Department of the Treasury - Internal Revenue Service

Form 1040 U.S. Individual Income Tax Return 2009 (99) IRS Use Only - Do not write or staple in this space.

For the year Jan. 1-Dec. 31, 2009, or other tax year beginning , 2009, ending , 20 OMB No. 1545-0074
Label L
Your first name and initial Last name Your social security number
(See A
B
steven e illingworth 514-82-4751
instructions)
E If a joint return, spouse's first name and initial Last name Spouse's social security number
L
Use the IRS
label. H Home address (number and street). If you have a P.O. box, see instructions. Apt. no. You must enter
Otherwise, E
R 720 nth 7th your SSN(s) above.
please print
E
or type. City, town or post office, state, and ZIP code. If you have a foreign address, see instructions. Checking a box below will not
salina, KS 67401 change your tax or refund.
Presidential
Election Campaign Check here if you, or your spouse if filing jointly, want $3 to go to this fund (see instructions) You Spouse
1 X Single 4 Head of household (with qualifying person). (See instructions) If
Filing Status 2 Married filing jointly (even if only one had income) the qualifying person is a child but not your dependent, enter
3 Married filing separately. Enter spouse's SSN above this child's name here.
Check only
one box. and full name here. 5 Qualifying widow(er) with dependent child (See instructions)
6a X Yourself. If someone can claim you as a dependent, do not check box 6a . . . . . . . .
Exemptions b Spouse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . }
(4) X if qual-
Boxes checked
on 6a and 6b 1
c Dependents: (3) Dependent's No. of children
(2) Dependent's relationship to ifying child on 6c who:
for child
(1) First name Last name social security number you tax credit lived with you 0
did not live with
you due to divorce
If more than four
dependents, see
or separation
(see instructions)
0
instructions and
Dependents on 6c
check here not entered above 0
Add numbers on
d Total number of exemptions claimed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . lines above 1
7 Wages, salaries, tips, etc. Attach Form(s) W-2 . . . . . . . . . . . . . . . . . . . . . . . 7 18,221.
Income 8a Taxable interest. Attach Schedule B if required . . . . . . . . . . . . . . . . . . . . . . 8a
Attach Form(s) b Tax-exempt interest. Do not include on line 8a . . . . . . . 8b
W-2 here. Also 9a Ordinary dividends. Attach Schedule B if required . . . . . . . . . . . . . . . . . . . . . . 9a
attach Forms b Qualified dividends (see instructions) . . . . . . . . . . . . 9b
W-2G and
1099-R if tax 10 Taxable refunds, credits, or offsets of state and local income taxes (see instructions) . . . . . 10
was withheld. 11 Alimony received . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

If you did not 12 Business income or (loss). Attach Schedule C or C-EZ . . . . . . . . . . . . . . . . . . . 12

get a W-2, 13 Capital gain or (loss). Attach Schedule D if required. If not required, check here . . . 13
see instructions. 14 Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . . . . . . . . . . . . . . 14
15a IRA distributions . . . . . 15a b Taxable amount (see instructions) 15b
16a Pensions and annuities . . 16a b Taxable amount (see instructions) 16b
Enclose, but do 17 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E . . . 17
not attach, any 18 Farm income or (loss). Attach Schedule F . . . . . . . . . . . . . . . . . . . . . . . . . 18
payment. Also,
19 Unemployment compensation in excess of $2,400 per recipient (see instructions) . . . . . . . 19
please use
Form 1040-V. 20a Social security benefits . . 20a b Taxable amount (see instructions) 20b
21 Other income. List type and amount (see instructions) See Attached 21 600.
22 Add the amounts in the far right column for lines 7 through 21. This is your total income 22 18,821.
23 Educator expenses (see instructions) . . . . . . . . . . . . 23
24 Certain business expenses of reservists, performing artists, and
fee-basis government officials. Attach Form 2106 or 2106-EZ . 24
Adjusted 25 Health savings account deduction. Attach Form 8889 . . . . . 25
Gross 26 Moving expenses. Attach Form 3903 . . . . . . . . . . . . 26
Income 27 One-half of self-employment tax. Attach Schedule SE . . . . . 27
28 Self-employed SEP, SIMPLE, and qualified plans . . . . . . . 28
29 Self-employed health insurance deduction (see instructions) . . 29
30 Penalty on early withdrawal of savings . . . . . . . . . . . . 30
31a Alimony paid b Recipient's SSN 31a
32 IRA deduction (see instructions) . . . . . . . . . . . . . . . 32
33 Student loan interest deduction (see instructions) . . . . . . . 33
34 Tuition and fees deduction. Attach Form 8917. . . . . . . . . 34
35 Domestic production activities deduction. Attach Form 8903 . . 35
36 Add lines 23 through 31a and 32 through 35 . . . . . . . . . . . . . . . . . . . . . . . . 36 0.
37 Subtract line 36 from line 22. This is your adjusted gross income . . . . . . . . . . . 37 18,821.
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see instructions. Form 1040 (2009)
UYA
Form 1040 (2009) steven e illingworth 514-82-4751 Page 2
Tax 38 Amount from line 37 (adjusted gross income) . . . . . . . . . . . . . . . . . . . . . . . . . . 38 18,821.
and
Credits
39a Check
if: { You were born before January 2, 1945,
Spouse was born before January 2, 1945,
Blind.
Blind.
Total boxes
checked 39a 0 }
Standard b If your spouse itemizes on a separate return or you were a dual-status alien, see instr. and check here
39b
Deduction
for -
40a Itemized deductions (from Schedule A) or your standard deduction (see left margin) . . . . . . 40a 5,700.
b If you are increasing your standard deduction by certain real estate taxes, new motor
People who
check any vehicle taxes, or a net disaster loss, attach Schedule L and check here (see instr.) 40b
box on line 41 Subtract line 40a from line 38 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 13,121.
39a or 39b, or
40b or who 42 Exemptions. If line 38 is $125,100 or less and you did not provide housing to a Midwestern displaced
can be
claimed as a
individual, multiply $3,650 by the number on line 6d. Otherwise, see instructions . . . . . . . . . . . . . . . 42 3,650.
dependent, 43 Taxable income. Subtract line 42 from line 41. If line 42 is more than line 41, enter -0- . . . . . . 43 9,471.
See instr.
44 Tax (see instructions). Check if any tax is from: a Form(s) 8814 b Form 4972 . . . . . . . . . . 44 1,004.
All others: 45 Alternative minimum tax (see instructions). Attach Form 6251 . . . . . . . . . . . . . . . . . 45
Single or
Married filing 46 Add lines 44 and 45 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 1,004.
separately, 47 Foreign tax credit. Attach Form 1116 if required . . . . . . . . . . 47
$5,700
48 Credit for child and dependent care expenses. Attach Form 2441 . . 48
Married filing
jointly or 49 Education credits from Form 8863, line 29 . . . . . . . . . . . . . 49
Qualifying Retirement savings contributions credit. Attach Form 8880 . . . . .
widow(er),
50 50
$11,400 51 Child tax credit (see instructions). . . . 51
Head of 52 Credits from Form: a 8396 b 8839 c 5695 52
household,
53 Other credits from Form: a 3800 b 8801 c 53
$8,350
54 Add lines 47 through 53. These are your total credits . . . . . . . . . . . . . . . . . . . . . 54 0.
55 Subtract line 54 from line 46. If line 54 is more than line 46, enter -0- . . . . . . . . . . . . . 55 1,004.
56 Self-employment tax. Attach Schedule SE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
57 Unreported social security and Medicare tax from Form: a 8919 . . . . . .
4137 b 57
Other 58 Additional tax on IRAs, other qualified retirement plans, etc. Attach Form 5329 if required . . . . . 58
Taxes 59 Additional taxes: a AEIC payments b Household employment taxes. Attach Schedule H 59
60 Add lines 55 through 59. This is your total tax . . . . . . . . . . . . . . . . . . . . . . . 60 1,004.
Payments 61 Federal income tax withheld from Forms W-2 and 1099 . . . . . . 61 1,586.
62 2009 estimated tax payments and amount applied from 2008 return . . . . . 62
63 Making work pay and government retiree credits. Attach Schedule M . . . . . 63 400.
If you have a 64a Earned income credit (EIC) . . . . . . . . . . . . . NO . . . . . . 64a
qualifying
child, attach b Nontaxable combat pay election . . . . 64b
Schedule EIC. 65 Additional child tax credit. Attach Form 8812 . . . . . . . . . . . . 65
66 Refundable education credit from Form 8863, line 16 . . . . . . . 66
67 First-time homebuyer credit. Attach Form 5405 . . . . . . . . . . 67
68 Amount paid with request for extension to file (see instructions) .. . 68
69 Excess social security and tier 1 RRTA tax withheld (see instr.) . . . 69
70 Credits from Form: a 2439 b 4136 c 8801 d 8885 70
71 Add lines 61, 62, 63, 64a, and 65 through 70. These are your total payments . . . . . . . . 71 1,986.
Refund 72 If line 71 is more than line 60, subtract line 60 from line 71. This is the amount you overpaid . . . . 72 982.
Direct deposit?
See instructions
73a Amount of line 72 you want refunded to you. If Form 8888 is attached, check here . . . . 73a 982.
and fill in 73b, b Routing number 101104928 c Type: X Checking Savings
73c, and 73d. d Account number 100710847
or Form 8888.
74 Amount of line 72 you want applied to your 2010 estimated tax 74
Amount 75 Amount you owe. Subtract line 71 from line 60. For details on how to pay, see instructions 75 0.
You Owe 76 Estimated tax penalty (see instructions) . . . . . . . . . . . . . 76
Do you want to allow another person to discuss this return with the IRS (see instructions)? Yes. Complete the following. No
Third Party
Designee's Phone Personal identification
Designee 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
Joint return? Your signature Date Your occupation Daytime phone number
See instructions
Keep a copy
retail 785-787-9742
Spouse's signature. If a joint return, both must sign. Date Spouse's occupation
for your
records.
Preparer's Date Check if Preparer's SSN or PTIN
Paid signature self-employed
Preparer's EIN
Firm's name (or
Use Only yours if self-employed), Phone no.
address, and ZIP code

UYA Form 1040 (2009)

 Additional Taxes on Qualified Plans OMB No. 1545-0074
Form 5329 (Including IRAs) and Other Tax-Favored Accounts
Department of the Treasury Attach to Form 1040 or Form 1040NR.
2009
Attachment
Internal Revenue Service (99) See separate instructions. Sequence No. 29
Name of individual subject to additional tax. If married filing jointly, see instructions. Your social security number

steven e illingworth 514-82-4751

Fill in Your Address Only Home address (number and street), or P.O. box if mail is not delivered to your home Apt. no.
If You Are Filing This
Form by Itself and Not City, town or post office, state, and ZIP code If this is an amended
With Your Tax Return return, check here
If you only owe the additional 10% tax on early distributions, you may be able to report this tax directly on Form 1040, line 58, or
Form 1040NR, line 54, without filing Form 5329. See the instructions for Form 1040, line 58, or for Form 1040NR, line 54.
Part I Additional Tax on Early Distributions
Complete this part if you took a taxable distribution (other than a qualified disaster recovery assistance distribution), before you reached
age 59 ½, from a qualified retirement plan (including an IRA) or modified endowment contract (unless you are reporting this tax directly on
Form 1040 or Form 1040NR—see above). You may also have to complete this part to indicate that you qualify for an exception to the
additional tax on early distributions or for certain Roth IRA distributions (see instructions).
1 Early distributions included in income. For Roth IRA distributions, see instructions . . . . . . . . . 1
2 Early distributions included on line 1 that are not subject to the additional tax (see instructions).
Enter the appropriate exception number from the instructions: . . . . . . . . . . . . . . 2
3 Amount subject to additional tax. Subtract line 2 from line 1 . . . . . . . . . . . . . . . . . . . . . 3
4 Additional tax. Enter 10% (.10) of line 3. Include this amount on Form 1040, line 58, or Form
1040NR, line 54 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 0.
Caution: If any part of the amount on line 3 was a distribution from a SIMPLE IRA, you may have
to include 25% of that amount on line 4 instead of 10% (see instructions).
Part II Additional Tax on Certain Distributions From Education Accounts
Complete this part if you included an amount in income, on Form 1040 or Form 1040NR, line 21, from a Coverdell
education savings account (ESA) or a qualified tuition program (QTP).
5 Distributions included in income from Coverdell ESAs and QTPs . . . . . . . . . . . . . . . . . . 5
6 Distributions included on line 5 that are not subject to the additional tax (see instructions) . . . . . 6
7 Amount subject to additional tax. Subtract line 6 from line 5 . . . . . . . . . . . . . . . . . . . . . 7
8 Additional tax. Enter 10% (.10) of line 7. Include this amount on Form 1040, line 58, or Form 1040NR, line 54 8 0.
Part III Additional Tax on Excess Contributions to Traditional IRAs
Complete this part if you contributed more to your traditional IRAs for 2009 than is allowable or you had an amount
on line 17 of your 2008 Form 5329.
9 Enter your excess contributions from line 16 of your 2008 Form 5329 (see instructions). If zero,
go to line 15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
10 If your traditional IRA contributions for 2009 are less than your
maximum allowable contribution, see instructions. Otherwise, enter -0- 10 0.
11 2009 traditional IRA distributions included in income (see instructions) 11
12 2009 distributions of prior year excess contributions (see instructions) 12
13 Add lines 10, 11, and 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
14 Prior year excess contributions. Subtract line 13 from line 9. If zero or less, enter -0- . . . . . . . 14 0.
15 Excess contributions for 2009 (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
16 Total excess contributions. Add lines 14 and 15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
17 Additional tax. Enter 6% (.06) of the smaller of line 16 or the value of your traditional IRAs on December 31, 2009
(including 2009 contributions made in 2010). Include this amount on Form 1040, line 58, or Form 1040NR, line 54 . 17 0.
Part IV Additional Tax on Excess Contributions to Roth IRAs
Complete this part if you contributed more to your Roth IRAs for 2009 than is allowable or you had an amount on line
25 of your 2008 Form 5329.
18 Enter your excess contributions from line 24 of your 2008 Form 5329 (see instructions). If zero, go to line 23 . . . 18
19 If your Roth IRA contributions for 2009 are less than your maximum
allowable contribution, see instructions. Otherwise, enter -0- . . . . . 19 0.
20 2009 distributions from your Roth IRAs (see instructions) . . . . . . . 20
21 Add lines 19 and 20 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
22 Prior year excess contributions. Subtract line 21 from line 18. If zero or less, enter -0- . . . . . . 22 0.
23 Excess contributions for 2009 (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
24 Total excess contributions. Add lines 22 and 23 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
25 Additional tax. Enter 6% (.06) of the smaller of line 24 or the value of your Roth IRAs on December 31, 2009
(including 2009 contributions made in 2010). Include this amount on Form 1040, line 58, or Form 1040NR, line 54 . 25 0.
For Privacy Act and Paperwork Reduction Act Notice, see the instructions. Form 5329 (2009)
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Form 5329 (2009) steven e illingworth 514-82-4751 Page 2
Part V Additional Tax on Excess Contributions to Coverdell ESAs
Complete this part if the contributions to your Coverdell ESAs for 2009 were more than is allowable or you had an
amount on line 33 of your 2008 Form 5329.
26 Enter the excess contributions from line 32 of your 2008 Form 5329 (see instructions). If zero, go to line 31 . . . . 26
27 If the contributions to your Coverdell ESAs for 2009 were less than the
maximum allowable contribution, see instructions. Otherwise, enter -0- 27 0.
28 2009 distributions from your Coverdell ESAs (see instructions) . . . . 28
29 Add lines 27 and 28 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
30 Prior year excess contributions. Subtract line 29 from line 26. If zero or less, enter -0- . . . . . . 30 0.
31 Excess contributions for 2009 (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
32 Total excess contributions. Add lines 30 and 31 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
33 Additional tax. Enter 6% (.06) of the smaller of line 32 or the value of your Coverdell ESAs on
December 31, 2009 (including 2009 contributions made in 2010). Include this amount on Form
1040, line 58, or Form 1040NR, line 54 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 0.
Part VI Additional Tax on Excess Contributions to Archer MSAs
Complete this part if you or your employer contributed more to your Archer MSAs for 2009 than is allowable or you
had an amount on line 41 of your 2008 Form 5329.
34 Enter the excess contributions from line 40 of your 2008 Form 5329 (see instructions). If zero, go to line 39 . . . . 34
35 If the contributions to your Archer MSAs for 2009 are less than the
maximum allowable contribution, see instructions. Otherwise, enter -0- 35 0.
36 2009 distributions from your Archer MSAs from Form 8853, line 8 . . . 36
37 Add lines 35 and 36 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
38 Prior year excess contributions. Subtract line 37 from line 34. If zero or less, enter -0- . . . . . . 38 0.
39 Excess contributions for 2009 (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
40 Total excess contributions. Add lines 38 and 39 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
41 Additional tax. Enter 6% (.06) of the smaller of line 40 or the value of your Archer MSAs on
December 31, 2009 (including 2009 contributions made in 2010). Include this amount on Form
1040, line 58, or Form 1040NR, line 54 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 0.
Part VII Additional Tax on Excess Contributions to Health Savings Accounts (HSAs)
Complete this part if you, someone on your behalf, or your employer contributed more to your HSAs for 2009 than is
allowable or you had an amount on line 49 of your 2008 Form 5329.
42 Enter the excess contributions from line 48 of your 2008 Form 5329. If zero, go to line 47 . . . . . 42
43 If the contributions to your HSAs for 2009 are less than the maximum
allowable contribution, see instructions. Otherwise, enter -0- . . . . . . 43 0.
44 2009 distributions from your HSAs from Form 8889, line 16 . . . . . . 44
45 Add lines 43 and 44 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
46 Prior year excess contributions. Subtract line 45 from line 42. If zero or less, enter -0- . . . . . . 46 0.
47 Excess contributions for 2009 (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 600.
48 Total excess contributions. Add lines 46 and 47 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 600.
49 Additional Tax. Enter 6% (.06) of the smaller of line 48 or the value of your HSAs on December 31, 2009
(including 2009 contributions made in 2010). Include this amount on Form 1040, line 58, or Form 1040NR, line 54 49 0.
Part VIII Additional Tax on Excess Accumulation in Qualified Retirement Plans (Including IRAs)
Complete this part if you did not receive the minimum required distribution from your qualified retirement plan.
50 Minimum required distribution, if any, for 2009 (including the minimum required distribution for 2008 that is
permitted to be made in 2009 for an individual with a required beginning date of April 1, 2009) (see instructions) . 50
51 Amount actually distributed to you in 2009 (plus any distributions actually made in 2008 that were permitted to
be made in 2009 for an individual with a required beginning date of April 1, 2009) . . . . . . . . . . . . . . . . 51
52 Subtract line 51 from line 50. If zero or less, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . 52 0.
53 Additional tax. Enter 50% (.50) of line 52. Include this amount on Form 1040, line 58, or Form 1040NR, line 54 . 53 0.
Under penalties of perjury, I declare that I have examined this form, including accompanying attachments, and to the best of my
Sign Here Only If You knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of
which preparer has any knowledge.
Are Filing This Form
by Itself and Not With
Your Tax Return Your signature Date
Preparer's Date Check if self- Preparer's SSN or PTIN
Paid signature employed
Preparer's
Use Only Firm's name (or yours
EIN
if self-employed),
address, and ZIP code
Phone no.
UYA Form 5329 (2009)
 OMB No. 1545-0074
Form 8889 Health Savings Accounts (HSAs)
Department of the Treasury
2009
Attachment
Internal Revenue Service Attach to Form 1040 or Form 1040NR. See separate instructions. Sequence No. 53
Name(s) shown on Form 1040 or Form 1040NR Social security number of HSA
beneficiary. If both spouses have
steven e illingworth HSAs, see the instructions 514-82-4751
Before you begin: Complete Form 8853, Archer MSAs and Long-Term Care Insurance Contracts, if required.
Part I HSA Contributions and Deduction. See the instructions before completing this part. If you are filing
jointly and both you and your spouse each have separate HSAs, complete a separate Part I for each
spouse.
1 Check the box to indicate your coverage under a high-deductible health plan (HDHP) during
2009 (see the instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Self-only Family
2 HSA contributions you made for 2009 (or those made on your behalf), including those made
from January 1, 2010, through April 15, 2010, that were for 2009. Do not include employer
contributions, contributions through a cafeteria plan, or rollovers (see the instructions). . . . . . . 2
3 If you were under age 55 at the end of 2009, and on the first day of every month during 2009, you
were, or were considered, an eligible individual with the same coverage, enter $3,000 ($5,950 for
family coverage). All others, see instructions for the amount to enter . . . . . . . . . . . . . . . . 3
4 Enter the amount you and your employer contributed to your Archer MSAs for 2009 from Form
8853, lines 3 and 4. If you or your spouse had family coverage under an HDHP at any time
during 2009, also include any amount contributed to your spouse’s Archer MSAs . . . . . . . . . 4
5 Subtract line 4 from line 3. If zero or less, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . 5
6 Enter the amount from line 5. But if you and your spouse each have separate HSAs and had
family coverage under an HDHP at any time during 2009, see the instructions for the
amount to enter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
7 If you were age 55 or older at the end of 2009, married, and you or your spouse had family
coverage under an HDHP at any time during 2009, enter your additional contribution amount
(see the instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
8 Add lines 6 and 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
9 Employer contributions made to your HSAs for 2009 . . . . . . 9 600.
10 Qualified HSA funding distributions . . . . . . . . . . . . . . . . 10
11 Add lines 9 and 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 600.
12 Subtract line 11 from line 8. If zero or less, enter -0-. . . . . . . . . . . . . . . . . . . . . . . . . . 12
13 HSA deduction. Enter the smaller of line 2 or line 12 here and on Form 1040, line 25, or Form
1040NR, line 25 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Caution: If line 2 is more than line 13, you may have to pay an additional tax (see instructions)
HSA Distributions. If you are filing jointly and both you and your spouse each have separate HSAs,
Part II
complete a separate Part II for each spouse.
14a Total distributions you received in 2009 from all HSAs (see the instructions) . . . . . . . . . . . . 14a
b Distributions included on line 14a that you rolled over to another HSA. Also include any excess
contributions (and the earnings on those excess contributions) included on line 14a that were
withdrawn by the due date of your return (see the instructions) . . . . . . . . . . . . . . . . . . . . 14b
c Subtract line 14b from line 14a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14c
15 Unreimbursed qualified medical expenses (see the instructions) . . . . . . . . . . . . . . . . . . . 15
16 Taxable HSA distributions. Subtract line 15 from line 14c. If zero or less, enter -0-. Also,
include this amount in the total on Form 1040, line 21, or Form 1040NR, line 21. On the dotted
line next to line 21, enter “HSA” and the amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
17a If any of the distributions included on line 16 meet any of the Exceptions to the Additional
10% Tax (see the instructions), check here . . . . . . . . . . . . . . . . . . . . . . . . . .
b Additional 10% tax (see the instructions). Enter 10% (.10) of the distributions included
on line 16 that are subject to the additional 10% tax. Also include this amount in the total on
Form 1040, line 60, or Form 1040NR, line 57. On the dotted line next to Form 1040, line 60, or
Form 1040NR, line 57, enter “HSA” and the amount. . . . . . . . . . . . . . . . . . . . . . . . . . 17b
For Paperwork Reduction Act Notice, see instructions. Form 8889 (2009)
UYA
SCHEDULE M Making Work Pay and Government OMB No. 1545-0074
(Form 1040A or 1040)
Department of the Treasury
Retiree Credits 2009
Attachment
Internal Revenue Service (99) Attach to Form 1040A, 1040, or 1040NR. See separate instructions. Sequence No. 166
Name(s) shown on return Your social security number
steven e illingworth 514-82-4751
1a Important: See the instructions if you can be claimed as someone else’s dependent or are filing Form 1040NR.
Check the “No” box below and see the instructions if (a) you have a net loss from a business, (b) you received
a taxable scholarship or fellowship grant not reported on a Form W-2, (c) your wages include pay for work
performed while an inmate in a penal institution, (d) you received a pension or annuity from a nonqualified
deferred compensation plan or a nongovernmental section 457 plan, or (e) you are filing Form 2555 or 2555-EZ.
Do you (and your spouse if filing jointly) have 2009 wages of more than $6,451 ($12,903 if married filing jointly)?
X Yes. Skip lines 1a through 3. Enter $400 ($800 if married filing jointly) on line 4 and go to line 5.
No. Enter your earned income (see instructions) . . . . . . . . . . . . 1a

b Nontaxable combat pay included on

line 1a (see instructions) . . . . . . . . . . . . . 1b
2 Multiply line 1a by 6.2% (.062) . . . . . . . . . . . . . . . . . . . . . . . . 2

3 Enter $400 ($800 if married filing jointly) . . . . . . . . . . . . . . . . . . . 3

4 Enter the smaller of line 2 or line 3 (unless you checked "Yes" on line 1a) . . . . . . . . . . . . . . 4 400.
5 Enter the amount from Form 1040, line 38*, or Form 1040A, line 22 . . . . 5 18,821.
6 Enter $75,000 ($150,000 if married filing jointly) . . . . . . . . . . . . . . . 6 75,000.
7 Is the amount on line 5 more than the amount on line 6?
X No. Skip line 8. Enter the amount from line 4 on line 9 below.
Yes. Subtract line 6 from line 5 . . . . . . . . . . . . . . . . . . . . . . 7

8 Multiply line 7 by 2% (.02) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

9 Subtract line 8 from line 4. If zero or less, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 400.

10 Did you (or your spouse, if filing jointly) receive an economic recovery payment in 2009? You
may have received this payment if you received social security benefits, supplemental security
income, railroad retirement benefits, or veterans disability compensation or pension benefits (see
instructions).
X No. Enter -0- on line 10 and go to line 11.
Yes. Enter the total of the payments received by you (and your spouse, if filing
jointly). Do not enter more than $250 ($500 if married filing jointly) }
. . . . . 10

11 Did you (or your spouse, if filing jointly) receive a pension or annuity in 2009 for services performed
as an employee of the U.S. Government or any U.S. state or local government from work not
covered by social security? Do not include any pension or annuity reported on Form W-2.
X No. Enter -0- on line 11 and go to line 12.
Yes. If you checked "No" on line 10, enter $250 ($500 if married filing jointly

12
13
and the answer on line 11 is "Yes" for both spouses)
If you checked "Yes" on line 10, enter -0- (exception: enter $250 if filing
jointly and the spouse who received the pension or annuity did not receive
an economic recovery payment described on line 10)
}
. . . . .

Add lines 10 and 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Subtract line 12 from line 9. If zero or less, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . .
11

12
13 400.
14 Making work pay and government retiree credits. Add lines 11 and 13. Enter the result here
and on Form 1040, line 63; Form 1040A, line 40; or Form 1040NR, line 60 . . . . . . . . . . . . . . . 14 400.
*If you are filing Form 2555, 2555-EZ, or 4563 or you are excluding income from Puerto Rico, see instructions.
For Paperwork Reduction Act Notice, see Form 1040A, 1040, or Schedule M (Form 1040A or 1040) 2009
1040NR instructions.
UYA
Nam e(s) s hown on Form Your social security num ber
1040
steven e illingworth 514-82-4751
Other Income - Supporting Details for Form 1040, Line 21
Enter sources of other income below: steven Not Applicable
1. 0. 0.
2. 0. 0.
3. Gambling Winnings reported on Form W-2G ......... 0. 0.
Other winnings where a Form W-2G not received ..... 0. 0.
4. Jury Pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0. 0.
5. Net Operating Loss carry forward from 2008 ......... 0. 0.
6. Foreign earned income exclusion from Form 2555. .... 0. 0.
7. Other Income from Schedule K-1 ................. 0. 0.
8. Income from personal property rental .............. 0. 0.
9. Child's income amount from Form 8814, line 12 ...... 0. 0.
10. MSA Distributions, Form 8853 ................... 0. 0.
11. Medicare Advantage MSA Distributions, Form 8853 ... 0. 0.
12. Long-term Care Distribution, Form 8853 ............ 0. 0.
13. Form 1099-MISC, Boxes 3 and 8 ................. 0. 0.
14. Alaska Permanent Fund dividends ................ 0. 0.
15. Coverdell ESA or Qualified Tuition Program ......... 0. 0.
16. Cancellation of a nonbusiness debt, Form 1099-C .... 0. 0.
17. Cancellation of a business debt, Partnership Sch K-1 . 0. 0.
18. HSA Distributions, Form 8889 . . . . . . . . . . . . . . . . . . . . 600. 0.
19. Alternative trade adjustment assistance payments .... 0. 0.
20. Recapture of prior year tuition and fees deduction ..... 0. 0.
21. Recapture of charitable contribution deduction of a
fractional interest in tangible personal property ....... 0. 0.
22. Recapture of charitable contribution deduction if no
exempt use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0. 0.
23. From 8891: 0. 0.
24. Income from Foreign Corporation, Form 5471 ........ 0. 0.
25. Hobby income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0. 0.
26. Income or loss from Section 1291, Form 8621 ....... 0. 0.
Total Other Income . . . . . . . . . . . . . . . . . . . . . . . . . . 600. 0.