Randall’s 2019 Tax Packet

Audit Defense Policy

Federal Tax Return

State Tax Return

Randall Petterson
 Audit Defense Policy
Defense code: CF4Q-WOAY-2019
Thanks for filing with Credit Karma Tax! We hope you won't need these
instructions. But if you do get audited on your 2019 return, we've partnered
with the pros at Tax Protection Plus to help you through it – all for free! Here’s
what you’ll need:

Instructions
1. Call Tax Protection Plus toll-free at 877-579-5602.
• Make the call within 30 days of hearing from the IRS or the state.
• If you’d prefer to have them call you, send an email to:
cases@taxprotectionplus.com.
• Make the subject line: Audit Defense Redemption.
• Include your name, phone number, and the best time to reach you
(within their business hours).
2. You’ll have to provide some personal info to get started, as well as:
• Your Defense code: CF4Q-WOAY-2019
• The tax return year: 2019
• Whether it’s a federal (IRS) or state audit
3. You’ll get an email with a secure link to upload your tax return and the audit
notice you received.

Policy Details
Your Audit Defense expires one year after 04/15/2020 or your e-file date
(whichever is later). If you’re not sure when you e-filed, you can find the date on
your Credit Karma Tax dashboard.

For more details about Audit Defense, visit

https://www.creditkarma.com/tax/programterms#3.

Randall Petterson
 1040 U.S. Individual Income Tax Return 2019
Department of the Treasury—Internal Revenue Service (99)
Form

OMB No. 1545-0074 IRS Use Only—Do not write or staple in this space.

Filing Status ✔ Single Married filing jointly Married filing separately (MFS) Head of household (HOH) Qualifying widow(er) (QW)
Check only If you checked the MFS box, enter the name of spouse. If you checked the HOH or QW box, enter the child’s name if the qualifying person is
one box.
a child but not your dependent. ▶
Your first name and middle initial Last name Your social security number
RANDALL PETTERSON 2 4 7 6 7 3 5 8 5
If joint return, spouse’s first name and middle initial Last name Spouse’s social security number

Home address (number and street). If you have a P.O. box, see instructions. Apt. no. Presidential Election Campaign
221 PINEVIEW DR Check here if you, or your spouse if filing
jointly, want $3 to go to this fund.
City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions). Checking a box below will not change your
PELZER, SC 29669 tax or refund. You Spouse
Foreign country name Foreign province/state/county Foreign postal code If more than four dependents,
see instructions and ✓ here ▶

Standard Someone can claim: You as a dependent Your spouse as a dependent

Deduction Spouse itemizes on a separate return or you were a dual-status alien

Age/Blindness You: Were born before January 2, 1955 Are blind Spouse: Was born before January 2, 1955 Is blind
Dependents (see instructions): (2) Social security number (3) Relationship to you (4) ✓ if qualifies for (see instructions):
(1) First name Last name Child tax credit Credit for other dependents

1 Wages, salaries, tips, etc. Attach Form(s) W-2 . . . . . . . . . . . . . . . . . . 1 13593

2a Tax-exempt interest . . . . 2a b Taxable interest. Attach Sch. B if required 2b
3a Qualified dividends . . . . 3a b Ordinary dividends. Attach Sch. B if required 3b
Standard
Deduction for— 4a IRA distributions . . . . . 4a b Taxable amount . . . . . . 4b
• Single or Married
filing separately,
c Pensions and annuities . . . 4c d Taxable amount . . . . . . 4d
$12,200 5a Social security benefits . . . 5a b Taxable amount . . . . . . 5b
• Married filing
jointly or Qualifying 6 Capital gain or (loss). Attach Schedule D if required. If not required, check here . . . . . . . ▶ 6
widow(er), 7a Other income from Schedule 1, line 9 . . . . . . . . . . . . . . . . . . . . 7a
$24,400
• Head of b Add lines 1, 2b, 3b, 4b, 4d, 5b, 6, and 7a. This is your total income . . . . . . . . . . . ▶ 7b 13593
household,
$18,350
8a Adjustments to income from Schedule 1, line 22 . . . . . . . . . . . . . . . . . 8a
• If you checked b Subtract line 8a from line 7b. This is your adjusted gross income . . . . . . . . . . . ▶ 8b 13593
any box under 12200
Standard 9 Standard deduction or itemized deductions (from Schedule A) . . . . . 9
Deduction, 10 Qualified business income deduction. Attach Form 8995 or Form 8995-A . . . 10
see instructions.
11a Add lines 9 and 10 . . . . . . . . . . . . . . . . . . . . . . . . . 11a 12200
b Taxable income. Subtract line 11a from line 8b. If zero or less, enter -0- . . . . . . . . . . . 11b 1393
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 11320B Form 1040 (2019)
 Form 1040 (2019) Page 2
12a Tax (see inst.) Check if any from Form(s): 1 8814 2 4972 3 12a 139
b Add Schedule 2, line 3, and line 12a and enter the total . . . . . . . . . . . . . . ▶ 12b 139
13a Child tax credit or credit for other dependents . . . . . . . . . . 13a
b Add Schedule 3, line 7, and line 13a and enter the total . . . . . . . . . . . . . . ▶ 13b 139
14 Subtract line 13b from line 12b. If zero or less, enter -0- . . . . . . . . . . . . . . . 14
15 Other taxes, including self-employment tax, from Schedule 2, line 10 . . . . . . . . . . . . 15
16 Add lines 14 and 15. This is your total tax . . . . . . . . . . . . . . . . . . ▶ 16
17 Federal income tax withheld from Forms W-2 and 1099 . . . . . . . . . . . . . . . 17 1100

• If you have a
18 Other payments and refundable credits:
qualifying child, a Earned income credit (EIC) . . . . . . . . . . . . . . . 18a 153
attach Sch. EIC.
• If you have b Additional child tax credit. Attach Schedule 8812 . . . . . . . . . 18b
nontaxable c American opportunity credit from Form 8863, line 8 . . . . . . . . 18c
combat pay, see
instructions. d Schedule 3, line 14 . . . . . . . . . . . . . . . . . 18d
e Add lines 18a through 18d. These are your total other payments and refundable credits . . . . . ▶ 18e 153
19 Add lines 17 and 18e. These are your total payments . . . . . . . . . . . . . . . ▶ 19 1253
20 If line 19 is more than line 16, subtract line 16 from line 19. This is the amount you overpaid . . . . . . 20 1253
Refund
21a Amount of line 20 you want refunded to you. If Form 8888 is attached, check here . . . . . . ▶ 21a 1253
Direct deposit? ▶ b Routing number 1 2 1 0 0 0 2 4 8 ▶ c Type: ✔ Checking Savings
See instructions.
▶ d Account number 2 2 1 1 5 9 8 3 9 4 2 5 3 7 3 7 3
22 Amount of line 20 you want applied to your 2020 estimated tax . . . . ▶ 22
Amount 23 Amount you owe. Subtract line 19 from line 16. For details on how to pay, see instructions . . . . . ▶ 23
You Owe 24 Estimated tax penalty (see instructions) . . . . . . . . . . . ▶ 24
Third Party Do you want to allow another person (other than your paid preparer) to discuss this return with the IRS? See instructions. Yes. Complete below.
Designee No
(Other than Designee’s Phone Personal identification
paid preparer) name ▶ no. ▶ number (PIN) ▶

Sign 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.
Here Your signature Date Your occupation If the IRS sent you an Identity
Protection PIN, enter it here
▲

Joint return?
MECHANIC (see inst.)
See instructions. Spouse’s signature. If a joint return, both must sign. Date Spouse’s occupation If the IRS sent your spouse an
Keep a copy for Identity Protection PIN, enter it here
your records. (see inst.)

Phone no. Email address

Preparer’s name Preparer’s signature Date PTIN Check if:
Paid 3rd Party Designee
Preparer Firm’s name ▶ Phone no. Self-employed
Use Only
Firm’s address ▶ Firm’s EIN ▶

Go to www.irs.gov/Form1040 for instructions and the latest information. Form 1040 (2019)
SCHEDULE 3 OMB No. 1545-0074
Additional Credits and Payments
2019
(Form 1040 or 1040-SR)
▶ Attach to Form 1040 or 1040-SR.
Department of the Treasury Attachment
Internal Revenue Service ▶ Go to www.irs.gov/Form1040 for instructions and the latest information. Sequence No. 03
Name(s) shown on Form 1040 or 1040-SR Your social security number
247673585
Part I Nonrefundable Credits
1 Foreign tax credit. Attach Form 1116 if required . . . . . . . . . . . . . . . . . . 1
2 Credit for child and dependent care expenses. Attach Form 2441 . . . . . . . . . . . . 2
3 Education credits from Form 8863, line 19 . . . . . . . . . . . . . . . . . . . . 3
4 Retirement savings contributions credit. Attach Form 8880 . . . . . . . . . . . . . . 4 139
5 Residential energy credit. Attach Form 5695 . . . . . . . . . . . . . . . . . . . 5
6 Other credits from Form: a 3800 b 8801 c 6
7 Add lines 1 through 6. Enter here and include on Form 1040 or 1040-SR, line 13b . . . . . . . 7 139
Part II Other Payments and Refundable Credits
8 2019 estimated tax payments and amount applied from 2018 return . . . . . . . . . . . 8
9 Net premium tax credit. Attach Form 8962 . . . . . . . . . . . . . . . . . . . . 9
10 Amount paid with request for extension to file (see instructions) . . . . . . . . . . . . . 10
11 Excess social security and tier 1 RRTA tax withheld . . . . . . . . . . . . . . . . . 11
12 Credit for federal tax on fuels. Attach Form 4136 . . . . . . . . . . . . . . . . . . 12
13 Credits from Form: a 2439 b Reserved c 8885 d 13
14 Add lines 8 through 13. Enter here and on Form 1040 or 1040-SR, line 18d . . . . . . . . . 14
For Paperwork Reduction Act Notice, see your tax return instructions. Cat. No. 71480G Schedule 3 (Form 1040 or 1040-SR) 2019
Form 8880 Credit for Qualified Retirement Savings Contributions OMB No. 1545-0074

2019
▶ Attach to Form 1040, 1040-SR, or 1040-NR.
Department of the Treasury Attachment
Internal Revenue Service ▶ Go to www.irs.gov/Form8880 for the latest information. Sequence No. 54
Name(s) shown on return Your social security number
RANDALL PETTERSON 247673585
You cannot take this credit if either of the following applies.

▲
!
CAUTION
• The amount on Form 1040 or 1040-SR, line 8b; or Form 1040-NR, line 35, is more than $32,000 ($48,000 if head of household;
$64,000 if married filing jointly).
• The person(s) who made the qualified contribution or elective deferral (a) was born after January 1, 2002; (b) is claimed as a
dependent on someone else’s 2019 tax return; or (c) was a student (see instructions).
(a) You (b) Your spouse
1 Traditional and Roth IRA contributions, and ABLE account contributions by the
designated beneficiary for 2019. Do not include rollover contributions . . . . . 1
2 Elective deferrals to a 401(k) or other qualified employer plan, voluntary employee
contributions, and 501(c)(18)(D) plan contributions for 2019 (see instructions) . . 2 1428
3 Add lines 1 and 2 . . . . . . . . . . . . . . . . . . . . . . 3 1428
4 Certain distributions received after 2016 and before the due date (including
extensions) of your 2019 tax return (see instructions). If married filing jointly, include
both spouses’ amounts in both columns. See instructions for an exception . . . 4
5 Subtract line 4 from line 3. If zero or less, enter -0- . . . . . . . . . . . 5 1428
6 In each column, enter the smaller of line 5 or $2,000 . . . . . . . . . . 6 1428
7 Add the amounts on line 6. If zero, stop; you can’t take this credit . . . . . . . . . . . . 7 1428
8 Enter the amount from Form 1040 or 1040-SR, line 8b;* or Form 1040-NR, line
35 . . . . . . . . . . . . . . . . . . . . . . . . . 8 13593
9 Enter the applicable decimal amount from the table below.

If line 8 is— And your filing status is—

Married Head of Single, Married filing
But not
Over— filing jointly household separately, or
over—
Enter on line 9— Qualifying widow(er)
--- $19,250 0.5 0.5 0.5
$19,250 $20,750 0.5 0.5 0.2
$20,750 $28,875 0.5 0.5 0.1 9 x 0 . 0.50
$28,875 $31,125 0.5 0.2 0.1
$31,125 $32,000 0.5 0.1 0.1
$32,000 $38,500 0.5 0.1 0.0
$38,500 $41,500 0.2 0.1 0.0
$41,500 $48,000 0.1 0.1 0.0
$48,000 $64,000 0.1 0.0 0.0
$64,000 --- 0.0 0.0 0.0
Note: If line 9 is zero, stop; you can’t take this credit.
10 Multiply line 7 by line 9 . . . . . . . . . . . . . . . . . . . . . . . . . . 10 714
11 Limitation based on tax liability. Enter the amount from the Credit Limit Worksheet in the instructions 11 139
12 Credit for qualified retirement savings contributions. Enter the smaller of line 10 or line 11 here
and on Schedule 3 (Form 1040 or 1040-SR), line 4; or Form 1040-NR, line 48 . . . . . . . . 12 139

* See Pub. 590-A for the amount to enter if you claim any exclusion or deduction for foreign earned income, foreign housing, or income from
Puerto Rico or for bona fide residents of American Samoa.
For Paperwork Reduction Act Notice, see your tax return instructions. Cat. No. 33394D Form 8880 (2019)
 Form 511
Oklahoma Resident Income Tax Return 2019
Your Social Security Number Place an ‘X’ in this AMENDED
box if this taxpayer
247-67-3585 is deceased
RETURN!
Place an ‘X’ in this
Spouse’s Social Security Number box if this is an
(joint return only) amended 511. See
Place an ‘X’ in this
Schedule
box if this taxpayer 511-I.
is deceased

Your first name Middle initial Last name

Please Print or Type
Name and Address

RANDALL PETTERSON
If a joint return, spouse’s first name Middle initial Last name

Mailing address (number and street, including apartment number, rural route or PO Box)

221 PINEVIEW DR
City State ZIP * NOTE: If claiming Special Exemption, see instructions on page 6 of 511 Packet.

PELZER SC 29669
Regular * Special Blind

Yourself
1 1 (a)

Exemptions
1 X Single
(b)
Spouse
2 Married filing joint return (even if only one had income)
Filing Status

3 Married filing separate (c)

Number of dependents
• If spouse is also filing, list Name:
name and SSN in the boxes Add the Totals from boxes (a), (b) and (c).
SSN: Enter the TOTAL here: 1
Note: If you may be claimed as a dependent on another return, enter “0” in the
4 Head of household with qualifying person Total box for your regular exemption.
5 Qualifying widow(er) with dependent child
• Please list the year spouse died in box at right: Age 65 or Over? (Please see instructions) Yourself Spouse

PART ONE: TO ARRIVE AT OKLAHOMA ADJUSTED GROSS INCOME Round to Nearest Whole Dollar
1 Federal adjusted gross income (from Federal 1040 or 1040-SR)................................................................................ 1 13,593 .00
2 Oklahoma Subtractions (provide Schedule 511-A)...................................................................................................... 2 .00
3 Line 1 minus line 2....................................................................................................................................................... 3 13,593 .00
4 Out-of-state income, except wages. Describe (4a)
(Provide Federal schedule with detailed description; see instructions)________________________________________ ...... 4b .00
5 Line 3 minus line 4b..................................................................................................................................................... 5 13,593 .00
6 Oklahoma Additions (provide Schedule 511-B)........................................................................................................... 6 .00
7 Oklahoma adjusted gross income (line 5 plus line 6)............................................................................................... 7 13,593 .00
(If line 7 is different than line 1, provide a copy of your Federal return.)
PART TWO: OKLAHOMA TAXABLE INCOME, TAX AND CREDITS
8 Oklahoma Adjustments (provide Schedule 511-C)...................................................................................................... 8 .00
9 Oklahoma income after adjustments (line 7 minus line 8)........................................................................................... 9 13,593 .00
STOP AND READ: If line 4b is zero, complete lines 10-11. If line 4b is more than zero, see Schedule 511-E and do not complete lines 10-11.
10 Oklahoma itemized deductions (from Schedule 511-D, line 11) or Oklahoma standard deduction
(Single or Married Filing Separate: $6,350 • Married Filing Joint or Qualifying Widow(er): $12,700 •
Head of Household: $9,350)................................................................................................................................. 10 6,350 .00
11 Exemptions: Enter the total number of exemptions claimed above........................ 1 X $1,000................... 11 1,000 .00
12 Total deductions and exemptions (add lines 10 and 11 or amount from Sch. 511-E, line 5).................................... 12 7,350 .00
13 Oklahoma Taxable Income (line 9 minus line 12)....................................................................................................... 13 6,243 .00
14 (a) Oklahoma Income Tax from Tax Table (see pages 21-32 of instructions) or if using Farm Income Averaging,
enter tax from Form 573, line 22 and enter a “1” in box on line 14...................................
(b) If paying the Health Savings Account additional 10% tax, add additional tax here .00 14a 133
and enter a “2” in box on line 14. If recapturing the Oklahoma Affordable Housing
Tax Credit, add recaptured credit here and enter a “3” in box on line 14. If making
an Oklahoma installment payment pursuant to IRC Section 965(h) and 68 O.S. Sec.
2368(K), add the installment payment here and enter a “4” in the box on line 14............ 14b .00
Oklahoma Income Tax (line 14a plus line 14b)...................................................................................... 14 133 .00
STOP AND READ: If line 7 is equal to or larger than line 1, complete lines 15 and 16. If line 7 is smaller than line 1, complete Schedules 511-F and 511-G.
15 Oklahoma child care/child tax credit (see instructions)............................................................................................. 15 .00
16 Oklahoma earned income credit (see instructions)................................................................................................... 16 8 .00
17 Credit for taxes paid to another state (provide Form 511TX).................................................................................... 17 .00
18 Form 511CR - Other Credits Form. List 511CR line number claimed here:............................................... 18 .00
19 Income Tax (line 14 minus lines 15-18) Do not enter less than zero.............................................................................. 19 125 .00
DO NOT PAY THIS AMOUNT. PAYMENT IS FIGURED ON LINE 43.
2019 Form 511 - Resident Income Tax Return - Page 2
The Oklahoma Tax Commission is not required to give actual notice to taxpayers of changes in any state tax law.

Name(s) shown Your Social

on Form 511: RANDALL PETTERSON Security Number: 247-67-3585
PART THREE: TAX, CREDITS AND PAYMENTS
20 Total from line 19........................................................................................................................................................20 125 .00
21 Use tax due on Internet, mail order, or other out-of-state purchases.......................................................................21 .00
(For use tax table, see page 11 of the Packet) If you certify that no use tax is due, place an ‘X’ here:
X
22 Balance (add lines 20 and 21)....................................................................................................................................22 125 .00
23 Oklahoma withholding (provide all W-2s, 1099s or other withholding statements).......... 23 423 .00
24 2019 estimated tax payments............. (qualified farmer )............................. 24 .00
25 2019 payment with extension................................................................................... 25 .00
26 Low Income Property Tax Credit (provide Form 538-H)........................................... 26 .00
27 Sales Tax Relief Credit (provide Form 538-S)........................................................... 27 40 .00
28 Natural Disaster Tax Credit (provide Form 576)........................................................ 28 .00
29 Credits from Form.............................................a) 577.............b) 578............29 .00
30 Amount paid with original return plus additional paid after it was filed
(amended return only)............................................................................................... 30 .00
31 Payments and credits (add lines 23-30)..................................................................................................................31 463 .00
32 Overpayment, if any, as shown on original return and/or prior amended return(s) or
as previously adjusted by Oklahoma (amended return only).....................................................................................32 .00
33 Total payments and credits (line 31 minus 32)........................................................................................................33 463 .00

PART FOUR: REFUND

34 If line 33 is more than line 22, subtract line 22 from line 33. This is your overpayment............................................34 338 .00
35 Amount of line 34 to be applied to 2020 estimated tax (original return only)
(For further information regarding estimated tax, see page 4 of the 511 Packet.)... 35 .00
Schedule 511-H provides you with the opportunity to make a financial gift from your refund to a variety of Oklahoma
organizations. Please place the line number of the organization from Schedule 511-H in the box below. If you give to
more than one organization, put a “99” in the box. Provide Schedule 511-H.............

36 Donations from your refund (total from Schedule 511-H)......................................... 36 .00

37 Total deductions from refund (add lines 35 and 36)..................................................................................................37 .00
38 Amount to be refunded to you (line 34 minus line 37)...............................................................................................38 338 .00

Direct Deposit Note: Is this refund going to or through an account that is located outside of the United States? Yes X No
Verify your account and routing numbers Deposit my refund in my:
are correct. If your direct deposit fails Routing
to process or you do not choose direct X checking account Number: 121000248
deposit, you will receive a debit card.
See the 511 Packet for direct deposit and Account
debit card information. savings account Number: 22115983942537373
PART FIVE: AMOUNT YOU OWE
39 If line 22 is more than line 33, subtract line 33 from line 22. This is your tax due.....................................................39 .00
40 a) Donation: Support the Oklahoma General Revenue Fund (original return only)...............................................40a .00
b) Donation: Public School Classroom Support Fund (original return only)........................................................ 40b .00
41 Underpayment of estimated tax interest (annualized installment method ............................................... ).....41 .00
(If you have an underpayment of estimated tax (line 41) & overpayment (line 34), see instructions.)
42 For delinquent payment add penalty of 5%.............................................. $_________________________________
plus interest of 1.25% per month.............................................................. $_________________________________ 42 .00
43 Total tax, donation, penalty and interest (add lines 39-42)........................................................................................43 .00
Under penalty of perjury, I declare the information contained in this document, and all Place an ‘X’ in this box if the Oklahoma Tax Commission
attachments and schedules, is true and correct to the best of my knowledge and belief. may discuss this return with your tax preparer....................

Taxpayer’s signature Date Spouse’s signature Date Paid Preparer’s signature Date

Taxpayer’s Spouse’s occupation Paid Preparer’s address and phone number

occupation
MECHANIC
Daytime Phone Daytime Phone
(optional) (optional)
(918)314-9643 (918)314-9643 Paid Preparer’s PTIN

Do not staple documentation to this form. To attach items, please use a paper clip.
Mailing Address for this form: P.O. Box 269045, Oklahoma City, OK 73126-9045
2019 Form 511
Resident Income Tax Return
2D Barcode Page
FAILURE TO SUBMIT THIS PAGE
WILL DELAY PROCESSING OF YOUR RETURN
State of Oklahoma
Claim for Credit/Refund of Sales Tax
2

538-S
Taxpayer’s Social If died in 2019 or 2020,
247-67-3585

FORM
Instructions on page 2.
Security Number: enter date of death:
Please read carefully as 0
Spouse’s Social If died in 2019 or 2020, an incomplete form may 1
Security Number: enter date of death: delay your refund. 9
Taxpayer’s first name, middle initial and last name

RANDALL PETTERSON PART 1: TAXPAYER INFORMATION

Spouse’s first name, middle initial and last name (if a joint return) Physical address in 2019 (if different than shown in mailing address section)

Mailing address (number and street, including apartment number, or rural route) PO BOX 701 KETCHUM, OK 74349
Place an ‘X’ if you or your spouse have a physical disability
221 PINEVIEW DR constituting a substantial handicap to employment (submit proof)

City, State and ZIP Place an ‘X’ if you or your spouse are 65 years of age or over
PELZER, SC 29669
Oklahoma resident for the entire year? X yes no

PART 2: DEPENDENT Note: Do not enter the taxpayer or spouse as a dependent. EXEMPTION INFORMATION
1. Dependents QUALIFIED EXEMPTIONS...
See Instructions 5.Yearly
(first name, middle initial, last name) If you have
additional dependents, please attach schedule. 2. Age 3. Social Security Number 4. Relationship Income A. Yourself.................... 1
B. Spouse.....................
C. Number of
dependents.............. 0
D. Total exemptions
claimed (add A-C).... 1
PART 3: GROSS INCOME: Enter taxable and nontaxable gross income and assistance received by ALL members of your household in the year 2019.

See “Total gross household income” definition on page 2 for examples of income. YEARLY INCOME
1 Enter total wages, salaries, fees, commissions, bonuses, and tips You may not enter negative amounts.
(including nontaxable income from your W-2s) .....................................................................1 13,593 .00
2 Enter total interest and dividend income received ..................................................................2 .00
3 Total of all dependents’ income (from Part 2, column 5).........................................................3 .00
4 Social Security payments (total including Medicare) ..............................................................4 .00
5 Railroad Retirement benefits ...................................................................................................5 .00
6 Other pensions, annuities and IRAs ........................................................................................6 .00
7 Alimony ...................................................................................................................................7 .00
8 Unemployment benefits ..........................................................................................................8 .00
9 Earned Income Credit (EIC) received in 2019..........................................................................9 .00
10 Nontaxable sources of income (specify) _____________________________________ ............ 10 .00
11 Enter gross (positive) income from rentals, royalties, partnerships, estates & trusts, and gains YOU MAY NOT ENTER NEGATIVE AMOUNTS
from the sale or exchange of property (taxable & nontaxable) (provide Federal return including schedules)..... 11 .00
12 Enter gross (positive) income from business and farm (provide Federal return including schedules) ........ 12 .00
13 Other income-including income of others living in your household (specify)____________________ 13 .00
14 Total gross household income (Add lines 1-13).................................................................. 14 13,593 .00
If line 14 is over income limits shown in steps 2 and 3 on back of this form, no credit is allowed.

PART 4: SALES TAX CREDIT COMPUTATION (For households with gross income below allowable limits, see steps 2 and 3 on back of form.)

15 Total qualified exemptions claimed in Box D above 1 x $40 (credit claimed)...... 15 40 .00
If you are filing a Form 511, carry the credit to
DIRECT DEPOSIT OPTION: For those NOT filing a Form 511. See page 2 for Refund Information. Form 511, line 27.
Is this refund going to or through an Deposit my refund in my: Routing
account that is located outside of Number:
the United States? checking account Account
Yes No savings account Number:
Under penalty of perjury, I declare the information contained in this document and any attachments is true and correct to the best of my knowledge and belief. If the Oklahoma Tax Commission may discuss this return
Taxpayer’s Signature and Date Spouse’s Signature and Date with your tax preparer, place an ‘X’ here:

Preparer’s Signature and Date

Occupation Occupation

MECHANIC