Prentice Hall 2013 Income Tax

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Form

1040

Department of the Treasury - Internal Revenue Service

(99)

U.S. Individual Income Tax Return
Last name

2011

OMB No. 1545-0074 IRS Use Only - Do not write or staple in this space. , 20

For the year Jan. 1-Dec. 31, 2011, or other tax year beginning

, 2011, ending

Your first name and initial

Your social security number

Heather
If a joint return, spouse's first name and initial

Laubert
Last name

584-11-3456
Spouse's social security number

Nikolay 123 main st

Laubert
Apt. no.

564-11-3457
Make sure the SSN(s) above and on line 6c are correct. Presidential Election Campaign Check here if you, or your spouse if filing jointly, want $3 to go to this fund. Checking a box below will not change your tax or refund.

Home address (number and street). If you have a P.O. box, see instructions.

City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions).

Chicago, IL 60123
Foreign country name Foreign province/county Foreign postal code

You

Spouse

Filing Status
Check only one box.

1 2 3 6a b c

Single

4

Head of household (with qualifying person). (See instructions.) If the qualifying person is a child but not your dependent, enter this child's name here.

X X X

Married filing jointly (even if only one had income) Married filing separately. Enter spouse's SSN above and full name here. 5

Qualifying widow(er) with dependent child

Exemptions

Yourself. If someone can claim you as a dependent, do not check box 6a . . . . . . . . Spouse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (2) Dependent's social security number (3) Dependent's relationship to you

}

Dependents:
Last name

If more than four dependents, see instructions and check here

(1) First name

(4) X if child under age 17 qualifying for child tax credit (see instr.)

Boxes checked on 6a and 6b No. of children on 6c who: lived with you did not live with you due to divorce or separation (see instructions) Dependents on 6c not entered above

2 0 0 0

d

Total number of exemptions claimed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Wages, salaries, tips, etc. Attach Form(s) W-2 . . . . . . . . . . . . . . . . . . . . . . . Taxable interest. Attach Schedule B if required . . . . . . . . . . . . . . . . . . . . . . Tax-exempt interest. Do not include on line 8a . . . . . . . Qualified dividends . . . . . . . . . . . . . . . . . . . . . 8b 9a 10 11 12 13 14 15b 16b 17 18 19 20b 21 22 9b Ordinary dividends. Attach Schedule B if required . . . . . . . . . . . . . . . . . . . . . . Taxable refunds, credits, or offsets of state and local income taxes . . . . . . . . . . . . . . Alimony received . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Business income or (loss). Attach Schedule C or C-EZ . . . . . . . . . . . . . . . . . . . Capital gain or (loss). Attach Schedule D if required. If not required, check here . . . . Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . . . . . . . . . . . . . . IRA distributions . . . . . Pensions and annuities . . 15a 16a b Taxable amount . . . . . . . b Taxable amount . . . . . . . 7 8a

Add numbers on lines above

Income
Attach Form(s) W-2 here. Also attach Forms W-2G and 1099-R if tax was withheld. If you did not get a W-2, see instructions.

7 8a b 9a b 10 11 12 13 14 15a 16a

2 78,000.

400. 75,250. 4,000.

Enclose, but do not attach, any payment. Also, please use Form 1040-V.

17 18 19 20a 21 22 23

Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E . . . Farm income or (loss). Attach Schedule F . . . . . . . . . . . . . . . . . . . . . . . . . Unemployment compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social security benefits . . 20a b Taxable amount . . . . . . . Other income. List type...
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