1040 DepartmentvofvthevTreasury—InternalvRevenuevService
U.S.vIndividualvIncomevTaxvReturn
(99)
2016 OMBv No.v 1545-0074v v IRSvUsevOnly—Dovnotv writevorvstaplevinvthisvspace.
Forv thev yearv Jan.v 1–Dec.v 31,v 2016,v orvotherv taxv yearv beginning ,v 2016,v ending Seevseparatevinstructions.
Last name ,v20v v Yourv firstv namev andv initial Yourvsocialvsecurityvnumber
Pierre Lappin 1v 2v 3v 4v 6v 6v 7v 8v 9
Ifv av jointv return,v spouse’sv firstv namev andv initial Last name Spouse’sv socialv securityv number
Jeanie Lappin 4v 4v 5v 6v 7v 9v 8v 7v 6
Homevaddressv(numbervandvstreet).vIfvyouvhavevavP.O.vbox,vseevinstructions. Apt. no.
cvMakevsurevthevSSN(s)vabov
ev andvonvlinev6cvarevcorre
123vCottontailvLane ct.
City,vtownvorvpostvoffice,vstate,vandvZIPvcode.vIfvyouvhavevavforeignvaddress,valsovcompletevspacesvbelowv(seevinstructions).
Presidentialv Electionv Campaign
Houston,vTX Checkvherevifvyou,vorvyourvspousevifvfilin
Foreignv countryv name Foreign province/state/county gv jointly,vwantv$3vtovgovtovthisvfund.vChe
ckingv avboxvbelowvwillvnotvchangevyour
vtaxvorv refund. You Spouse
1 Single 4
FilingvStatus
2 Headv ofv householdv (withv qualifyingv person).v (Seev instr
✔v Marriedvfilingvjointlyv(evenvifvonlyvonevhadvincome uctions.)v Ifv thev qualifyingv personv isv av childv butv notv yourv depend
) ent,v enterv this
Checkvonlyvone 3 child’sv namev here.v a
vbox. Marriedvfilingvseparately.vEntervspouse’svSS 5 Qualifyingv widow(er)v withv dependentvchild
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Exemptions ✔v
v .
Yourself.vIfvsomeonevcanvclaimvyouvasvavdependent,vdovnotvcheckvboxv6av .v v .v v .v v .v
} Boxesvchecked
v onv6avandv6b 2
No.vofvchildren
6 ✔v v
Spouse (4) ✓if child under age 17 v onv6cvwho:
c Dependents: (2) Dependent’s (3) Dependent’s
a .v v .v v .v v .v v .v vsocial
.v v .security
v v .v vnumber
.v v .v v .v v .relationship
v v .v v .v vto .you
v v .v v .qualifying
v v .v v .vfor
v child
.v v .tax
v v credit
.v v . • livedvwithvyou
(1) First
v name Last name (see instructions) • didvnotvlivevwith
v v . v youvduevtovdivor
b cev orvseparation
(seevinstructions)
Dependentsvonv6
cv notventeredvab
ove
Ifvmorevthanvfourvdep Addvnumbersvon 2
endents,vseevinstructi
onsvandvcheckvhere
va
dv v Totalvnumbervofvexemptionsvclaimedv v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v . linesvabovev a
v v .
7 Wages,vsalaries,vtips,vetc.vAttachvForm(s)vW-2 .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v . 7 70,000
Income
8av v Taxablevinterest.vAttachvSchedulevBvifvrequiredv .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v . 8a 3,000
bv v Tax-exemptvinterest.vDovnotvincludevonvlinev8av .v v .v v . 8b 2,000
AttachvForm(s) 9av Ordinaryv dividends.vAttachvSchedulevBvifv required .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v . 9a
v 5,000
vW-
2vhere.vAlso
attachvForms bv v Qualifiedvdividends ................................................................ 9b 5,000
W- 10 Taxablevrefunds,vcredits,vorvoffsetsvofvstatevandvlocalvincomevtaxesv v .v v .v v .v v .v v .v v . 10
2Gvandv1099- 11 Alimonyvreceivedv .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v . 11
Rvifvtaxvwasv
12 Businessvincomevorv(loss).vAttachvSchedulevCvorvC-EZv .v v .v v .v v .v v .v v .v v .v v .v v .v v . 12
withheld.
13 Capitalvgainvorv(loss).vAttachvSchedulevDvifvrequired.vIfvnotvrequired,vcheckvherev a 13 4,000
14 Othervgainsvorv (losses).vAttachvFormv4797v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v . 14
Ifv youv didv not
getvavW-2,
seevinstructions. 15av v IRAv distributionsv v . bv Taxablevamount 15b
16av v Pensionsvandvannuities .v v .v v16
15a .
b
16a bv Taxablevamount
.v v .v
.
17 Rentalv realvestate,vroyalties,vpartnerships,vSvcorporations,vtrusts,vetc.vAttachvSchedulev 17 10,000
E 18
18 Farmvincomevorv(loss).vAttachvSchedulevFv .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v 19
v .
20b
19 Unemploymentvcompensationv v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v
v21
v .
20av v Socialvsecurityvbenefits 20a bv Taxablevamount .v v .v v . 22 92,000
21 Otherv income.v Listv typev andv amount
22 Combinevthevamountsvinvthevfarvrightvcolumnvforvlinesv7vthroughv21.vThisvisvyourvtotalvincomev a
23 Educatorv expenses E lthv savingsvaccountv deduction.vAttachv For
Adjustedv .v v .v v .v v .v v .v v .v v .v v .v v .v v .v Z mv 8889v v .
GrossvIn v .
25 H 26 Movingvexpenses.vAttachvFormv3903v v .v v
.v v .v v .v v .v v .
come 24 Certainvbusinessvexpensesvofvreservists,vperformingvartists,van e
dvfee-basisvgovernmentvofficials.vAttachvFormv2106vorv2106- a 27 Deductiblevpartvofvself-
, Chapter 3, Problem 78
employm 23
entvtax.v
AttachvS
chedulev 24
SEv . 25
28 Self- 26
employ
27
edvSEP,
vSIMPL 28
E,vandv 29
qualifie 30
dvplans .v v .
31av32 5,
29 Self- 0
employ 33
0
edvhealt 34
0
hvinsura 35
ncevded
uction .v v .v v .v v .
30 Penaltyv
onvearly 3456 78899
v withdra
walvofvs
avingsv .
v v .v v .
v v .v v .
v v .
31av v Alimony
vpaidv v bv Reci
pient’svSSNv a
32 IRAvded
uctionv .
v v .v v .
v v .v v .
v v .v v .
v v .v v .
v v .v v .
v v .v v .
33 Student
vloanvint
erestvde
ductionv
.v v .v v .
v v .v v .
v v .v v .
v v .
34 Tuitionv
andvfee
s.vAttac
hvFormv
8917v.v
v .v v .v
v .v v .v
v .v v .
35 Domesti
cv produc
tionv acti
vitiesv de
duction.v
Attachv F
ormv 890
3
36
Addvlinesv23vthroughv35v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v . 36 5,000
37 Subtractvlinev36vfromvlinev22.vThisvisvyourvadjustedvgrossvincome .v v .v v .v v .v v . a 37 87,000
ForvDisclosure,vPrivacyvAct,vandvPaperworkvReductionvActvNotice,vseevseparatevinstructions. Cat.v No.v 11320B Formv 1040v (2016)
, Form
1040 DepartmentvofvthevTreasury—InternalvRevenuevService
U.S.vIndividualvIncomevTaxvReturn
(99)
2016 OMBv No.v 1545-0074v v IRSvUsevOnly—Dovnotv writevorvstaplevinvthisvspace.
Forv thev yearv Jan.v 1–Dec.v 31,v 2016,v orvotherv taxv yearv beginning ,v 2016,v ending Seevseparatevinstructions.
Last name ,v20v Yourv firstv namev andv initial Yourvsocialvsecurityvnumber
Angelina Carlyle 1v 6v 7v 8v 8v 5v 5v 4v 4
Ifv av jointv return,v spouse’sv firstv namev andv initial Last name Spouse’sv socialv securityv number
Homevaddressv(numbervandvstreet).vIfvyouvhavevavP.O.vbox,vseevinstructions. Apt. no.
cvMakevsurevthevSSN(s)vabov
ev andvonvlinev6cvarevcorre
1234vMainvStreet ct.
City,vtownvorvpostvoffice,vstate,vandvZIPvcode.vIfvyouvhavevavforeignvaddress,valsovcompletevspacesvbelowv(seevinstruction
s). Presidentialv Electionv Campaign
Checkvherevifvyou,vorvyourvspousevifvfilin
Dayton,vOH gv jointly,vwantv$3vtovgovtovthisvfund.vChe
Foreignv countryv name Foreign province/state/county ckingv avboxvbelowvwillvnotvchangevyour
vtaxvorv refund. You Spouse
1 ✔v vSingle 4 Headv ofv householdv (withv qualifyingv person).v (Seev instructions.)v
FilingvStatus
2 Marriedvfilingvjointlyv(evenvifvonlyvonevhadvincome) Ifv thev qualifyingv personv isv av childv butv notv yourv dependent,v enter
Checkvonlyvonev 3 Marriedvfilingvseparately.vEntervspouse’svSSNvabove v thisv child’svnamevhere.va
box. vandvfullvnamevhere.va 5 Qualifyingv widow(er)v withv dependentvchild
Boxesvchecked
Exemptions 6a
b
✔v v Yourself.vIfv someonev canvclaimv youv asv avdependent,v dovnotvcheckv boxv 6a .......................
Spouse
} v onv6avandv6b
No.vofvchildren
1
c .v v .v v .v v .v v .v v .v v .v v .v v .v v(2).v Dependent’s
Dependents: v .v v .v v .v v .v v .v v(3)
.vDependent’s
v .v v .v v .v v .v (4)
v .v✓vif.child
v v .vunder
v . age 17 v onv6cvwho:
social security number relationship to you
qualifying for child tax credit • livedvwithvyou
(1) First name Last name (see instructions) • didvnotvlivevwith
v youvduevtovdivor
cev orvseparation
Ifvmorevthanvfourv (seevinstructions)
dependents,vseev Dependentsvonv6
instructionsvandv cv notventeredvab
ove
checkvhereva
Addvnumbersvon 1
dv v Totalvnumbervofvexemptionsvclaimedv v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v . linesvabovev a
v v .
7 Wages,vsalaries,vtips,vetc.vAttachvForm(s)vW-2 .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v . 7
Income
8av Taxablevinterest.vAttachvSchedulevBvifvrequiredv .v .v .v .v .v .v .v .v .v .v .v . 2,000
.................................................................................................... 8avbv Tax-
AttachvForm(s)
exemptvinterest.vDovnotvincludevonvlinev8a ................................ 8b
vW-
2vhere.vAlsovat 9av Ordinaryvdividends.vAttachvSchedulevBvifvrequiredv .v .v .v .v .v .v .v .v .v .v .
tachvFormsvW .................................................................................................... 9avbv Qualifiedvdividends 9b
-2Gvandv1099- 10 Taxablevrefunds,vcredits,vorvoffsetsvofvstatevandvlocalvincomevtaxesv v .v v .v v .v v .v v .v v . 10
Rvifvtaxvwasvw
11 Alimonyvreceivedv .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v . 11 195,000
ithheld.
12 Businessvincomevorv(loss).vAttachvSchedulevCvorvC-EZv .v v .v v .v v .v v .v v .v v .v v .v v .v v . 12
13 Capitalvgainvorv(loss).vAttachvSchedulevDvifvrequired.vIfvnotvrequired,vcheckvherev a 13
Ifv youv didv not 14 Othervgainsvorv (losses).vAttachvFormv4797v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v . 14
getvavW-2,
seevinstructions. 15av v IRAv distributionsv v . bv Taxablevamount 15b
16av v Pensionsvandvannuities .v v .v v16
15a .
b
16a bv Taxablevamount
.v v .v
.
17 Rentalv realvestate,vroyalties,vpartnerships,vSvcorporations,vtrusts,vetc.vAttachvSchedulev 17
E 18
18 Farmvincomevorv(loss).vAttachvSchedulevFv .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v 19
v .
20b
19 Unemploymentvcompensationv v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v
v21
v .
20av v Socialvsecurityvbenefits 20a bv Taxablevamount .v v .v v . 22 197,000
21 Otherv income.v Listv typev andv amount
22 Combinevthevamountsvinvthevfarvrightvcolumnvforvlinesv7vthroughv21.vThisvisvyourvtotalvincomev a
23 Educatorv expenses 27 D artvofvself-
Adjustedv .v v .v v .v v .v v .v v .v v .v v .v v .v v .v e employmentvtax.vAttachvSchedulevSEv .
GrossvIn v . d 28 Self-
u employedvSEP,vSIMPLE,vandvqualifiedvpla
come 24 Certainvbusinessvexpensesvofvreservists,vperformingvartists,van
c ns
dvfee-basisvgovernmentvofficials.vAttachvFormv2106vorv2106-
t 29 Self-employedvhealthvinsurancevdeduction .v v
EZ i
b 30 Penaltyvonvearlyvwithdrawalvofvsavingsv .v v
25 Healthvsavingsv accountv deduction.vAttachv Formv8889v v
l .v v .v v .v v .v v .
.
e 31av v Alimonyvpaidv v bv Recipient’svSSNv a
26 Movingvexpenses.vAttachvFormv3903v v .v v .v v .v v .v v .v v
v . p 32 IRAvdeductionv .v v .v v .v v .v v .v v .v v .v v .v
v .v v .v v .v v .v v .
, Chapter 4, Problem 71
33 Student 23
vloanvint
erestvde
ductionv 24
.v v .v v . 25
v v .v v .
26
v v .v v .
v v . 27 9,
28 9
34 Tuitionv
5
andvfee 29
8
s.vAttac 30
hvFormv
8917v.v 31av32
v .v v .v 33
v .v v .v
34
v .v v .
35
35 Domesti
cv produc
tionv acti
vitiesv de
duction.v
Attachv F
ormv 890
3
36
Addvlinesv23vthroughv35v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v .v v . 36 9,958
37 Subtractvlinev36vfromvlinev22.vThisvisvyourvadjustedvgrossvincome .v v .v v .v v .v v . a 37 187,042
ForvDisclosure,vPrivacyvAct,vandvPaperworkvReductionvActvNotice,vseevseparatevinstructions. Cat.v No.v 11320B Formv 1040v (2016)