7

81040 ffiTftffififfi#trtrRdJffi 2@tG OMBNo. 154Hx)74 tfi8 t s6 Only-Do not s,riE oi staple h thig epaca
For the yaar Jan 1-Dc. 31, 2016, or other ta( year beginning 2016, onding separate instructions.
*Ha.o
,

W L3' 5*61
rocH
socuriBnumbs

and strq. you hav6a a Md(asurethessN(dabove

I *d*[*e""*[rtaa.
13il
, town or post keekhnthJ Eecton Gampaignt

t([l, oryour spotBe tr lSBg

nt $3 b go b'fi,s tfid. ElEklrE
counuy nanE ldow *# fl, clttrr$ yilfr iax o.
box
You Llgsrsa
Filing Stfrls t Heqd of het,*sld Mlh q[*ryirll$ pe.son] tse ltstrwtions.] tf
2 tr I*aried filing jointly(6wntf onryonehad inmme) the qrrdifyirE person is a chikj but no* yow dependefit, nler this

Check only one 3 tr Ma*id filing sparately. Enter spouso s S$N above c.hid's narnefnva. )
box. and firll narne here, ) widow{ei with dopende* c*rild
6a Youlse*f. lf sorneone can claim you aB a dpndnt, do not check box 0a Eoxas clrsclted
Exempffons S t
bn sn6aard
l{o. of drlldrca
e Depso.ramsl (a) /itotSduild6tEs17
qr@imfudtdh,(clrdil
o{lerrho,
o fivedwiUryorr
Rrstnemo Ldoamo (60 irEfudins) . dd Dotllvaxri0r
you drrabdrroirre
or soparetiolr
lf more than four (sse hsilrucdons)
dependents, ses Deprldcitn on 0c
instructions and tloterbrcdaDoYa
check here )fl aaa*rrb.,*on l-'i-'l
d Total numbrof claimed lhresehove > LlJ
7 L0ro00
lncome
8a
Wagns, sabies, tips, etc. Attach Fonn(s) W.2
Taxable interest. Attach Schech.de B if reguired -
b fax-exgrFt inter6t. Do nqt indude on line 8a . 4
Attach Folm(sl
W-2 here. Also
& Ordirwy dMdends. p*tach Scheduh B'it required
dtach Forms b Qualifieddividnds ,.19t
II\I-2G and to Taxable rEf{rnds, qBdits, or of&ts of state and local i{rcgme ta(6s
1099-R
was wilhhdd.
iftax 11 Alimony received
72 Business incorne or (loss). Attach Scfiedule C or C-EZ
tA Capital gain or 0oss). Attach Sc*redub D lf required. It nd rcquired, chec* here ) t]
lf you did not
get aW-2,
'14 O&er gairs or (osses). Afiach Form 4797 .
$ee instructions. 15a lmdistributions lrs"l I lbTaxauleamount
l6a penskrnsandannuities m b raxableamount
17 Rental real estate, royalties, partnrships, S corporation$, trusts, etc. Attach Schedute E
18 Fann income or (oss)- AttEch Schedule F .
1$ Unmdoyment compensafion
tu Socidsecuritybenr*t"lm"l I lbTaraHeamorrt
tl Oter irmme. Ust type and amu.mt
n Combire the amounts in the far dglrt column for llnes 7 tfttough 21. Thb is todincome ) llovp -_
% Eduqtorexpenses
Adiusted 24 Certain busirE6ssgrses of resenisfis, performing artbts, ad
Gross fee6b gcnFrrrrldtt offioi,&' Aitach fontt 21tS x 2106.
lncome % l-lanh savirBs aocount de&rtior. Attach Form 8889
6 Mo{,urg$(pefiss.AttachForm3[ng
n h. Attadl Schdule
Deduct'He part of self-employrnent SE
* Str-mployd SEP, SIMPLE, ard qualified plans
N EeH-employed health insurance deduction
30 Penalty on early withdrawal ot sarrings .

8la Alimonypakl b Hecipienfs$SN >_

A. lRAdeduction .
3tl Student loan interes* deductlon .
34 Tuition arrdfees. Attach Form8917.
35 Domeetic production activftieo dedqction. Attrch Form 8903
36 AddlinEs2SthroughSS
-9ZA__-
ForDise{ocute,F'nuacy@an<f P+errorkReduofionActl!&otce,6eesoprabinstnratroE Cd. No.1132tB rsrvr'104{l gotol
Form 1040 (2016) Page2
38 Amount from line 37 (adjusted gross income)

Tax and 39a Check

ir:
I I vou were born before January 2, 1952, f]
I D Spouse was born before January 2,1952, I
stino. I tot"t oor".
etinO. J checked ] 39a
-ttor,cT
Credits
lf your spouse itemizes on a separate return or you were a dual-status alien, check here > 39bE
Standard fi Itemized deductions (from Schedule A) or your standard deduction (see left margin) L'10(;'
Deduction
for- Subtract line 40 from line 38
. People who Exempiions lf line 38 is $155,550 or less, muttiply $4,050 by the number on line 6d. Otherwise, see instnrctions
check any
box on line Taxable income. Subtract line 42 from line 41. lf line 42 is more than line 41 , enter -0-
39a or 39b or
who can be
Tax (see instructions). Check if any from: a E Form(s) 8814 b I Form 4972 c J
claimed as a Alternative minimum tax (see instructions). Attach Form 6251
dependent,
see Excess advance premium tax credii repayment. Attach Form 8362
instructions. Add lines 44.45. and 46
o All others:
Foreign tax credit. Attach Form 1 1 1 6 ii required .
Single or
Manied filing Credit for child and dependent care expnses. Attach Form 2441
separately,
$6.300 Education credits from Form 8863, line 19
Manied filing Retirement savings contributions credit. Attach Form 8880
iointlv or
hualitying Chifd tax credit. Attach Schedule 8812, if required.
widow(er),
Residential energy credits. Attach Form 5695
$12,600
Head of OthercreditsfromForm: f] 8801 " I
a n3800 b
household, Add lines 48 through 54. These are your total credits
$9,300
SUbtractline55fromline47'lflinei5ismorethanline47,enter-&.>
57 Self-employment tax. Attach Schedule SE
Other 58 Unreported social security and Medicare tax from Form: a I at Sz b n 8919
59 Additional tax on lRAs, other qualified retirement plans, etc. Attach Form 5329 if required
Taxes Household employment taxes from Schedule H
60a
b First-time homebuyer credit repayment. Attach Form 5405 if required
61 Health care: individual responsibility (see instructions) Full-year coverage I
62 Taxes from: a f] Form 8959 b fl Form 8960 c I Instructions; enter code(s)
63 Add lines 56
Payments 64 Federal income tax withheld from Forms W-2 and 1099
65 2016 estimated tax payments and amount applied from 2015 retum
lf you have a
66a Eamed income credit (EIC)
qualifying
child, attach b Nontaxable combat pay election [ 66b
Schedule ElC. G7 Additional child tax credit. Attach Schedule 8812
68 American opportunity credit from Form 8863, line I
69 Net premium tax credit. Attach Form 8962 .
70 Amount paid with request for extension to file
71 Excess social security and ti6r 1 RRTA tax withheld
72 Credit for federal tax on fuels. Attach Form 4136
73 CredkfromForm: a Izass b [f Ressved c f]eSas a n
74 AddlinesM,65,66a,and67throtEh73'TheseareyoUrtotalpaymenb>
Refund 75 lf 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 io you. lf Form 8888 is attached, check > here n
Direct deposil? > b Routing number )cType: Checking ISavings I
see > d Accountnumber
instructions.
Tl Amount of line 75 vou want to Your 2017 estimated tax >
78 Amount you owe, Subtract line 74 {rom line 6.3. For details on how to pay, see instructkrns }
You Owe 79 Estimated tax penalty (see instructions) I Ze
Third party Do you want to allow another person to discuss this return with the IRS (see instructions)? fl V.r. Complete below. n Xo
Desisnee 3ffi:E'b :l"E ::H#(iiiit'ndi*> [-J-TTT]
Sign
Here Date Your occupation Daytime phon number
Joint return? See ra --i>Jr''Jt-* .'-t. ,^'a
t -. r' 'r..-
t.-:: il,-r -/
''\ l
(J -- \r
inskuctions.
Keep a copy lor signature. retum, both must sign. tfthe IBS seflt you an ldefltity Protection
your records. PlN, enter il
hHe
PrinVType prepare/s name
Paid chck Xif
setf-employed
Preparer
Firm's gN >
Use Only
Firm's address >
www.irs.govlforml040 rorm 1040 (zoto)
7

SCHEDULE B OMB No. 1545-0074

(Form 1040A or 1O{0} lnterest and Ordinary Dividends
(Rev. January 2014
tlopartment of the Treasr
>Attach to Form or t0tm.
1O{OA
2@16
Attachmeit
lntemal R6wu6 Ss\ric6 ) lnformatlon about Schedule B and its tnsrtruetons la alwww.ir&got ldrduleb.
Name(s) showil on reurm Your social security number
Tah,"- z3-q5- 67>1
Part I List name of payer. lf any interest is from a sellor-financed mortgage and the Amount
buyer used the property as a personal residence, see instructions on back and list
lnterest social security number and addres )

(See instructions
on back and the
instructions for
Form 1040A, or
Form 1040,
line 8a.)

Note lf you
received a Form
1099-lNT, Fonn
1099-OlD, or
substitute
statement trom
a brokerage firm,
list the firm's
name as the
payer and enter
2 Add the amounts on line 1
the total interest Excludable interest on series EE and I U.S. savings bonds issued after 1989.
shown on that Attach Form 8815 .
form. Subtract line 3 from line 2. Enter the result here and on Form 1040A, or Form

Note: lf line 4 is over $1 must Part lll. Amount

Part ll Ust name of payer )
Ordinary
Affi-t -,--sre-q-;-----------.-------------. ----------.:
Dividends
(See instructions
on back and the
instructions for
Form 10404, or
Form 1040,
lino ga.)

Note: lf you
received a Form
1099-DlV or
substiMe
statemnt from
a brokerage firm,
list the firm's
name as the
payer and enter
the ordinary
dividends shown
6 Add the amounts on line 5. Enter the total here and on Form 1040A, or Form
on that form. 1

over lS1 Part lll.

You must complete this part if you (a! had over $1,500 of taxable interest or ordinary dMdends; (b) had a
foreign account; or (cl received a distibution from, or wre a grantor of, or a transferor to, a foreign Mrst

Part lll 7a At any time during 2016, did yol have a financial interest in or signature adhority over a financial
account (such as a bank accourt, securities account, or brokerage account) located in a breign
Foreign country? See instructions
Accounts lf "Yes," ar6 you required to file FinCEN Form 114, Report of Forcign Bank and Financial
and Trusts Accounts (FBAR), to report that financial interest or signature authority? See FinCEN Form 114
(See and its instructions for filing requiremenB and exceptions to those requirements .
instructions on b lf you are required to file FinCEN Form 114, ents the name of the foreign country where the
financial account is located )
back.)

During 2016, did you receive a distribution from, or were you the grantor of, or transforor to, a
foreign trust? lf "Yes," have to file Form 3520. See inslructions on back .
For Paperwork Reducdon Act Notioe, see your tax retum insilructiono. Cet No.17146N Schedule I Form 10t(rA or 1O{Ol 2016
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