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Your first name and
initiel
2@14
OMB No. 1545-0074
, 2014, ending
Only-Do
IRS Use
Last name
a
A
Apt. no
iiyou nave
i
roreigri
iddresi, jiso compiiie ipacei netow
tse-e instructions).
Foreign postal
FilingStatus 1x sinsre
2 ,Married filing jointly (even if only one had income)
Check only
3' Married filing separately. Enter spouse's SSN above
one box.
and full name here. >
6a
Exemptions
4_,
dependents,
name
Last
(g)
^]2]Dependents
social
security number
lnCOme
Attach Formts)
W.2 here. Also
attach Forms
W-2G and
1099-R if tax
was withheld.
lf you did not
get a W-2,
see instructions.
,
,-ggellsrrudtions)
l
d
Total number of exernptions claimed
7
b
. .t', ,,,.', .
.
b
Qualified
dividends
..
.1.
15a lRAdistributions
, !ilr.
16a Pensionsandannuities. .... t6a'
.
f E
101,
1',I
12
check
13
h
1!.
16b
Farmincomeor(loss).Attara.iii$eh;dubF
Unemployment compen-satioii
rglpl'ts-
j)
15b,
b Taxable
t9
...
.
.
17
18
j
19
20b
" ?0"
21
Other income..t i6i'tipe-iio amount
22
Combine the amounts in the far
23
24
Educatorexpenses ..
21
column for lines
7l
21. This
is
total income
>22
5.101
23
Certain business expenses of reservists, performing artists, and
.
fee'basis government officials. Attach Form 2106 or 2106-EZ . .
Health savings account deduction. Attach Form 88Bg .
Moving expenses. Attach Form 3903
Deductible part of self-employment tax. Attach Schedule SE . . . .
.
29
Self-employed SEP, SIMPLE, and qualified plans .
Setf-employed health insurance deduction
30
Penalty on early withdrawal of savings
paid b Recipient's SSN >
lRAdeduction
..............
31a Alimony
34
51
',
18
33
not entered above
ooo,XtTff"
10.
.
Rental real estate, royalties, partriitstrips, S cotpoijtions, irusts, etc. Attach
32
:
'
9a
17
28
(see instruc$ons)
-::..' 9b
.
27
or saParation
ga
... .,
10 Taxable refunds, credits, or offsets of state and local income taxes
11 Alimony received
12 Business income or (loss). Attach Schedufe Cql,GEZ
13 Capital gain or (loss). Attach Schedule D if required.:lf not required,
14 Other gains or (losses). Attach Form 4797.:..'
25
;"i 3,l."tj,I?#l*
Tax-exempt interest. Do not include on line 8a
9a Ordinarydividends.Attach ScheduleBifrequired . ..
25
..;
" '.''.',r."''..,.'.....'..,lines
...,'.' ....,....
7
','""
.
8a Taxable interest. Attach Schedule B if required
Wages,salaries,tips,etc.AttachForm(s)W-2
20a Social security
Adiusted
Gross
lncome
f,-ff;$'my* li,ilI,li; *,,
...-, ,.:.. ,,1
>'
spouse
I *i:""."[T["d
pependent's"
four
see
nere
refund You
.
relatior
name
Presidontial Electlon Campaign
Check here if you, or your spouse if filing
jointly, wanl $3 to go to lhis fund. Checking
a box below witl not change your tax or
this child's name here, >
Qualifying widow(er) with dependent child
5
instructions and
cnecK
Code
Make sure the ssN(s) above
ano on une 6c are correcl.
Head of household (with qualifying person). (See instructions.)
lf the qualifying person is a child but not your dependent, enter
Yourself. lf someone can claim you as a dependent, do not check box 6a
i-Defeno-nG:
(1) First
rf more than
not write or staple in lhis space.
See separate instructions
.20
Student loan interest deduction
Tuition and fees. Attach Form 8917
.
24
25
2E
27.
28.
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31 .
34
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