Affordable Care Act Worksheet
US
2015
Name: CHELSEA FERGUSON
SSN: 601-25-3380
X No
Did the taxpayer, spouse, or any dependent receive insurance through the Marketplace? See Form 8962 ..............
Yes
Was the taxpayer, spouse, or any dependent granted a Marketplace exemption or do you want to apply for
a Marketplace, household income, or gross income exemption? See Form 8965 ...................................... X Yes
No
CHELSEA FERGUSON
X Had a minimum essential coverate and/or is applying for or was granted an exemption for the entire year
Had a minimum essential coverage and/or is applying for or was granted an exemption for part of the year
Check the boxes for each month
Did not have minimum essential coverage and is not claiming an exemption for any part of the year
this person did not have minimum
essential coverage and is NOT
January
February
March
April
May
June
claiming an exemption on Form 8965....
July
August
September
October
November
December
Had a minimum essential coverage and/or is applying for or was granted an exemption for the entire year
Had a minimum essential coverage and/or is applying for or was granted an exemption for part of the year
Check the boxes for each month
Did not have minimum essential coverage and is not claiming an exemption for any part of the year
this person did not have minimum
essential coverage and is NOT
January
February
March
April
May
June
claiming an exemption on Form 8965....
July
August
September
October
November
December
MARIA FERGUSON
X Had a minimum essential coverage and/or is applying for or was granted an exemption for the entire year
Had a minimum essential coverage and/or is applying for or was granted an exemption for part of the year
Check the boxes for each month
Did not have minimum essential coverage and is not claiming an exemption for any part of the year
this person did not have minimum
essential coverage and is NOT
January
February
March
April
May
June
claiming an exemption on Form 8965....
July
August
September
October
November
December
LARRY FERGUSON
X Had a minimum essential coverage and/or is applying for or was granted an exemption for the entire year
Had a minimum essential coverage and/or is applying for or was granted an exemption for part of the year
Check the boxes for each month
Did not have minimum essential coverage and is not claiming an exemption for any part of the year
this person did not have minimum
essential coverage and is NOT
January
February
March
April
May
June
claiming an exemption on Form 8965....
July
August
September
October
November
December
Had a minimum essential coverage and/or is applying for or was granted an exemption for the entire year
Had a minimum essential coverage and/or is applying for or was granted an exemption for part of the year
Check the boxes for each month
Did not have minimum essential coverage and is not claiming an exemption for any part of the year
this person did not have minimum
essential coverage and is NOT
January
February
March
April
May
June
claiming an exemption on Form 8965....
July
August
September
October
November
December
Had a minimum essential coverage and/or is applying for or was granted an exemption for the entire year
Had a minimum essential coverage and/or is applying for or was granted an exemption for part of the year
Check the boxes for each month
Did not have minimum essential coverage and is not claiming an exemption for any part of the year
this person did not have minimum
essential coverage and is NOT
January
February
March
April
May
June
claiming an exemption on Form 8965....
July
August
September
October
November
December
Had a minimum essential coverage and/or is applying for or was granted an exemption for the entire year
Had a minimum essential coverage and/or is applying for or was granted an exemption for part of the year
Check the boxes for each month
Did not have minimum essential coverage and is not claiming an exemption for any part of the year
this person did not have minimum
essential coverage and is NOT
January
February
March
April
May
June
claiming an exemption on Form 8965....
July
August
September
October
November
December
Had a minimum essential coverage and/or is applying for or was granted an exemption for the entire year
Had a minimum essential coverage and/or is applying for or was granted an exemption for part of the year
Check the boxes for each month
Did not have minimum essential coverage and is not claiming an exemption for any part of the year
this person did not have minimum
essential coverage and is NOT
January
February
March
April
May
June
claiming an exemption on Form 8965....
July
August
September
October
November
December
Oc 2015 Universal Tax Systems, Inc. and/or its affiliates and licensors.
All rights reserved.
USW10408
Form
1040 U.S. Individual Income Tax Return 2015
Department of the Treasury - Internal Revenue Service
(99)
For the year Jan. 1-Dec. 31, 2015, or other tax year beginning
Your first name and initial
OMB No. 1545-0074
,2015, ending
IRS Use Only-Do not write or staple in this space.
See separate instructions.
,20
Last name
Your social security number
CHELSEA FERGUSON
601-25-3380
Last name
Spouse's social security number
Home address (number and street). If you have a P.O. box, see instructions.
Apt. no.
123 ANY STREET
k
l
If a joint return, spouse's first name and initial
City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions).
COLUMBUS OH 43211Foreign country name
Filing Status
Check only one
box.
Exemptions
Foreign province/state/county
1
2
3
6a
b
c
d Total number of exemptions claimed
social security number
relationship to you
602-25-3380DAUGHTER
603-25-3380SON
for child tax credit
(see instructions)
X
X
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Wages, salaries, tips, etc. Attach Form(s) W-2
. . . . . . . . . . . . . . . . . . . . .
7
Taxable interest. Attach Schedule B if required
. . . . . . . . . . . . . . . . . . . .
8a
Tax-exempt interest. Do not include on line 8a
. . . .
8b
Attach Forms(s)
Ordinary dividends. Attach Schedule B if required
. . . . . . . . . . . . . . . . . . .
9a
W-2 here. Also
Qualified dividends . . . . . . . . . . . . . . . . . . .
9b
attach Forms
Taxable refunds, credits, or offsets of state and local income taxes . . . . . . . . . . . .
10
W-2G and
Alimony
received
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
11
1099-R if tax
was withheld.
Business income or (loss). Attach Schedule C or C-EZ . . . . . . . . . . . . . . . . .
12
Capital gain or (loss). Attach Schedule D if required. If not required, check here j
13
If you did not
Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . . . . . . . . . . . .
14
get a W-2,
IRA distributions . . . . 15a
b Taxable amount . . . . .
15b
see instructions.
Pensions and annuities . 16a
b Taxable amount . . . . .
16b
Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E
17
Farm income or (loss). Attach Schedule F
. . . . . . . . . . . . . . . . . . . . . . .
18
Unemployment compensation
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19
Social security benefits . 20a
b Taxable amount . . . . . 20b
Other income. List type and amount
21
Combine the amounts in the far right col for lines 7 through 21.This is your total income j 22
Reserved
. . . . . . . . . . . . . . . . . . . . . . .
23
Adjusted
Certain business expenses of reservists, performing artists,
Gross
and fee-basis gov. officials. Attach Form 2106 or 2106-EZ
24
Income
25 Health savings account deduction. Attach Form 8889 . .
25
26 Moving expenses. Attach Form 3903 . . . . . . . . . .
26
27 Deductible part of self-employment tax. Attach Schedule SE 27
28 Self-employed SEP, SIMPLE, and qualified plans . . . .
28
29 Self-employed health insurance deduction
. . . . . . .
29
30 Penalty on early withdrawal of savings . . . . . . . . .
30
31a Alimony paid b Recipient's SSNj
31a
32 IRA deduction . . . . . . . . . . . . . . . . . . . . .
32
1,548.
33 Student loan interest deduction
. . . . . . . . . . . .
33
34 Reserved
. . . . . . . . . . . . . . . . . . . . . . .
34
35 Domestic production activities deduction. Attach Form 8903 35
36 Add lines 23 through 35
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
36
37 Subtract line 36 from line 22. This is your adjusted gross income . . . . . . . . . . j 37
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions.
BCA
7
8a
b
9a
b
10
11
12
13
14
15a
16a
17
18
19
20a
21
22
23
24
Presidential Election Campaign
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
Single
4 X Head of household (with qualifying person). (See instructions.)
Married filing jointly (even if only one had income)
If the qualifying person is a child but not your dependent, enter
Married filing separately. Enter spouse's SSN above
this child's name here.j
and full name here. j
5
Qualifying widow(er) with dependent child
X Yourself. If someone can claim you as a dependent, do not check box 6a . . . . . .
checked on
j Boxes
6a and 6b
1
Spouse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(4) v/ if child under No. of children
Dependents:
(2) Dependent's
(3) Dependent's
age 17 qualifying
If more than (1) First name
Last name
four depen- MARIA FERGUSON
dents, see
instructions LARRY FERGUSON
and check
here j
Income
Foreign postal code
Make sure the SSN(s) above
and on line 6c are correct.
6c who:
.onlived
. did notwithliveyouwith
2
you due to divorce
or separation
(see instructions)
Dependents on 6c
not entered above
0
0
Add numbers
on lines above
3
j
37,900.
845.
1,800.
40,545.
1,548.
38,997.
Form
1040 (2015)
US1040$2
CHELSEA FERGUSON
Form 1040 (2015)
601-25-3380
38 Amount from line 37 (adjusted gross income) . . . . . . . . . . . . . . . . . . . . . .
39a Check
You were born before Jan. 2, 1951,
Blind.
j Total boxes
if:
Spouse was born before Jan. 2, 1951,
Blind.
checked j 39a
b If your spouse itemizes on a separate return or you were a dual-status alien, check here j 39b
40 Itemized deductions (from Schedule A) or your standard deduction (see left margin) . .
41 Subtract line 40 from line 38 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
42 Exemptions. If line 38 is $154,950 or less, multiply $4,000 by the number on line 6d. Otherwise, see instructions .
43 Taxable income. Subtract line 42 from line 41. If line 42 is more than line 41, enter -0- . .
44 Tax (see instructions). Check if any from: a
Form(s) 8814 b
Form 4972 c
45 Alternative minimum tax (see instructions). Attach Form 6251 . . . . . . . . . . . . .
46 Excess advance premium tax credit repayment. Attach Form 8962 . . . . . . . . . . . .
47 Add lines 44, 45, and 46 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . j
48 Foreign tax credit. Attach Form 1116 if required . . . . . .
48
552.
49 Credit for child and dependent care expenses. Attach Form 2441 .
49
50 Education credits from Form 8863, line 19 . . . . . . . .
50
16.
51 Retirement savings contributions credit. Attach Form 8880
51
1,433.
52 Child tax credit. Attach Schedule 8812, if required . . . .
52
53 Residential energy credits. Attach Form 5695 . . . . . . .
53
54 Other credits from Form: a
3800 b
8801 c
54
55 Add lines 48 through 54. These are your total credits . . . . . . . . . . . . . . . . . .
56 Subtract line 55 from line 47. If line 55 is more than line 47, enter -0- . . . . . . . . . . j
Tax and
Credits
2
Page
38
38,997.
40
41
42
43
44
45
46
47
9,250.
29,747.
12,000.
17,747.
2,001.
j
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(er),
$12,600
Head of
household,
$9,250
Other
Taxes
Payments
If you have a
qualifying
child, attach
Schedule EIC.
Refund
Direct deposit?
See instructions.
Amount
You Owe
Third Party
Designee
Sign
Here
57 Self-employment tax. Attach Schedule SE . . . . . . . . . . . . . . . . . . . . . . . .
58 Unreported social security and Medicare tax from Form: a
4137
b
8919 . . .
59 Additional tax on IRAs, other qualified retirement plans, etc. Attach Form 5329 if required NO
.
60a Household employment taxes from Schedule H . . . . . . . . . . . . . . . . . . . . . .
b First-time homebuyer credit repayment. Attach Form 5405 if required . . . . . . . . . . .
61 Health care: individual responsibility (see instructions)
Full-year coverage X . . . .
62 Taxes from: a
Form 8959 b
Form 8960 c
Instructions; enter code(s)
63 Add lines 56 through 62. This is your total tax . . . . . . . . . . . . . . . . . . . . . j
2,465.
64 Federal income tax withheld from Forms W-2 and 1099 . .
64
65 2015 estimated tax payments and amount applied from 2014 return
65
1,847.
66a Earned income credit (EIC) . . . . . . . . . . . . . . .
66a
b Nontaxable combat pay election 66b
567.
67 Additional child tax credit. Attach Form 8812 . . . . . . .
67
68 American opportunity credit from Form 8863, line 8 . . . .
68
69 Net premium tax credit. Attach Form 8962 . . . . . . . .
69
70 Amount paid with request for extension to file . . . . . . .
70
71 Excess social security and tier 1 RRTA tax withheld . . .
71
72 Credit for federal tax on fuels. Attach Form 4136 . . . . .
72
Re73 Credits from Form: a
2439 b
73
served c
8885 d
74 Add lines 64, 65, 66a, and 67 through 73. These are your total payments . . . . . . . j
75 If line 74 is more than line 63, subtract line 63 from line 74. This is the amount you overpaid
76a Amount of line 75 you want refunded to you. If Form 8888 is attached, check here j
Routing
Savings
j c Type: Checking
j
b number
Account
j
d number
77 Amount of line 75 you want applied to your 2016 estimated tax j 77
78 Amount you owe. Subtract line 74 from line 63. For details on how to pay, see instructions . . . j
79 Estimated tax penalty (see instructions) . . . . . . . . .
79
Do you want to allow another person to discuss this return with the IRS (see instructions)?
Yes.
2,001.
85.
85.
FORM 1099
4,879.
4,794.
4,794.
74
75
76a
78
Complete below.
X
No
Designee's
Personal identification
Phone
number (PIN)
name
no.
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.
j
j
Your signature
Joint return?
See instructions.
Keep a copy for
your records.
55
56
57
58
59
60a
60b
61
62
63
2,001.
Date
k
l Spouse's signature. If a joint return, both must sign.
Print/Type preparer's name
Paid
AARP FOUNDATION TAX-AIDE
Preparer Firm's name j
Use Only Firm's address j
www.irs.gov/form1040
BCA
j
Your occupation
CUSTOMER SERVICE
Date
Preparer's signature
Daytime phone number
614-555-4422
If the IRS sent you an Identity
Protection PIN, enter
it here (see inst.)
Spouse's occupation
Date
Check
if
self-employed
Firm's EIN
PTIN
j
Phone no.
Form
1040 (2015)
Qualifying Child Information
(Form 1040A or 1040)
Department of the Treasury
Internal Revenue Service
(99)
1040A
........
j
j
OMB No. 1545-0074
j
Earned Income Credit
SCHEDULE EIC
2015
1040
EIC
Complete and attach to Form 1040A or 1040 only if you have a qualifying child.
Information about Sch EIC (Form 1040A or 1040) and its instructions is at www.irs.gov/scheduleeic.
Name(s) shown on return
Attachment
Sequence No.
43
Your social security number
CHELSEA FERGUSON
601-25-3380
| See the instructions for Form 1040A, lines 42a and 42b, or Form 1040, lines 66a and 66b, to make sure that
Before you begin:
|
!
CAUTION
|
|
(a) you can take the EIC, and (b) you have a qualifying child.
Be sure the child's name on line 1 and social security number (SSN) on line 2 agree with the child's social security card.
Otherwise, at the time we process your return, we may reduce or disallow your EIC. If the name or SSN on the child's
social security card is not correct, call the Social Security Administration at 1-800-772-1213.
If you take the EIC even though you are not eligible, you may not be allowed to take the credit for up to 10 years. See the
instructions for details.
It will take us longer to process your return and issue your refund if you do not fill in all lines that apply for each qualifying child.
Qualifying Child Information
1
2
Child 1
Child's name
First name
If you have more than three qualifying
children, you have to list only three to get
the maximum credit.
MARIA
FERGUSON
Child 2
Last name
First name
Child 3
Last name
LARRY
FERGUSON
First name
Last name
BRIANA
BYERS
Child's SSN
The child must have an SSN as defined in
the instructions for Form 1040A, lines 42a
and 42b, or Form 1040, lines 66a and 66b,
unless the child was born and died in 2015.
If your child was born and died in 2015 and
did not have an SSN, enter "Died" on this
line and attach a copy of the child’s birth
certificate, death certificate, or hospital
medical records.
3
602-25-3380
2005
Year
Child's year of birth
If born after 1996 and the child
is younger than you (or your
spouse, if filing jointly), skip lines
4a and 4b; go to line 5.
4 a Was the child under age 24 at the end of
2015, a student, and younger than you (or
your spouse, if filing jointly)?
b Was the child permanently and totally
disabled during any part of 2015?
X
Yes.
Go to line 5.
No.
Go to line 4b.
Yes.
X
No.
The child is not a
Go to line 5. qualifying child.
5
604-25-3380
1989
Year
If born after 1996 and the child
is younger than you (or your
spouse, if filing jointly), skip lines
4a and 4b; go to line 5.
X
Yes.
If born after 1996 and the child
is younger than you (or your
spouse, if filing jointly), skip lines
4a and 4b; go to line 5.
No.
Go to line 5.
Go to line 4b.
X
Yes.
No.
The child is not a
Go to line 5. qualifying child.
X
Yes.
Go to line 5.
X
Yes.
No.
Go to line 4b.
No.
The child is not a
Go to line 5. qualifying child.
Child's relationship to you
(for example, son, daughter, grandchild,
niece, nephew, foster child, etc.)
6
603-25-3380
2003
Year
DAUGHTER
SON
SISTER
Number of months child lived with
you in the United States during 2015
|
If the child lived with you for more
than half of 2015 but less than 7
months, enter "7."
| If the child was born or died in 2015
12 months
and your home was the child's home
for more than half the time he or she
Do not enter more than 12
was alive during 2015, enter "12".
months.
For Paperwork Reduction Act Notice, see your tax
return instructions.
BCA
12
months
Do not enter more than 12
months.
12
months
Do not enter more than 12
months.
Schedule EIC (Form 1040A or 1040) 2015
601-25-3380
1099G DETAIL REPORT - 2015
Payer
------------------------------
T|S
---
FRANKLIN COUNTY JOB & FAMILY
X
Unemployment
Received Repaid
------------1800
---1800
Withholding
Federal
State
------------180
--180
1040
1040A
............
j Information about Form 2441 and its separate instructions 1040NR 2441
2441
............
j
Form
Child and Dependent Care Expenses
j Attach to Form 1040, Form 1040A, or Form 1040NR.
OMB No. 1545-0074
2015
Name(s) shown on return
Attachment
Sequence No. 21
Your social security number
CHELSEA FERGUSON
601-25-3380
Department of the Treasury
Internal Revenue Service
Part I
is at www.irs.gov/form2441.
(99)
Persons or Organizations Who Provided the Care - You must complete this part.
(If you have more than two care providers, see the instructions.)
1
(a)
Care provider's
name
ST JOSEPHS
(b) Address
(number, street, apt. no., city, state, and ZIP code)
448 SUNSET STREET
COLUMBUS
OH 43207-
Did you receive
dependent care benefits?
No
Yes
(c) Identifying number
(SSN or EIN)
(d) Amount paid
(see instructions)
35-9253380
j
j
2,400.
Complete only Part II below.
Complete Part III on page 2.
Caution. If the care was provided in your home, you may owe employment taxes. If you do, you cannot file Form 1040A. For details,
see the instructions for Form 1040, line 60a, or Form 1040NR, line 59a.
Part II
2
Credit for Child and Dependent Care Expenses
Information about your qualifying person(s). If you have more than two qualifying persons, see the instructions.
(c) Qualified expenses
(a) Qualifying person's name
(b) Qualifying person's social
you incurred and paid in 2015
First
Last
security number
for the person listed in column (a)
MARIA
FERGUSON
602-25-3380
1,400.
LARRY
FERGUSON
603-25-3380
1,000.
3 Add the amounts in column (c) of line 2. Do not enter more than $3,000 for one qualifying person
or $6,000 for two or more persons. If you completed Part III, enter the amount from line 31 . . . . . . .
4 Enter your earned income. See instructions
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
5 If married filing jointly, enter your spouse's earned income (if you or your spouse was a student or was
disabled, see the instructions); all others, enter the amount from line 4 . . . . . . . . . . . . . . .
6 Enter the smallest of line 3, 4, or 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7 Enter the amount from Form 1040, line 38; Form 1040A, line 22;
38,997.
or Form 1040NR, line 37 . . . . . . . . . . . . . . . . . . .
7
8 Enter on line 8 the decimal amount shown below that applies to the amount on line 7
If line 7 is:
If line 7 is:
But not
Decimal
But not
Decimal
over
amount is
Over
over
amount is
$0-15,000
.35
$29,000-31,000
.27
15,000-17,000
.34
31,000-33,000
.26
17,000-19,000
.33
33,000-35,000
.25
19,000-21,000
.32
35,000-37,000
.24
21,000-23,000
.31
37,000-39,000
.23
23,000-25,000
.30
39,000-41,000
.22
25,000-27,000
.29
41,000-43,000
.21
27,000-29,000
.28
43,000-No limit
.20
9 Multiply line 6 by the decimal amount on line 8. If you paid 2014 expenses in 2015, see
the instructions
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10 Tax liability limit. Enter the amount from the Credit
2,001.
Limit Worksheet in the instructions . . . . . . . . . . . . . .
10
11 Credit for child and dependent care expenses. Enter the smaller of line 9 or line 10 here and
on Form 1040, line 49; Form 1040A, line 31; or Form 1040NR, line 47 . . . . . . . . . . . . . . . .
For Paperwork Reduction Act Notice, see your tax return instructions.
3
4
2,400.
37,900.
5
6
37,900.
2,400.
Over
BCA
8
0.23
X.
552.
9
552.
11
Form
2441 (2015)
Department of the Treasury
Internal Revenue Service (99)
Child Tax Credit
1040
.........
1040A
OMB No. 1545-0074
j
SCHEDULE 8812
(Form 1040A or 1040)
j
1040NR
Information about Schedule 8812 and its separate instructions is at
www.irs.gov/schedule8812.
8812
Name(s) shown on return
!
Attachment
Sequence No.
47
Your social security number
CHELSEA FERGUSON
Part I
2015
.........
j Attach to Form 1040, Form 1040A, or Form 1040NR.
601-25-3380
Filers Who Have Certain Child Dependent(s) with an ITIN (Individual Taxpayer Identification Number)
Complete this part only for each dependent who has an ITIN and for whom you are claiming the child tax credit.
If your dependent is not a qualifying child for the credit, you cannot include that dependent in the calculation of this credit.
CAUTION
Answer the following questions for each dependent listed on Form 1040, line 6c; Form 1040A, line 6c; or Form 1040NR, line 7c, who has an ITIN
(Individual Taxpayer Identification Number) and that you indicated is a qualifying child for the child tax credit by checking column (4) for that dependent.
A
For the first dependent identified with an ITIN and listed as a qualifying child for the child tax credit, did this child meet the substantial
presence test? See separate instructions.
Yes
B
No
For the second dependent identified with an ITIN and listed as a qualifying child for the child tax credit, did this child meet the substantial
presence test? See separate instructions.
Yes
C
No
For the third dependent identified with an ITIN and listed as a qualifying child for the child tax credit, did this child meet the substantial
presence test? See separate instructions.
Yes
D
No
For the fourth dependent identified with an ITIN and listed as a qualifying child for the child tax credit, did this child meet the substantial
presence test? See separate instructions.
Yes
No
Note: If you have more than four dependents identified with an ITIN and listed as a qualifying child for the child tax credit, see separate instructions
and check here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .j
Part II
1
Additional Child Tax Credit Filers
1040 filers:
1040A filers:
1040NR filers:
Enter the amount from line 6 of your Child Tax Credit Worksheet (see the
Instructions for Form 1040, line 52).
Enter the amount from line 6 of your Child Tax Credit Worksheet (see the
Instructions for Form 1040A, line 35).
Enter the amount from line 6 of your Child Tax Credit Worksheet (see the
Instructions for Form 1040NR, line 49).
j
1
2,000.
If you used Pub. 972, enter the amount from line 8 of the Child Tax Credit Worksheet in the publication.
1,433.
Enter the amount from Form 1040, line 52; Form 1040A, line 35; or Form 1040NR, line 49 . . . . . . . . . .
2
567.
Subtract line 2 from line 1. If zero, stop; you cannot take this credit
3
37,900.
Earned income (see separate instructions) . . . . . . . . . . . . . . . . . . .
4a
Nontaxable combat pay (see separate
instructions) . . . . . . . . . . . . . . . . . .
4b
5
Is the amount on line 4a more than $3,000?
No. Leave line 5 blank and enter -0- on line 6.
X Yes. Subtract $3,000 from the amount on line 4a. Enter the result . . . . . 5
34,900.
5,235.
6
Multiply the amount on line 5 by 15% (.15) and enter the result . . . . . . . . . . . . . . . . . . . . . . . .
6
Next. Do you have three or more qualifying children?
X No. If line 6 is zero, stop; you cannot take this credit. Otherwise, skip Part III and enter the smaller of
line 3 or line 6 on line 13.
Yes. If line 6 is equal to or more than line 3, skip Part III and enter the amount from line 3 on line 13.
Otherwise, go to line 7.
For Paperwork Reduction Act Notice, see your tax return instructions.
Schedule 8812 (Form 1040A or 1040) 2015
2
3
4a
b
BCA
Schedule 8812 (Form 1040A or 1040) 2015
Part III
9
10
11
12
Withheld social security, Medicare, and Additional Medicare taxes from
Form(s) W-2, boxes 4 and 6. If married filing jointly, include your spouse’s
amounts with yours. If your employer withheld or you paid Additional
Medicare Tax or tier I RRTA taxes, see separate instructions . . . . . . .
1040 filers:
Enter the total of the amounts from Form 1040, lines
27 and 58, plus any taxes that you identified using code
"UT" and entered on line 62.
1040A filers:
Enter -0-.
1040NR filers: Enter the total of the amounts from Form 1040NR,
lines 27 and 56, plus any taxes that you identified using
code "UT" and entered on line 60.
Add lines 7 and 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
Enter the total of the amounts from Form 1040, lines
66a and 71.
1040A filers:
Enter the total of the amount from Form 1040A, line
42a, plus any excess social security and tier 1 RRTA
taxes withheld that you entered to the left of line 46
(see separate instructions).
1040NR filers: Enter the amount from Form 1040NR, line 67.
Subtract line 10 from line 9. If zero or less, enter -0- . . . . . . . . .
Enter the larger of line 6 or line 11 . . . . . . . . . . . . . . . . . .
Next, enter the smaller of line 3 or line 12 on line 13.
. . .
j
. . .
7
8
9
1040 filers:
Part IV Additional Child Tax Credit
13 This is your additional child tax credit
j
10
. . . . . . . . . . . . . . . . . . . .
11
12
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13
. . . . . . . . . . . . . . . . . . . .
1040
..........
1040A
..........
1040NR
BCA
Page
567.
..........
8
601-25-3380
Enter this amount on
Form 1040, line 67,
Form 1040A, line 43, or
Form 1040NR, line 64.
............................
j
7
CHELSEA FERGUSON
Certain Filers Who Have Three or More Qualifying Children
Schedule 8812 (Form 1040A or 1040) 2015
Form
8880
OMB No. 1545-0074
Credit for Qualified Retirement Savings Contributions
j Attach to Form 1040, Form 1040A, or Form 1040NR.
j Information about Form 8880 and its instructions is at www.irs.gov/form8880.
Department of the Treasury
Internal Revenue Service
2015
Attachment
Sequence No.
54
Name(s) shown on return
Your social security number
CHELSEA FERGUSON
601-25-3380
You cannot take this credit if either of the following applies.
|
The amount on Form 1040, line 38; Form 1040A, line 22; or Form 1040NR, line 37 is more than $30,500 ($45,750 if head of
household; $61,000 if married filing jointly).
CAUTION
| The person(s) who made the qualified contribution or elective deferral (a) was born after January 1, 1998, (b) is claimed as a
dependent on someone else's 2015 tax return, or (c) was a student (see instructions).
1 Traditional and Roth IRA contributions for 2015. Do not include rollover
(a) You
(b) Your spouse
!
contributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2 Elective deferrals to a 401(k) or other qualified employer plan, voluntary
employee contributions, and 501(c)(18)(D) plan contributions for 2015
(see instructions)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3 Add lines 1 and 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4 Certain distributions received after 2012 and before the due date
(including extensions) of your 2015 tax return (see instructions). If
married filing jointly, include both spouses' amounts in both columns.
See instructions for an exception . . . . . . . . . . . . . . . . . . . . .
5 Subtract line 4 from line 3. If zero or less, enter -0- . . . . . . . . . . . .
6 In each column, enter the smaller of line 5 or $2,000 . . . . . . . . . .
7 Add the amounts on line 6. If zero, stop; you cannot take this credit . .
8 Enter the amount from Form 1040, line 38*; Form 1040A, line 22;
or Form 1040NR, line 37 . . . . . . . . . . . . . . . . . . . . . . . . .
9 Enter the applicable decimal amount shown below:
If line 8 is Over -
$18,250
$19,750
$27,375
$29,625
$30,500
$36,500
$39,500
$45,750
$61,000
But not
over $18,250
$19,750
$27,375
$29,625
$30,500
$36,500
$39,500
$45,750
$61,000
1
2
3
1,000.
1,000.
4
5
6
845.
155.
155.
. . . . . . . . . . . . . . . .
And your filing status is Married
Head of
filing jointly
household
Enter on line 9 .5
.5
.5
.5
.5
.5
.5
.2
.5
.1
.5
.1
.2
.1
.1
.1
.1
.0
.0
.0
8
155.
7
38,997.
Single, Married filing
separately, or
Qualifying widow(er)
.5
.2
.1
.1
.1
.0
.0
.0
.0
.0
Note: If line 9 is zero, stop; you cannot take this credit.
10 Multiply line 7 by line 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11 Limitation based on tax liability. Enter the amount from the Credit Limit Worksheet in the
instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12 Credit for qualified retirement savings contributions. Enter the smaller of line 10 or line 11 here
and on Form 1040, line 51; Form 1040A, line 34; or Form 1040NR, line 48 . . . . . . . . . . . . . . .
9
X.
0.100
10
16.
11
1,449.
12
16.
* See Pub. 590-A for the amount to enter if you are filing Form 2555, 2555-EZ, or 4563 or you are excluding income from Puerto Rico.
For Paperwork Reduction Act Notice, see your tax return instructions.
BCA
Form
8880 (2015)
Form
8965
Department of the Treasury
Internal Revenue Service
OMB No. 1545-0074
Health Coverage Exemptions
2015
j Attach to Form 1040, Form 1040A, or Form 1040EZ.
Information about Form 8965 and its separate instructions is at www.irs.gov/form8965
j
Name as shown on return
Attachment
Sequence No.
Your social security number
CHELSEA FERGUSON
601-25-3380
75
Complete this form if you have a Marketplace-granted coverage exemption or you are claiming a coverage exemption
on your return.
Marketplace-Granted Coverage Exemptions for Individuals: If you and/or a member of your tax household
Part I
have an exemption granted by the Marketplace, complete Part I.
(a)
Name of Individual
(b)
SSN
(c)
Exemption Certificate Number
1
2
3
4
5
6
Part II
7a
b
Coverage Exemptions Claimed on Your Return for Your Household
Are you claiming an exemption because your household income is below the filing threshold?.
. . . . . .
Are you claiming a hardship exemption because your gross income is below the filing threshold? .
Part III
. . . .
Yes
X
No
Yes
X
No
Coverage Exemptions Claimed on Your Return for Individuals. If you and/or a member of your tax
household are claiming an exemption on your return, complete Part III.
(a)
Name of Individual
(b)
SSN
(c)
Exemption
Type
(d)
(e)
Full Jan
Year
(f)
Feb
8
CHELSEA FERGUSON601-25-3380
B
X
X
9
MARIA FERGUSON
602-25-3380
B
X
X
10
LARRY FERGUSON
603-25-3380
B
X
X
(g)
Mar
(h)
Apr
(i)
(j)
May June
(k)
July
(l)
(m)
Aug Sept
(n)
Oct
(o)
Nov
(p)
Dec
11
12
13
For Privacy Act and Paperwork Reduction Act Notice, see your tax return instructions.
BCA
Form
8965 (2015)
US8879$1
Form
IRS e-file Signature Authorization
8879
Department of the Treasury
Internal Revenue Service
OMB No. 1545-0074
j
j
Do not send to the IRS. This is not a tax return.
j Keep this form for your records.
Information about Form 8879 and its instructions is at www.irs.gov/form8879.
2015
k
l
Submission Identification
Number (SID)
Taxpayer's name
Social security number
CHELSEA FERGUSON
601-25-3380
Spouse's name
Spouse's social security number
Part I
1
2
3
4
5
Tax Return Information-Tax Year Ending December 31, 2015 (Whole Dollars Only)
Adjusted gross income (Form 1040, line 38; Form 1040A, line 22; Form 1040EZ, line 4) . . . .
Total tax (Form 1040, line 63; Form 1040A, line 39; Form 1040EZ, line 12) . . . . . . . . . . .
Federal income tax withheld (Form 1040, line 64; Form 1040A, line 40; Form 1040EZ, line 7) .
. .
. .
. .
Refund (Form 1040, line 76a; Form 1040A, line 48a; Form 1040EZ, line 13a; Form 1040-SS, Part I, line 13a) .
Amount you owe (Form 1040, line 78; Form 1040A, line 50; Form 1040EZ, line 14).
Part II
. . . . . . . .
38,997.
85.
2,465.
4,794.
1
2
3
4
5
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 examined a copy of my electronic individual income tax return and accompanying schedules and
statements for the tax year ending December 31, 2015, and to the best of my knowledge and belief, it is 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 acknowledgment of receipt or reason for 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 authorization. To revoke (cancel) a payment, I must contact the U.S. Treasury Financial Agent at
1-888-353-4537. Payment cancellation requests must be 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 receive 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 electronic income tax return and, if applicable my Electronic Funds Withdrawal Consent.
Taxpayer's PIN: check one box only
X
I authorize
to enter or generate my PIN
ERO firm name
Enter five digits, but
as my signature on my tax year 2015 electronically filed income tax return.
do not enter all zeros
I will enter my PIN as my signature on my tax year 2015 electronically filed income tax return. Check this box only if you are
entering your own PIN and your return is filed using the Practitioner PIN method. The ERO must complete Part III below.
Your signature j
Date j
Spouse's PIN: check one box only
I authorize
to enter or generate my PIN
ERO firm name
Enter five digits, but
as my signature on my tax year 2015 electronically filed income tax return.
do not enter all zeros
I will enter my PIN as my signature on my tax year 2015 electronically filed income tax return. Check this box only if you are
entering your own PIN and your return is filed using the Practitioner PIN method. The ERO must complete Part III below.
Spouse's signature j
Date j
Practitioner PIN Method Returns Only-continue below
Part III
Certification and Authentication-Practitioner PIN Method Only
ERO's EFIN/PIN. Enter your six-digit EFIN followed by your five-digit self-selected PIN.
98765
Do not enter all zeros
I certify that the above numeric entry is my PIN, which is my signature for the tax year 2015 electronically filed income tax return
for the taxpayer(s) indicated above. I confirm that I am submitting this return in accordance with the requirements of the Practitioner PIN method
and Publication 1345, Handbook for Authorized IRS e-file Providers of Individual Income Tax Returns.
ERO's signature j
Date j
ERO Must Retain This Form - See Instructions
Do Not Submit This Form to the IRS Unless Requested To Do So
For Paperwork Reduction Act Notice, see your tax return instructions.
BCA
Form
8879 (2015)
US 1040
Name:
Three - Year Tax Summary
2015
CHELSEA FERGUSON
Gross Income
Wages and salaries ........................
Interest and dividends ........................
Business income ............................
Sale of assets - gain or loss ..................
Pension and IRA distributions ................
Rents, royalties, etc ........................
Unemployment and social security ..........
Other income ..............................
Total gross income ............................
Adjustments to Income ......................
Adjusted gross income ......................
Itemized or Standard Deductions
Medical expense deduction ..................
Taxes ......................................
Interest ....................................
Contributions ................................
Miscellaneous deductions ....................
Other itemized deductions ....................
Total deductions ............................
Exemptions ..................................
Taxable Income ............................
Tax (2015 - 1040, line 44) ....................
Alternative minimum tax ....................
Other taxes ................................
Credits and Payments
Credits ......................................
Withholding ................................
EIC and Additional Child Tax Credit ..........
Estimated tax payments ....................
Other payments ............................
Total credits and payments ..................
Tax liability after credits ......................
Estimated tax penalty ........................
Refund or (Balance Due)
......................
Federal marginal tax bracket ................
Tax preparation fee ..........................
State refund or (balance due)
1st resident state refund (balance due)........
2nd resident state refund (balance due) ......
1st part-year state refund (balance due) ......
2nd part-year state refund (balance due) ......
1st nonresident state refund (balance due) ....
2nd nonresident state refund (balance due)....
3rd nonresident state refund (balance due)....
4th nonresident state refund (balance due) ....
5th nonresident state refund (balance due) ....
NOTES FOR 2015:
Oc 2015 Universal Tax Systems, Inc. and/or its affiliates and licensors.
SSN:
2012
2013
601-25-3380
2014
37,900.
845.
1,800.
40,545.
1,548.
38,997.
0
0
9,250.
12,000.
17,747.
2,001.
0
0
85.
2,001.
2,465.
2,414.
6,880.
85.
0.0
All rights reserved.
%
0.0
%
4,794.
15.0 %
USSUMRY1