Your 1040
tax form guide.
Simplify your filing process this tax season.
• Not a deposit • Not FDIC or NCUSIF insured • Not guaranteed by the institution • Not insured by any federal government agency • May lose value
Form
1040
2011
(99)
Department of the Treasury—Internal Revenue Service
U.S. Individual Income Tax Return
For the year Jan.Before
1–Dec. 31, 2011,
or other
tax year beginning
you
complete
your
OMB No. 1545-0074
IRS Use Only—Do not write or staple in this space.
See separate instructions.
2011, ending
, 20
taxes, use the tax, form
sections below
to discuss
Your social security number
retirement planning opportunities with your financial advisor.
Your first name and initial
Last name
Spouse’s social security number
Last name
If a joint return, spouse’s first name and initial
Note: Federal income tax laws are complex and subject to change. The information in this brochure is based on current
interpretations of the law and is not guaranteed. Neither the company nor its representatives give legal or tax advice.
consult
your Ifattorney
answers to specific questions.
Apt. no.
Home addressPlease
(number
and street).
you haveora tax
P.O.advisor
box, seefor
instructions.
Make sure the SSN(s) above
▲
City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions).
Foreign country name
Filing Status
Check only one
box.
Exemptions
Foreign postal code
Foreign province/county
1
4
Single
Is a strategy in place to help save
Married filing jointly (even if only one had income)
2
3
the qualifying person is a child but not your dependent, enter this
child’s name here. ▶
5
Qualifying widow(er) with dependent child
Yourself. If someone can claim you as a dependent, do not check box 6a .
Spouse
. .
Dependents:
Dependents:
(1) First name
.
.
.
.
.
.
.
.
.
Check here if you, or your spouse if filing
jointly, want $3 to go to this fund. Checking
a box below will not change your tax or
refund.
You
Spouse
Head of household (with qualifying person). (See instructions.) If
for educational expenses?
Married filing separately. Enter spouse’s SSN above
and full name here. ▶
6a
b
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
}
(4) ✓disposable
if child under age
17
want
to check your
income
Dependent’s
Last name(2) Dependent’s You may(3)
qualifying for child tax credit
social
security
number
relationship
to
you
and
talk
with
your
financial
advisor
to
see
(1) First name
Last name
(see instructions)
if you could be a suitable candidate for an
IRA, a variable annuity or other supplemental
If How
moremuch
than four
do you have in liquid assets?
retirement investment opportunity.
dependents,
see assets — any in low
Where are the
interest-bearing
instructions
and money markets or
certificates
check
here ▶of deposit (CD)?
c
d
Total number of exemptions claimed
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
7
Wages, salaries, tips, etc. Attach Form(s) W-2
. . . . . . . . . . .
8a Taxable interest. Attach Schedule B if required . . . . . . . . . . .
Are any of your assets invested in tax-exempt securities? What is
8b
b Tax-exempt
interest.
Door
not
include
on line 8a . . .
the goal of your investment(s)
— the tax
benefits
the
income?
Attach Form(s)
9a Ordinary dividends. Attach Schedule B if required . . . . . . . . . .
W-2 here. Also
b Qualified dividends . . . . . . . . . . Are
. you
9b paying capital
attach Forms
10
Taxable refunds, credits, or offsets of state and local income
taxes
. that
. lost
. . .
W-2G and
gains on
a fund
1099-R if tax
11
Alimony received . . . . . . . . . . . money
. . this
. .year?
. .If the
. . .
capital gains amount here is
was withheld.
. . . large,
. . it’s
. possible
. . .
How old are you? If 12
you’reBusiness
at least income or (loss). Attach Schedule C or C-EZ unusually
▶
70½, how are you managing
yourgain or (loss). Attach Schedule D if required. If not
13
Capital
required,
heremade
an asset
wascheck
sold that
minimum distributions?
If required
you did not
14
Other gains or (losses). Attach Form 4797 . . . . money
. . available
. . . for
. a. new
. .
get
a W-2,
investment. (Please refer to
Are
you retired? Are15you
to
a looking
IRA distributions
.
15a
b Taxable
. .
see
instructions.
Schedule
D.) amount
supplement
your retirement income
16
a
Pensions
and
annuities
16a
b
Taxable
amount
.
.
from qualified plans? Do you think it
.
.
7
8a
.
9a
.
.
10
11
12
13
Income
.
.
.
.
Rental
real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E
would be beneficial17
to discuss
suitable
Enclose,
but do
income-planning
strategies
to help
18
Farm
income or (loss). Attach Schedule F . . . . . . . . . . . . . .
not
attach,your
any income for life with
protect
19
Unemployment compensation . . . . What
. . is. the. makeup
. . .of your
. . retirement
. . . .
your financial
payment.
Also, advisor?
portfolio? Are there any other suitable
20a Social security benefits 20a
20a
b
Taxable
amount
please use
options that can help potentially . . .
Form 1040-V.
21
Other income. List type and amount
lessen the tax consequences?
Adjusted
Gross
Income
22
Combine the amounts in the far right column for lines 7 through 21. This is your total income
23
Educator expenses
24
Certain business expenses of reservists, performing artists, and
fee-basis government officials. Attach Form 2106 or 2106-EZ
25
Health savings account deduction. Attach Form 8889
.
26
Moving expenses. Attach Form 3903 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
Penalty on early withdrawal of savings .
Alimony paid b Recipient’s SSN ▶
32
IRA deduction . . . . . . .
Do you still have any
loans?
33outstanding
Student student
loan interest
deduction . .
34
Tuition and fees. Attach Form 8917 .
35
36
37
.
.
.
▶
.
.
14
15b
16b
17
18
19
20b
Boxes checked
on 6a and 6b
No. of children
on 6c who:
• lived with you
• did not live with
you due to divorce
or separation
(see instructions)
Dependents on 6c
not entered above
Add
numbers
on
Are
you a small
lines above ▶
business owner?
You may find
that investing in
qualified benefit
plans, such as
401(k), SEP IRA
or defined
benefit plans,
may potentially
help reduce your
business income.
You may want
to take the time
to evaluate your
rental property
debt and other
interest-bearing
loans for possible
deductibility —
if appropriate.
21
22
23
.
Are you self-employed?
can youpart
take
of a tax. Attach Schedule SE .
27 If so,
Deductible
ofadvantage
self-employment
qualified retirement investment plan? Are you happy with
28
Self-employed SEP, SIMPLE, and qualified plans
. .
your current plan? Would you like to potentially save money
Self-employed health insurance deduction
. . . .
in a tax-advantaged 29
vehicle?
30
31a
and on line 6c are correct.
Presidential Election Campaign
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24
25
26
27
28
29
30
31a
32
33
Are you making a contribution to an IRA
or spousal IRA of $5,500? For people 50
and over, an additional $1,000 catch-up
provision is available, allowing you to
contribute a maximum of $6,500.
34
Domestic production activities deduction. Attach Form 8903
35
Add lines 23 through 35 . . . . . . . . . . . . .
Subtract line 36 from line 22. This is your adjusted gross income
.
.
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions.
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▶
36
37
Cat. No. 11320B
Form
1040
(2011)
Page 2
Form
(2011)
Are1040
there
children or grandchildren to whom money or assets can
be gifted to potentially
help from
reduce
income?
If so,
you can .
38
Amount
linetaxable
37 (adjusted
gross
income)
Tax
gift and
$14,000 per donor per donee in 2016 with no consequences.
Credits
39a
Check
if:
{
.
.
.
.
You were born before January 2, 1947,
Spouse was born before January 2, 1947,
.
.
Blind.
Blind.
.
}
.
.
.
.
.
38
.
Total boxes
checked ▶ 39a
39a
Do you have a retirement
plan?
is it working
spouse itemizes
onIfaso,
separate
return orforyou were a dual-status alien, check here ▶ 39b
b If your investment
Standard
you? If not, you may want to discuss with your financial advisor
Deduction
40
Itemized deductions (from Schedule A) or your standard deduction (see left margin) . .
for—
what other allocation and distribution options are suitable for
Subtract line 40 from line 38
. . . . . . . . . . . . . . . . . . .
• your
People
who 41
needs.
check any
42
Exemptions.
Multiply
$3,700
by
the number on line 6d . . . . . . . . . . . .
box on line
39a or 39b or 43
Taxable income. Subtract line 42 from line 41. If line 42 is more than line 41, enter -0- . .
who can be
claimed as a
Form 4972 c
962 election
44
Tax (see instructions). Check if any from: a
Form(s) 8814 b
dependent,
45
Alternative minimum tax (see instructions). Attach Form 6251 . . . . . . . . .
see
instructions.
▶
46
Add lines 44 and 45 . . . . . . . . . . . . . . . . . . . . .
• All others:
47
Foreign tax credit. Attach Form 1116 if required . . . .
47
Single or
Married
filing
48advantage
48
Credit for
and dependent
care
expenses. Attach Form 2441
Are you
taking
of child
improved
education
incentives?
separately,
49
49
49
Education
credits from
8863, offer
line 23 . . . . .
Coverdell Education
Savings Accounts
andForm
529 plans
$5,800
tax-advantaged
Married
filing
50 savings.
Retirement savings contributions credit. Attach Form 8880
50
jointly or
51
Child tax credit (see instructions) . . . . . . . .
51
Qualifying
widow(er),
52
52
Residential
energy
credits.
Attach
Form
5695
.
.
.
.
$11,600
3800 b
8801 c
53
Other credits from Form: a
53
Head of
household,
54
Add
lines
47
through
53.
These
are
your
total
credits
.
.
.
.
. . . . . . . .
$8,500
55
Subtract line 54 from line 46. If line 54 is more than line 46, enter -0-
56
Self-employment tax. Attach Schedule SE . . . .
Other
If you are younger than 59½, you may qualify for an exception to
57
Unreported social security and Medicare tax from Form:
. . . .
a
4137
.
.
.
.
.
b
.
.
.
.
. .
8919
.
.
the 10% penalty for early withdrawal. Exceptions include disability,
Taxes
58
Additional tax on IRAs, other qualified retirement plans, etc. Attach Form 5329 if required
.
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▶
. . . .
69
Credit for federal tax on fuels. Attach Form 4136 . . . .
70
Credits from Form: a
2439 b
8839 c
8801 d
8885 71
Add lines 62, 63, 64a, and 65 through 71. These are your total payments .
.
.
.
.
▶
medical expenses, health insurance premiums, first-time home
buyers, higher59a
education
expenses
and substantially
periodic
Household
employment
taxes from equal
Schedule
H . . . . . .
payments over life expectancy.
b First-time homebuyer credit repayment. Attach Form 5405 if required
60
Other taxes. Enter code(s) from instructions
61
lines 55Isthrough
Thisway
is your
total
tax
Are you withholdingAdd
too much?
there a60.
better
to put
those
.
.
.
extra dollars to
in a pretax
or tax-deferred
investment
option?
62use —
Federal
income
tax withheld from
Forms W-2
and 1099
Payments
.
.
If you have a
64a Earned income credit (EIC) . . . . . . .
qualifying
Are you participating in company-sponsored retirement plans
b Nontaxable combat pay election
64b
child,
thatattach
may reduce taxable wages or a Roth IRA that will reduce
Schedule
EIC. income?
Additional
tax credit.limits,
Attachespecially
Form 8812for. . .
65
investment
Increasedchild
contribution
those age 50 66
or older,
can help
you take advantage
tax-deferred
American
opportunity
credit from of
Form
8863, line 14
retirement plans.
.
62
63
.
.
.
.
64a
.
.
.
.
First-time homebuyer credit from Form 5405, line 10 .
Amount paid with request for extension to file . . .
.
.
.
.
.
.
65
66
Always consult
your estimated
tax advisor
adjusting
exemptions.
63with 2011
taxbefore
payments
and amount
applied from 2010 return
67
68
69
70
71
72
▶
.
.
74a
b
d
▶
Sign
Here
Paid
Preparer
Use Only
75
76
54
55
56
57
58
60
61
67
68
Amount of line 73 you want refunded to you. If Form 8888 is attached, check here . ▶
▶ c Type:
Routing number
Checking
Savings
Account number
Amount of line 73 you want applied to your 2012 estimated tax ▶ 75
Amount you owe. Subtract line 72 from line 61. For details on how to pay, see instructions ▶
77
77
Estimated tax penalty (see instructions) . . . . . . .
Do you want to allow another person to discuss this return with the IRS (see instructions)?
Designee’s
name ▶
Phone
no. ▶
72
73
74a
76
Yes. Complete below.
No
Personal identification
▶
number (PIN)
Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief,
they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Your signature
▲
Joint return? See
instructions.
Keep a copy for
your records.
44
45
46
Excess social security and tier 1 RRTA tax withheld
Direct deposit?
See
▶
instructions.
Third Party
Designee
43
59a
59b
Can you use your refund to make an IRA deposit for the year and
If line 72 is more than line 61, subtract line 61 from line 72. This is the amount you overpaid
73
Refund
get a jump start?
Amount
You Owe
40
41
42
Date
Your occupation
Daytime phone number
Contact your financial advisor
or tax
advisor today so youIf the
can
work
Date
Spouse’s occupation
IRS sent you an Identity Protection
PIN, enter it
together to file your taxes this year — and plan for next year.
here (see inst.)
Spouse’s signature. If a joint return, both must sign.
Print/Type preparer’s name
Firm’s name
Preparer’s signature
Date
▶
Firm's EIN
Firm’s address ▶
Phone no.
Check
if
self-employed
PTIN
▶
Form 1040 (2011)
Federal income tax laws are complex and subject to change. The information is based on current interpretations of the law
and is not guaranteed. Neither the company nor its representatives give legal, tax or financial advice. Please consult your
attorney or tax advisor for answers to specific questions.
Nationwide Investment Services Corporation, member FINRA. Home Office: One Nationwide Plaza, Columbus, OH 43215-2220.
Nationwide, the Nationwide N and Eagle and Nationwide is on your side are service marks of Nationwide Mutual Insurance
Company. © 2015 - 2016 Nationwide
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