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1 Department of the Treasury - Internal Revenue Service (99) 00 U.S. Individual Income Tax Return 0 OMB. -00 For the year Jan. -Dec., 0, or other tax year eginning,0, ending,0 Form Your first name and initial If a oint return, spouse's first name and initial SANDY ADAMS ELM Apt. no. k City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces elow (see instructions). First name Last name Last name Home address (numer and street). If you have a P.O. ox, see instructions. Foreign country name Foreign province/state/county Foreign postal code If more than four dependents, see instructions and check here () Attach Forms(s) W- here. Also attach Forms W-G and 099-R if tax was withheld. If you did not get a W-, see instructions. 6a c d Single Married filing ointly (even if only one had income) Married filing separately. Enter spouse's SSN aove and full name here.. Last name Wages, salaries, tips, etc. Attach Form(s) W () Dependent's social security numer..... this child's name here. Yourself. If someone can claim you as a dependent, do not check ox 6a Total numer of exemptions claimed Ordinary dividends. Attach Schedule B if required Qualified dividends Taxale refunds, credits, or offsets of state and local income taxes Alimony received Business income or (loss). Attach Schedule C or C-EZ () Dependent's relationship to you Capital gain or (loss). Attach Schedule D if required. If not required, check here Other gains or (losses). Attach Form 9 IRA distriutions Pensions and annuities Taxale amount. Sutract line 6 from line. This is your adusted gross income For Disclosure, Privacy Act, and Paperwork Reduction Act tice, see separate instructions. IRS Use Only-Do not write or staple in this space. l See separate instructions. Make sure the SSN(s) aove and on line 6c are correct. Presidential Election Campaign Check here if you, or your spouse if filing ointly, want $ to go to this fund. Checking a ox elow will not change your tax or refund. You Spouse Head of household (with qualifying person). (See instructions.) If the qualifying person is a child ut not your dependent, enter Qualifying widow(er) with dependent child Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E Farm income or (loss). Attach Schedule F Other income. List type and amount Comine the amounts in the far right col for lines through.this is your total income Reserved Certain usiness expenses of reservists, performing artists, and fee-asis gov. officials. Attach Form 06 or 06-EZ Health savings account deduction. Attach Form 8889 Moving expenses. Attach Form 90 Deductile part of self-employment tax. Attach Schedule SE Self-employed SEP, SIMPLE, and qualified plans Self-employed health insurance deduction Penalty on early withdrawal of savings IRA deduction Student loan interest deduction Reserved Spouse Dependents: 8a Taxale interest. Attach Schedule B if required 0 Tax-exempt interest. Do not include on line 8a 9a a 6a 8 9 Unemployment compensation 0a Social security enefits. 0a a Alimony paid Recipient's SSN 6 Domestic production activities deduction. Attach Form 890 Add lines through 8 9 Taxale amount Taxale amount a Your social security numer FRED ADAMS AUSTIN T 80- Filing Status Check only one ox. Exemptions Income Adusted Gross Income AVA ADAMS JANEY ADAMS a 6a GRANDCHILD DAUGHTER () Spouse's social security numer 8a 9a v / if child under. age qualifying for child tax credit (see instructions) Boxes checked on 6a and 6. 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 aove Add numers on lines aove,000.,000., Form 00 (0)

2 US00$ Form 00 (0) Tax and Credits Standard Deduction Add lines 8 through. These are your total credits Sutract line from line. If line is more than line, enter -0- for- People who check any ox on line 9a or 9 or who can e claimed as a dependent, see instructions. All others: Single or Married filing separately, $6,00 Married filing ointly or Qualifying widow(er), $,600 Head of household, $9,0 Other Taxes Payments If you have a qualifying child, attach Schedule EIC. Refund Direct deposit? See instructions. Amount You Owe Third Party Designee Sign Here Joint return? See instructions. Keep a copy for your records. Paid Preparer Use Only k l 8 9a a a If your spouse itemizes on a separate return or you were a dual-status alien, check here. Exemptions. If line 8 is $,90 or less, multiply $,000 y the numer on line 6d. Otherwise, see instructions Credit for child and dependent care expenses. Attach Form Credit for federal tax on fuels. Attach Form 6. Reserved c 888 d Credits from Form: a 9 Add lines 6, 6, 66a, and 6 through. These are your total payments.,00.. Do you want to allow another person to discuss this return with the IRS (see instructions)?. Complete elow. Designee's Phone Personal identification name no. numer (PIN) Under penalties of perury, I declare that I have examined this return and accompanying schedules and statements, and to the est of my knowledge and elief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is ased on all information of which preparer has any knowledge. Your signature Your occupation Daytime phone numer Spouse's signature. If a oint return, oth must sign. Print/Type preparer's name Amount from line (adusted gross income) Check if: Itemized deductions (from Schedule A) or your standard deduction (see left margin) Sutract line 0 from line 8 Tax (see instructions). Check if any from: Add lines,, and 6 Foreign tax credit. Attach Form 6 if required Education credits from Form 886, line 9 Retirement savings contriutions credit. Attach Form 8880 Child tax credit. Attach Schedule 88, if required Residential energy credits. Attach Form 69 Other credits from Form: a Taxes from: ntaxale comat pay election Self-employment tax. Attach Schedule SE Unreported social security and Medicare tax from Form: a Form 899 Form 8960 c Instructions; enter code(s) 0 estimated tax payments and amount applied from 0 return Amount paid with request for extension to file Excess social security and tier RRTA tax withheld Sutract line from line 6. For details on how to pay, see instructions Preparer's signature 899 Additional tax on IRAs, other qualified retirement plans, etc. Attach Form 9 if required Household employment taxes from Schedule H First-time homeuyer credit repayment. Attach Form 0 if required Add lines 6 through 6. This is your total tax Federal income tax withheld from Forms W- and 099 Additional child tax credit. Attach Form 88 American opportunity credit from Form 886, line 8 Net premium tax credit. Attach Form 896 If line is more than line 6, sutract line 6 from line. This is the amount you overpaid Estimated tax penalty (see instructions) (see instructions). Attach Form 6 Excess advance premium tax credit repayment. Attach Form 896 Health care: individual responsiility (see instructions) Earned income credit (EIC) 66 a Total oxes checked 9a Full-year coverage 6a Amount of line you want refunded to you. If Form 8888 is attached, check here Routing numer c Type: Checking Savings d Account numer Amount of line you want applied to your 06 estimated tax 8 9 FRED & SANDY ADAMS You were orn efore Jan., 9, Spouse was orn efore Jan., 9, Taxale income. Sutract line from line. If line is more than line, enter -0- Alternative minimum tax Amount you owe. AARP Foundation Tax-Aide Firm's name Kinnelon Volunteer Fire Co Firm's address 0 Kiel Avenue BUTLER NJ 00 Form(s) 88 Form 9 c c NO Blind. Blind. a a WORKER Spouse's occupation WORKER 9,000.. Check if self-employed Firm's EIN a a 8 If the IRS sent you an Identity Protection PIN, enter it here (see inst.) PTIN Page,000.,600.,00. 6,000. 6,00.,6.,6., ,00.,.,. S00 Phone no Form 00 (0)

3 US889$ Form Department of the Treasury Internal Revenue Service Taxpayer's name Spouse's name 889 Sumission Identification Numer (SID) k l IRS e-file Signature Authorization Do not send to the IRS. This is not a tax return. Keep this form for your records. Information aout Form 889 and its instructions is at Social security numer FRED ADAMS OMB. -00 Spouse's social security numer SANDY ADAMS Part I Tax Return Information-Tax Year Ending Decemer, 0 (Whole Dollars Only) Adusted gross income (Form 00, line 8; Form 00A, line ; Form 00EZ, line ) Total tax (Form 00, line 6; Form 00A, line 9; Form 00EZ, line ). Federal income tax withheld (Form 00, line 6; Form 00A, line 0; Form 00EZ, line ). Refund (Form 00, line 6a; Form 00A, line 8a; Form 00EZ, line a; Form 00-SS, Part I, line a). Amount you owe (Form 00, line 8; Form 00A, line 0; Form 00EZ, line ). Part II Taxpayer Declaration and Signature Authorization (Be sure you get and keep a copy of your return), ,00.,. Under penalties of perury, I declare that I have examined a copy of my electronic individual income tax return and accompanying schedules and statements for the tax year ending Decemer, 0, and to the est of my knowledge and elief, it is true, correct, and complete. I further declare that the amounts in Part I aove are the amounts from my electronic income tax return. I consent to allow my intermediate service provider, transmitter, or electronic return originator (ERO) to send my return to the IRS and to receive from the IRS (a) an acknowledgment of receipt or reason for reection of the transmission, () the reason for any delay in processing the return or refund, and (c) the date of any refund. If applicale, I authorize the U.S. Treasury and its designated Financial Agent to initiate an ACH electronic funds withdrawal (direct deit) entry to the financial institution account indicated in the tax preparation software for payment of my federal taxes owed on this return and/or a payment of estimated tax, and the financial institution to deit the entry to this account. This authorization is to remain in full force and effect until I notify the U.S. Treasury Financial Agent to terminate the authorization. To revoke (cancel) a payment, I must contact the U.S. Treasury Financial Agent at Payment cancellation requests must e received no later than usiness days prior to the payment (settlement) date. I also authorize the financial institutions involved in the processing of the electronic payment of taxes to receive confidential information necessary to answer inquiries and resolve issues related to the payment. I further acknowledge that the personal identification numer (PIN) elow is my signature for my electronic income tax return and, if applicale my Electronic Funds Withdrawal Consent. Taxpayer's PIN: check one ox only I authorize to enter or generate my PIN ERO firm name Enter five digits, ut as my signature on my tax year 0 electronically filed income tax return. do not enter all zeros I will enter my PIN as my signature on my tax year 0 electronically filed income tax return. Check this ox only if you are entering your own PIN and your return is filed using the Practitioner PIN method. The ERO must complete Part III elow. Your signature Spouse's PIN: check one ox only I authorize Spouse's signature Kinnelong Volunteer Fire Co Kinnelong Volunteer Fire Co to enter or generate my PIN ERO firm name Enter five digits, ut as my signature on my tax year 0 electronically filed income tax return. do not enter all zeros I will enter my PIN as my signature on my tax year 0 electronically filed income tax return. Check this ox only if you are entering your own PIN and your return is filed using the Practitioner PIN method. The ERO must complete Part III elow. Practitioner PIN Method Returns Only-continue elow 0//06 0//06 Part III Certification and Authentication-Practitioner PIN Method Only ERO's EFIN/PIN. Enter your six-digit EFIN followed y your five-digit self-selected PIN. I certify that the aove numeric entry is my PIN, which is my signature for the tax year 0 electronically filed income tax return for the taxpayer(s) indicated aove. I confirm that I am sumitting this return in accordance with the requirements of the Practitioner PIN method and Pulication, Handook for Authorized IRS e-file Providers of Individual Income Tax Returns. ERO's signature S00 Kinnelong Volunteer Fi Do not enter all zeros 0//06 ERO Must Retain This Form - See Instructions Do t Sumit This Form to the IRS Unless Requested To Do So For Paperwork Reduction Act tice, see your tax return instructions. 889 Form (0)

4 Form 896 Department of the Treasury Internal Revenue Service Name as shown on return OMB. -00 Attach to Form 00, Form 00A, or Form 00EZ. Information aout Form 896 and its separate instructions is at Attachment Sequence. Your social security numer FRED & SANDY ADAMS Complete this form if you have a Marketplace-granted coverage exemption or you are claiming a coverage exemption on your return. Marketplace-Granted Coverage Exemptions for Individuals: If you and/or a memer of your tax household Part I have an exemption granted y the Marketplace, complete Part I. (a) Name of Individual Health Coverage Exemptions () SSN 0 (c) Exemption Certificate Numer 6 Part II Coverage Exemptions Claimed on Your Return for Your Household a Are you claiming an exemption ecause your household income is elow the filing threshold?. Are you claiming a hardship exemption ecause your gross income is elow the filing threshold?. Part III Coverage Exemptions Claimed on Your Return for Individuals. If you and/or a memer of your tax household are claiming an exemption on your return, complete Part III. (a) Name of Individual () SSN (c) Exemption Type (d) (e) (f) (g) (h) (i) () (k) (l) (m) (n) (o) (p) Full Jan Fe Mar Apr May June Aug Sept Oct v Dec Year 8 AVA ADAMS H 9 0 For Privacy Act and Paperwork Reduction Act tice, see your tax return instructions. 896 Form (0)

5 Affordale Care Act Worksheet US 0 Name: FRED & SANDY ADAMS SSN: Did the taxpayer, spouse, or any dependent receive insurance through the Marketplace? See Form 896 Was the taxpayer, spouse, or any dependent granted a Marketplace exemption or do you want to apply for a Marketplace, household income, or gross income exemption? See Form 896 FRED ADAMS SANDY ADAMS AVA ADAMS JANEY ADAMS.... Had a minimum essential coverate and/or is applying for or was granted an exemption for the entire year Feruary Feruary Feruary Feruary Feruary Feruary Feruary Feruary co 0 Universal Tax Systems, Inc. and/or its affiliates and licensors. All rights reserved. USW008

6 Affordale Care Act Worksheet US 0 Name: FRED & SANDY ADAMS SSN: Had a minimum essential coverate and/or is applying for or was granted an exemption for the entire year Had a minimum essential coverate and/or is applying for or was granted an exemption for part of the year Feruary Had a minimum essential coverate and/or is applying for or was granted an exemption for the entire year Had a minimum essential coverate and/or is applying for or was granted an exemption for part of the year Feruary Total numer of oxes checked per month, maximum of Total numer of oxes checked per month for individuals 8 or over One-half the numer of oxes checked per month for individuals under 8 Add lines and for each month.... Multiply line y $ for each month, maximum of $9.. Jan Fe Mar Apr May Jun Jul Aug Sept Oct v Dec Sum of the numer of oxes checked on line aove for the year Household Income.. Enter the total modified AGI for any dependent included in this return who is required to file a tax return - F if zero Filing threshold Sutract line 8 from line Multiply line 9 y % Is line 0 more than $9?.... Amount calculated ased on the flat dollar amount worksheet,6. Divide line y Multiply line 6 y $0 Multiply line 0 y the numer of months for which line is more than zero. Smaller of line or line ,000. 0,600., co 0 Universal Tax Systems, Inc. and/or its affiliates and licensors. All rights reserved. USW009

7 US Preparer Use Form 0 Name: FRED & SANDY ADAMS SSN: Preparer Use Fields Question Answer Are you or your spouse a Veteran from the US Armed Force Other than English what language is spoken in your home Do you or any memer of your household have a disaility Preparer Initials QR Initials Taxpayer Reminders co 0 Universal Tax Systems, Inc. and/or its affiliates and licensors. All rights reserved. USWPRUSE

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