1040 U.S.

Individual Income Tax Return 2021 (99)

Form Department of the Treasury—Internal Revenue Service

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 your spouse. If you checked the HOH or QW box, enter the child’s name if the qualifying
one box.
person is a child but not your dependent a
Your first name and middle initial Last name Your social security number
Stephen T Holbrook 212-33-5988
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
755 2nd Ave SW Check here if you, or your
spouse if filing jointly, want $3
City, town, or post office. If you have a foreign address, also complete spaces below. State ZIP code
to go to this fund. Checking a
Hickory NC 286022730 box below will not change
Foreign country name Foreign province/state/county Foreign postal code your tax or refund.
You Spouse

At any time during 2021, did you receive, sell, exchange, or otherwise dispose of any financial interest in any virtual currency? Yes No

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, 1957 Are blind Spouse: Was born before January 2, 1957 Is blind
Dependents (see instructions): (2) Social security (3) Relationship (4)  if qualifies for (see instructions):
(1) First name Last name number to you Child tax credit Credit for other dependents
If more
than four
dependents,
see instructions
and check
here a
1 Wages, salaries, tips, etc. Attach Form(s) W-2 . . . . . . . . . . . . . . . . 1 13,804.
Attach 2a Tax-exempt interest . . . 2a 2b
b Taxable interest . . . . .
Sch. B if
3a Qualified dividends . . . 3a b Ordinary dividends . . . . . 3b
required.
4a IRA distributions . . . . 4a b Taxable amount . . . . . . 4b
5a Pensions and annuities . . 5a b Taxable amount . . . . . . 5b
Standard 6a Social security benefits . . 6a b Taxable amount . . . . . . 6b
Deduction for— a
7 Capital gain or (loss). Attach Schedule D if required. If not required, check here . . . . 7
• Single or
Married filing 8 Other income from Schedule 1, line 10 . . . . . . . . . . . . . . . . . . 8
separately,
$12,550 9 Add lines 1, 2b, 3b, 4b, 5b, 6b, 7, and 8. This is your total income . . . . . . . . . a 9 13,804.
• Married filing 10 Adjustments to income from Schedule 1, line 26 . . . . . . . . . . . . . . . 10
jointly or
11 Subtract line 10 from line 9. This is your adjusted gross income . . . . . . . . . a 11 13,804.
Qualifying
widow(er),
$25,100
12a Standard deduction or itemized deductions (from Schedule A) . . 12a 12,550.
• Head of b Charitable contributions if you take the standard deduction (see instructions) 12b 300.
household,
$18,800 c Add lines 12a and 12b . . . . . . . . . . . . . . . . . . . . . . . 12c 12,850.
• If you checked 13 Qualified business income deduction from Form 8995 or Form 8995-A . . . . . . . . . 13
any box under
Standard 14 Add lines 12c and 13 . . . . . . . . . . . . . . . . . . . . . . . 14 12,850.
Deduction,
see instructions.
15 Taxable income. Subtract line 14 from line 11. If zero or less, enter -0- . . . . . . . . . 15 954.

For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Form 1040 (2021)
Form 1040 (2021) Page 2
16 Tax (see instructions). Check if any from Form(s): 1 8814 2 4972 3 . . 16 96.
17 Amount from Schedule 2, line 3 . . . . . . . . . . . . . . . . . . . . 17
18 Add lines 16 and 17 . . . . . . . . . . . . . . . . . . . . . . . . 18 96.
19 Nonrefundable child tax credit or credit for other dependents from Schedule 8812 . . . . . 19
20 Amount from Schedule 3, line 8 . . . . . . . . . . . . . . . . . . . . 20
21 Add lines 19 and 20 . . . . . . . . . . . . . . . . . . . . . . . . 21
22 Subtract line 21 from line 18. If zero or less, enter -0- . . . . . . . . . . . . . . 22 96.
23 Other taxes, including self-employment tax, from Schedule 2, line 21 . . . . . . . . . 23 0.
24 Add lines 22 and 23. This is your total tax . . . . . . . . . . . . . . . . a 24 96.
25 Federal income tax withheld from:
a Form(s) W-2 . . . . . . . . . . . . . . . . . . 25a 980.
b Form(s) 1099 . . . . . . . . . . . . . . . . . . 25b
c Other forms (see instructions) . . . . . . . . . . . . . 25c
d Add lines 25a through 25c . . . . . . . . . . . . . . . . . . . . . . 25d 980.
26 2021 estimated tax payments and amount applied from 2020 return . . . . . . . . . . 26
If you have a
qualifying child, 27a Earned income credit (EIC) . . . . . . . . . . . . . . 27a 1,164.
attach Sch. EIC.
Check here if you were born after January 1, 1998, and before
January 2, 2004, and you satisfy all the other requirements for
taxpayers who are at least age 18, to claim the EIC. See instructions a
b Nontaxable combat pay election . . . . 27b
c Prior year (2019) earned income . . . . 27c
28 Refundable child tax credit or additional child tax credit from Schedule 8812 28
29 American opportunity credit from Form 8863, line 8 . . . . . . . 29
30 Recovery rebate credit. See instructions . . . . . . . . . . 30
31 Amount from Schedule 3, line 15 . . . . . . . . . . . . 31 1,672.
32 Add lines 27a and 28 through 31. These are your total other payments and refundable credits a 32 2,836.
33 Add lines 25d, 26, and 32. These are your total payments . . . . . . . . . . . a 33 3,816.
34 If line 33 is more than line 24, subtract line 24 from line 33. This is the amount you overpaid . . 34 3,720.
Refund
35a Amount of line 34 you want refunded to you. If Form 8888 is attached, check here . . . a 35a 3,720.
Direct deposit? ab Routing number 0 5 5 0 0 3 2 0 1 a c Type: Checking Savings
See instructions. a
d Account number 2 3 9 3 9 5 9 3 6 2
36 Amount of line 34 you want applied to your 2022 estimated tax . . a 36
Amount 37 Amount you owe. Subtract line 33 from line 24. For details on how to pay, see instructions . a 37
You Owe 38 Estimated tax penalty (see instructions) . . . . . . . . . a 38
Third Party Do you want to allow another person to discuss this return with the IRS? See
Designee instructions . . . . . . . . . . . . . . . . . . . . a Yes. Complete below. No
Designee’s Phone Personal identification
name a no. a number (PIN) a
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
Sign 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
F

Joint return? Loader/Unloader (see inst.) a

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.) a
Phone no. (772)667-0824 Email address
Preparer’s name Preparer’s signature Date PTIN Check if:
Paid Self-employed
Preparer
Firm’s name a Self-Prepared Phone no.
Use Only a a
Firm’s address Firm’s EIN
Go to www.irs.gov/Form1040 for instructions and the latest information. BAA REV 02/17/22 Intuit.cg.cfp.sp Form 1040 (2021)
SCHEDULE 3 OMB No. 1545-0074
Additional Credits and Payments
(Form 1040)
Department of the Treasury
a Attach to Form 1040, 1040-SR, or 1040-NR. 2021
Attachment
Internal Revenue Service a Go to www.irs.gov/Form1040 for instructions and the latest information. Sequence No. 03
Name(s) shown on Form 1040, 1040-SR, or 1040-NR Your social security number
Stephen T Holbrook 212-33-5988
Part I Nonrefundable Credits
1 Foreign tax credit. Attach Form 1116 if required . . . . . . . . . . . . . . 1
2 Credit for child and dependent care expenses from Form 2441, line 11. Attach
Form 2441 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Education credits from Form 8863, line 19 . . . . . . . . . . . . . . . . . 3
4 Retirement savings contributions credit. Attach Form 8880 . . . . . . . . . . 4
5 Residential energy credits. Attach Form 5695 . . . . . . . . . . . . . . . 5
6 Other nonrefundable credits:
a General business credit. Attach Form 3800 . . . . . . . . 6a
b Credit for prior year minimum tax. Attach Form 8801 . . . . 6b
c Adoption credit. Attach Form 8839 . . . . . . . . . . . . 6c
d Credit for the elderly or disabled. Attach Schedule R . . . . . 6d
e Alternative motor vehicle credit. Attach Form 8910 . . . . . 6e
f Qualified plug-in motor vehicle credit. Attach Form 8936 . . . 6f
g Mortgage interest credit. Attach Form 8396 . . . . . . . . 6g
h District of Columbia first-time homebuyer credit. Attach Form 8859 6h
i Qualified electric vehicle credit. Attach Form 8834 . . . . . 6i
j Alternative fuel vehicle refueling property credit. Attach Form 8911 6j
k Credit to holders of tax credit bonds. Attach Form 8912 . . . 6k
l Amount on Form 8978, line 14. See instructions . . . . . . 6l
z Other nonrefundable credits. List type and amount a
6z
7 Total other nonrefundable credits. Add lines 6a through 6z . . . . . . . . . . 7
8 Add lines 1 through 5 and 7. Enter here and on Form 1040, 1040-SR, or 1040-NR,
line 20 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
(continued on page 2)
For Paperwork Reduction Act Notice, see your tax return instructions. BAA REV 02/17/22 Intuit.cg.cfp.sp Schedule 3 (Form 1040) 2021
Schedule 3 (Form 1040) 2021 Page 2

Part II Other Payments and Refundable Credits

9 Net premium tax credit. Attach Form 8962 . . . . . . . . . . . . . . . . . 9 1,672.
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 Other payments or refundable credits:
a Form 2439 . . . . . . . . . . . . . . . . . . . . . 13a
b Qualified sick and family leave credits from Schedule(s) H and
Form(s) 7202 for leave taken before April 1, 2021 . . . . . . 13b
c Health coverage tax credit from Form 8885 . . . . . . . . 13c
d Credit for repayment of amounts included in income from earlier
years . . . . . . . . . . . . . . . . . . . . . . . . 13d
e Reserved for future use . . . . . . . . . . . . . . . . 13e
f Deferred amount of net 965 tax liability (see instructions) . . . 13f
g Credit for child and dependent care expenses from Form 2441,
line 10. Attach Form 2441 . . . . . . . . . . . . . . . 13g
h Qualified sick and family leave credits from Schedule(s) H and
Form(s) 7202 for leave taken after March 31, 2021 . . . . . 13h
z Other payments or refundable credits. List type and amount a
13z
14 Total other payments or refundable credits. Add lines 13a through 13z . . . . . 14
15 Add lines 9 through 12 and 14. Enter here and on Form 1040, 1040-SR, or 1040-NR,
line 31 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1,672.
BAA REV 02/17/22 Intuit.cg.cfp.sp Schedule 3 (Form 1040) 2021
Form 8962 Premium Tax Credit (PTC)
OMB No. 1545-0074

2021
a Attach to Form 1040, 1040-SR, or 1040-NR.
Department of the Treasury Attachment
Internal Revenue Service a Go to www.irs.gov/Form8962 for instructions and the latest information. Sequence No. 73
Name shown on your return Your social security number
Stephen T Holbrook 212-33-5988
A. If you, or your spouse (if filing a joint return), received, or were approved to receive, unemployment compensation for any week beginning during 2021,
check the box. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a
B. You cannot take the PTC if your filing status is married filing separately unless you qualify for an exception. See instructions. If you qualify, check the box a

Part I Annual and Monthly Contribution Amount

1 Tax family size. Enter your tax family size. See instructions . . . . . . . . . . . . . . . . . 1 1
2a Modified AGI. Enter your modified AGI. See instructions . . . . . . . . . 2a 13,804.
b Enter the total of your dependents’ modified AGI. See instructions . . . . . . 2b
3 Household income. Add the amounts on lines 2a and 2b. See instructions . . . . . . . . . . . . 3 13,804.
4 Federal poverty line. Enter the federal poverty line amount from Table 1-1, 1-2, or 1-3. See instructions. Check the
appropriate box for the federal poverty table used. a Alaska b Hawaii c Other 48 states and DC 4 12,760.
5 Household income as a percentage of federal poverty line (see instructions) . . . . . . . . . . . . 5 108 %
6 Reserved for future use . . . . . . . . . . . . . . . . . . . . . . . . . . .
7 Applicable figure. Using your line 5 percentage, locate your “applicable figure” on the table in the instructions . . 7 0.0000
8a Annual contribution amount. Multiply line 3 by b Monthly contribution amount. Divide line 8a
line 7. Round to nearest whole dollar amount
8a 0. by 12. Round to nearest whole dollar amount
8b 0.
Part II Premium Tax Credit Claim and Reconciliation of Advance Payment of Premium Tax Credit
9 Are you allocating policy amounts with another taxpayer or do you want to use the alternative calculation for year of marriage? See instructions.
Yes. Skip to Part IV, Allocation of Policy Amounts, or Part V, Alternative Calculation for Year of Marriage. No. Continue to line 10.
10 See the instructions to determine if you can use line 11 or must complete lines 12 through 23.
Yes. Continue to line 11. Compute your annual PTC. Then skip lines 12–23 No. Continue to lines 12–23. Compute
and continue to line 24. your monthly PTC and continue to line 24.
(a) Annual enrollment (b) Annual applicable (c) Annual (d) Annual maximum (e) Annual premium tax (f) Annual advance
Annual SLCSP premium premium assistance
premiums (Form(s) contribution amount credit allowed payment of PTC (Form(s)
Calculation (Form(s) 1095-A, (subtract (c) from (b); if
1095-A, line 33A) (line 8a) (smaller of (a) or (d)) 1095-A, line 33C)
line 33B) zero or less, enter -0-)

11 Annual Totals
(c) Monthly
(a) Monthly enrollment (b) Monthly applicable (d) Monthly maximum (f) Monthly advance
contribution amount (e) Monthly premium tax
Monthly premiums (Form(s) SLCSP premium premium assistance payment of PTC (Form(s)
(amount from line 8b credit allowed
Calculation 1095-A, lines 21–32, (Form(s) 1095-A, lines (subtract (c) from (b); if 1095-A, lines 21–32,
or alternative marriage (smaller of (a) or (d))
column A) 21–32, column B) zero or less, enter -0-) column C)
monthly calculation)

12 January 183. 398. 0. 398. 183. 91.

13 February
14 March 435. 396. 0. 396. 396. 266.
15 April 435. 396. 0. 396. 396. 266.
16 May 435. 396. 0. 396. 396. 266.
17 June 435. 396. 0. 396. 396. 266.
18 July 435. 396. 0. 396. 396. 266.
19 August 442. 403. 0. 403. 403. 217.
20 September 442. 403. 0. 403. 403. 217.
21 October 442. 403. 0. 403. 403. 217.
22 November 442. 403. 0. 403. 403. 217.
23 December 442. 403. 0. 403. 403. 217.
24 Total premium tax credit. Enter the amount from line 11(e) or add lines 12(e) through 23(e) and enter the total here 24 4,178.
25 Advance payment of PTC. Enter the amount from line 11(f) or add lines 12(f) through 23(f) and enter the total here 25 2,506.
26 Net premium tax credit. If line 24 is greater than line 25, subtract line 25 from line 24. Enter the difference here and
on Schedule 3 (Form 1040), line 9. If line 24 equals line 25, enter -0-. Stop here. If line 25 is greater than line 24,
leave this line blank and continue to line 27 . . . . . . . . . . . . . . . . . . . . . 26 1,672.
Part III Repayment of Excess Advance Payment of the Premium Tax Credit
27 Excess advance payment of PTC. If line 25 is greater than line 24, subtract line 24 from line 25. Enter the difference here 27
28 Repayment limitation (see instructions) . . . . . . . . . . . . . . . . . . . . . . 28
29 Excess advance premium tax credit repayment. Enter the smaller of line 27 or line 28 here and on Schedule 2
(Form 1040), line 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
For Paperwork Reduction Act Notice, see your tax return instructions. BA REV 02/17/22 Intui Form 8962 (2021)
Form 8962 (2021) Page 2
Part IV Allocation of Policy Amounts
Complete the following information for up to four policy amount allocations. See instructions for allocation details.
Allocation 1
30 (a) Policy Number (Form 1095-A, line 2) (b) SSN of other taxpayer (c) Allocation start month (d) Allocation stop month

Allocation percentage (g) Advance Payment of the PTC

(e) Premium Percentage (f) SLCSP Percentage
applied to monthly Percentage
amounts

Allocation 2
31 (a) Policy Number (Form 1095-A, line 2) (b) SSN of other taxpayer (c) Allocation start month (d) Allocation stop month

Allocation percentage (g) Advance Payment of the PTC

(e) Premium Percentage (f) SLCSP Percentage
applied to monthly Percentage
amounts

Allocation 3
32 (a) Policy Number (Form 1095-A, line 2) (b) SSN of other taxpayer (c) Allocation start month (d) Allocation stop month

Allocation percentage (g) Advance Payment of the PTC

(e) Premium Percentage (f) SLCSP Percentage
applied to monthly Percentage
amounts

Allocation 4
33 (a) Policy Number (Form 1095-A, line 2) (b) SSN of other taxpayer (c) Allocation start month (d) Allocation stop month

Allocation percentage (g) Advance Payment of the PTC

(e) Premium Percentage (f) SLCSP Percentage
applied to monthly Percentage
amounts

34 Have you completed all policy amount allocations?

Yes. Multiply the amounts on Form 1095-A by the allocation percentages entered by policy. Add all allocated policy amounts and non-
allocated policy amounts from Forms 1095-A, if any, to compute a combined total for each month. Enter the combined total for each month on
lines 12–23, columns (a), (b), and (f). Compute the amounts for lines 12–23, columns (c)–(e), and continue to line 24.
No. See the instructions to report additional policy amount allocations.

Part V Alternative Calculation for Year of Marriage

Complete line(s) 35 and/or 36 to elect the alternative calculation for year of marriage. For eligibility to make the election, see the instructions for line 9.
To complete line(s) 35 and/or 36 and compute the amounts for lines 12–23, see the instructions for this Part V.
(a) Alternative family size (b) Alternative monthly (c) Alternative start month (d) Alternative stop month
35 Alternative entries contribution amount
for your SSN

(a) Alternative family size (b) Alternative monthly (c) Alternative start month (d) Alternative stop month
36 Alternative entries contribution amount
for your spouse’s
SSN
REV 02/17/22 Intui Form 8962 (2021)
D-400 (59)  2021 Individual Income Tax Return DOR
< Staple All Pages of Your North Carolina Department of Revenue Use
Only
Return and W-2s Here Amended Return
)RUFDOHQGDU\HDURU¿VFDO\HDUEHJLQQLQJ 21 DQGHQGLQJ $UH\RXDYHWHUDQ" <HV No X
STEPHEN T HOLBROOK ,V\RXUVSRXVHDYHWHUDQ" <HV No
755 2ND AVE SW Your SSN: 212335988 :HUH\RXJUDQWHGDQDXWRPDWLFH[WHQVLRQWR¿OH\RXU
HICKORY NC 28602 CATAW 6SRXVH¶V661 IHGHUDOLQFRPHWD[UHWXUQHJ)RUP"
)LOLQJ6WDWXV X 6LQJOH 0DUULHG)LOLQJ-RLQWO\ 0DUULHG)LOLQJ6HSDUDWHO\ <HV No X
+HDGRI+RXVHKROG 4XDOLI\LQJ:LGRZ HU <HDUVSRXVHGLHG
:HUH\RXDUHVLGHQWRI1&IRUWKHHQWLUH\HDU" <HV No X 5HWXUQIRUGHFHDVHGWD[SD\HU Date of death:
:DV\RXUVSRXVHDUHVLGHQWIRUWKHHQWLUH\HDU" <HV No 5HWXUQIRUGHFHDVHGVSRXVH Date of death:
1&(GXFDWLRQ(QGRZPHQW)XQG<RXPD\FRQWULEXWHWRWKH1&(GXFDWLRQ(QGRZPHQW)XQGE\PDNLQJDFRQWULEXWLRQRUGHVLJQDWLQJVRPHRUDOORI
\RXURYHUSD\PHQWWRWKH)XQG7RPDNHDFRQWULEXWLRQHQFORVH)RUP1&('8DQG\RXUSD\PHQWRI 0 7RGHVLJQDWH\RXURYHUSD\PHQW
WRWKH)XQGHQWHUWKHDPRXQWRI\RXUGHVLJQDWLRQRQ3DJH/LQH(See instructions for information about the Fund.)
6HOHFWER[LI\RXRULIPDUULHG¿OLQJMRLQWO\\RXUVSRXVHZHUHRXWRIWKHFRXQWU\RQ$SULODQGD86FLWL]HQRUUHVLGHQW
6HOHFWER[LIUHWXUQLV¿OHGDQGVLJQHGE\([HFXWRU$GPLQLVWUDWRURU&RXUW$SSRLQWHG3HUVRQDO5HSUHVHQWDWLYH

FS 1 PP N DT N OC N TPRES N SPRES N VT N SVT N

HOLB 755 28602 DS N EA N TD SD FDEXT N

STEPHEN T HOLBROOK 212335988 CATAW

NC 28602

755 2ND AVE SW HICKORY

06 13804 16 0 26C 0

7020159023
07 0 18 Y 0 26E 0

09 0 20A 195 EU

10A 0 20B 0 27 0

10B 0 21A 0 29 0

11 S Y I N 21B 0 30 0

11 10750 21C 0 31 0

13 04210 21D 0 32 0

14 1286 26A 0 34 127

15 68 26B 0

TN 7726670824 PN PP
Sign Return Below X Refund Due 127 Payment Due 0
I declare and certify that I have examined this return and accompanying schedules and statements, and to &KHFNKHUHLI\RXDXWKRUL]HWKH1RUWK&DUROLQD'HSDUWPHQWRI5HYHQXH
WKHEHVWRIP\NQRZOHGJHDQGEHOLHIWKH\DUHWUXHFRUUHFWDQGFRPSOHWH WRGLVFXVVWKLVUHWXUQDQGDWWDFKPHQWVZLWKWKHSDLGSUHSDUHUEHORZ

7726670824
<RXU6LJQDWXUH Date 6SRXVH¶V6LJQDWXUH ,I¿OLQJMRLQWUHWXUQERWKPXVWVLJQ Date &RQWDFW3KRQH1R(Include area code)
PAID PREPARER USE ONLY ,ISUHSDUHGE\DSHUVRQRWKHUWKDQWD[SD\HUWKLVFHUWL¿FDWLRQLVEDVHGRQDOOLQIRUPDWLRQRIZKLFKWKHSUHSDUHUKDVDQ\NQRZOHGJH

SELF PREPARED
3DLG3UHSDUHU¶V6LJQDWXUH Date 3UHSDUHU¶V&RQWDFW3KRQH1XPEHU(Include area code) 3UHSDUHU¶V)(,1661RU37,1

If REFUND, mail return to: 1&'(372)5(9(18(32%2;55$/(,*+1&

If you ARE NOT due a refund, mail return, any payment, and D-400V to: 1&'(372)5(9(18(32%2;5$/(,*+1&

REV 02/15/22 INTUIT.CG.CFP.SP

D-400 2021 Page 2 (59)
/DVW1DPH )LUVW&KDUDFWHUV HOLBROOK <RXU6RFLDO6HFXULW\1XPEHU 212335988

D-400 Line-by-Line Information

6. )HGHUDO$GMXVWHG*URVV,QFRPH 6. 13804
7. $GGLWLRQVWR)HGHUDO$GMXVWHG*URVV,QFRPH 7. 0
8. $GG/LQHVDQG 8. 13804
9. 'HGXFWLRQV)URP)HGHUDO$GMXVWHG*URVV,QFRPH 9. 0
10. Child Deduction
D(QWHUWKHQXPEHURITXDOLI\LQJFKLOGUHQIRUZKRP\RXZHUHDOORZHGDIHGHUDOFKLOGWD[FUHGLW 10a. 0
E(QWHUWKHDPRXQWRIWKHFKLOGGHGXFWLRQ E 0
11. N.C. Standard Deduction 11. Y
11. 1&,WHPL]HG'HGXFWLRQ 11. N
11. Deduction amount 11. 10750
12. D$GG/LQHVEDQG 12a. 10750
E6XEWUDFWDPRXQWRQ/LQHDIURP/LQH E 3054
13. 3DUW\HDU5HVLGHQWVDQG1RQUHVLGHQWV7D[DEOH3HUFHQWDJH 13. 0.4210
14. 1&7D[DEOH,QFRPH 14. 1286
15. 1&,QFRPH7D[ 15. 68
16. 7D[&UHGLWV 16. 0
17. 6XEWUDFW/LQHIURP/LQH 17. 68
18. &RQVXPHU8VH7D[ 18. 0
<RXFHUWLI\WKDWQR&RQVXPHU8VH7D[LVGXH Y
19. $GG/LQHVDQG 19. 68

North Carolina Income Tax Withheld

20a. <RXUWD[ZLWKKHOG 20a. 195

E 6SRXVH¶VWD[ZLWKKHOG E 0

Other Tax Payments

21a. HVWLPDWHGWD[ 21a. 0

E 3DLGZLWKH[WHQVLRQ E 0
21c. 3DUWQHUVKLS 21c. 0
21d. S Corporation 21d. 0
22. $PHQGHG5HWXUQV2QO\3UHYLRXVSD\PHQWV 22. 0
23. 7RWDO3D\PHQWV 23. 195
24. $PHQGHG5HWXUQV2QO\3UHYLRXVUHIXQGV 24. 0
25. 6XEWUDFW/LQHIURP/LQH 25. 195
26a. Tax Due 26a. 0
E 3HQDOWLHV E 0
26c. ,QWHUHVW 26c. 0
26d. $GG/LQHVEDQGFDQGHQWHUWKHWRWDORQG 26d. 0
EU ([FHSWLRQWR8QGHUSD\PHQWRI(VWLPDWHG7D[ EU
26e. ,QWHUHVWRQWKH8QGHUSD\PHQWRI(VWLPDWHG,QFRPH7D[ 26e. 0
27. Pay this Amount 27. 0
28. Overpayment 28. 127

Amount of Refund to Apply to:

29. $PRXQWRI/LQHWREHDSSOLHGWR(VWLPDWHG,QFRPH7D[ 29. 0

30. 1&1RQJDPHDQG(QGDQJHUHG:LOGOLIH)XQG 30. 0
31. 1&(GXFDWLRQ(QGRZPHQW)XQG 31. 0
32. 1&%UHDVWDQG&HUYLFDO&DQFHU&RQWURO3URJUDP 32. 0
33. $GG/LQHVWKURXJK 33. 0
34. Amount to be Refunded 34. 127

7KLVSDJHPXVWEH¿OHGZLWKWKH¿UVWSDJHRIWKLVIRUP REV 02/15/22 INTUIT.CG.CFP.SP

D-400 Sch PN (59) 2021 Part-Year Resident and
8-23-21 Nonresident Schedule DOR
Use
North Carolina Department of Revenue Only

,I\RXHQWHUDWD[DEOHSHUFHQWDJHRQ)RUP'/LQHEHFDXVH\RXRU\RXUVSRXVHLIPDUULHG¿OLQJMRLQWO\ZHUHQRWIXOO\HDUUHVLGHQWVRI1RUWK&DUROLQD
during tax year 2021, you must attach this schedule to Form D-400. Importantly, you must attach both pages of this schedule to Form D-400. If you do not,
the Department may be unable to process your return.

Last Name (First 10 Characters) HOLBROOK Your Social Security Number 212335988

$SDUW\HDUUHVLGHQWRUDQRQUHVLGHQWZKRUHFHLYHVLQFRPHIURP1&VRXUFHVPXVWFRPSOHWHWKLVIRUPWRGHWHUPLQHWKHSHUFHQWDJHRIWRWDOLQFRPHIURPDOO
VRXUFHVWKDWLVVXEMHFWWR1&WD[<RXDUHD“part-year resident” if you moved to N.C. and became a resident during the tax year, or you moved out of
N.C. and became a resident of another state during the tax year. You are a “nonresident”LI\RXZHUHQRWDUHVLGHQWRI1&DWDQ\WLPHGXULQJWKHWD[\HDU
Important: Refer to the Instructions before completing this form.

NRT N PYT Y 10 01 21 12 31 21 22 5811

NRS N PYS N 23 13804
Part A. Residency Status
Taxpayer is: (Select applicable box) Spouse is: (Select applicable box)
Full-Year Resident Nonresident X Part-Year Resident Full-Year Resident Nonresident Part-Year Resident
Date N.C. residency began Date N.C. residency ended Date N.C. residency began Date N.C. residency ended
10 01 21 12 31 21
,I\RXDQG\RXUVSRXVHZHUHERWKIXOO\HDUUHVLGHQWVRI1&stop here; do not complete Parts B and C. Do not attach Schedule PN to Form D-400.
Part B. Allocation of Income for Part-Year Residents and Nonresidents
COLUMN A COLUMN B
Total Income Total Income Amount of Column A
from all sources subject to N.C. tax

1. Wages, Salaries, Tips, Etc. 1. 13804 5811

2. Taxable Interest 2. 0 0
3. Taxable Dividends 3. 0 0
4. 7D[DEOH5HIXQGV&UHGLWVRU2ႇVHWV
of State and Local Income Taxes 4. 0 0
5. Alimony Received 5. 0 0
6. Business Income or (Loss) 6. 0 0
7. Capital Gain or (Loss) 7. 0 0
7020959023

8. Other Gains or (Losses) 8. 0 0

9. Taxable Amount of IRA Distributions 9. 0 0
10. Taxable Amount of Pensions
and Annuities 10. 0 0
11. Rental Real Estate, Royalties, Partnerships,
S-Corps, Estates, Trusts, Etc. 11. 0 0
12. Farm Income or (Loss) 12. 0 0
13. Unemployment Compensation 13. 0 0
14. 7D[DEOH3RUWLRQRI6RFLDO6HFXULW\%HQH¿W
DQG5DLOURDG5HWLUHPHQW%HQH¿WV 14. 0 0
15. Other Income 15. 0 0
16. Total Income 16. 13804 5811

COLUMN A COLUMN B
North Carolina Adjustments Enter the amount from Amount of Column A
Form D-400 Schedule S subject to N.C. tax
17. Additions
a. Interest Income From Obligations of States Other Than N.C. 17a. 0 0
b. Deferred Gains Reinvested Into an Opportunity Fund 17b. 0 0
c. Bonus Depreciation 17c. 0 0
d. IRC Section 179 Expense 17d. 0 0
e. 2WKHU$GGLWLRQVWR)HGHUDO$GMXVWHG*URVV,QFRPH7KDW5HODWHWR*URVV,QFRPH 17e. 0 0
18. Total Additions 18. 0 0

REV 02/15/22 INTUIT.CG.CFP.SP

D-400 Sch. PN 2021 Page 2 (59)

Last Name (First 10 Characters) HOLBROOK Your Social Security Number 212335988
Part B. Allocation of Income for Part-Year Residents and Nonresidents (continued)
COLUMN A COLUMN B
Enter the amount from Amount of Column A
Form D-400 Schedule S subject to N.C. tax
19. Deductions
a. State or Local Income Tax Refund 19a. 0 0
b. Interest Income From Obligations of the United States
or United States’ Possessions 19b. 0 0
c. Taxable Portion of Social Security and
 5DLOURDG5HWLUHPHQW%HQH¿WV 19c. 0 0
G %DLOH\5HWLUHPHQW%HQH¿WV 19d. 0 0
e. Bonus Asset Basis 19e. 0 0
f. Bonus Depreciation 19f. 0 0
g. IRC Section 179 Expense 19g. 0 0
K 2WKHU'HGXFWLRQV)URP)HGHUDO$GMXVWHG*URVV
Income That Relate to Gross Income 19h. 0 0
20. Total Deductions 20. 0 0
21. 7RWDO,QFRPH0RGL¿HGE\1&$GMXVWPHQWV 21. 13804 5811

Part C. Part-Year Residents and Nonresidents Taxable Percentage

22. Enter the Amount From Column B, Line 21 22. 5811

23. Enter the Amount From Column A, Line 21 23. 13804
24. Part-Year Residents and Nonresident Taxable Percentage 24. 0.4210

REV 02/15/22 INTUIT.CG.CFP.SP

D-400 Sch PN-1 (59) 2021 Other Additions and
12-7-21 Other Deductions DOR
Use
North Carolina Department of Revenue Only

If you enter an amount on Form D-400 Schedule PN, Part B, Line 17e or Line 19h, you must attach this schedule to Form D-400. If this Schedule is not
attached to Form D-400, the Department may be unable to process the tax return.

Last Name (First 10 Characters) HOLBROOK Your Social Security Number 212335988

Part A. Other Additions to Federal Adjusted Gross Income That Relate to Gross Income

COLUMN A COLUMN B
Enter the amount from Amount of Column A
Form D-400 Schedule S subject to N.C. tax

1. S-Corporation Shareholder Built-in Gains Tax 1. 0 0

2. Amount by Which Federal Basis Exceeds State Basis for
Property Disposed of in 2021 2. 0 0
3. Unabsorbed Net Operating Loss Deduction 3. 0 0
4. State, Local, or Foreign Income Tax Deducted by an S Corporation, Partnership,
or Estate and Trust 4. 0 0
5. Withdrawal of 529 Plan Contributions Not Used for
Permissible Purpose 5. 0 0
6. 'LVFKDUJHRI4XDOL¿HG3ULQFLSDO5HVLGHQFH,QGHEWHGQHVV 6. 0 0
7. 4XDOL¿HG(GXFDWLRQ/RDQ3D\PHQWV3DLGE\(PSOR\HU 7. 0 0
8. Business Meal Deduction in Excess of 50% 8. 0 0
9. Discharge of Certain Student Loan Debt 9. 0 0
10. Reserved for Future Use 10. 0 0
11. Total Other Additions 11. 0 0

Part B. Other Deductions From Federal Adjusted Gross Income That Relate to Gross Income

12. &HUWDLQ5HWLUHPHQW%HQH¿WV5HFHLYHGE\D5HWLUHG0HPEHURIWKH8QLWHG6WDWHV$UPHG
Forces Not Deducted on Form D-400 Schedule PN, Part B, Line 19d 12. 0 0
13. Recognized IRC Section 1400Z-2 Gain 13. 0 0
14. Gain From the Disposition of Exempt N.C. Obligations Issued
Before July 1, 1995 14. 0 0
15. Exempt Income Earned or Received by a Member of a Federally
Recognized Indian Tribe 15. 0 0
16. Amount by Which State Basis Exceeds Federal Basis for Property
Disposed of in 2021 16. 0 0
17. Ordinary and Necessary Business Expense Reduced or not Allowed Due to
Claiming a Federal Tax Credit in Lieu of a Deduction 17. 0 0
18. Personal Education Savings Account Deposits 18. 0 0
19. Certain State Emergency Response and Disaster Relief Reserve Fund Payments 19. 0 0
20. Certain Economic Incentive Payments 20. 0 0
21. Certain N.C. Grant Payments 21. 0 0
22. Certain Net Operating Loss Carrybacks 22. 0 0
23. Excess Net Operating Loss Carryforward 23. 0 0
24. Excess Business Loss 24. 0 0
25. Business Interest Limitation 25. 0 0
26. Reserved for Future Use 26. 0 0
27. Total Other Deductions 27. 0 0

REV 02/15/22 INTUIT.CG.CFP.SP