Sample IRS m 1040
Form
1040
Department of the Treasury
' Internal Revenue Service
(99)
U.S. Individual Income Tax Return
For the year Jan. 1 - Dec. 31, 2017, or other tax year beginning
2017
, 2017, ending
OMB No- IRS Use Only
, 20
' Do not write or staple in this space.
See separate instructions.
Your first name and initial
Last name
Your social security number
If a joint return, spouse's first name and initial
Last name
Spouse's social security number
Home address (number and street). If you have a P.O. box, see instructions.
Apt. no.
City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions).
PHOENIX, AZ 85007
Foreign country name
Filing Status
Check only
one box.
Exemptions
Foreign province/state/county
1
2
3
X Single
4
Married filing jointly (even if only one had income)
Married filing separately. Enter spouse's SSN above & full
name here. . G
5
Foreign postal code
J
Make sure the SSN(s) above
and on line 6c are correct.
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
Head of household (with qualifying person). (See
instructions.) If the qualifying person is a child
but not your dependent, enter this child's
name here. . G
Qualifying widow(er) (see instructions)
6a X Yourself. If someone can claim you as a dependent, do not check box 6a. . . . . . . . . . .
Boxes checked
on 6a and 6b. . .
No. of children
on 6c who:
b
Spouse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
c Dependents:
(2) Dependent's
(3) Dependent's
(4) b if
child under ? lived
social security
relationship
with you. . . . . .
age 17
number
to you
qualifying for
? did not
child
tax
credit
Last
name
(1) First name
(see instructions) live with you
If more than four
dependents, see
instructions and
check here. . . G
1
1
due to divorce
or separation
(see instructions). .
Dependents
on 6c not
entered above. .
Add numbers
on lines
claimed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . above. . . . . . G
Daughter
X
d Total number of exemptions
7 Wages, salaries, tips, etc. Attach Form(s) W-2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
Income
8 a Taxable interest. Attach Schedule B if required . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8a
b Tax-exempt interest. Do not include on line 8a. . . . . . . . . . . . . .
8b
9 a Ordinary dividends. Attach Schedule B if required. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9a
Attach Form(s)
b Qualified dividends. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9b
W-2 here. Also
attach Forms
10 Taxable refunds, credits, or offsets of state and local income taxes . . . . . . . . . . . . . . . . . . . . . 10
W-2G and 1099-R
11 Alimony received . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
if tax was withheld.
12 Business income or (loss). Attach Schedule C or C-EZ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
If you did not
13 Capital gain or (loss). Attach Schedule D if required. If not required, check here. . . . . . . . . . G
13
get a W-2,
14 Other gains or (losses). Attach Form 4797. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
see instructions.
15 a IRA distributions. . . . . . . . . . . . 15 a
b Taxable amount. . . . . . . . . . . . . 15 b
16 a Pensions and annuities . . . . . 16 a
b Taxable amount. . . . . . . . . . . . . 16 b
17 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E. 17
18 Farm income or (loss). Attach Schedule F. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
19 Unemployment compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
20 a Social security benefits . . . . . . . . . . 20 a
b Taxable amount. . . . . . . . . . . . . 20 b
21 Other income. List type and amount
21
22 Combine the amounts in the far right column for lines 7 through 21. This is your total income. . . . . . . . . . . . . G 22
23 Educator expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Adjusted
24 Certain business expenses of reservists, performing artists, and fee-basis
government officials. Attach Form 2106 or 2106-EZ . . . . . . . . . . . . . . . . . . . . 24
Gross
25 Health savings account deduction. Attach Form 8889. . . . . . . . 25
Income
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
31 a Alimony paid b Recipient's SSN . . . . G
31 a
32 IRA deduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
33 Student loan interest deduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
34 Reserved for future use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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. . . . . . . . . . . . . . . . . . . . . G 37
BAA For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions.
FDIA0112L 10/19/17
2
35,430.
35,430.
0.
35,430.
Form 1040 (2017)
Form 1040 (2017)
Tax and
Credits
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,
$6,350
Married filing
jointly or
Qualifying
widow(er),
$12,700
Head of
household,
$9,350
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
Joint return?
See instructions.
Keep a copy
for your records.
Page 2
38 Amount from line 37 (adjusted gross income). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
39 a Check
You were born before January 2, 1953,
Blind.
Total boxes
Spouse was born before January 2, 1953,
if:
Blind.
checked G 39 a
b If your spouse itemizes on a separate return or you were a dual-status alien, check here . . . . . . . . . G 39 b
Itemized deductions (from Schedule A) or your standard deduction (see left margin) . . . . . . . . . . . . . . . . . . . .
Subtract line 40 from line 38. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Exemptions. If line 38 is $156,900 or less, multiply $4,050 by the number on line 6d. Otherwise, see instrs. . . . . .
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
c
Form(s) 8814
b
Form 4972 . . . . . . . . . . . . . . . . . . . . . . . . . . .
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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G
48 Foreign tax credit. Attach Form 1116 if required. . . . . . . . . . . . .
48
49 Credit for child and dependent care expenses. Attach Form 2441 . . . . . . . . . .
49
50 Education credits from Form 8863, line 19. . . . . . . . . . . . . . . . . .
50
51 Retirement savings contributions credit. Attach Form 8880. . .
51
52 Child tax credit. Attach Schedule 8812, if required . . . . . . . . . .
52
1,000.
53 Residential energy credit. Attach Form 5695. . . . . . . . . . . . . . . -
54 Other crs from Form: a
54
3800 b
8801 c
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-. . . . . . . . . . . . . . . . . . G
57 Self-employment tax. Attach Schedule SE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
58 Unreported social security and Medicare tax from Form: a
8919. . . . . . . . . . . . . . . . . . . . . . .
4137 b
59 Additional tax on IRAs, other qualified retirement plans, etc. Attach Form 5329 if required. . . . . . . . . . . . . . . . . . .
60 a 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
62 Taxes from: a
Form 8959 b
Form 8960 c
Instrs; enter code(s)
63 Add lines 56 through 62. This is your total tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G
64 Federal income tax withheld from Forms W-2 and 1099 . . . . - estimated tax payments and amount applied from 2016 return. . . . . . . .
65
66 a Earned income credit (EIC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
66 a
670.
b Nontaxable combat pay election . . . . . G 66 b
67 Additional child tax credit. Attach Schedule 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
73 Credits from Form: a
73
2439 b
Reserved c
8885
d
74 Add lines 64, 65, 66a, and 67 through 73. These are your total payments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . G
75 If line 74 is more than line 63, subtract line 63 from line 74. This is the amount you overpaid . . . . . . . . . . . . . . .
76 a Amount of line 75 you want refunded to you. If Form 8888 is attached, check here. . G
G b Routing number . . . . . . . .
G c Type:
Checking
Savings
G d Account number. . . . . . . .
77 Amount of line 75 you want applied to your 2018 estimated tax. . . . . . . . G 77
78 Amount you owe. Subtract line 74 from line 63. For details on how to pay, see instructions. . . . . . . . . . . . . . . G
79 Estimated tax penalty (see instructions). . . . . . . . . . . . . . . . . . . .
79
Do you want to allow another person to discuss this return with the IRS (see instructions)?. . . . . . . . . . .
Designee's
name
Phone
no.
G
FDIA0112L
10/19/17
35,430.
40
41
42
6,350.
29,080.
8,100.
43
20,980.
-
2,680.
0.
- a
60 b
61
62
63
1,000.
1,680.
74
75
76 a
1,392.
78
1,331.
2,680.
1,043.
2,723.
X Yes. Complete below.
Personal identification
number (PIN)
G
No
G
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 accurately list all amounts and sources of income I received during the tax year. Declaration of preparer (other than taxpayer) is based on all
information of which preparer has any knowledge.
Your signature
Date
Your occupation
Daytime phone number
A Spouse's signature. If a joint return, both must sign.
Print/Type preparer's name
Paid
Preparer
Use Only
38
Preparer's signature
SALES
Date
If the IRS sent you an Identity Protection
PIN, enter it
here (see inst.)
Spouse's occupation
Date
Check
if
PTIN
self-employed
Firm's name
G
Firm's address G
Firm's EIN G
Mesa, AZ 85206
Phone no.
Form 1040 (2017)