E
&
1040
(99)
Department of the Treasury-Internal Revenue Service
u.s. Individual Income Tax Return
U))
1)115
~\!:V
For the year Jan. H)ee. 31, 2015, or other lax year beginning Your first name a . ilial
Last name
OMS No. 1545-0074
IRS Use Only-Do not write or Slaple in this space.
,2015, ending
See separate instructions.
Your social security number
e;\f l t:J
Last name
Spouse's social security number
Apt. no.
City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions).
... Make sure the SSN(s) above
and on line 6c are correct.
Presidential EJection campaign
,Check here nyou, or your spouse Hfiling
-=Fo-r-:eig-n-c-o-u-ntC-ry-na-m-e---------------r=-:----:--:----c-------,-,:::-..,---,...,.-,.--i' jointly, want $3 to go 10 Ihis fund. Checking
Foreign province/state/county
Foreign postal code a box below will not change your tax or
refund.
D
Filing Status
1
2
~arried filing jointly (even if only one had income)
Single Check only one
box.
3
D Married filing separately. Enter spouse's SSN above
Exemptions
6a
and full name here. .. b
4
D
5
D
(2) Dependent's
soclal security number
(3) Dependent's
relationship to you
Income
Attach Form(s)
W-2 here. Also
attach Forms
W-2Gand
1099-R if tax
was withheld.
If you did not
get a W-2,
see instructions.
Boxes checked
7
claimed
Add numbers on
.
lines above ~
Wages, salaries, tips, etc. Attach Form(s) W-2 Sa
Taxable interest. Attach Schedule B if required b
Tax-exempt interest. Do not include on line 8a 9a
b
<--.::8b==-.l.-_ _ _ _ _ _-'-_
Ordinary dividends. Attach Schedule B if required Qualified dividends L...:.9b=-'--_ _ _ _ _--'_ _
10
Taxable refunds, credits, or offsets of state and local income taxes
11
Alimony received . 12
Business income or (loss). Attach Schedule C or C-EZ .
13
Capital gain or (loss). Attach Schedule 0 if required. If not required, check here ~
14
Other gains or (losses). Attach Form 4797 . 15a
17
b Taxable amount
IRA distributions.
1158 1 C" 0
b Taxable amount
Pensions and annuities . 1Sa .
? tot£? b Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E
18
Farm income or (loss). Attach Schedule F .
t.t
19
Unemployment compensation
20a
21
22
b Taxable amount
Social security benefits ....
1 2O=a:::...l..I_ _ _ _ _ _--'_--'
Other income. List type and amount Combine the amounts in the far column for lines 7
.
23
Educator expenses 24
Certain business expenses of reservists, performing artists, and
fee-basis government officials. Attach Foon 2106 or 21 06-EZ
25
Health savings account deduction. Attach Form 8889
26
Moving expenses. Attach Form 3903
Z7
Deductible part of self-employment tax. Attach Schedule SE
28
Self-employed SEP, SIMPLE, and qualified plans .
29
Self-employed health insurance deduction 30
Penalty on early withdrawal of savings. 31a
Alimony paid
32
IRA deduction . b Recipient's SSN ~ _
_'!""""'-'-_ __
33
Student loan interest deduction . 34
Tuition and fees. Attach Form 8917. 35
Domestic production activities deduction. Attach Form 8903
36
37
Add lines 23 through 35 . Subtract line 36 from line 22. This is on 6cwho:
• lived with you
• did not live with
you due to divorce
Dependents on 6c
not entered above
D
Total number of
on 6a and6b
No. of children
or separation
(see instructions)
o
16a
Adjusted
Gross
Income
.
(4) .r if child under age 17
qualifying lor child tax credH
(see instructions)
If more than four
dependents, see
instructions and
check here ..
d
D spouse
child's name here...
Qualifying widow(er) with dependent child
use
Dependents:
You
Head 01 household (w~h qualifying person). (See instructions.) If
the qualifying person is a child but not your dependent, enter this
D Yourself. If someone can claim you as a dependent, do not check box 6a
DS
D
Income
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate ins1Jvctions.
0
2
Page 2
Form 1040 (2015)
38
Amount from line 37 (adjusted gross income)
Tax and Credits 398
Check {
if:
Standard
Deduction
for­
• People who
check any
box on line
39a or 39b or
who can be
claimed as a
dependent,
see
instructions.
• All others:
Single or
Married filing
separately,
$6,300
Married filing
jointly' or
Qualifying
widow(erj,
$12,600
Head of
household,
40
41
r -_ _ _ _---'b
$9,250
Sign
Here
If your spouse itemizes on a separate return or you were a dual-status alien, check here..
Itemized deductions (from Schedule A) or your standard deduction (see left margin)
Subtract line 40 from line 38
Tax (see instructions). Check if any from: a 0 Form(s) 8814 b 0 Form 4972 c
Alternative minimum tax (see instructions). Attach Fonm 6251 .
Excess advance premium tax credit repayment. Attach Form 8962
47
Add lines 44, 45, and 46
48
49
50
51
52
53
Retirement savings contributions credit. Attach Form 8880
Child tax credit. Attach Schedule 8812, if required.
Residential energy credits. Attach Form 5695
0
0
Other credits from Form: 8
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
60a
3800 b
8801
c
Self-employment tax. Attach Schedule SE
Unreported social security and Medicare tax from Fonm:
a
0
4137
Taxes from:
63
Add lines 56
First-time homebuyer credit repayment. Attach Form 5405 if required
Health care: individual responsibility (see instructions)
8919
8
0
Fonm 8959
b
0
Form 8960
totaltax
c
.
Full-year coverage
0
Instructions; enter code(s) _ __
.
Federal income tax withheld from Fonms W-2 and 1099
2015 estimated tax payments and amount applied from 2014 retum
Earned income credit (EIC)
67
Nontaxable combat pay election L66=b'-'-_ _ _ _ _ _- ' - _
Additional child tax credit. Attach Schedule 8812
68
American opportunity credit from Form 8863, line 8
b
b
Additional tax on IRAs, other qualified retirement plans, etc. Attach Fonm 5329 if required
Household employment taxes from Schedule H
b
61
62
668
----
Foreign tax credit. Attach Fonm 1116 if required .
54
57
58
59
0
Credit for child and dependent care expenses. Attach Form 2441
Education credits from Form 8863, line 19
55
69
Net premium tax credit. Attach Fonm 8962 .
70
71
72
Amount paid with request for extension to file
73
74
Credits from Form: a
2439 b II Reserved c
8885 d
Add lines 64, 65, 66a, and 67
73. These are your total
Excess social security and tier 1 RRTA tax withheld
Credit for federal tax on fuels. Attach Fonm 4136
D~~;:rt;-~-:--:--:-~-.;:-
75
76a
Routing number
Account number
Amount of line 75
Amount you owe. Subtract line 74 from line 63. For details on how to
79
Estimated tax
(see
79
Do you want to allow another person to discuss this return with the IRS (see instructions)?
Personal identification
Phone
Designee's
number (PIN)
..
no...
name ..
Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belie!,
they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge,
Your occupation
Daytime phone number
Date
~ Your signature
Joint return? See
instructions.
Keep acopy for ,
your records.
Paid
Preparer
Use Only
Blind. } Total boxes
Blind. checked". 39a
46
Direct deposit?" b
.. d
instructions.
77
78
Amount
Third Party
DeSignee
0
Exemptions. If line 38 is $154,950 or less, multiply $4,000 by the number on line 6d. Otherwise, see instructions·
45
See
VouOwe
0
You were born before January 2,1951,
Spouse was bom before January 2, 1951,
.
Taxable income. Subtract line 42 from line 41. If line 42 is more than line 41, enter -0­
65
Refund
.......
43
44
Payments 64
If you have a
qualifying
child, attach
Schedule EIC.
0
•.
42
56
Other
Taxes
0
.
Spouse's signature. If a jOint retum, both must sign.
Date
Spouse's occupation
If the IRS sent you an Identity Protection
PIN, enter it
here (see inst.)
PrintIType preparer's name
Firm's name to
Firm's address to
www.lrs.govlforml040
I
Preparer's signature
I Date
I I I I I I I
Check D if j I PTIN
self-employed
Firm's EIN to
Phone no.
Form 1040 (2015)