rte rnin Reeonseven 8) £1040 Gis"inaividua income Tax Return [20 19 | nano. 15864074 173 Use Ony—Do ot new sen i spe Fling Seatus [singe C1 wenicsing ony (J Maric ting spare FS) [Head otneusno HOH C] Guniting wid OW) Nota ceckoniy “Typ cnoaiaete HFS bo, rh hao Tancisa yeu sched the OH er GH box ever hid namo fe using pron 8 we sla but ot our epenert auras and mit Castro ‘Your social secu mbar FIRST M LAST SSN XX) XXXX Want etry spouse's fate and ia ial taste ‘Spouse's social sear nib (LEAVE BLANK) (LEAVE BLANK) Hone airs urbe ard ster, Fyoubivea O;box eas. Gay rr Aocmm | Presiden con Conpcin 1234 YOUR ADDRESS ST. or 134 “post Vorfrée auoeess essere oor ozitn oan a oe lam EP ak, Fm ladg ART as Sei es bl Fae aa eg eteeeieer CIty / TOWN, ST 12345 feserire [1 You [pe Ferspn ouny name Fog pewneslaaiaroty Fos 6 | re an ou dept, (if providing one) seceatetorsend tee >] Standard Someone con claim: (] You ssacenendent (] Yur souso asa sopenet Deduction] spouse temses ona spar tun or you ere a chat ttus aon AaerBinness You] Wareborn bets mary 2.1955 CT tebind Spouse: [1] Wat bom bore January2, 1855] te bie Dependents (ee nsucions) eo (0 iar cos race (Festa Late nite" Gear oe eyes o o o o (ZEAVE BLANK) o o o o 1 ages saes ips, ote Aah Fos 2 ae + | -0- 2a Tavererptinteet zm | __-0- Toate teen Ser sieges [a man 3a Quatieg vende zx | =0= » Ouray woes ntzen seh Biequies [3 Seteaonte | 4a monotone | =0= Tape eourt 2 saidectired| ¢ porsone an ermutn we | =0= atoaemout 2 2... [as Moses vest 2 Sootseeuty borers = |__-0- Taxa anourt 2 stredtog | a captal gan or ees tach SetedulD reaured naira, check he +m [se [ -0- EEE) ro omereomerom scree 39 SEE ATTACHED 1096 ¢ 1099-010 za |_AMOUNT™ tet 1 Ad ines 126 3b A 45, 8a 7a Ts you ttl ncoME ‘AMOUNT? FESS | 00 sectmetstoincare tm sede, toe 22 =0= hpecteina [_bSubtact ine a omline 7. Theis your ested gross income =0= Stora deducton or temized deduction rom Schade usted tines income eter. Ach Form 955 or Form 595-8 Aisne ard 10 Taxable income, Suotctin 1rom ins 27 6rB6, ena-0- =0= For Daclosire, Privacy Ac, and Paperwork Reduction Act Notice, ce seperate insructions ae ies Fan 1080 255) “THE AMOUNT SHOULD BE THE TOTAL FOR ALL BILLS BEING REPORTED FOR DISCHARGE. DEFINITIONS FOR FILING STATUSES SINGLE - SINGLE HEAD OF HOUSEHOLD = SINGLE BUT WITH DEPENDENTS (KIDS) QUALIFYING WIDOWER - WIDOW (2 YEARS OR LESS AFTER DEATH OF SPOUSE) GENERAL DELIVERY, 1234 POST OFFICE ADDRESSForm 1040 (2012 Page 2 2a Tax|see inst } Check tany trom Forms: 4 [_] e814 2 [_] 4972 3 [) s2a| (BLANK) LEAVE ts ebiaeatnnrie > [am |_ BEANE 80 Chid tex erect or eect for other dependents sa0| (BLANK) tse i nha =| 11 Sim tent nao rm 1S chrono Swab ‘ te Atm tn os 17 Fadera income tax wahheld from Fors W-2 anci 1099 SEB ATTACHED 1036 6 1999-019 | 47 | AMOUNT* (crmanmon LAS ter parents an refundable cect: Geis os emdeorecene sso|_(BLANK) ‘b Additional child tax erect. Attach Schedule B612 teb| (BLANK) ‘© American opportunity ered trom Form 8863, line 8 - sec] (BLANK) Scheduled, tne 14 sea (BLANK) (© Add lines 18a through 18d, These are your total other payments and refundable credits > | 100 -0- tetas ira to oma a > [Fs aeons Refund tine 19s mote rani 16, abate 1 ose 1. TH isthe mount you eveBai ~. [ao | =0- Amount of ine 20 you wont refunded te you. i Form 8888 9 attached, checkhewe ss. LD | aie = B= Bree ai? outha number OCR [DCL DECC >eTvpe: [Cloneomna C] Savnoe Semmens yg accouncrumber |_| (yuk [rdal [banking |infay 22 Amount of Ine 20 you want applied to your 2020 estimated tax > | ee mi EiRourk snot yon rc io Per Gantt re > [| —o- YouOwe 4 tana py nmin > les] -0- Third Party 09,00 wantto allow anotner person (oer than yourpad preparer to cscves this rum wth the RS? See natuctions. [_] Yes. Complele below. Designee no fae oo repel Bim See an ieee CTT Sign Sees ees eee eee Here “Your signature ae sl erecta deed {the IFS sent you an Icentity Bbaxrs|"""Rithorizeg | feecer tarts etna BY: Fisur Mat GaTE | Representative [rhe ee TR REN RTE eet ene Praneno (XXX) _XXX-XXXX Email accrens email@domain.com tate Seana Soe Sk Tore Paid Cara party Desisnee Prepater aay maa Clearer 30 Only Ee Tae Seromer sco nec Ra ao *THE AMOUNT SHOULD BE THE TOTAL FOR ALL BILLS BEING REPORTED FOR DISCHARGE.