
S
R
TBD
$
-$150,000
$117,800
2 HOUSEHOLD FURNITURE,FURNISHINGS,APPLIANCES
(Identify.)
-$5,000
Vaiious.
$0
3. JEWELRY,ANTIQUES,ART,COIN COaECTIONS,etc.
(Identify.)
None.
Pl9»f 0l4
P«rm Approved lar QpttoAfli Um
MdM Coond ofCofiMi
Fl^t42{Rov.Jmutry l.mi
SCHEDULE OF ASSETS AND DEBTS
(Family LauO
CsttOCMftseeautDL K303014 mu
nMMguiHVaflev
CURRENT GROSS AMOUNT OF MONEY
FAIR MARKET
OWED OR
VALUE
PROP ACQUIRED
ENCUMBRANCE
ITEM
NO.
SEP.
ASSETS DESCRIPTION
DATE
S
$
4. VEHICLES.BOATS,TRAILERS(Doscia» and attach copy of
ttOadoeumenQ
2005 Honda Accord
Travel Trailer
R
R
TBD
TBD
$2,200
TBD
$0
$17,319
5. SAVIN6SACC0UNTS fAcoounf name,acoou/ilnuniter.
bank,andbna^.Attach a^yoflatest statement.}
None.
6. CHECKING ACCOUNTS(Account name and number, bank,
and brand}. Attach copydlateststatement}
Chase Checking 0299
Comerica Checking 0591
TBD
TBD
$24.79
•<$100
$0
$0
7. CREDIT UNION.OTHER DEPOSIT ACCOUNTS fAccourtf
name and number, banK and branch. Mtach copy oflated
statement}
None.
a. CAl^(Give location.}
Nominal.
9. TAX REFUND
See taxes.
10. UFE INSURANCE WITH CASH SURRENDER OR LOAN
VALUE (Attardr copy ofdedaration page for each poifty.;
None.
fL>142(Itov.jMtoy 1.900Q
SCHEDULE OF ASSETS AND DEBTS
(Family Law)
P«(a2«(4
ITEM
NO.
SEP.
DATE
PROP AOSUIRED
ASSETS DESCRIPTION
CURRENT GROSS AMOUNT OF MONEY
FAIR MARKET
OWED OR
VALUE
ENCUMBRANCE
$
$
11. STOCKS,BONDS,SECURED NOTES.MUTUAL FUNDS
(Sim cerU^te numberandeUech cbpy ofthe ceitiScete or
copy ofAitosf stetemenL)
None.
12 RETIREMENT AND PENSIONS CAaacftcqpyof/atosf
City ofSan Jose
-$1,119,828.17
$0
-$50,560
$0
13. PROFIT-SHARING,ANNUITIES,IRAS, DEFERRED
COMPENSATION CAHecft oopy oflateststatement)
Voya Financial - City ofSan Jose
14. ACCOUNTS RECEIVABLE AND UNSECURED
NOTES(Attadt copy oTeac/i.J
15. PARTNERSHIPS AND OTHER BUSINESS INTERESTS
(Attach oopy
mosteunent K-l form and Srdtedu^ C.)
None.
16. OTHER ASSETS
None.
17. TOTAL ASSETS FROM CONTINUATION SHEET
® 1,327,803 ^ 135,119
18. TOTAL ASSETS
ft>«42|Rov.JcKcuy 1.200^
SCHEDULE OF ASSETS AND DEBTS
(FamHyLaw)
ITEM
NO.
DEBTS-SHOWTO WHOM OWED
SEP.
PROP.
TOTAL
OWING
DATE
INCURRED
$4,076.72
4/2019
$
19. STUDENT LOANS(Give details.}
None.
20. TfiXBS(Givedeteils.)
None.
21. SUPPORT ARREARAGES(Affscfi copies oforders and statements.)
None.
22. LOANS—UNSECURED(Give bank name end loan numberand atta^copy oflatest
sfatemenL)
None.
23. CREDIT CARDS(Ghre cterElot's name and address atuithe account ntmdrer. Attach
avyoflatestslatemenL)
American Airlines AAdvantage Aviator Red Mastercard 9120
R
24. OTHER DEBTS fSpeciiy.;:
None.
25. TOTAL DEBTS FROM(XINTINUATION SHEET
$4,076.72
26. TOTAL DEBTS
27. I
1(Spedty number):.
.|>ases are attached as continuation sheets.
I declare under penalty of peijury under the laws of the State of Catlfomia that the foregdng la tree and correct
Dato:6\"^\\^
ROC PIFFRRINI
!
tTURGOFOEClAIUNT)
(TYPE OR PniNT NAME)
FUI42pie*. JSRuaiy t. 20091
SCHEDULE OF ASSETS AND DEBTS
(Family Law)
PegeOetO
Loan aiaiemeni
A/ERiWEsr
MOtteACt
PO Box 77404
Ewing.NJ 00628
statement Date;
STATEMENT ENCLOSED
Account Number
03/18/19
0101797819
Payment Due Date
Amount Due
04/01/19
$1,070.61
Contact Us
• OITOlOe 000065270 OICLSE 0071<l3b 43 AFDlSli
Member Service/Pay By Ptiono: 800-364-6636
Website: tiltpsyAnartwo3tORllns.meitwe3t.com/banking/
■i PI
ROC MILLER PIFFERINISR
PO BOX 1495
E-mail: mertwest® loanadmlnl8traUon.com
TWAIN HARTE OA 95383-1495
'Qualiflsd Writlon Roquntt, ncUflcoHom ot error, or
reqittsto for Intormatlon eoneemtng your toon must Ira
dlroded to PO Box 77423 Ewtng NJ oeeas
Account information
Explanation of /Unount Due
Property Address
and UtOan Dovotopmeni (HUO) ot 800043^387. or go to
8 you ara expcrftncbig HruncUl OuncuSy; You nuy eat On U.3. Ocpvbnent of KouUng
22657 TAMARACK OR
wy.vi.lnjdiir~ml1lnnUli.nfuM.vAn.rim bar,8.1 idkmrmno.
TWAIN HARTE, CA 85363
Outstanding Principal
Deferred Prindpal
organtulJortt tn your area.
$117,800.62
$0.00
$0.00
Escrow Balance
Maturity Dale
Interest Rate (Unbt April 2025)
Prepayment Penalty
Principal
$203.76
$316.49
Inleroet
Escrow (for Taxes and Insurance)
$0.00
SO.OO
$522.25
Other
Match 2048
Cunent Payment Duo 04/01/19
Total Fees Charged Snce Last StatotnonI
3E500%
NONE
S28.11
Overdue Amount
SS22.2S
$1,070.61
Total Amount Due
Transaction Activity (02/20/2019 to 03/18/2019)
Oats
Description
02/28/19
02/2019 PAYMT • THANK YOU
LATE CHAflQE ASSESSED
03/18/19
Past Payments Bieakdovm
Clierges
Payments
$28.11
raurparmrmososeppaedioonteecwortfosaiowucoqiimdscacptejrcufpapncni
Paid Sinco Last Statement
Principal
$202.66
Interest
$319.59
Eacrow (Taxes and Insurance)
Fold Year to Dale
$606.33
$960.42
SO.OO
$0.00
Other
Poos
$0.00
S78.33
$0.00
$600.58
$1,645.08
'Unapplied Funds
Total
$0.00
$78.33
SO.OO
IMPCRTANT MESSAGES
Meriwast Mortgage can doss your loan wiUtoul missing a beati We offer easy loan pne-approvafs, ires appraisals, and with our
local precessit^, we can dosa your loan In as little as two weeksl Start out on the ti^l note with Meriwest Mortgage. Leam
more at Merfwesl.com/nnor1gage
See Reverse Side For Additional Important Information Please return this potUon with your payment
RocMfflarPifiertnlSr
MflKfl ChflCto Payable Tl>:
ChedntetorayourmkfrOMW
Twain Hdrte CA 95383-1495
pefunalMpmuaonhfttbecn
updatod on (ho revoM d this
MERIWEST
MORTBACS
payment coupon.
Payment Duo Dale:
Current Payment:
Account Number.
04/01/19
$522.25
Past Duo Amount:
0101797819
Amount
Endcsed
$
$.522 ?S
Unpaid Late Charges:
$26.11
Other Fees:
TOTAL AMOUNT DUE:
$0.00
$1,07aei
ptsasa Ho not icea, tafia ottttfita
Aher 04/17/19 Pay:
$1,096.72
ehockoreojpan.
LateQiargo
Additional Principal
s
Additional Escrow
Other Fees
S
S
Total Arrmunl paid
S
S
Picjsa onfy use
crtiocic trX
PAYMENT PROCESSING CENTER
PC BOX 54040
LOS /tiNGELES, OA 90054-0040
Ilihl
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□BaDDooaiiDir7i7ai')ODii3vai5aoooooo5Eas5oaoaaa5M6BbODaQaiD7a(3]roaoDaaast>]ii
Q3
IMPORTANT INFORMATION
Please Read Carefully
Paymsnt Information:
Payments are due and payaltle l>y Uie Payirent Due Date. Payments can Iw made online through our website (if offered)or you can access our Automated
Teleithone System by calling the number Hsled on this statement, tf you wish to pay try check, please t» sure to:
1. Remove your coupon from the trottcm of your loan statement and send it along with your check or money order to the address strewn on the coupon.
2. Do not send cash. DO NOT include correspondence with your payment.
3. When sending your monthly payment via ovemight carrier, express or certified mail, or if sending a principal payment separate from your monthly payment,
please use the following address: l^yment Processing 42S Phillips Blvd, Ewing, NJ 08618. When sending a principal payment only, please remember to
indicate 'principal only* along with your loan number in the memo section of your check. PLEASE NOTE:Additional principal payments can only be made
with, or after your current month's payment. NO principal payments can bo applied to loans that are not current,
4. Do notsend partial payments.The disposition of a partial payment received may depend on a number of factors Including but not limited to: the amount
ofthe partial payment r^ether your loan is dellquent, the investor of your loan, whether your loan contains an escrow feature,the number oftimes a partial
payment was received within a 12 month period, whether your loan is being or has been modified. For any of these reasons,a partial payment may be(1)
relumed to you,(2)applied to your loan,(3)accepted but held In a non-Interest bearing unapplied funds account until you send us additional funds sufficient
lo equal a full periodic payment due.
5. If payment Is In excess of the amount due, you musi Indicate on the coupon how the excess Is to tre applied. Monies rocolvod In excess of(he payment
due that arc not Identified for application may be used to make multiple payments,which could make your loan currant or 1 month prepsdd.
Remaining monies may be applied first to pay any othor balances duo,such asfees and advances,if permitted by applicable law.
6. We reserve the right to redeprisit returned checks. Redeposit end relumed dieck fees win be charged unless prohibited by low.
Important Contact Information
Please Include your account number on ALL corrospondence. DO NOT SEND correspondonco with your payment
Pavmonta
Tax Bills
tnsumnee
Collections
All other Corresoondenee
PO Box 54040
Current Tax BUI not
PC Box 202028
PO Box 77407
PO Box 77404
Borence,SO 29502-2028
mycoveragelnfo.com
Ewtng, NJ 08628
FAX 609-538-4017
Ewing, NJ 08628
FAX 609-538-4005
Los Angeles,OA S00S4-0040needed (please see
below tor details)
PIN;CEN300
TO THE EXTENT YOUR OBUGATtON HAS BEEN DISCHARGED OR IS SUBJECT TO THE AUTOMATIC STAY IN A BANKRUPTCY PROCEEDING.
THIS LOAN STATEMENT IS FOR INFORMATIONAL PURPOSES ONLY AND DOES NOT CONSTITUTE A DEMAND FOR PAYMENT OR AN ATTEMPT
TO COLLECT INDEBTEDNESS AS YOUR PERSONAL OBUGATION,
Automatic Payment(ACH):
We offer a free,convenient service tlial automatically debits your payment each month from your checking or savings account. To take advardage of tliis
service, visit our website (If offered)and complete the Automatic Payment(ACH)AuttrorizaliOT or contact Member Service directly.
Payoff RequosI
A written request should be submUtsd in advance for a payoff statement. You may request a payoff slalemeni bo faxed to you by calling 1-877-7PAYOFF
(1-877-772-9833)(a fee(or faxing applies,if permitted by applicable law). Reese have available your account number,social security number,the payoff
date, and your lex number. No vertial information can be provided.
Automated Loan Information:
You can access your loan Informafien 24 hours a day,7 days a week by calling our Member Service automated telephone system or by going online at the
web address llsled on the reverse side of(his statement(if offered). Please have your account number and social security number available.
Sorvicomembors Civil Rollof Act(SCRA):
Eligible servlcemambers end (heir spouses or civil partners may receive proleclions under the SCRA.To find out how to detarmlno If you are eligible for
protections under SCRA and to receive Instructions on how to Invoke your rights, please contact us at Ihe number listed.
Insurance Coverage:
All loans are required to have adequate property Insurance in force el ell limes.Including flood insurance.If the property Is situated In a special Rood liazard
area. Acceptable Itazard and extended dwelling insurance coverage amounts ata equal to 100% of the full Insured value of Ihe Improvements,or equal to Ihe
loan balance, 11 greater than 80% ofthe replacement costs. Flood insurance must equal Ihe lesser of all loan balances,the full structure replacement cost
value Of NFIP llood coverage maximum for the property type. There may be,at lender discreUan,situations where the Hood coverage cannot be lower than
80% of the replacament costs.Please rxmsult your insurance agent lo detennlne the adequacy of your coverages. At time of renewal or If changing insurance
companies,please direct any evidence of insurance coverage through one of Ihe following methods: through Ihe website at mycoverageinfo.cam usir^ PIN:
CEN300,by fox:(843)413-7133 or maa to;PO Box 202028 Florence,SC 29502-2028. Failure 10 provide evidence of adequate insurance may result In Ihe
placement of coverage at your expense.
If your properly is damaged by fire. Rood or by any othor cause, you must noUiy usimmediately and we will instruct you on how lo proceed.
Propoity Taxes:
If you received your Real Estate tax bill for an Hem Ural Is included on your Annual Escrow Statement, please keep It for your records as we receive Ihe(ax
informalion directly from your taxing authority. II is not necessary lo contact or mail us this infonnatlon. However,If you receive a dellnqueni tax billfnolice,
please forward bill to us at DelinquentTaxes@Ioanadminlslration.com for review and handling.
Supplemental tax bills are generally bonowei's respansibilily as the bills are sent directly lo the borrowers from your tax office and no Informafion or
reporting regarding these bills are provided to us. However, If your closing agent colleoted funds at Ihe time of settlement of your loan in antidpalion of a
supplemental lax bill being Issued, then please submit to us for review at SupplementalTaxes@loanadminlstraUon.com.
All Tax ExempUon requests must be submiUed by YOU directly to your lax office. It approved, please fonvard the documenlation lo us at
TaxExemptlon^loanadmlnistration.com
Please print any changes to your name or address below:
Name:
Street:
City;
State:
Home Phone:
Zip:.
.Business Phono:
E-mail Address:.
Please mark(he reason for the change and attach a copy of the recorded document,license, decree, or certificato
if applicable.
( )Address Change
( )Name Change
( )Marriage
( )Divorce
()Doath
moktSaci
800-364-6636
ROC MILLER PIFFERINI SR
PC BOX 1495
TWAIN HARTE CA 95383-1495
DELINQUENT NOTICE
Notice Date: March 18,2019
Account Number 0101797819
Scheduled Due Date: March 01,2019
Dear Member(s):
Your loan payment due on March 01,2019 remains unpaid and a late charge has now been assessed.
Future charges can be avoided by making your payments when due.
Please send the following amount at once:
Regular Monthly Payment:$522.25
Total Accrued Late Charges: $26.11
Amount Due:$548.36*
*Thls does not Include other fees and costs that might be due on your loan.
If payment has been sent, you can verify that It was received by calling our automated account
Information center at 800-364-6636. If you did not Include the late charge with your payment, It Is still due
and should be included with your next payment.
We encourage you to contact us as soon as possible. We may be able to work with you to find a mutually
agreeable way to resolve the delinquency and preserve homeownership.
If your payment Is not received by the end of the current month, we are notifying you that we may report
Information about your account to credit bureaus. Late payments, missed payments,or other defaults on
your account may be reflected In your credit report.
This is an attempt to collect a debt and any Information obtained will be used for that purpose.
Qucdified Written Requests, notifications of enor or requests for information concerning your loan must be
directed to:
PO Box 77423
Ewing, NJ 08^8
Sincerely,
lean Senriclng Department
198
NOTICE:SEE REVERSE SIDE FOR IMPORTANT INFORMATION
OSTSTOS 090985870 05CL58 OOVlSSt. 93
NOTICE REGARDING DEBT DISCHARGED IN BANKRUPTCY - If you have received a discharge of
your personal liability in connection with the mortgage loan referenced In this notice, this notice is for
Informational purposes only and is not an attempt to collect a debt that has been discharged as the result
of a bankruptcy proceeding. You no longer have any personal liability in connection with this mortgage
loan and nothing In this notice Is intended to state or Imply otherwise. This notice is being sent wl^ the
respect to our tien rights against the mortgaged property only. Any action taken is for the sole purpose of
protecting our lien Interest In the mortgaged property including the right to foreclose the mortgaged
property. If you wish to retain your property, you may pay the amount due under the loan. Failure to make
such payments to retain your property may only result In our exercising any lien rights against the
mortgaged property and will not result In any personal liability to you.
NOTICE REGARDING THE BANKRUPTCY AUTOMATIC STAY - This notice Is for informational
purposes only and Is not an attempt to collect a debt in violation of the tiankruptcy automatic stay, if you
are In an active bankruptcy, your loan will be administered in your l>ankruptcy case. You have no
affirmative obligation to respond to this notice, but we do ask that you provide us with your|}ankruptcy
case number,chapter.Jurisdiction, and your attorney's name and phone numtrer so that we may property
code your account to reflect your active bankruptcy case status.
THIS VALIDATED REGISTRATION CARD OR A FACSIMILE COPY IS TO BE KEPT WITH THE
VEHICLE FOR WHICH IT IS ISSUED. THIS REQUIREMENT DOES NOT APPLY WHEN THE
VEHICLE IS LEFT UNATTENDED. IT NEED NOT BE DISPLAYED. PRESENT IT TO ANY PEACE
OFFICER UPON DEMAND. IF YOU DO NOT RECEIVE A RENEWAL NOTICE, USE THIS FORM
TO PAY YOUR RENEWAL FEES OR NOTIFY THE DEPARTMENT OF MOTOR VEHICLES OF THE
PLANNED NON-OPERATIONAL STATUS (PNO) OF A STORED VEHICLE. RENEWAL FEES MUST
BE PAID ON OR BEFORE THE REGISTRATION EXPIRATION DATE OR PENALTIES WILL BE
DUE PURSUANT TO CALIFORNIA VEHICLE CODE SECTIONS 9552 - 9554.
EVIDENCE OF LIABILITY INSURANCE FROM YOUR INSURANCE COMPANY MUST BE PROVIDED
TO THE DEPARTMENT WITH THE PAYMENT OF RENEWAL FEES. EVIDENCE OF LIABILITY
INSURANCE IS NOT REQUIRED WITH REGISTRATION RENEWAL OF OFF-HIGHWAY VEHICLES,
TRAILERS, VESSELS, OR IF YOU FILE A PNO ON THE VEHICLE.
WHEN WRITING TO DMV, ALWAYS GIVE YOUR FULL NAME, PRESENT ADDRESS, AND THE
VEHICLE MAKE, LICENSE, AND IDENTIFICATION NUMBERS.
DO NOT DETACH - REGISTERED OWNER INFORMATION
REGISTRATION CARD VALID FROM: 02/22/2019 TO: 02/22/2020
YR IST SOLD
HOND
2005
LICENSE NUKBBIl
TYPE Lie
VLF CLASS
8ERY582
11
2018
2005
VEHICLE ID NUMBER
BODY TYPE MODEL
JHMCN36405C005195
TYPE VEHICLE USB
DATE ISSUED
02/25/19
AUTOMOBILE
CC/ALCO
DT FEE RECVD
55
02/25/19
STICKER ISSUED
P5206165
PR EXP DATE: 02/22/2019
AMOUNT PAID
REGISTERED CWNER
$
PIFFERINI ROC
22657 TAMARACK DR
AMOUNT DUE
148.00
PO BX 1495
CASH
148.00
CHCK
CRDT
TWAIN HARTE
CA
148.00
AMOWJT RECVD
95383
CROWS AUTO SLS
1141 S 1ST ST
SAN JOSE
CA
95110
HOG
B44 5J 0014800 0023 CS
HOG 022519 11
8ERy582 195
A/ERiWESr
CREDIT UNION
Acco unt Number:
Statement Period;
9621997
09/0t/2019 to 03/31/2019
Page:
1 of 1
P.O^S309S3
San Jaaa,CASS1S3-S3S3
ACCOUNT SUMiVIARY
arZ-MERIWEST (877-637-4937)
vmw.merbvostxom
Total Loans:
$17,319.23
ROC PIFFERINI
201 W MISSION ST
IMPORTANT MESSAGES
JOSE OA 95110-1701
It's time to elevate your rate with a Merlwest share
certiflcatel Merlwest Is offering promotional rates on
certificate terms to meet your savings needs. Check
out our new 15-month certificate or take advantage
of our flexible 8-month liquid certificate, with
unlimited deposits and up to sk(6)withdrawals per
month. Open online at meriwesLcom/certpromo. Or
call 877-637-4937 to learn more.
Federally Insured by NCUA
MEMBER STATEMENT OF ACCOUNT
At Merfwest, You're in the driver's seat. Own a new car with monthly payments you can afford, with low rates, up to 100%
financing and terms up to 96 months. We can also help you refinance your current auto loan. And now, save energy and money
with our new Meriwest Eco-Auto Loan for qualified cars! Learn more at meriwest.com/autoloans today!
LOANS
LOAN ID: 01(2016 KEYSTONE SPRINGDALE 303BH)
Annual Percentage Rate(APR) 5.24%
Daily Periodic Rate .014356%
Type: Fixed Rate
TRANSACTION DETAILS
Trans
Transaction
Transaction
Finance
Late
Date
Description
Amount
Charge
Charge Principal
Change to
Balance*
New
03/01
03/18
03/31
Beginning Balance
Payment
-340.00
Ending Balance for 2016 KEYSTONE SPRINGDALE 303BH
Next Payment Amount $335.73 due on 04/20/2019
53.08
-286.92
$17,606.15
17,319.23
$17,319.23
2019 Totals Year-to-Date
Total finance charge in 2019
Total finance charge in 2018
282.31
983.35
'Daily Balance Method: We figure the interest charge on your account by applying the periodic rate to the'unpaid balance'
of your account for each day In the billing cyde. The'unpaid balance' Is the balance each day after payments, credits, and
unpaid interest charges to that balance have been subtracted and new advances, insurance premiums or other charges have
been added to your unpaid balance. This gives us the unpaid balance. There is no grace period for interest calculation.
Y-T-D SUMMARIES (includes closed share accounts)
Total YTD Dividends :$0.00
*'* Relationship Advantage Program Information
Your Relationship Advantage plan level for April Is Homeowner.
At the end of each month your plan Is determined based on a combination of your average deposit and loan balances.
In case of errors or questions about your statement, telephone us at 1-877-MERIWEST (1-877-637-4937) or write us at
Meriwest Credit Union, Attn: Support Services, P.O. Box 530953, San Jose, OA 95153-5353.
Page 3 of4
CHASEO
Match 22 2019[hiough A^nl 19. 2019
JPMoigan Chase Bank, N A
Acfwuni Numhtti,
POBox 182051
000000925800299
Columbus. OH 43218- 2051
CUSTOMER SERVICE INFORMATION
Web silo
00347SS9 ORE 703 219 11019 NNNKNNMNNNN
1 000000000 IS 0000
ROC PIFFERINI
201 W MISSION ST
SAN JOSE OA 95110-1701
Chase.com
Sotvtoo Conlof
1-800-935-9935
Deal and Hard of Hearing
Para Espanoi
1-800-242-7383
Intomalional Calls
1-713-262-1679
1-877-312-4273
We updated our disclosures
On March 17, 2019, we published an updalod vorsicn of our Deposit Account Agrocmonl and the documert explaining our
Additional Banking Services and Foes You can got the talosl agreements at chase com'd sclosures. at a branch or by
request when you call us Here's what you should know
•
We're using a payment network that supports real time payments When you send or receive a real-time payment,
you confirm that you're not acting on the tieliall ol someone who is not a U S citi/en or resident (General Account
Terms, Section I, Rules governing your account)
•
We've reduced the Ctiaso wire(oo to send an inlomationat wire n a loroign currency to S5 (lor transfer when you
use chase.com or the Chase Mobile'" app As a reminder, there is no Chase wire foe when your transfer is equal to
S5,(X)0 U S dollars or more. Also, there is never a Chase wire fee to send a wire from a Chase Premier Plus
Checking®" with enhanced military benefits. Chase Sapphire®" Checking, or Chase Private Client Checking®"
account
PleEise call us at the number on this statement if you have any questions
CHECKING SUMMARY
ctiaso Premier Plus Checking
AUOUNT
Beginning Balance
S24,79
Ending Balance
$24.79
Annual Percentage Yield Earned This Period
0 00°o
Thank you for your military service and commitment to our country Your monthly service foe was waived as a benofK of
Chase Military Banking
1 o' 2
https://oneview.jpmchase.net/OneVievv/stmtPrintSubmit.star
4/29/2019
Page 4 of4
^
Match 22. 2019 through Apnl 19. 2019
Account Numt>ef
000C009258D0299
IN CASE OP ERRORS OR QUESTIONS ABOUT YOUR ELECTRONIC FUNDS TRANSFERS: Call us at 1•866-564*2262 or wrile us at the
address ort the front of this statement(notvporsonal accounts contact Customer Service)immodiatoty if you think your statement or receipt is
incorrect or if you need nnore information akioul a Irartsfer listed on(he statement or receipt
For personal accounts only: We must hear from you rro later than 60days after we sent you the FIRST statement on which the problem or error
appeared. Be prepared to give us the fcdowing inlomvition
•
Your rvime and account rujmber
•
The doOar amount cl the suspected error
•
A description cl the error or transfer you are unsure of. wtw you believe i is an error, or why you need more mformatron
We wiQ investi9ate your complaini and wiH conect any error promptly. Iiwe take more ttun 10 business days(or 20 business days for new
accounts)to do tto. we wiC credit your account for the arrvnint you frimk is m encr so that you will have use of the money during the time it takes
us to cornplote our investigation
IN CASE OF ERRORS OR QUESTIONS ABOUT NON-ELECTRONIC TRANSACTIONS: Contact the barrk immediatety if your statement is
tncorroct or if you r>ood more information about aity norveiectrortic transactions(chocks or deposits)on this statement if any such error appears
you must noti^ the bartk m wntmg no later than 30days after the statement was made avatlat>le to vcu For more complele detadn. goo the
Account Rules and Reculaticns or other appticabte account agreement that governs your account Deposil products arm services are ofterod t>y
JPMorgan Chase BanlT. N A Member FOlw
JPHAergan Chaoe Banic, N.A. Memt>er FDtC
P*3a 2 d 2
https://oneview.jpmchase.net/OneView/stmtPrintSubmit.star
4/29/2019
Summary Information
11/14/2018
OFFICE OF RETIREMENT SERVICES
THE OFFICE OF
1737 North First Street. Suite 600
San Jose, CA 95112
Retirement Services
408-794-1000
retirement.dept@sanjoseca.gov
http://www.sjretirement.com
CITY OF SAN JOSE
Summary Information
ROC M PIFFERINI
Date of Birth:
11/30/1968(49.96)
Current Employer(s): City of San Jose
Employment Date:
06/18/2006
Current Status:
Active
Entry Date:
06/18/2006
Information As Of:
11/03/2018
Current Plan:
Police
Employment Service: 12.34616
Benefit Service:
12.34616
Contribution Type
Taxable
Employee Contributions: $236,118.07
Non-Taxable
Interest Earned
Total
$0.00
$23,166.04
$259,284.11
Employer Contributions:
$0.00
$860,544.06
$0.00
$860,544.06
Voluntary Contributions:
$0.00
$0.00
$0.00
$0.00
$236,118.07
$860,544.06
Totals:
https://wvvw.s]retlrementcom/sjpolicefire/PGWebMember.exe
$23,166.04 $1,119,828.17
1/1
SANTOSE
CAMMLCV VtJRrN\Ml£T
Voya Financial
At Your Service
PO Box 990070
voyaretirementpians.conVcustom/sanlose
Hartford, CT0619&0070
Q 1-800-584-6001
00237H 3133301 DQD 03 003
PO BOX 1495
National Relay Service (Hearing Impaired); 711
Automated Voice Response System avallatole 24/7
Representatives are available Monday thru Friday,
TWAIN HARTECA 95383-1495
0:00 a.m.- 9:00 p.m. ET
ROC M PIFFERINI
January 01, 2019- March 31, 2019
' Your Account Balance as of
CITY OF SAN JOSE DEF COMP PLAN
Location: POLICE
March 31, 2019
$50,560.60
Your Current Investment Mix
Your Account Summary
Account Balance on 01/01/2019
Your Confrltjutlons
Withdrawals
$80,246.37
stability of Principal
100%
$7.06
$0.00
investment Earnings
$307.17
Account Balance on 03/31/2019
$60,660.60
Vested Balance
$50,560.60
Contributions YTD
S7.06
Protect yourself. Opt-in for a healthier financial life and
experience more with simple and secure e-dellvery.
Your Personal Performance
Your return for the quarter
Your return for the prior 12 months
0.61%
-2.10%
Past performance is no guarantee of future results. Data
above as of most recent calendar quarter end. Important
information regarding calculation meOiodoiogy can tie found
in the Message sectlofl.
See Messages on Page 2
S-RSTM-0001
PLAN 1 INVEST I PROTECT
OET STARTED HERE: Sign-bi to ycur pisn website or ratpsV/my.voyexsrn. Reglstar ysur
device end Dpl.|n le teutonicdetiveiy By vfsilixi: >My Prafile>Pre(e>ences>Psperless
We want you to protect yourselfand your accounts while esperlencing more of everything
yeuTI need to become heelBiiernnanciaiiy, When you go digitsl, you ere cresting the first
line of dehrtee to protect your privacy and ksop your account beallhy end stcurs.
SAN TOSE
January 01, 2019 - March 31, 2019
rAPiuLn Jium vsju''
Voya Financial
ROC M PIFFERiNI
PO Box 990070
Hartford, CT06199^»70
Your Estimated Monthly Income in Retirement
if you were age 65 today and about to retire, it's estimated ttiat your retirement accounl(s)could gerrerate this amount
ftOT'
$272.00
''
of Income every month In retirement for life.
The Monthly Income amount is pre-tax and assumes you are retiring today at age 65. it is based on your most recent month-end account
tiaiance. important Information regarding calculation methodology can be found In the Message section.
About You
ROC M PIFFERINI
07/01/2006
About Your Plan
Activity Statement for Your 457 Plan 666779
Your Current investment Portfolio for Plan 666779
Stability of Principal
San Jose Stable Value Option
550.246-37
$307,17
$50,560.60
Total
$50,246.37
S307.17
$50,660.60
Unit/Share prices ere displayed lo four decimal places.
Allocation of Future Contributions for Plan 666779
San Jose Stable Value Option
Total
"
Activity by Source of Contributions for Plan 666779
Employee PreTax
$50,246.37
$307,17
$50,560.60 100.0%
Total
$50,246.37
$307.17
$50,560.60
Transaction Detail for Plan 666779
Contrlbullons
02/22/2019 Employee PreTax
Total
San Jose Stable Value Option
Contributions
N/A
N/A
$7.06
$7.06
Messages for Plan 666779
YOUR PERSONAL PERFORMANCE The returns shown are estimated dollar-weighted rates of return in your account, assuming evenly
distributed cashflow throughout the period. The actual timing of cash news Into and out of your account may cause your actual retums to differ
from these estimates. Past performance Is no guarantee of future results.
cojit/flued on next page
S-RSTM-0001
PLAN I INVEST I PROISCT
Paae2of6
SANTOSE
January 01, 2019-March 31, 2019
rMfOLO# fiUXM OliXV
Voya Financial
ROC M PIFFERINI
PO Box 990070
Hartford, CT 06199-0070
conSmedfrom provtous page
Messages for Plan 666779
If you would like to schedule an appointment to discuss your City of San Jose 457 Deferred Compensation Plan or PTC Deferred Compensation
Plan account(s), contact the San Jose office at 1.408.881.0110 or the City of San Jose Human Resources office in City Hall at 1.408.975.1455.
ESTIMATED MONTHLY RETIREMENT INCOME If your Statement displays a monthly retirement Income figure,the following information Is
Important. The Estimated Monthly Retirement Income Is designed to provide a tietter understanding of what you might expect in retirement. Based
on your current retirement account l>alance In this plan and the assumptions noted below, a monthly pre-tax lifetime retirement Income has been
estimated.
The estimate above assumes you are 65 and retiring today. But that may not be the case. To estimate what your future monthly income might be
based on your age,cunent and ongoing retirement savings, please log into your plan's website.
The monthly pre-tax lifetime Income that Is estimated to be generated by the balance shown above assumes you are age 65 and are making a lump
sum purchase of a single life immediate annuity today which would pay you a level Income amount each month as long as you live. Note that
inflation wlli erode your spending power over time. The projected amount of the annuity income|»yment is based on the combinata'on of the Society
of Actuaries' Annuity 2000 Basic Mortatity Table assuming an equal mix of males and females and recent Immediate Annuity interest rates from the
Pension Benefit Guaranty Corporation(PBGC),a federal agency created by ERISA. The estimates are hypothetical and for illustrative purposes
only and do not represent cunent or future perfomnance of any specific investment.
No representations, wananties or guarantees are made as to the accuracy of any projections or calculations. This Information does not serve,
either directly or indirectly, as legal, financial or tax advice and you should always consult a qualified professional legal, financial and/or tax advisor
when making decisions related to your Individual tax situation. All lnvestments carry a degree of risk and past performance Is not a guarahtee of
future results.
Insurance products, annuities and funding agreements Issued by Voya Retirement Insurance and Annuity Company("VRIAC")One Orange Way,
Windsor, CT 06095, which Is solely responsible for meeting its obligations. Plan Administrative services provided by VRIAC or Voya Institutional
Plan Ser^ces, LLC. All companies are members of the Voya Mmlly of companies. Securities distributed by or offered through Voya
Financial Partners,LLCjmember SIPC)or other broker-dealers with which it has a selling agreentenL
This statement contains time sensitive financial Information. Please review the statement carefully and report any discrepancies or transactions that
you did not Initiate or request by calling one of our customer service representatives at the 1-800 Customer Service phone number provided above
within 30 days of the date of this statement. Automated Voice Response System is available 24/7. Representatives are available Monday thru
Friday,8a.m.to9 p.m., ET or visit our web site at www.voyaretirementpians.com. The Company wili invest^ate any ciaim and detennine, in Its
sole discretion, whether an adjustment is warranted. Failure to report any discrepancy within 30 days wlli Indicate that you are in agreement with
transactions In your account as reported in this statement.
Voya Excessive Trading Policy - Voya has an Excessive Trading Policy and monitors fund transfer activity. To view Voya's Excessive Trading
Policy refer to vwvw.vovaretirementDlans.com or your plan's website, or to obtain a copy of Voya's Excessive Trading Policy contact our customer
service department at the numlier on the front of this statement.
|
I
Agreementsto Share Trading Information with Funds For Information please refer to wvwv.vovaretlrementDlans.com or your plan's website.
|
Redemption Fees For information please refer to vvww.vovaretirementpians.com or your plan's website, or each fund's prospectus.
;
TAKE ADVANTAGE OF CURRENT CONTRiBUTiON LIMITS For 2019, you may be able to contribute a maximum of $19,000 to your 403(b)or
'
401(k)retirement plan (possibly up to $22,000 for certain 403(b) participants)- and, unless your 457 plan is sponsored by a nonprofit organization,
i
If you turn 50 during 2019,you can also take advantage ofthe 50 plus Catch-up Provision, v^lch permits you to contribute an additional $6,000
during the coming year if permitted under the terms of your plan. Employees in 457 plans can save up to $38,000(2x the $19,000 maximum)
j
ttirough the Normal Retirement Age(NRA)Catch-up Provisions. You may not use b^the NRA and the 50 plus catch-ups In the 457 plan In the
same year.
Youshould consider the Investment objectives, risks, charges,and expenses ofthe fnvesfmenf options careMly before Investing.
I
Prospectuses conblnlng this and otherInformation can be obtiilned by contacting yourlocal representative. Please read the
I
Information carehrlly befare Investing.
,
Getting too much paper from Voya? Visit your plan's website and team more about how to sign up for e-Oellvery.
j
S-RSTM4)001
PLAN I INVEST I PROTECT
Page 3 of6
VOVA.
#nNAKCIAl
SANTOSE
January 01, 2019 - March 31. 2019
Voya Financial
ROC M PIFFERINI
PO Box 990070
Hartford, CT 06199-0070
Investment Performance for Plan 666779
Average Annual Total Returns as of: 03/31/2010
THE PERFORMANCE DATA QUOTED REPRESENTS PAST PERFCHIMANCE. PAST PERFORT/ANCE DOES NOT GUARANTEE FUTURE
RESULTS. FOR IvIONTK-END PERFORMANCE WHICH MAY 6E LOWER OR HIGHER THAN THE PERFORMANCE DATA SHOWN
PLEASE CALL 800-584-6001. INVESTMENT RETURN AND PRINCIPAL VALUE OF
INVESTIffiNT WILL FLUCTUATE SO
THAT,WHEN SOLD.AN INVESTMENT MAY BE WORTH MORE OR LESS THAN THE ORIGINAL COST.
These numbers reflect total Separate Account chargee,ranging from 0.00% to 0.14% on an annual basis. Thay also assume reinveslmenl e( at! dividends
(otdtnaiy income and capital gains)and ate net of managementfees end other furxl operatirtg expenses. See'AddlUonel Notes* section for charges
by investrrteni option.
DEPENDING UPON THE TYPE OP CONTRACT IN WHICH YOU PARTICIPATE,YOU HAVE EfTHER RECEIVEO DiSCLOSURE
BOOiOETS FOR THE SEPARATE ACCOUNT AND/OR FUND PROSPECTUSES. YOU SHOULD CONSIDER THE INVESTMENT
OBJECTIVES,RISKS AND CHARGES.AND EXPENSES OF THE VARIABLE PRODUCT AND ITS UfOERLYING FUND OPTIONS
CAREFULLY BEFORE INVESTING. THE DISCLOSURE BOOKLET CONTAINS THIS AND OTHER INFORMATION. ANYONE WHO
WISHES TO OBTAIN A FREE COPY OF THE SEPARATE ACCOUNT DISCLOSURE BOOKLET ANCVOR FUND mOSPECTUSES MAY
CAU THEIR Vt3YA REPRESENTATIVE OR THE NUMBER ABOVE. PLEASE READ THE SEPARATE ACCOUNT DISCLOSURE
BOOKLET ANDKffi THE FUND PROSPECTUSES CAREFULLY BEFORE INtSSTING.
Relume less than one year ate not annuaiUed. Fund Inception Dale Is the dale ol Inc^lon for the underlying lund,and Is the dale used In
calculating the periodic returns. This date may oisc precede foe portfolio's inclusion In the product.
Stability of Principal
Money Market
2573-Vanguard Federal Money Mrkt Fnd Inv
0.11%
0.57%
Z03%
0.70%
The 7-day annuallzed Subaccount yield as of 03/31/2019 is 2.36%, which more closely reflects current earnings.(1)
0,37%
07/13/1981
Stable Value
9906-Sen Jose Stable Value Option
This fund Is not part of a separate account.
0.47%
Bonds
Intletlon-Protected Bond
179&-BlackRock Infl Pro! Bnd Port lost
0.39%
3.23%
1.64%
1.41%
3.07%
06>/2e/2004
0.53%
3.45%
3.52%
2.73%
6.15%
12/30/1994
0.53%
1.94%
Z64%
1.30%
5.56%
09/18/1986
791 -VanguardTrgt Retire2015Fnd Inv
1296-VanguardTrgt Retire 2020 Fnd Inv
926 -Vanguard Trgt Retire 2025 Fnd Inv
0.27%
6.48%
3.72%
4.63%
9.10%
10^27/2003
0.27%
7.79%
3.67%
5.50%
10.04%
0ert)7/2006
0.27%
8.78%
3.69%
5.92%
10.60%
m7/2003
1297-Vanguard
0.28%
9.50%
3.56%
6.24%
11.49%
06/07/2006
793 -Vanguard Trgt Retire 2035 Fnd Inv
0.28%
10.16%
3.41%
6.54%
12.12%
10/27/2003
129B-Vanguard Trgt Retire 2040 Fnd Inv
0.28%
10.92%
3Z3%
6.61%
12.40%
06/07/2006
794 -Vanguarti Trgt R^ire 2045 Fnd Inv
0.29%
11.44%
3.13%
6.93%
12.47%
10/27/2003
1299-Vanguard
ReUre 2050 Fnd Inv
2473-Vanguard
Retire 20SS Fnd Inv
3447-Vanguard Trgt ReUre 2060 Fnd Inv
8995-Vanguard T^l Retire 2065 Fnd Inv
0.29%
11.46%
3.12%
6.93%
12.47%
06A37/2006
0.29%
11.46%
3.14%
6.90%
10.05%
08/18/2010
0.29%
11.45%
3.10%
6.90%
9.71%
01/19/2012
0.29%
11.44%
3.09%
6.79%
07/12^2017
795 -Vanguard Trgt Retire Income Fnd Inv
Lifestyle
i277-A9gresslve Custom Lifestyle Port
1276-Conservatlve Custom Lifestyle Port
1279-Moderate Custom Lifestyle Pott
0.26%
5.46%
3.77%
3.99%
6.55%
10/27/2003
0.48%
12,65%
5.59%
7.99%
13.15%
10«)2/2006
0-36%
4.82%
4.14%
4.71%
6.74%
10/02/2006
0.44%
8.78%
4.77%
6.37%
10.06%
10A)2/2006
Intermediate-Term Bond
3871-Looml8 Sayles Core Pius B«id Fund N
World Bond
3289-Templeton Global Bond VIP Fd 1
Asset Allocation
Ulecycle - Index
Rebre 2030 Fnd Inv
Large Cap Value
Large Blend
conUnuedon nexfpage
S-RSTM-0001
riAN I iNvesT I PBorecT
SANTQSE
January 01,2019- March 31, 2019
Voya Financial
ROCMPIFFERINI
PO Box 990070
Hartford, CT 06199-0070
conUnuedfrom pmvlous page
Investment Performance for Plan 666779
Average Annuai Total Returns as of: 03/31/2019
See Performance Introduction Page for Additional information
10-Yr/
Fund Number investment Onlirms
Total cKpenscs
3-Mo
2453-Pamassus Core Equity Fund inst
566 -Vanguard instit index Fnd inst
2208-Varrguard Toti Stck MM Index Fd Inst
Large Value
2926-AMG Yaclctman Fund I
7926-Vanguard Equity income Fund Adm
Large Cap Growth
Fund Inception
inccntlon
Date
10.64%
15.50%
04/28/2006
10-73%
15.74%
07/31/1990
10.19%
15.90%
07/07/1997
7.77%
16.34%
07/06/1992
11,07%
15.26%
08/13/2001
Large Growth
603 -American Funds Growth Fnd RS
0.47%
13,84%
7.50%
11.71%
15,66%
12/01/1973
1600-Fjdeiity Adv New insights Fund i
0-88%
15.31%
6.02%
10.60%
15.33%
07/31/2003
Smali/Mid/Speciaity
Mid-Cap Blend
816-JPMorgan Mid Cap Value FundL
1197-Vanguard Mid-Cap index Fund inst
Mid-Cap Growth
6095-Janus Hndrsn Enterprise Fund N
14.66%
15.80%
11/13/1997
16.74%
16.52%
05/21/1998
09/01/1992
Small Blend
1196-Vanguard Smaii-Cap Index Fund Mst
07/07/1997
Small Growth
4733-Emerald Growth Fund inst
10/01/1992
Small Value
2094-Janus Hndrsn Small Cap Value Fund i
Specialty - Real Estate
07/06C009
662-VY Cianon Real Estate Port inst
01/24/1969
Global I International
Diversified Emerging Mkts
1954-Oppenheimer Devetoping Markets Fnd Y
Foreign Large Blend
09A)7/2005
98e9-Vanguard Total Inii Stk index Fd Adm
04^1996
Foreign Large Growth
617-Amencan Funds EuroPaciflo RS
04/16/1964
Foreign Small/Mid Blend
27S1-DFA inti Small Comp Portfolio inst
09/30/1996
-11.22%
The risks of investing In small company slacks rrray include relativsly low Irsdlng voiumos, a grealer degree of ctiango in earnings and greater
ehoit-Ierm voialiilty.
Foreign Investing involves special rteks such as currency fluctuation end public disclosure, as well as economic and political risks.
Some ol the Funds irtvesl In securities guaranteed by the U.S. GovemmenI as to the lirrtely payment of principal arM inletesl; however,shares of the
FurMsare not Insured nor guaranteed.
High yielding rrxedUncome securities generally are subject lo greats market liuclualtons end risks of loss of income and principal Hum are
inveslmenis in lower yielding lixed-lncome eecurllies.
Sector funds may involve greater-Ihan average risk and are often more voialiiether)funds holding e diversified portfolio ofslocks In many
industries. Examples include: banking, biotechnology, chemicals,energy,environmenlel services, natural resources, precious melels,technology,
lalecirmmunications, and ulililles.
These numbers reflect the fund's InveslmenI advisory fees, other fund expenses, and the annual doduclion from the Separate Account as staled below:
AMG Yaddman Fundi, BiackRock Inll Prot Bnd Port InsI, Emerald Growth Fund, FIdeillyAdv Now Insights Fund I, Oppenhelmer Devoioplng Markets Fnd Y,
Tempieton Global Bond VIP Fd 1, VY Clarion Real Estate Port Inst, Vanguard Federal Money Mrkt Fnd inv:0.00%
Aggressive Custom Lifestyle Port, Consorvallve Custom Lifestyle Port, JPMorgan Mid Cap Value Fund L. Janus Hndrsn Small Cap Value Fund I, Moderate
Custom Lifestyle Port. Parnassus Core Equity Fund inst:0.04%
American Funds EuroPacillc RS, American Funds Growth Fnd R5:04)5%
AilOtherfunds:0.14%
conllnved on nextpage
S-RSTM4)001
Page 5 of 6
VOVA.
aiAN I INVEST I PROTECT
#p]NAneiAL
SANjQSE
January01. 2019-March31. 2019
cjunur* sarmuuitr
Vo/a Finarwial
ROC M PIFFERINI
PO Box 990070
Hartford. 0700199-0070
•jju.
....
contlnuedfmmpisvlouspego
Additional Notes
YOU COULD LOSE MONEY BY INVESTING IN THE FUND.ALTHOUGH THE FUND SEEKS TO PRESERVE THE VALUE OF YOUR
INVESTMENT AT $1.00 PER SHARE.IT CANNOT GUARANTEE IT WILL DO SO.AN INVESTIVENT IN THE FUND IS NOT
INSURED OR GUARANTEED BY THE FEDERAL DEPOSIT INSURANCE CORPORATION OR ANY OTHER GOVERNMENT AGENCY.THE
FUND'S SPONSOR HAS NO LEGAL OBLIGATION TO PROVIDE HNANCIAL SUPPORT TO THE FUND.AND YOU SHOULD NOT
EXPECT THAT THE SPONSOR WILL PROVIDE FINANCIAL SUPPORT TO THE FUND AT ANY TIME.
StaUo Value Options Inrasis In Voya's Stalulizer managed separate aooount annuay contract,Issued by Voya RdiienienI Insurance and Annuity Company.
TIte contract ptovides for declarod credited Interest rates tliat ore set In advance.The declared rotes are net of an expenses.Guarantees of
principal and Interest are based on the claims paying ability of Voya Retirement Insurance and Annuity Company.Staltle Value Option is not a
registered Investment company and Is not registered wHh the Securities and Exchange Commission. This Investment option is not part of Separate
Account D.
The CURRENT rate for the San Jose Stable Value Option Fund 9905- Is 2.34%,expressed as an annual effBclive yield, and Is guaranloed not to drop below
2.34% through 0600/2019.
The current rate is net of expensos.The expense for the Stable Value Option is 000%.
bivestments in Target Retirement Funds are subject to the risks of their underlying funds.The year In the fund nanw refers to the approximate year
(the target date)vdten an Investor bi the fund would retire and leave the work force.The fund will gradually stiifl its empliasisfrom more aggressive
Investments to more conservatlvs ones based on its target date. An Investment in the Target Retiremont Fund is not guaranteed at anytime.Including
cn or after the target date.
The Aggressive Allocation Portfolio Is not a registered Investment company and has not been registered wiUi the Securities and Exchange Commission.
The Conservativa Allocation Portfolio Is not a registered InvestmonI company and has not been reglstorod with the Securities and Exchange Ccmmisslon.
The Moderate Allocation Portfolio Is not a registered Investment company and has not been reglstorod with the Securities end Exchange Commission.
The Investment Option is neither a mutual fund nor part of a Separate Airaouni. The returns listed do not Include the impact of eonlract charges.
Please refer to the contract or disclosure book to determine whicli Fixed Interest Options are available for your specific plan. The Investment Option
is offered through Voya Retlroment Insurance and Annuity Company.
(1)THE CURRENT YIELD REFLECTS THE DEDUCTION OF ALL CHARGES THAT ARE DEDUCTED FROM THE TOTAL RETURN
QUOTATIONS SHOWN.
Insurance products,armultlas otul funding agreements issued by Voya Retirement insurance and Annuity Comparty,One Orange Way Wimisor,CT OBOfSS,
(VRIAC),wtiich Is solely rospcnsibla for meeting its obl^iations. Plan administrative services provldod by VRIAC or Voya Institidional Plan Servtoes,
LLC.AO companies are matntrera of the Voya family cf companies.Securities ate distributed by or offered through Voya Rnandal Partnaro, LLC(member
SIPC)or other broker-dealers with which It has a selling agreement.
S-RSTM-0CX)1
PIAN I INVEST I PROTECT
Page6 Of6
STFD 1 THF TRANSACTION STMT FORMAT
STMT .
CO 10048 OP
ACTION
COID
PROD CODE DDA
ACCT
CURR CODE
ACTN
POST
8000810591
PAGE
1
EFFECTIVE CHECK NUMBER
TRACE ID
* 03/26
119/04/30 12.27.42
MS 50852 ACTION COMPLETE
ACCT COND
SHORT NAME ROC PIFFERINI
SEARCH FROM 119/03/26 THRU 119/03/28
TRAN AMOUNT D/C OD
BALANCE
DESCRIPTION
10.23
D
1,950.92
MCP10325233206734929 WM SUPERCENTER #Wal-Mart SAN JOSE CA 1370
* 03/26
68.60
D
1,882.32
MCP10326113206289048 DBA SAN CARLOS 7602 W SAN SAN JOSE CA 1370
* 03/27
50.00
D
1,832.32
MCP10327012916258024 SPARTAN STATION SAN JOSE CA 1370
* 03/27
120.00
D
1,712.32
MCA10326224510493793 W/D AT 1092 BLOSSOM HILL RD SAN JOSE CA 1370
* 03/27
30.15
D
1,682.17
MCP10327060837489025 BIG 5 SPORTING GOODS 2 SONORA CA 1370
* 03/27
35.41
D
1,646.76
MCP10327152254634358 WAL-MART #2030Wal-Mart Su SONORA CA 1370
* 03/27
16.00
D
1,630.76
MCP10327175915937299 TWAIN HAR 18711 TIFFEN TWAIN HARTE CA 1370
* 03/28
7.77
D
1,622.99
MCS10327092522365583 BLACK OAK CAFE TUOLUMNE CA 1370
PF: 1-HELP 3-PLVL 7-SB 8-SF 9-ASUM 10-TRIG 11-CUTO -STSM
3270 PASSTHRU EMULATION
04/30/19
09:27:42
STFD 1 THF TRANSACTION STMT FORMAT
STMT
•
CO 10048 OP
ACTION
PROD CODE DDA
CURR CODE
ACTN
POST
COID
ACCT
119/04/30 12.27.50
MS 50852 ACTION COMPLETE
8000810591
PAGE
2
EFFECTIVE CHECK NUMBER
TRACE ID
* 03/28
ACCT COND
SHORT NAME ROC PIFFERINI
SEARCH FROM 119/03/26 THRU 119/03/28
TRAN AMOUNT D/C OD
BALANCE
DESCRIPTION
25.65
D
1,597.34
MCS10327111731386548 SONORA RENTALS SONORA CA 1370
* 03/28
4.28
D
1,593.06
D
1,478.07
MCS10327155328308312 ACCESSDVD LODI CA 1370
* 03/28
114.99
MCP10328095035469424 TWAIN HARTE LUMBER & H TWAIN HARTE CA 1370
* 03/28
7.50
D
1,470.57
MCP10328122820584610 TWAIN HAR 18711 TIFFEN TWAIN HARTE CA 1370
* 03/28
340.00
D
1,130.57
MCA10328130548264499 W/D AT U.S. BANKUS BANK TWA TWAIN HARTE CA 1370
* 03/28
3.00
D
1,127.57
MCA10328130548264499 OTH BANK FEE U.S. BANKUS BA TWAIN HARTE CA 1370
* 03/28
3.00
C
1,130.57
I-GEN119032800000214 OTH BANK FEE U.S. BANKUS BA TWAIN HARTE CA 1370
* 03/28
2.50
D
1,128.07
MCA10328130548264499 NON-COMERICA ATM USAGE FEE - W/D 1370
PF: 1-HELP 3-PLVL 7-SB 8-SF 9-ASUM 10-TRIG 11-CUTO -STSM
3270 PASSTHRU EMULATION
04/30/19
09:27:50
STFD 1 THE TRANSACTION STMT FORMAT
STMT •
ACTION
CO 10048 OP
COID
PROD CODE DDA
ACCT
8000810591
SHORT NAME ROC PIFFERINI
3
SEARCH FROM 119/03/26 THRU
POST
EFFECTIVE CHECK NUMBER
TRAN AMOUNT D/C OD
TRACE ID
DESCRIPTION
CURE CODE
ACTN
119/04/30 12.27.56
MS 50852 ACTION COMPLETE
ACCT COND
PAGE
* 03/28
2.50
C
I-GEN119032800000215 NON-COMERICA ATM USAGE FEE - W/D 1370
* 03/28
1274
350.00
D
119/03/29
BALANCE
1,130.57
780.57
48000011903280581928 CHECK (SUBSTITUTE)
* 03/29
3,615.39
C
4,395.96
00948819086002212529 CITY OF SAN JOSE DIR DEP 190323
03/29
323.25
D
MCS10327144841139226 MR. STOR ALL 209-553-0950 CA 1370
4,072.71
03/29
4,060.71
12.00
D
MCS10327160300288313 CHINA HOUSE OF TWAIN HARTE CA 1370
* 03/29
15.42
D
4,045.29
MCS10328143609948342 CKE*THE ROCK TWAIN HARTE CA 1370
* 03/29
100.00
D
3,945.29
MCA10328185447976617 W/D AT Black Oak Casinol9400 T TUOLUMNE CA 1370
* 03/29
3.50
D
3,941.79
MCA10328185447976617 OTH BANK FEE Black Oak Casinol TUOLUMNE CA 1370
PF:
1-HELP 3-PLVL 7-SB 8-SF 9-ASUM 10-TRIG 11-CUTO -STSM
3270 PASSTHRU EMULATION
04/30/19
09:27:57
STFD 1 THF TRANSACTION STMT FORMAT
119/04/30 12.28.02
STMT •
CO 10048 OP
MS 50852 ACTION COMPLETE
ACTION
COID
ACCT COND
PROD CODE DDA
ACCT
8000810591
SHORT NAME ROC PIFFERINI
CURR CODE
PAGE
4
SEARCH FROM 119/03/26 THRU
ACTN
POST
EFFECTIVE CHECK NUMBER
TRAN AMOUNT D/C OD
TRACE ID
DESCRIPTION
*
03/29
3.50
119/04/01
BALANCE
3,945.29
C
I-GEN119032900005684 OTH BANK FEE Black Oak Casinol TUOLUMNE CA 1370
*
03/29
MCA10328185447976617
*
03/29
I-GEN119032900005685
*
*
*
2.50
3,942.79
D
NON-COMERICA ATM USAGE FEE - W/D
2.50
1370
3,945.29
C
NON-COMERICA ATM USAGE FEE - W/D
1370
03/29
15.00
D
MCP10329152750095149 BEAR CREEK STAT TUOLUMNE CA 1370
03/29
60.79
D
MCP10329181236752977 COSTCO GAS #103 MANTECA CA 1370
3,930.29
04/01
3,859.50
10.00
D
3,869.50
MCS10329091046421131 BLACK OAK CAFE TUOLUMNE CA 1370
*
04/01
4.28
D
3,855.22
MCS10329160708020191 ACCESSDVD LODI CA 1370
*
04/01
MCA10330221738491196
20.00
PF: 1-HELP 3-PLVL 7-SB 8-SF 9-ASUM 10-TRIG 11-CUTO
3270 PASSTHRU EMULATION
D
W/D AT 1092 BLOSSOM HILL RD SAN JOSE
04/30/19
3,835.22
CA 1370
•STSM
09:28:02
STFD 1 THF TRANSACTION STMT FORMAT
STMT
■
CO 10048 OP
ACTION
PROD CODE DDA
CURR CODE
ACTN
POST
COID
ACCT
119/04/30 12.28.06
MS 50852 ACTION COMPLETE
ACCT COND
SHORT NAME ROC PIFFERINI
8000810591
PAGE
5
EFFECTIVE CHECK NUMBER
TRACE ID
SEARCH FROM 119/03/26 THRU 119/04/03
TRAN AMOUNT D/C OD
BALANCE
DESCRIPTION
* 04/01
40.00
D
3,795.22
MCP10401024420140212 SUNOL SUPER STO SUNOL CA 1370
* 04/01
62.90
MCP10401111655494614 Pet Pals
D
3,732.32
Pet Pals Dis SOQUEL CA 1370
* 04/01
20.00
D
3,712.32
MCA10401104241368547 W/D AT 333 W SANTA CLARA ST SAN JOSE CA 1370
* 04/01
600.00
D
3,112.32
1,800.00
C
4,912.32
20.00
D
4,892.32
48000011904010848984 WITHDRAWAL
* 04/02
48000011904020199148 DEPOSIT
* 04/02
MCS10401162602440086 PAMF 1071 BLOSS SAN JOSE CA 1370
* 04/02
1214
100.00
D
4,792.32
D
4,773.32
97000011904020028778 CHECK (SUBSTITUTE)
* 04/03
19.00
MCP10403030401277250 SPARTAN STATION SAN JOSE CA 1370
PF: 1-HELP 3-PLVL 7-SB 8-SF 9-ASUM 10-TRIG 11-CUTO -STSM
3270 PASSTHRU EMULATION
04/30/19
09:28:06
STFD 1 THF TRANSACTION STMT FORMAT
STMT
CO 10048 OP
ACTION
COID
PROD CODE DDA
ACCT
CURR CODE
ACTN
119/04/30 12.28.09
MS 50852 ACTION COMPLETE
ACCT COND
8000810591
SHORT NAME ROC PIFFERINI
PAGE
SEARCH FROM 119/03/26 THRU 119/04/05
D/C OD
BALANCE
POST
6
TRAN AMOUNT
EFFECTIVE CHECK NUMBER
DESCRIPTION
TRACE ID
* 04/03
4,728.32
45.00
MCP10403212013237023 NNT QUINS CREEK GAS172194 GLENDALE OR 1370
4,721.57
* 04/04
6.75
D
MCS10403080000354275 TACO BELL #2420 FREMONT CA 1370
4,689.16
* 04/04
32.41
D
MCP10404185840707459 ARCO#07013ARCO SEATTLE WA 1370
* 04/04
155.91
D
4,533.25
00948819093000974293 TWAIN HARTE COMM THCSD
* 04/05
4,513.79
19.46
D
MCP10405080900226170 WAL-MART #43941221 S HAYF SPOKANE WA 1370
* 04/05
37.03
D
4,476.76
MCP10405151241899965 HAYFORD EXPRESS SPOKANE WA 1370
* 04/05
400.00
D
4,076.76
MCA10405091407307461 W/D AT U.S. BANKUS BANK SPOKANE SPOKANE WA 1370
* 04/05
3.00
D
4,073.76
PF:
MCA10405091407307461 OTH BANK FEE U.S. BANKUS BANK S SPOKANE WA 1370
1-HELP 3-PLVL 7-SB 8-SF 9-ASUM 10-TRIG 11-CUTO -STSM
3270 PASSTHRU EMULATION
04/30/19
09:28:10
STFD 1 THF TRANSACTION STMT FORMAT
STMT
•
CO 10048 OP
ACTION
PROD CODE DDA
CURR CODE
ACTN
POST
COID
ACCT
8000810591
PAGE
7
EFFECTIVE CHECK NUMBER
TRACE ID
*
119/04/30 12.28.17
MS 50852 ACTION COMPLETE
ACCT COND
SHORT NAME ROC PIFFERINI
SEARCH FROM 119/03/26 THRU 119/04/08
TRAN AMOUNT D/C OD
BALANCE
DESCRIPTION
04/05
3.00
C
4,076.76
I-GEN119040500000768 OTH BANK FEE U.S. BANKUS BANK S SPOKANE WA 1370
*
04/05
MCA10405091407307461
*
04/05
I-GEN119040500000769
*
2.50
04/05
D
4,074.26
NON-COMERICA ATM USAGE FEE - W/D 1370
2.50
C
4,076.76
NON-COMERICA ATM USAGE FEE - W/D 1370
101.08
D
3,975.68
MCP10405170144355375 NNT UNIVERSITY BOOK632EWU CHENEY WA 1370
*
04/05
MCP10405155626917022
*
*
15.25
D
3,960.43
Campus Bo 124 E. Sinto SPOKANE WA 1370
04/08
537.42
D
MCS10405091042343926 BELLEVUE COLL N 4255642309 WA 1370
27.17
D
04/08
3,423.01
3,395.84
MCS10405085607381247 LONGHORN BARBEC SPOKANE WA 1370
*
04/08
75.47
D
3,320.37
MCP10406172420891761 THE NORTH FACE #47714 W M SPOKANE WA 1370
PF: 1-HELP 3-PLVL 7-SB 8-SF 9-ASUM 10-TRIG 11-CUTO -STSM
3270 PASSTHRU EMULATION
04/30/19
09:28:17
City of San Jose
Pay Group:
Pay Begin Dale:
Pay End Date:
200 liast Santa Clara Street
San Jose. CA 95113-1905
POL-City of San Jose•Police
02/24/2019
Business Unit:
Advice Ui
461J204
03/09/2019
Advice Date:
03/15/2019
CSJBU
TAX DATA:
Federal
Employee ID:
Department:
109095
Tax Status:
Married
S/M-2 inc
4160 Jade Street
S030-Police-Field Patrol
Allowances:
0
Capitola,CA 95010
0
Location:
Police-Field Patrol
Job Title:
Police Oflicer
Pay Rate:
S4.904.00 Biweekly
Roc M KfTerini
Addl. Percent:
Addl. Amount:
HOURS AND EARNINGS
TAXES
—- Current -
Descrrptfnn
POST Pav Advanced
RetentionTremium Pay CIT
Regular
Ilrm/ntv
Paifilnp*
Ilrm/Otv
4.910130
4.137730
80.00
392.81
480.00
480.00
419.00
80.00
60.00
1.00
20.00
61.300000
28.120000
Uniform Allowance Bi-Wcekly
Vacation Leave
Overtime for Pav
61.300000
105.521820
1.5
YTD
Rfltg
331.02
3.678.00
19.00
Fflminy
riirrwit
VTD
2.356.86 Fed Withholdng
1,986.12 Fed MED/EE
25.684.70 CA Wiihholdng
1,033.30
4.971.27
28.12
6.00
168.72
1.226.00
2.004.91
40.00
60.00
2.452.00
6.331.32
Overtime for Comp % 1.0
Comp-Time Taken
Comp Time Extended
3.00
Sick Leave
BEFORE-TAX DEDUCTIO.NS
Suner20
Delta Dental
VSP SignatuK
Retircinent Contribution
TOTAL:
Ctifrenl
61.30
275.85
20.00
1,226.00
83.03
2.65
YTD
VEAR-TO-DATE
15.90 Poliee Amateur Athletie Found
48.96
968.26
5.809.56
1.062.10
Dwrimln
498.18 Benenu Adminitlration Fee
8.16
TOTAL GROSS
Current
AFTER-TAX DEDUCTIONS
VTn
0.21
3.50
Current
VTn
1.26 Sutter20
21.00 Delu Denial
747.26
4.483.56
50.30
7.00
301.80
42.00
0.77
5574.05
4.62
32.468.85
3.71
Basic Life Ins Fee - Sworn
1.02
6.12
Employee Assistance Program
0.00
46.80
22.26 'TAXABLE
FED TAXABLE GROSS
TOTALTAXES
TOTAL DEDt'CnONS
NET PAY
7.660.86
6.598.76
33.894.42
1.684.56
8.218.29
1.065.81
40.267.02
6.394.86
4.910.49
25.653.87
VACATION
SICK LEAVE
43.7
-^Earned
- Taken
30.8
10.5
18.5
End Balance
8JlgJ9
nwerliilinn
VTn
Life Insurance - Basic
Retirement Contribution
Start Balance
Adjustments
1.68456
E.MPLOYER PAID BENEFITS
Curfwn
Benefits Administiation Fee
6572.601 TOTAL:
575.71
2.671.31
183.90
1.00
4.50
TOTAL:
PtKrinlHin
109.72
541.54
0.0
20.0
0.0
34.S
8.9
40.0
NET PAV DISTRIBUTION
Account Number
Advice »4613204
TOTAL:
Checking
Checking
325024543998
8000810591
Deposit Aiiiftunt
9.24
4.901.25
4.910.49
Additional leave balance infoimation can be found on the Express Timesheet located under Time and Attendance on the Home page or at the following menu path: Main Menu >
CSJ Express Time Entry > CSJ TCFE Express Page.
MESSAGE:
City of San Jose
Pay Group:
POL-City ofSan Jose - Police
Pay Begm Date; ' 03/10/2019
03/23/2019
Pay End Date:
200 East Santa Clara Street
S8nJosc.CA 951I3<1905
Roc M PifrerinI
4160 Jade Street ^65
Capitola.CA 95010
Business Unit:
CSJBU
Advice Ui
Advice Dale:
4620164
03/29/2019
TAX DATA:
Federal
CA State
Employee ID:
Department:
109095
5030-Police-Field Patrol
Tax Status:
Mairied
S/M-2 inc
0
0
Location:
Job Title:
Police»FicId Patrol
Police Officer
Addl. Percent:
Pay Rate:
$4,904.00 Biweekly
Allowances:
Addl. Amount:
HOURS AND EARNIISGS
TAXES
Current —
POST Pay Advanced
Retentioa'Premiuni Pay CIT
Regular
Osertime for Comp @ 1.0
Comp>Time Taken
Comp Time Extended
Overtime for Pay 1.5
Bnt.
Hri/niv
4.910130
80.00
4.137750
61.300000
YTD
nnfrimlnn
Hn/Olv
392.81
560.00
80.00
331.02
560.00
80.00
4.904.00
499.00
Sick Lea^e
Uniform Allowance Bi*Weekly
Vacation Leave
2,749.67 Fed Withholdng
2.317.14 Fed MED/EE
30.588.70 CA Withholdng
3.00
1.00
4.50
61.30
275.85
60.00
6.331.32
20.00
1.226.00
6.00
168.72
40.00
2.452.00
AfTER'TAX DEDfCTIOXS
BEFORE>TAX DEDI'CTIOXS
Retiremeat Contribution
CurretH
968 26
>TD
000
498.18
Delta Dental
000
VSP Signature
0.00
1590
48.96
TOTAL:
Current
YTD
968.26
Benefits Administration Fee
7J40.861 TOTAL:
1.031.44
9.249.73
657.31
3.50
24.50
farrtflt
HU
5,574.05
0.00
38.042.90
4.483J6
Delta Dental
0.00
301.80
Benefits Adxnmisiretion Fee
0.00
42.00
Employee Assistance Program
0.00
46.80
Life Insurance•Basic
0.00
4.62
Basic Life Ins Fee•Sworn
0.00
6.12
Retirement Contribution
1.26 Saner 20
0.00
3.S0
2S.76 *TAXABLE
TOTAL TAXES
TOTAL DEDUCTIONS
NET PAY
5.627.83
4.659.57
1.031.44
971.76
45.894.85
38.553.99
9.249.73
7.36662
3.624.63
29.278.50
SICK LEAVE
10.5
^ Earned
-Taken
400
22.2
20.0
00
0.0
4a6
12.6
End Biltncc
3,014.47
FED TAXABLE GROSS
43.7
369
* Adjustments
81.60
343.16
TOTAL GROSS
VACATION
YEAH-TO-DATE
Stan Balance
5,577.95
EMPLOYER PAID BEXEFITS
Current
6.777.82 Police Amateur Athletic Found
Suner 20
vm
60668
183.90
TOTAL:
DMfripttofi
Cufrgflt
NET PAY DISTRIBUTION
Advice 44620164
TOTALj
Aemiint Type
Checking
Checking
Aernunl Numher
325024543998
8000810591
DepMil Amniinl
9.24
3.615.39
3.624.63
Additional leave balance information can be found on the Express Timcsheet located under Time and Attendance on the Home page or at the following menu path; Main Menu >
CSJ Express Time nntr>' > CSJ TCFE Express Page.
MESSAGE:
Cit>-ofSan Jose
Pay Group:
POL-City ofSan Jose ■ Police
Business L'nil;
CSJBU
200 East Santa Clara Street
Pay Begin Date:
03/24/2019
Advice
4627084
San Jose. CA 95113-1905
Pay End Date:
04/06^019
Advice Due:
04'I2/2019
Roc M PifTerlni
4160 Jade Street «65
Capitola.CA 95010
Employee ID:
109095
De^rtment:
5030-Poltce-Field Patrol
Location:
Police-Field Patrol
Job Title:
Police Officer
Pay Rate:
$4,904.00 Biweekly
TAX DATA:
Federal
Tax Status:
Married
CA Stale
S/M-2 inc
0
0
Allowances:
Addl. Percent:
Addi. Amount:
HOURS AND EARNINGS
TAXES
—• Current —
DcMripitpq
POST Pay Advanced
RetentiofVPremium Pay CIT
VTD
Rat#
Hra/f)ty
Farnlnaa
Ura/OtY
4.910130
4.137750
80.00
80.00
392.81
331.02
640.00
640.00
2.648.16 Fed MEO/EE
Regular
61.300000
70.00
4.291.00
Sick Leave
61.300000
10.00
613.00
34.879.70 CA WilMioldng
1,839.00
Uniform Allowance Bt-Weekly
Overtime for Comp (Ql 1.0
Comp-Time Taken
Comp Time Extended
Overtime for Pay @ 1.5
28.120000
1.00
28.12
569.00
30.00
7.00
3.00
1.00
Vacation Leave
garnlwo*
J2Q£x2Bi2flJl
3,142.48 Fed Wiihholdng
Cmxcfll
vrn
592.22
6.170.17
80.65
737.96
336.43
3.350.90
196.84
183.90
61.30
4.50
275.85
60.00
6.331.32
2.45200
40.00
TOTAL;
AFTER-TAX DEDUCTIOXS
BEFORE-TAX PEDUCTIOXS
Dwcription
Sutler 20
Delta Dental
VSP Signature
Retirement Contribution
Cnrrenl
vrn
83.03
265
8.16
581.21
96826
7.746.08
gwripllOn
Deneltts AdmiRistratsGD Fee
18.55 Police Amateur Athletic Found
10.259.03
EMPLOYER PAID BE.NEFITS
VTD PMcripiiftn
Ctimnt
0.21
1.47
3.50
Currtnt
\TD
747.26
5,230.82
Benefili Administration Fee
50.30
7.00
352.10
49.00
Employee Assistance Program
15.60
62.40
Suiter 20
28.00 Delta Dental
57.12
Life Insurance - Basic
Retirement Contribution
Basic l.ife Ins Fee •Sworn
TOTAL;
Current
YTD
VEAR-TO-DATE
Start Balance
'
Earned
-Taken
Adjustments
End Balance
1.062.10
8.402.96 TOTAL;
0.77
5.39
5.574.05
43.616.95
102
7.14
29.47 'TAXABLE
3.71
TOTAL CROSS
FED TAXABLE CROSS
TOTAL TAXES
TOTAL PEPt'CTIONS
5.655.95
4,593.85
1.009.30
1.06581
3.580.84
51.550 80
43.147.84
10.259.03
8.43243
32.859.34
VACATION
SICK LEAVE
43.7
43.1
10.5
25.8
40.0
30.0
00
0.0
46J
6J
NET PAY
NET PAY DISTRIBUTION
Advice ii4627084
TOTAL:
Acmint Type
Checking
Checking
Arratint Ntimher
325024543998
8G008I059I
Dtpoilt AntfiunK
9.24
3.571.60
3.580.84
Additional leave balance infonnation can be found on the Express Timesheet located under Time and Attendance on the Home page or at the following menu path; Main Menu >
CSJ Express Time Entry > CSJ TCFE Express Page.
.MESSAGE;
City of San Jose
Pay Group:
Pay Begin Date:
Pay End Date:
200 East Santa Clara Street
SanJose.CA 95113.1905
Roc M Pifferinl
4160 Jade Street ^^65
Capitola.CA 95010
Employee ID:
109095
Department:
POL.City ofSan Jose - Police
Business Unit:
CSJBU
04/07/2019
04/20/2019
Advice iV:
Advice Date:
4634002
04/26/2019
Location:
5030.Police«FieId Patrol
Poticc-Ficld Patrol
Job Title:
Police OfRcer
Pay Rate:
S4.904.00 Biweekly
TAX DATA:
Federal
CA State
Tax Status:
Married
S/M-2 inc
0
0
Allowances:
Addl. Percent:
Addl. Amount:
HOURS AND EARNINGS
TAXES
VTD
D#*griptton
POST Pay Advanced
Retention/Prenituni Pay CIT
Regular
Uniform Allowance Bi-Weekly
Vacation Leave
Hw/Qly
Farnlngx
4910130
4.137750
80.00
80 00
392.81
331.02
61 300000
70.00
4.291.00
28 120000
1.00
28.12
61 300000
10.00
613.00
Overtime for Comp ^ 1.0
3,535.29 Fed Wtihholdng
2.979.18 Fed MEO/EE
39.170.70 CA Withholdng
720.00
720.00
639.00
8.00
50.00
3.00
1.00
18390
61 30
4.50
275.85
60 00
6.33U2
Sick Leave
30.00
1.83900
TOTAL;
Currwit
Sutler 20
Delta Dental
83.03
265
VSP Signatitre
Retirement Contribution
AFTER»TAX DEDtCTIOXS
VTP
21.20 Police Anuleur AiMctic Fowtd
8 16
65 28
96826
8.714.34
0.21
3.S0
1.68 Simei20
31.30 Delia Denul
Benefits Administraiion Fee
Lire Insunmce• Basic
Retirctnent Contribution
TOTAL;
1.061.10
TOTAL CROSS
Current
YTD
YEAR-TO-DATE
Start Balance
'
Earned
-Taken
Adjustments
End Balance
9.463.06 TOTAL;
3.71
FED TAXABLE GROSS
336.43
3.687.33
L009J0
UJ68J3
818.61
E.MPLOYER PAID BENEFITS
VTl) Deeerinllon
f""""
664.24 Denefitf Admioislraiion Fm
6.762.39
224.96
Comp-Time Taken
BEFORE«TAX DEDt CnO.NS
VTD
592.22
00.65
3.065.00
Comp Time Extended
Overtime for Pay ^ 1 5
DMcriptioa
Cufreai
ruirent
\"m
747.26
5.978.08
30.30
7.C0
0.77
402.40
36.00
6.16
3.374.03
49.191.00
Basic Life Ins Fee•Sworn
1.02,
Employee Assistance Program
000
8.16
62.40
33.18 'TAXABLE
TOTAL DEDIICTIOISS
TOTAL TAXES
XET PAV
3,633.93
4.393.83
1.009.30
1.063.81
3.380.84
37.206.73
47.741.69
11.268.33
9.498.24
36.440.18
VACATION
SICK LEAVE
43.7
10.3
492
50.0
29.3
30.0
0.0
00
43.0
lao
XET PAY DISTRIBUTION
Affitiint Niimher
Advice 64634002
TOTAL;
Cheeking
Checking
323024543998
8000810391
Dennsit Amniint
9.24
3.571.60
3J80.g4
Additional leave balance information can be found on Ihe Express Timesheet located under Time and Attendance on the Home page or at the following menu path: Main Menu >
CSJ Express Time Entry > CSJ TCFE Express Page.
MESSAGE:
[17116]"
£4
0«p*rtmon{ of thi TrMBury— Internal Ravenue Service
(Q9]
£ IU4U U.S. Indlvlduat Income Tax Return
For t^-s year Jsn 1-Dec.31,2017. or other taxyearbeQirtniRg
0MB No. 1S45-0074 { inSUuOny-Da not wnie or slapio >n imi epaee.
ilo
.2017. ending
See separate instructions.
Vour first name arrd initial
Your social security number
ROC M
PIFFERINI
II a joint ratum. spouso'a first name and initial
551 I 53 I 5651
Spouse's social sacuifty number
Last name
JOANNA L
PIFFERINI
564 I 89 I 5273
Home address(number and street). 11 you tiava a P.O. box.see instructions.
Apt. no.
A
Make sure the SSNfs) above
and on line 6c are correct.
PO BOX 1495
Presidential Election Campaign
Oty,town or post oHice. slate, and ZIP code. I< ycu have a laraign address, also complete spaces beiow (see instructions).
ructions).
Check here if you, or yw toouw .f fling
TWAIN HARTE CA 95383
Foreign country name
postal codT abaibdowwiilnoldiangeyoirtaxor
" "o S®
r«tiiiHiiiw»uuw»«
Foreign province/slate/county
Ifttwd.
Filing Status
Check only one
Exemptions
4 Q
O Head of housr
household t«vfth qualifying person). (See Instructions.!
1 D Single
2 ES Married filing jointly (even if only one had Income)
3 n Married filing separately. Enter spouse's SSN ^ove
II the qualifying person is a Child but not your dapendeni. enter this
llthequaiifyin
child's name
name fhore. ^
child's
and full name here. ►
box.
6«
b
(see inslructions)
® r~|
D Qualifying
Oualifylng widow(er)
wi
rt check
[S Yourself. If someone can claim you as a dependent, do not
check box
box 6a
6a
US Spouse
■
c Dependents:
(1) Ftrslnims
RCC
M
□you □spouee
I
(2) Dg»«r>dent's
aoobitccurlly number
Laslflame
| (3)
(3) Oependent's
OtpenCent's |
reistioRsnio to
1} B""
on Ba and 6b
No. of children
an Be who:
(4) /if child under age 17
qualiiying for cMd tv ctedil
• lived with you
(tee indructicns)
• did not live wtlh
you due to divorce
or eeperatlan
{•ee inetructions)
i24l97i 2698 [SON
PIFFERINI
T~
2
Oependentf en Be
not entered above
d
lnCOni6
'
Attach Form(s)
j
8s
Add number* on
lines above P
Total numoer of exemptions claimed
Wages, salaries, tips. etc. Attach Form(s) W-2
7
Taxable interest. Attach Schedule B if required
{to
b Tax-exempt interest. Do not include on line 8a . . - j 8b I
Ordinary dividends. Attach Schedule B if required
W-2 here. AJso
I
attach Forms
W-2G and
1099-Rlftax
waswithhdd.
Qualified dividends
10
^2
13
If you did not
get a W-2,
"«°a W 2'^°'
instructions,
see instructions.
I 9b !
Gross
Gross
Income
InCOm©
^
Taxable refunds, credits, or offsets of state and local income taxes
10
Alimony received
Business Income or poss). Attach Schedule C or C-EZ
Capital gain or (loss). Attach Schedule 0 if required. If not required, check here ^
14 Other gains or Oosses). Attach Form 4797
""S" IRA distributions .
•
11
Q
13
-
hsa
12
_14
I b Taxableamount .
J5b
168
Pensions and annuities ; 16a
1 b Taxableamount
17
Rental real estate, royalties, partnerships. S corporations, trusts, etc. Attach Schedule E
17
16
Farm income or (loss). Attach Schedule F
18
19
Unemployment compensation
16t
19
2Ca Social security benefits | 20a i
AdjUStod
Adjusted
Sa
i
| b Taxable amount
. . .
21
Other Income.
22
CorrAnetheamount8inih3f3rr!ghtco!umnforlires7throj^2t.ThisisyourtotalittCMne ^
23
Educator expenses
24
Form 1099MISC
p
1
21
21.120
22
240,633
p™
_23
25
Certain business expenses of reservists, performing amsts. and
fee-basis5ovemmentoff;ciais-AttachFcrm2l06of2l06-£Z
Health savings account deduction. Attach Form 8889
_2S
26
Moving expenses, Attach Form 3903
27
Deductible part of self-empioyinent tax. Attach Schedule SE . _27
28
29
Self-employed SEP, SIMPLE, and qualified plans
Self-employed health Insurance deduction . .
30
31a
Penally on early withdrawai of savings
Alimony paid b Recipient's SSN ►
_30
31a
32
IRA deduction
_32
33
Student loan Interest deduction
_33
34
Tuition and fees. Attach Form SSI 7
34
Sg
35
Domestic production acthities deduction, Attach Form 8903
35
SS
36
Add lines 23 through 35
37
Subtract line 36 frcm line 22. This is your adjusted gross income
_ 26
.
.
.
.
10/02/15
1 > 4 92
_28
_29
Fwr Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions.
'.'or.
gio
_36
►
37
Cat. No. 11320B
Form 1040 (2017)
[17116] ROC M & JOANNA L PIFE'ERINI
551-53-5651
Page 2
pOTi i040 (2017)'
Tax and
38
Amount from line 37(adlusted gross income)
39a
Check I Q You were bom before January 2,1953,
if:
^ l~l Spouse was bom before January 2.1953.
I~i Blind. i checked ► 39a
If your spouse itemizes on a separate return or you were a dual-status alien, check here>' 39bn
Credits
standard
Deduction
tor—
•People who
check any
box on line
39a or 39b or
who can be
claimed as a
40
Itemized deductions (from Schedule A) or your standard deduction (see left margin)
41
Subtract line 40'rom line 38
42
Exemptions. I' line 38 is $156,90C or less, multiply $4,050 by the nijml>5r on line 6d. Otherwise, see instructions
42
43
Taxable income. Subtract line 42 from line 41. if line 42 Is more than line 41, enter -0-
43
44
Tax (see instructions). Check if any from; a □ Form(s) 8814
b □ Form 4972 c D
47
48
Foreign tax credit. Attach Form 111611 required .
49
Credit for child and dependent care expenses. Attach Form 2441
49
50
Education credits from Form 8863. line 19
50
51
I=1etirement savings contributions creoit. Attach Form 8880
51
52
62
53
Child tax credit. Attach Schedule SS12, if required.
Residential energy credits. Attach Form 5695
. .
Head of
54
Other credits from Form; a Q 3800 b D 8801
household,
$9,350
55
Married filing
jointty or
Oualifying
widowteri,
$12,700
Other
Taxes
39.901
56
Add lines 48 through 54. These are your total credits
Subtract line 55 from line 47. If line 55 is more than line 47, enter -0-
56
57
Self-employment tax. Attacn Scneduie SE
57
39.901
2.984
If you have a
qualifying
59
60a
^
48
.
.
53
c [I]
54
Taxes from; a KlFwrnSSSS
63
Add lines 56 through 62. This is your total tax
64
Federal Income tax withheld from Forms W-2 and 1099
65
2017 estimated tax payments and amount applied from 2016 return
b
58
59
60a
First-time homebuyer credit repayment. Attacit Form 5405 if required
62
66a
b □ 8319
Additional tax on IRAs, other qualified retirement plans, etc. Attach Form 5329 if required
Household employment taxes from Schedule H
bQ Form 8960
60b
Full-year coverage Ki .
■
,
61
o Q Instructions; enter code(s) _
.
.
.
63
40.885
Nontaxable combat pay election | 66b [
67
Additional child tax credit. Attach Schedule 8812
68
American opportunity credit from Form 8863. line 8
69
Net premium tax credit. Attach Form 8962 .
Amount paid with request for extension to file
.
.
■
.
71
Excess social security and Tier 1 RRTA tax withheld
72
Credit for federal tax on fuels. Attach Form 4136
73
Credis frotTi Fom; a [j 2439 b 0 kssc's; c Q 8885 d D
74
Add lines 64, 65, 65a, and 67 through 73. These are your total payments
75
If line 74 is more than line 63, subtract line 63 from line 74. This is the amount you overpaid
76a
>Mnount of line 75 you want refunded to you. If Form 8888 is attached, check here
See
d
40.885
Account number
76a
I
I
I !
1 . J ... i
I
Amount of line 75 you want applied to your 2018 estimated tax ► | 77
Amount
78
Amount you owe. Subtract line 74 from line 63. ror details on how to pay, see instructions
You Owe
79
Sign
Keep a copy tor
your records.
Phone
DONALD
Preparer
Use Only
►
BYFIELD
.
. ..
408 -295-0777
Yes. Complete below.
Personal identification
number (PIN)
Q No
80148
Under pa-,a.lies si pejury. I deciara that I have eu.T.i)ed Ihis lelisn and acconpanyin^ schedules and statanienu, and Is the best of my hmnttadja aru] pel.af. they are inie. cwracl, and
accuiaKdyiiS all amounlawxlaoiacet of incane I received cunnglhataiyev Pesieialienci<pnipaiaf(oiherihenleipe)'er)isbaudOflalilnfcnnetions(wn;cii(iret>era'haaenyXnewladea.
Dale
Your signature
>
Spouse's signature. If a joint return, both must sign.
anature
DONALD BYFIELD
Firrn-sname P DONALD D BYFIELD
Firtii's address P 1960 FRUITD.ALE AVE
RAN JOSE OA 95123
Go to iiVW,v.re-gov/Form1040 for instructions and the latest intormEtion.
Daytime phone numbar
Your occupation
POLICE
Pnnt/Type preparer's name
Paid
| 79 I
Designeo's
Here
Joint return? See
inslTJCtiohs.
Estimated tax penalty (see instructions)
Do you want to allow anothsr person to discuss this return with the IRS (see instnjotions)?
nameP-
75
► o Type: Q Checking Q Savings
77
Third Party
Oesignee
235
43.120
62
.
Earned Income credit (EIC)
Direct deposit? ^ b Routing number
instructions.
.
.
.
Health care: individual responsibility (see instructions)
70
Refund
.
61
Child, attach
Schedule Etc.
.
45
Unreported social security and Medicare tax from Form; a □ 4137
58
b
Payments
44
47
separately,
$6,350
Married filing
.
0
0
46
• All others:
Single or
.
46
45
dependent,
instructions.
37.648
201.493
12.150
189.343
39.901
41
Alternative minimum tax (see inetructions). Attach Furm 6251
Excess advance premium tax credit repayment. Attach Form 8962
Add lines 44,45, and 46
see
239.141
38
Q Blind.
|
Total boxes
Spouse'
OFFICER
II the IRS sent you an IdenLty ffrotacbon
PIN. srtw It
hara (see intl.)
Check CS il
PTIN
03-13-2018 s^-omployod P00073913
Firm's EIN P
Phone no.
408-295-0777
Form 1040 (2017)
itemized Deductions
0M6 No. 1545-0074
^ Go to www./rs.gohr/Sc/iedu/eA for instructions and the latest information.
Oeosrtnienl of the Treasury
Internal Revenue Service
i®i7
> Attach to Form 1040.
&
Medical
and
Dental
Expenses
Seouence No.07
Your (ocJal Mcurtty number
Name(s)shown on Form 104Q
ROC M
AtlBChmeni
Caution: If you are claiming a net qualified disaster loss ori Form 4684, see the instructions for line 26.
(
551-53-5651
JOANNA L PIFFERINI
Caution: Do not include expenses reimbursed or paid by others,
1 Medical and dental expenses(see instructions)
2 Enter amount from Form 1040, line 38 [jJ
3 Multiply line 2 by 7.5% (0.075), . , ,
1
239,141^
. , , . , [sj
4 Subtract line 3from line 1. If line 3 is more than line 1. enter -0- . ,
5 State and local (check only one box):
a Kl Income taxes, or
1
b D General saies taxes
|
6 Real estate taxes(see instructions)
_6_
7 Personal property taxes
7
8 Other taxes. List type and amount ► AUTO LICENSE
«
CABIN
[Ij
22,582
9 Add lines 5 throuoh 8
10 Home mortgage interest and points reported to you on Form 1098
10
8, 677
11 Home mortgage interest not reported to you on Form 1098. If paid BB
to the person from whom you bought the home, see instructions H|
and show that person's name, ioentlfying rfo., and address ^
SECOND HOME
H
TRAILER
Si
12 Points not reprorted to you on Form 109S. See instructions for
special rules
12
4, 04:
13 Mortgage Insurance premiums (see instructions)
14 investment Interest. Attach Form 4952 if required. See instructions
\C--i
|l4i
13,911
15 Add lines tOthrouoh 14
16 Gifts by cash or check. If you made any gift of S250 or more,
S
see instructions. SEE STATEMENT
16
50!
17 Other than by cash or check. If any gift of $250 or more, see ^
Instructions. You must attach Form 8283 if over $500 • - •
17
18 Carryover from prior year
65(
[18,
1,155
19 Add lines 16 through 18
Casualty and
20 Casualty or theft ioss{es) other than net qualified disaster losses. Attach Form 4684 and
Theft Losses
enter the amount from line 18 of that form. See instructions
Job Expenses
21 Unreimbursed employee expenses—iob travel, union dues,
and Certain
Miscellaneous
Deductions
job education, etc. Attach Foim 2106 or 2106-EZ If required, ^
See instructions. ► SEE STATEMENT
22 Tax preparation fees
^
3. 41!
22
35(
23 Other expenses—investment, safe deposit box. etc. List type ^
and amount ►
S
24 Add lines 21 through 23
25 Enter amount from Form 1040, line 38 [^j
26 Multiply line 25 by 2% (0,02)
239, 141
.^1
27 Subtract line 26 from line 24. If line 26 is more than line 24, enter -0-
Otf}^
28 Other—from list in instructions. List type and amount ►
Miscellaneous
Deductions
Total
itemized
Deductions
29 Is Form 1040, line 38, over Si 56,900?
D No. Your deduction is not limited. Add the amounts in the far right coiumn .
for lines 4 through 28, Also, enter this amount on Form 1040. line 40.
SlYes. Your deduction may be timlted. See the Itemized Deductions
37.648
[
Worksheet in the instructions to figure the amount to enter.
30 If you elect to itemize deductions even though they are less than your standard
deduction, check here
For Paperwork Reduction Act Notice, see the Instructions for Form 1040.
►
Cat. No. 17i4SC
Schedule A (Form 104012017
Supplemental Income and Loss
SCHEDULE E
(Form 1040)
OUB No. 1545-0074
(From rental real estate, royalties, partnerships, S corporations, estates, trusts, REMlCs, etc.)
► AttachtoForm1040,1040NR, or Form 1041.
^ Go to www.ln.gov/ScheduleE for instructions and the latest Information.
Departmeni of the Treasury
Internal Revenue Service(99)
Sequence No. 13
Your eocial security number
Name(s)
iame(s)shown on return
ROC
IOC M
M &&
47
JOA^
JOANNA L PIFFERINI
551-53-5651
Income or Loss From Rental Real Estate and Royalties Note: if you are In the business of renting personal property, use
Schedule C or C-EZ (see instructions). If you are an individual, report farm rental income or loss from Form 4835 on page 2. line 40.
A Did you make any payments in 2017 that would require you to file Formfs) 1099? (see instructions)
□ Yes Kl No
B If "Yes," did you or will you file required Forms 1099?
□ Yes Kl No
la
A
Physical address of each property (street, city, state, ZIP code
13506 27TH AVE NE Seattle WA 98125
Type of Property
(from list below)
For each rental real estate property listed
Fair Rental
Personal Use
Days
Days
above, report the number of fair rental and
personal use days. Check the QJV box
i
only if you meet the requir^ents to file as
a qualified joint venture. See instructions.
365
Type of Property:
1 Single Family Residence
3 Vacation/Short-Term Rental 5 Land
7 Self-Rental
2 Mutti-Famiiy Residence
4 Commercial
8 Other (describe)
Income:
3
Rents received
4
Royalties received
|
6 Royalties
Properties:
10.500
Expenses:
5
Advertising
_S
6
Auto and travel (see instructions)
_6
7
8
Cleaning and maintenance
Commissions
_7
_8
9
5 > 618
Insurance
_9
10
Legal and other professional fees
_10
782
11
Management fees
_11
140
12
Mortgage interest paid to banks, etc. (see instructions)
_12
8, 677
13
Other interest
J3
14
Repairs
_14
15
Supplies
_15
16
Taxes
_16
17
Utilities
J7
18
19
20
Depreciation expense or depletion
Other (list) ► OTHER EXPENSE STMT # 1
Total expenses. Add lines 5 through 19
21
Subtract line 20 from line 3 (rents) and/or 4 (royalties). If
219
2,39
4,310
37
22,517
19 I
result is a (loss), see instructions to find out If you must
file Form6198
22
_21
-12, 017
Deductible rental real estate loss after limitation, if any.
on Form 8582 (see instructions)
22 [(
23a Total of ail amounts reported on line 3 for all rental properties
b Total of all amounts reported on line 4 for all royalty properties
c Total of all amounts reported on line 12 for all properties
d Total of all amounts teportsd on line 18 for all properties
)(
. . . .
23a
.
23b
.
.
.
10.
10, 500
23c
23d
^
^
e Total of all amounts reported on line 20 for ali properties
22,
24
25
Income. Add positive amounts shown on line 21. Do not include any losses
Losses. Add royalty losses from line 21 and rental real estate losses from line 22. Enter total losses here .
26
Total rental real estate and royalty Income or Goss). Combine lines 24 and 25. Enter the result here.
If Parts 11, IK, !V. and line 40 on page 2 do not apply to you, also enter this amount on Form 1040, line
17, or Form 1040NR, line 18. Otherwise, include this amount in the total on line 41 on page 2
For Paperwork Reduction Act Notice, see the separate instructions.
Cat. No 113441.
.
-
.
Schedule E (Form 1040) 2017
Schedule E (Forni 1040)2017
AtiachtiBnl Sequence No.13
Name(s)shown on return. Do not enter name and social security number If shown on other side.
ROC M
Page2
Your social security number
& JOANNA L PIFFERINI
551-53-5651
Caution: The IRS compares amounts reported on your tax return with amounts shown on Schedule(s) K-1.
I^Qm
Income or Loss From Partnerships and S Corporations Note: if you report a loss from an at-risx activity for which
any amount Is not at risk, you must check the box In column (e) on line 28 and attach Form 6198. See Instructions.
27
Are you reporting any loss not allowed in a prior year due to the at-risk, excess farm loss, or basis limitations, a prior year
unallowed loss from a passive activity (if that loss was not reported on Form 8582), or unreimbursed partnership expenses? If
you answered "Yes," see instructions before completing this section.
□ Yes iX No
(b) Enter P for
partnership; S
(a) Name
for S corporation
(c) Check If
Id) Employer
(e) Check If
foreign
idantlficatlon
any amount is
partnership
number
not at risk
□
□
□
□
Nonpasslve Income and Loss
Passive Income and Loss
(f) Passive loss allowed
(attach Form 8582 If requited)
(O) Passive Income
9i) Nofipassive loss
(i) Section 179 expenso
G) Nonpasslve income
from Schedule K-1
from S^edule K-1
deduction Irom Form 4SS2
from Schedule K-1
Totals
Totals
Add columns (g) and (j) of line 29a
Add columns (f), (h), and (I) of lins 29b
Total partnership and S corporation income or (loss). Combine lines 30 and 31, Enter the
result here and include in the total on line 41 below
Part 111
Income or Loss From Estates and Trusts
32
(b) Employer
(a) Name
Idantlficatlon number
Nonpasslve Income and Loss
Passive income and Loss
|c) Passive deduction or loss allowed
(attach Femt 8582 If required)
(d) Passive income
(e) Deduction or loss
(f) Other Income from
from Schedule K-1
from Schedule K-1
Schedule K-1
Totals
Totals
j
Add columns (d) and (f) of line 34a
Add columns (c) and (e) of line 34b
Total estate and trust Income or (loss). Combine lines 35 and 36. Enter the result here and
Include in the total on line 41 below
El
3'
Income or Loss From Real Estate Mortgage Investment Conduits (REMICs)—Residual Holder
jTxZZ
I (b) Employer
Identification T
number
^'KSucCs)''
(d)from
Taxable
income0,(riel
Schedule
Unaloss)
lb
(d) Taxable Income (net loss)
from Schedules O, Une lb
Combine columns (d) and (e) only. Enter the result here and include In the total on line 41 below
Summary
Net farm rental Income or (toss) from Form 4835. .Also, complete line 42 below
Total Income or floss). Combine lines 26,32,37,39, and 40. Enter the result here end on Foim
Reconciliation of farming and fishing Income. Enter your gross
farming and fishing Income reported on Form 4835, line 7; Schedule K-1
(Form 1065), box 14, code B; Schedule K-1 (Form 1120.S), box 17, code
V; and Sch^ule K-1 (Form 1041), box 14, coda F (see instructions) . . I
Reconciliation for real estate professionals. If you were a real estate
professional (see Instructions), enter the net Income or (loss) you rf^orted
anywhere on Form 1040 or Form 1040NR from all rental real estate activitios
In which you materially participated under the passive activity loss rules . . 1 43 1
I? n
i. i i„
(o)incomBi
SchedulesQ,
(o) Income from
Schedules Q, line 3b
J.I.
STFD 1 THF TRANSACTION STMT FORMAT
STMT •
CO 10048 OP
ACTION
COID
PROD CODE DDA
ACCT
8000810591
CURR CODE
PAGE
ACTN
POST
8
EFFECTIVE CHECK NUMBER
119/04/30 12.28.27
MS 50852 ACTION COMPLETE
ACCT COND
SHORT NAME ROC PIFFERINI
SEARCH FROM 119/03/26 THRU 119/04/08
TRAN AMOUNT
D/C
OD
BALANCE
DESCRIPTION
3,207.79
112.58
D
04/08
MCP10406180154727102 CARHARTT RETAIL LLCS30 W SPOKANE WA 1370
94.74
D
3,113.05
04/08
MCP10406172438907154 10502 CRESCENT COURT707 W SPOKANE WA 1370
94.74
D
3,018.31
04/08
MCP10406183535454921 10502 CRESCENT COURT707 W SPOKANE WA 1370
TRACE ID
*
4;
*
*
*
04/08
MCS10406195001884382
*
*
*
14.68
D
MCS10407014204573867 Nike Inc. Beaverton WA 1370
21.24
D
04/08
3,003.63
2,982.39
SQU*SQ *BEN & J Spokane WA 1370
04/08
9.00
D
MCS10406165910489671 RIVER PARK SQUA SPOKANE WA 1370
19.00
D
04/08
MCS10406181209444980 VILLAGE CENTRE SPOKANE WA 1370
40.89
D
04/08
MCS10407085556355640 WOLFFYS HAMBURG AIRWAY HEIGHT WA 1370
2,973.39
2,954.39
2,913.50
PF: 1-HELP 3-PLVL 7-SB 8-SF 9-ASUM 10-TRIG 11-CUTO -STSM
3270 PASSTHRU EMULATION
04/30/19
09:28:28
STFD 1 THF TRANSACTION STMT FORMAT
STMT '
CO 10048 OP
ACTION
PROD CODE DDA
CURR CODE
ACTN
POST
COID
ACCT
119/04/30 12.28.31
MS 50852 ACTION COMPLETE
8000810591
PAGE
9
EFFECTIVE CHECK NUMBER
TRACE ID
ACCT COND
SHORT NAME ROC PIFFERINI
SEARCH FROM 119/03/26 THRU 119/04/09
TRAN AMOUNT D/C OD
BALANCE
DESCRIPTION
* 04/08
35.82
D
2,877,68
MCP10407175513022007 MAVERIK #558 SPOKANE WA 1370
* 04/08
16.50
D
2,861.18
MCS10407140636704632 SQU*SQ *BLISSFU Spokane WA 1370
* 04/08
43.54
D
2,817.64
MCP10407160109421570 BARNESNOB 15310 E. Ind SPOKANE WA 1370
* 04/08
43.51
D
2,774.13
MCP10408131716658183 ARCO#07013ARCO SEATTLE WA 1370
* 04/08
1275
1,823.00
D
951.13
D
923.92
97000011904080977577 CHECK (SUBSTITUTE)
* 04/09
27.21
MCS10407153206817485 UNCLES GAMES PU SPOKANE VALLE WA 1370
* 04/09
39.00
D
884.92
MCS10407213358930232 SHORT STOP #7 CLE ELUM WA 1370
* 04/09
4.99
D
879.93
MCS10408150501433605 LIL PANTRY - NO GRANTS PASS OR 1370
PF: 1-HELP 3-PLVL 7-SB 8-SF 9-ASUM 10-TRIG 11-CUTO -STSM
3270 PASSTHRU EMULATION
04/30/19
09:28:32
STFD 1 THF TRANSACTION STMT FORMAT
STMT •
CO 10048 OP
ACTION
PROD CODE DDA
COID
ACCT
CURR CODE
ACTN
POST
119/04/30 12.28.35
MS 50852 ACTION COMPLETE
8000810591
PAGE
10
EFFECTIVE CHECK NUMBER
TRACE ID
* 04/09
ACCT COND
SHORT NAME ROC PIFFERINI
SEARCH FROM 119/03/26 THRU 119/04/12
TRAN AMOUNT
D/C
OD
BALANCE
DESCRIPTION
45.84
D
834.09
MCS10408130526979084 SHELL OIL 10014 GRANTS PASS OR 1370
* 04/09
10.00
D
824.09
MCP10409014107135090 SUNOL SUPER STO SUNOL CA 1370
* 04/10
47.27
D
776.82
MCP10410160306279827 SUNOL SUPER STO SUNOL CA 1370
* 04/10
56.03
D
720.79
MCP10410102600012570 SAVEMART #48 0AKDALE.CA14 OAKDALE CA 1370
* 04/10
34.10
D
686.69
00948819099005851137 AAA LIFE INS PREM 041019
* 04/11
64.50
D
622.19
MCP10411164827111048 BEAR CREEK STAT TUOLUMNE CA 1370
* 04/11
12.86
D
609.33
MCP10411165524263450 RITE AID STORE - 6015 OAKDALE CA 1370
* 04/11
2.98
D
606.35
MCP10411161900523303 TWAIN HAR 18711 TIFFEN TWAIN HARTE CA 1370
PF: 1-HELP 3-PLVL 7-SB 8-SF 9-ASUM 10-TRIG 11-CUTO -STSM
3270 PASSTHRU EMULATION
04/30/19
09:28:35
STFD 1 THF TRANSACTION STMT FORMAT
STMT •
CO 10048 OP
ACTION
CODE DBA
COID
ACCT
CODE
ACTN
POST
8000810591
PAGE
11
JTOMBER
EFFECTIVE CHECK
TRACE ID
*
119/04/30 12.28.39
MS 50852 ACTION COMPLETE
04/12
ACCT COND
SHORT NAME ROC PIFFERINI
SEARCH FROM 119/03/26 THRU 119/04/12
BALANCE
TRAN AMOUNT D/C OD
DESCRIPTION
3,571.60
C
4,177.95
00948819100007595970 CITY OF SAN JOSE DIR DEP 190406
*
04/12
MCS10410165304463153
*
04/12
40.00
D
4,137.95
Eproson House Twain Harte CA 1370
70.00
D
4,067.95
MCS10411115930673774 ASF*CLASS 5 FIT 800-5258967 CA 1370
*
04/12
48.10
D
4,019.85
MCS10411131306405710 SONORA RENTALS SONORA CA 1370
*
04/12
8.20
D
4,011.65
MCS10411174233175117 DEL RIO CLEANER OAKDALE CA 1370
*
04/12
MCA10412071937342123
*
04/12
MCA10412071937342123
*
400.00
3,611.65
2.50
D
3,609.15
NON-COMERICA ATM USAGE FEE - W/D 1370
04/12
I-GEN119041200000797
D
W/D AT EL DORADO SAVINGS BA TWAIN HARTE CA 1370
2.50
C
3,611.65
NON-COMERICA ATM USAGE FEE - W/D 1370
PF: 1-HELP 3-PLVL 7-SB 8-SF 9-ASUM 10-TRIG 11-CUTO -STSM
3270 PASSTHRU EMULATION
04/30/19
09:29:03
STFD 1 THF TRANSACTION STMT FORMAT
STMT
■
CO 10048 OP
ACTION
PROD CODE DDA
CURR CODE
ACTN
POST
COID
ACCT
119/04/30 12.29.12
MS 50852 ACTION COMPLETE
8000810591
PAGE
12
EFFECTIVE CHECK NUMBER
TRACE ID
ACCT COND
SHORT NAME ROC PIFFERINI
SEARCH FROM 119/03/26 THRU 119/04/15
TRAN AMOUNT D/C OD
BALANCE
DESCRIPTION
* 04/12
2.00
D
3,609.65
MCA10412071937342123 OTH BANK FEE EL DORADO SAVI TWAIN HARTE CA 1370
* 04/12
2.00
C
3,611.65
I-GEN119041200000798 OTH BANK FEE EL DORADO SAVI TWAIN HARTE CA 1370
* 04/12
38.61
D
3,573.04
MCP10412144807092416 BEAR CREEK STAT TUOLUMNE CA 1370
* 04/15
100.00
C
3,673.04
27.98
D
3,645.06
48000011904151119518 DEPOSIT
* 04/15
MCS10411111224412313 BLACK OAK CAFE TUOLUMNE CA 1370
* 04/15
24.05
D
3,621.01
MCS10411194746805834 CKE*THE ROCK TWAIN HARTE CA 1370
* 04/15
19.99
D
3,601.02
MCS10410161737468527 HOTEL AT BLACK TUOLUMNE CA 1370
* 04/15
4.51
D
3,596.51
MCS10412131500954499 TACO BELL #3452 JACKSON CA 1370
PF: 1-HELP 3-PLVL 7-SB 8-SF 9-ASUM 10-TRIG 11-CUTO -STSM
3270 PASSTHRU EMULATION
04/30/19
09:29:13
STFD 1 THF TRANSACTION STMT FORMAT
STMT
■
CO 10048 OP
ACTION
COID
PROD CODE DDA
CURR CODE
ACTN
POST
ACCT
119/04/30 12.29.16
MS 50852 ACTION COMPLETE
ACCT COND
8000810591
PAGE
13
EFFECTIVE CHECK NUMBER
TRACE ID
SHORT NAME ROC PIFFERINI
SEARCH FROM 119/03/26 THRU 119/04/17
TRAN AMOUNT D/C OD
BALANCE
DESCRIPTION
* 04/15
8.04
D
3,588.47
MCS10412142838410200 NEW BEGINNINGS PLACERVILLE CA 1370
* 04/15
3.98
D
3,584.49
MCP10412173731462527 RALEY'S #422 PLACERVILLE CA 1370
* 04/15
42.01
D
3,542.48
MCP10415025421143782 SUNOL SUPER STO SUNOL CA 1370
* 04/15
540.00
D
3,002.48
MCA10415111008376058 W/D AT 333 W SANTA CLARA ST SAN JOSE CA 1370
* 04/15
1215
100.00
D
2,902.48
97000011904151115022 CHECK (SUBSTITUTE)
* 04/16
16.98
D
2,885.50
MCP10415224219636195 WAL Wal-Mart Super 340315 SAN JOSE CA 1370
* 04/16
66.88
D
2,818.62
00948819106001351409 CINTI LIF INS CO INSUR PREM 190415
* 04/17
886.00
D
1,932.62
MCS10416175538888929 AAA INSURANCE 800-922-8228 CA 1370
PF: 1-HELP 3-PLVL 7-SB 8-SF 9-ASUM 10-TRIG 11-CUTO -STSM
3270 PASSTHRU EMULATION
04/30/19
09:29:16
STFD 1 THF TRANSACTION STMT FORMAT
STMT
CO 10048 OP
ACTION
PROD CODE DDA
CURR CODE
ACTN
POST
COID
ACCT
8000810591
PAGE
TRACE ID
*
*
14
EFFECTIVE CHECK NUMBER
04/17
119/04/30 12.29.19
MS 50852 ACTION COMPLETE
ACCT COND
SHORT NAME ROC PIFFERINI
SEARCH FROM 119/03/26 THRU 119/04/19
TRAN AMOUNT
D/C
OD
BALANCE
DESCRIPTION
14.40
D
1,918.22
MCP10416222900250970 WAL-MART #58845095 ALMADE SAN JOSE CA 1370
1,892.23
25.99
D
04/17
MCP10417092728554345 TRACTOR S 1580 EAST F OAKDALE CA 1370
57.44
D
1,834.79
*
04/17
*
MCP10417133412813144 TWAIN HARTE PHAR18711 TIF TWAIN HARTE CA 1370
1,807.99
26.80
D
04/17
MCP10417134021880887 TWAIN HARTE PHAR18711 TIF TWAIN HARTE CA 1370
*
04/18
*
*
D
1,583.24
1,340.24
MCS10416144651830100 CLOVIS AVE SELF FRESNO CA 1370
2.50
D
04/19
1,337.74
MCA10419084846355426
*
224.75
MCS10416144541829101 CLOVIS AVE SELF FRESNO CA 1370
243.00
D
04/18
INQ AT EL DORADO SAVINGS BANK TWAIN HARTE 1370
04/19
I-GEN119041900000775
2.50
C
1,340.24
INQ AT EL DORADO SAVINGS BANK TWAIN HARTE 1370
PF; 1-HELP 3-PLVL 7-SB 8-SF 9-ASUM 10-TRIG 11-CUTO -STSM
3270 PASSTHRU EMULATION
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09:29:19
STPD 1 THF TRANSACTION STMT FORMAT
STMT
CO 10048 OP
ACTION
COID
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ACCT
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ACTN
POST
ACCT COND
8000810591
PAGE
04/19
MCA10419084915355496
★
*
*
*
*
*
*
15
EFFECTIVE CHECK NUMBER
TRACE ID
*
119/04/30 12.29.22
MS 50852 ACTION COMPLETE
SHORT NAME ROC PIFFERINI
SEARCH FROM 119/03/26 THRU 119/04/22
TRAN AMOUNT
DESCRIPTION
340.00
D/C
OD
04/19
2.50
1,000.24
D
W/D AT EL DORADO SAVINGS BA
BALANCE
TWAIN HARTE CA 1370
997.74
D
MCA10419084915355496 NON-COMERICA ATM USAGE FEE -■
2.50
C
04/19
W/D 1370
1-GEN119041900000776 NON-COMERICA ATM USAGE FEE -■
2.00
D
04/19
W/D 1370
1,000.24
998.24
MCA10419084915355496 OTH BANK FEE EL DORADO SAVl TWAIN HARTE CA 1370
1,000.24
2.00
C
04/19
1-GEN119041900000777 OTH BANK FEE EL DORADO SAVl TWAIN HARTE CA 1370
04/19
36.66
D
MCP10419175717119968 BEAR CREEK STAT TUOLUMNE CA 1370
11.80
D
04/22
MCS10419133226401082 NEW BEGINNINGS PLACERVILLE CA 1370
15,23
D
04/22
MCP10419175852536885 RALEY'S #422 PLACERVILLE CA 1370
963.58
951.78
936.55
PF: 1-HELP 3-PLVL 7-SB 8-SF 9-ASUM 10-TRlG 11-CUTO -STSM
3270 PASSTHRU EMULATION
04/30/19
09:29:22
STFD 1 THF TRANSACTION STMT FORMAT
STMT
CO 10048 OP
Action
coid
PROD CODE DDA
ACCT
CURR CODE
POST
ACTN
acct cond
8000810591
PAGE
EFFECTIVE CHECK
TRACE ID
*
04/22
*
04/22
*
04/22
119/04/30 12.29.25
MS 50852 ACTION COMPLETE
16
NUMBER
SHORT NAME ROC PIFFERINI
SEARCH FROM 119/03/26 THRU 119/04/24
TRAN AMOUNT
D/C
CD
DESCRIPTION
30.43
D
MCP10420130246484464 RALEY'S #422 PLACERVILLE CA 1370
34.00
D
00948819112005578022 ALLSTATE LIFE INS.PREM. 042019
20.00
D
BALANCE
906.12
872.12
852.12
00948819112005578023 ALLSTATE LIFE INS.PREM. 042019
*
04/22
835.12
*
04/23
783.42
*
04122
17.00
D
00948819112005578021 ALLSTATE LIFE INS.PREM. 042019
51.70
D
MCS10422155243826430 ULTIMATE TANNIN SAN JOSE CA 1370
97.88
D
685.54
00948819112006660487 AMERICAN GEN LIF INS PAYMT
•k
04/23
.06
C
685.60
20.01
D
665.59
I-GEN119042300000871 INTEREST
04/24
MCP10424154342403362 SPARTAN STATION SAN JOSE CA 1370
PF: 1-HELP 3-PLVL 7-SB 8-SF 9-ASUM 10-TRIG 11-CUTO -STSM
3270 PASSTHRU EMULATION
04/30/19
09:29:26
STFD 1 THF TRANSACTION STMT FORMAT
STMT •
CO 10048 OP
ACTION
COID
PROD CODE DDA
ACCT
CURR CODE
ACTN
POST
8000810591
PAGE
17
EFFECTIVE CHECK NUMBER
TRACE ID
119/04/30 12.29.29
MS 50852 ACTION COMPLETE
ACCT COND
SHORT NAME ROC PIFFERINI
SEARCH FROM 119/03/26 THRU 119/04/26
TRAN AMOUNT D/C OD
BALANCE
DESCRIPTION
04/24
3.53
D
662.06
MCP10424160300985470 HUDSONNEWS ST8871512 MONT SAN JOSE CA 1370
04/25
3.10
D
658.96
MCS10424155933797894 PEETS B SAN JOSE CA 1370
04/25
6.39
D
652.57
MCP10424203400088770 HUDSONNEWS ST8871512 MONT SAN JOSE CA 1370
04/25
15.37
D
637.20
MCP10425161153658169 ARCO#82660OAKDA OAKDALE CA 1370
04/25
15.60
D
621.60
MCP10425191231674377 ZAK'S AUTO SHAC TWAIN HARTE CA 1370
04/25
50.00
D
571.60
MCP10425232109806915 COSTCO GAS #103 MANTECA CA 1370
04/25
79.37
D
492.23
MCP10425163700741990 COSTCO WHSE #10 MANTECA CA 1370
04/26
3,571.60
C
4,063.83
00948819114009297469 CITY OF SAN JOSE DIR DEP 190420
PF: 1-HELP 3-PLVL 7-SB 8-SF 9-ASUM 10-TRlG 11-CUTO -STSM
3270 PASSTHRU EMULATION
04/30/19
09:29:30
STFD 1
STMT CO 10048 OP
ACTION
COID
PROD CODE DDA
ACCT
CURE CODE
ACTN
THF TRANSACTION STMT FORMAT
8000810591
119/04/30 12.29.32
MS 50852 ACTION COMPLETE
ACCT COND
SHORT NAME ROC PIFFERINI
SEARCH FROM 119/03/26
PAGE
18
TRAN AMOUNT D/C OD
POST
EFFECTIVE CHECK NUMBER
DESCRIPTION
TRACE ID
04/26
38.40
THRU 119/04/29
D
BTiLANCE
4,025.43
MCS10424131357709869 MICHAEL D CARLT 000-000-0000 CA 1370
04/26
320.00
D
MCA10426105252533575 W/D AT U.S. BANKUSB SAN JOSE S
.00
D
04/26
MCA10426105252533575 OTH BANK FEE U.S
04/26
I-GEN119042600000233 OTH BANK FEE U.S
3,705.43
SAN JOSE CA 1370
3,702.43
BANKUSB SAN
SAN JOSE CA 1370
,00
C
BANKUSB SAN
SAN JOSE CA 1370
,50
04/26
MCA10426105252533575 NON-COMERICA ATM USAGE
04/26
2.50
I-GEN119042600000234 NON-COMERICA ATM USAGE
04/29
25.98
3,705.43
D
FEE - W/D 1370
C
FEE - W/D 1370
D
3,702.93
3,705.43
3,679.45
MCS10425111405430108 SONORA RENTALS SONORA CA 1370
04/29
369.40
D
3,310.05
MCS10426204444917860 AAA INSURANCE 800-922-8228 CA 1370
PFi
1-HELP 3-PLVL 7-SB 8-SF 9-ASUM 10-TRIG 11-CUTO -STSM
3270 PASSTHRU EMULATION
04/30/19
09:29:33
STFD 1 THF TRANSACTION STMT FORMAT
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CO 10048 OP
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COID
PROD CODE DDA
ACCT
8000810591
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ACTN
POST
19
EFFECTIVE CHECK NUMBER
TRACE ID
04/29
119/04/30 12.29.36
MS 50852 ACTION COMPLETE
ACCT COND
SHORT NAME ROC PIFFERINI
SEARCH FROM 119/03/26 THRU 119/04/29
TRAN AMOUNT
D/C
OD
BALANCE
DESCRIPTION
201.37
D
3,108.68
MCP10427142800695667 COSTCO WHSE #01 SANTA CLARA CA 1370
04/29
33.47
D
3,075.21
MCP10429001516120381 SUNOL SUPER STO SUNOL CA 1370
04/29
360.00
D
2,715.21
MCA10429011916282799 W/D AT 1092 BLOSSOM HILL RD SAN JOSE CA 1370
PF: 1-HELP 3-PLVL 7-SB 8-SF 9-ASUM 10-TRIG 11-CUTO -STSM
3270 PASSTHRU EMULATION
04/30/19
09:29:36
AiiiortcflfiAltlincs
AAdvantage ^
AAdvantage® Aviator® Red Mastercard® Statement
I Account Ending 9120 |
Statement Period 03/06/19-04/05/19
ROCMPIFFERINISR
I
Account Activity
Page 1 of 6
Payment Information
Previous Balance as of 03/06/19
Payments-iTiank You
$4,623.93
Statement Balance:
$700.00
•
Purchases
-1-
$66.98
Fees Charged
•F
$0.00
Interest Charged
*
$85.81
Statement Balance as of 04/05/19
e
$4,076.72
Minimum Payment Due:
$125.71
Payment Due Date:
05/02/19
Late Payment Vl/arning: If we do not receive your minimum payment by the
date listed above, you may have to pay a late fee of up to $39.00.
Minimum Payment Warning: If you make only the minimum payment each
$4,076.72
period, you will pay more in interest and it will take you longer to pay off your
balance. For example:
If you make no
You will pay off the
And you will end up
^ APR Details begin on page 5 In the Interest Charge
Calculation section.
^ Transaction details begin on page 3.
additional charges using
balance shown on this
this card and each month
statement in about...
paying an estimated total
you pay...
Total Revolving Credit Line
Only the minimum
$4,500.00
payment
Includes $900,00 cash advance line
Available Revolving Credit Line
$423.28
$158.00
17 years
$10,769.00
3 years
$5,688.00
(Savings a $5,081.00)
as of 04/05/19
Available for cash advances $423.28
> If you would like Information about credit counseling services, please call S0O-S7O-1403.
Repayment Information based on activity and APR's on your account as of the closing date.
Total Miles Sent to American Airlines
SEE INSIDE: You may have additional important messages Inside.
AAdvantage Program
^ For details see pages
NOTICE;S£E REVERSE SIDE OR END OF STATEMENT FOR IMPORTANT INFORMATION
Waystopay:
Payment Coupon
^ Av!atorMastefcard.coin
Q Barclays Mobile App
86fr92a-M75 1T2.. KlJUPfS
S4.076.72
SlateiiiGnt Balance as of 04/0S/19: {>j<ai!!iii < ii hiiii H/iij
AnicriC4rtAJfliti«5
w
AAdvantage ^
$125.71
05/02/19
Mliilmuiii Payinenl Due:
Payment Due Date:
/tmount Enclosed; $
—,
,
Make cheek payable to Barclays. Allow 7-tO dayi for USPS delivery.
AB 01 012545 03178 B 51 C
ROCMPIFfERINI 5R
201 W MISSION ST
SAN JOSE CA 95110-1701
Q OiKkftfaddres!, email and ce>H;«dungts.Ccnipl(tefom on the back.
Barclays
P.O. Box 60517
Cltyof Industry,CA 91716-0517
I|IiIm|Im|I|.I>|iII
514flinDQT7S115DQD01SS71DDHD7b75fl
#BARCIAYS
Important Information
Page 2 of 6
Information About Credit Bureau Reporting: We may report information about your
account to credit bureaus. Late payments, missed payments, or other defaults on your
account may be reflected in your credit report.
Annual Fee. If your account has an annual fee, it will be billed each year. We will give you
advance notice on your billing statement prior to the assessment of the annual fee. You may
choose to call us at 8e6-928-3075 wlthin^S days of receiving such notice to discuss
alternative products that may be available or to close your account so that the fee will not
be billed. If your account is closed, any outstanding reward points or miles on your account
may be forfeited at that time. Payment of the annual fee does not affect our abii'tty to dose
your account and/or to ilmrt your transactions.
Mobile: To download the Barclays Mobile App,text MOBILE to 53818.
Phone; Call US at 866-928-3075 and we will process your payment.
Ail payments made via web, mobile app or pay by phone by 11:59 p.m. ET wiii be credited
to your account that same day.
Overnight Payments:Send overnight courier service or U.S.P.S. Priority Mail payments to
REMITCO,Card Services, Lock Box 60517,2525 Corporate Park, Suite 250, Monterey Park,
CA,91754. A payment received at this addreu by 5 p.m.PT that otherwise meets the
requirements of a conforming payment wiii be cr^rted to your account that same day.
How We Wiii Calculate Interest. We use a method called 'daily balance* Onciuding new
purchases). We cdculate inter«t separately for each 'Balance Subject to Interest Rate.*
These include for example. Purchases at the current rate. Balance Transfers at the current
rate. Cash Advances at the current rate, and different promotional balances. Your monthly
Payment Information: Each billing cycle, you must pay at least the Minimum Payment Due billing statement shows each 'Balance Subject to interest Rate.*
shown on your monthly statement by its Payment Due Date. Both the Minimum Payment
Due and Payment Due Date are not^ on your statement and on your home page when you To calculate interest, we first calculate a daily balance for each Balance Subject to Interest
login to AviatotMastercard.com. At any time you may pay nrare than the Minimum Payment Rate. We start with the balance,for that Balance Subject to interest Rate, as of the end of
Due up to the full amount you owe us, however you cannot'pay ahead*. This means that if the previous day. We add any interest calculated on the previous da/s balance.(This means
you pay more than the required Minimum Payment Due in any billing cycle or if you ntake
interest is compounded daily). We add any new Purchases, Balance Transfers or Cash
more than one payment in a billing cycle, you will still need to pay the next month's
Advances to the appropriate balance,subtract any new payments or credits from the
appropriate balance,and make other adjustments. A cr^lt balance is treated as a balance
required Minimum Payment Due by your next Payment Due Date. Remember to make all
of zero. We then multiply each daily balance by the applicable daily periodic rate. We do this
checks payable to Barclays. Please allow 7to 10 days for the U.S. Postal Service to
for each day in the billing period. That gives us the daily interest. We add up all the daily
deliver your payment to us. Upon our receipt, your available credit may not be
interest for all of the daily balances to get the total interest for the billing period.
increased by the payment amount for up to 7 days to ensure the funds from the
bank on which your payment is drawn are collected and not returned. When you
provide a check as payment on this Account, you authorize us to either use the information Accrual of Interest and How to Avoid Paying interest on Purchases. Your due date is
at least 23 days after the close of each billing cycle. On Purchases, Interest begins to accrue
from your check to make a one-time electronic fund transfer from your account or to
as of the transactlori date. However, you can avoid paying Interest on Purchases In any
process the payment as a check transaction. When we use information from your check to
make an electronic fund transfer,funds may be withdrawn from your account as soon as the given billing cycle if you pay your Statement Balance in full by the Payment Due Date. You
may also avoid paying interest on Purchases if either Paragraph A or Paragraph B of this
same day we receive your payment, and you will not receive your check back from your
section applies to your account
ffnanciai institution. For inquiries, please call 866-928-3075.
Lost or Stolen Card: Your credit card is issued by Bardays Bank Delaware. If your card is
lost or stolen, please contact us immediately at 866-928-3075 at any time.
Mailed Payments: A conforming payment received by us by 5 p.m. PI wiii be aedited to
your account the day of receipt. A 'conforming payment* is a payment that: 1)is mailed
using the enclosed envelope and payment coupon included with this statement or mailed
with a payment coupon printed from AviatorMastercard.com to Barclays, P.O. Box 60517,
City of industry, CA 91716-0517; and 2)is in the form of a single, non-folded check or
money order rnade payable in U.S. dollars from a U.S. based institution. Any payment that
does not meet these requirements, or any payment with multiple checks or money orders,
additional correspondence,staples, paperclips, etc. wiii be considered a'non-conforming
payment* which may delay the crediting of the payment for up to 5 days.
Other Payment Options:
Web: Visit AtdatorMastercard.com to set up your payments.
A.if you have Purchase balances with a0% promotional APR, you can avoid paying interest
on those Purchase balances during the promotional period, and the following Paragraph B
wiii not apply to your account.(However,to avoid a late fee, pay at least your Minimum
Payment Due.)
B, If you have Purchase balances with an APR that is greater than 0%,and you also have
other types of promotional balances on your account, you still may be able to avoid paying
interest on those balances without paying your Statement Balance in full. If this applies to
your Account, you wiii see a Paragraph titled 'Avoiding interest on Purchases(Grace
Period)' appearing directly below the interest Charge Calculation section on the front of
this Statement This will show the amount you can pay by the Payment Due Date and still
avoid interest charges on your Purchase balances. This amount may differ from your
Statement Balance. It may differ because you currently have certain promotional APR
Continued on page 4
Make Changes to your contact information below
Name
Address
City
State
Home Phone
Work Phone
Email Address
Zip
#BARCLAYS
Page 4 of 6
lalances, and the nonpayment of these balances will not affect your grace period on
■urchases, provided you pay all other balances on your account. (However, to avoid a late
ee, pay at least your Minimum Payment Due.)
=or Balance Transfers, interest will accrue from the transaction date which generally will be
he day the p^ accepts the Check. For Cash Advances, Interest will accrue from the
ransaction date which generally will be the day you take the Cash Advance. Please note
hat purchases of Cash Equivalents, which include money orders, travelers checks, foreign
urrency, lottery tickets, gambling chips and wire transfers, are treated as Cash Advances
ind do not have a grace period. See your Cardmember Agreement for more information.
tUnlmum Interest Charge; This fee, if Imposed, appears in the Summary of Fees as a
'Minimum Interest Charge" or "Minimum Charge."
to Pre-Set Spending Limit: "No Pre-Set Spending Limit" does not mean unlimited,
spending. It means we may permit you from time to time at our disaetlon to make certain
drarges that will cause your outstanding balance to exceed your revolving credit line. Any
luch charge will be considered on an individual basis and such evaluation will be based on
rour account spending and payment history as well as your experience with other creditors,
f you exceed your revolving credit line, then you must pay, with your Minimum Payment
}ue, the amount by which your balance excels your revolving credit line, including
imounts due to Purchases, Cash Advances, Interest charges. Fees, or other charges.
1.
The purchase must have been made in your home state or within 100 miles of your
2.
current mailing address, and the purchase price must have been more than $50.
(Note; Neither of these are necessary if your purchase was based on an advertisement
we mailed to you, or If we own the company that sold you the goods or services.)
You must have used your credit card for the purchase. Purchases made with cash
advances from an ATM or with a check that accesses your credit card account do not
qualify.
You must not yet have fully paid for the purchase.
3.
If all of the criteria above are met and you are still dissatisfied with the purchase, contact us
fn writing at;
Card Services
P.O. Box 8802
Wilmington, DE 19899-8802.
While we Investigate, the same rules apply to the disputed amount as discussed above.
After we finish our Investigation, we will tell you cur decision. At that point, If we think you
owe an amount and you do not pay, we may report you as delinquent.
Please refer to your Cardmember Agreement for additional information about the terms of
your Account.
Credit Bureau Disputes; If you believe that an entry we have made on your credit bureau
eport is inaccurate or Incomplete, please contact the reporting agency directly or contact us
It Card Services, P.O. Box 8803 Wilmington, DE19899-8801. Please Include your name;
(our account number; the cred'rt reporting agency where you received the bureau report a
lescription of the error; and why you believe It is an error. We wili promptly investigate,
lotify you of our findings, and send an update to the credit bureaus If warranted within 30
"2019 Barclays Bank Delaware, member FDIC
fays.
Miat To Do If You Think You Find A Mistake On Your Statement
f you think there is an error on your statement, write to us at;
lard Services
>0. Box 8802
JVilmington, DE 19899-8802.
nyour letter, give us the following Information:
>
Account Information; Your name and account number.
>
I
Dollar amount; The dollar amount of the suspected error.
Description of problem: If you think there is an error on your bill, describe what you
believe Is wrong and why you believe It Is a mistake.
fou must contact us within 60 days after the error appeared on your statement.
Tou must notify us of any potential errors In wrft/ng. You may call us, but If you do we are
lot required to investigate any potential errors and you may have to pay the amount In
question.
Afhile we investigate whether or not there has been an error, the following are true;
>
We cannot try to collect the amount in question, or report you as deiinquent on that
amount
I
The charge in question may remain on your statement, and we may continue to
charge you interest on that amount. But If we determine that we made a mistake,
you will not have to pay the amount in question or any interest or other fees related
to that amount.
I
While you do not have to pay the amount in question, you are responsible for the
I
We can apply any unpaid amount against your aedit limit.
remainder of your balance.
four Rights If You Are Dissatisfied With Your Credit Card Purchases
f you are dissatisfied with the goods or services that you have purchased with your credit
rard, and you have tried in good faith to correct the problem with the merchant, you may
lave the right not to pay the remaining amount due on the purchase.
fo use this right, all of the following must be tme;
Visit AviatorMastercard.com or use the Barclays Mobile App
AAdvantage® Aviator® Red Mastercard® Statement
I Account Ending 9120 |
Statement Period 03/06/19-04/05/19
ROCMPIFFERINl SR
Page 3 of 6
IMPORTANT NOTICE;
You may allow Authorized Users to use your Account. Barclays provides account Information to the credit reporting agencies for all account users, Including Authorized Users. This
information could Impact an Authorized User's credit score. For help or questions about Authorized Users, please contact us by calling the phone number on the back of your credit card.
IMPORTANT REMINDER: VERIFY AND UPDATE YOUR ACCOUNT INFORMATION NOW.
Periodically, as part of our Know Your Customer(KYC) program • a requirement of the USA PATRIOT Act• we'll ask you to verify and update the personal information on your account.
This includes your nante, address, authorized users (If any) and your country of citizenship.
Please take a few minutes to verify your information now by logging In to your account online at AviatorMastercard.com and clicking "Review and update your profile", or call us using
the number on the back of your card. If you have recently verlfl^ your data online or through our customer care center, please disregard this reminder.
Transaclions
Transaction Date
Posting Date
Description
Mar 22
Payment Received
Amount
Payment;
Mar 22
COfVIEftlCA BANK
•$700.00
Total payments for this period
•S700.00
Purchase Activity for ROC M PiFFERINi SR carci ending 9120
i
Mar 29
MarSI
CITY SPORTS CLUB
9492558100 CA
Mar 29
Mar 31
CITY SPORTS CLUB
9492558100 CA
CITY SPORTS CLUB
9492558100 CA
I
I
Mar 29
Total purchase activity for this period
* To see activity after this staUmant period, visit AvIatorMastercardeom
Fees and Interest
Transaction Date
Posting Date
Description
Amount
Fees Charged
No fees charged for this period
Total fees for this period
Interest Charged
Apr 05
Apr 05
Interest Charge On Purchases
Total Interest for this period
2019 Year-to-Date Totals
Total fees charged in 2019
$163.00 I
Total interest charged in 2019
$306.56 I
This Ye»r-K)-date summary refleca the Fees and Interest charged on billing statements vdth closing dates In 2019,
and does not reflect any subsequent fee and/or Interestadjustments.
Visit AviatOfMasiercarcl.com or use the Barclays (Viobile App
AAdvantage® Aviator® Red Mastercard® Statement
I Account Ending 9120 |
Statement Period 03/06/19-04/05/19
ROCMPIFFERINI SR
Interest Charge Calculation
Type of Balance
Page 5 of 6
O.iy. Ill Hilliiiii (ydi; . 31
Promotional
Balance Subject
Annual Percentage
Interest
Rate End Date
to Interest Rate
Rate(APR)
Charge
Purchases
$4,345.47
Standard Purchases
23.244i(v)
Balance Transfers
23.24%(v)
Standard Balance Transfers/Checks
Cash Advances
27.49%(v)
Standard Cash Advance
I
I
j
^Your Annual Parcantage Rate(APR) h the annual interest rateonyouraccount(v)» Variable Rate that varies with the market based on the Prime Rate.
See the 'Important Information'section of this statement for more Information about how we calculate interest.
AVOIDING INTEREST ON PURCHASES (GRACE PERIOD):
If you have a 0% promotional APR on all of your Purchase balances, you can avoid paying Interest on those balances during the applicable promotional period. However, pay at least
your Minimum Payment Due to avoid a late fee.
If you have both Purchase balances with an APR greater than 0<)i and you also have other promotional balances on your Account, you can avoid paying Interest on your Purchases by
paying S 4,076.72 (this amount Includes any Minimum Payment Due required to avoid a late fee). Please refer to the "Accrual of Interest and How to Avoid Paying Interest on
Purchases" paragraph on the back of this Statement for further detail.
Miles DeU-iils
IVIlles earned on American Airlines purchases
<
Miles earned on all other purchases
61
Miles sent to American Airlines AAdvantage Program
61
YOU'RE READY TO TAKE FLIGHT WITH THE AADVANTAGE* AVIATOR* RED MASTERCARD*
You earn 2X AAdvantage* miles for every one dollar spent on eligible American Airlines purchases and 1X AAdvantage* miles for all
other purchases.
• First cheded bag free on eligible bags
• Preferred boarding for you and up to 4 companions on your reservation for all American Airlines operated flights
Visit AviatorMastercard.com or use the Barclays Mobile App
AAdvantage® Aviator® Red Mastercard® Statement
ROCMPIFFERINISR
|
Account Ending 9120 |
Statement Period 03/06/19-04/05/19
Page 6 of 5
Visit AviatorMastercard.com or use the Barclays Mobile App