1040 U.S. Individual Income Tax Return 2015

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1 Form - (99) 1040 U.S. Individual Tax Return For the year Jan. 1-Dec. 31,, or other tax year beginning,, ending, 20 Your first name and initial Last name If a joint return, spouse's first name and initial Home address (number and street). d Total number of exemptions claimed 7 Wages, salaries, tips, etc. Attach Form(s) W a Taxable interest. Attach Schedule B if required a b Tax-exempt interest. Do not include on line 8a b Attach Form(s) W-2 here. Also 9a Ordinary dividends. Attach Schedule B if required a attach Forms b Qualified dividends b W-2G and 10 Taxable refunds, credits, or offsets of state and local income taxes R if tax 11 Alimony received was withheld. 12 Business income or (loss). Attach Schedule C or C-EZ Capital gain or (loss). Attach Schedule D if required. If not required, check here 13 If you did not get a W-2, 14 Other gains or (losses). Attach Form see 15a IRA distributions a b Taxable amount b 16a Pensions and annuities.. 16a b Taxable amount b 17 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E Farm income or (loss). Attach Schedule F Unemployment compensation a Social security benefits.. 20a b Taxable amount b 21 Other income Combine the amounts in the far right column for lines 7 through 21. This is your total income Reserved Certain business expenses of reservists, performing artists, and fee-basis government officials. Attach Form 2106 or 2106-EZ Health savings account deduction. Attach Form Moving expenses. Attach Form Deductible 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 a Alimony paid b Recipient's SSN 31a 32 IRA deduction Student loan interest deduction Reserved Domestic production activities deduction. Attach Form Add lines 23 through Subtract line 36 from line 22. This is your adjusted gross income For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate Adjusted Gross Last name IRS Use Only-Do not write or staple in this space. See separate Your social security number Spouse's social security number PINTO BEAN GARBANZO RD Make sure the SSN(s) above and on line 6c are correct. City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions). Presidential Election Campaign DENVER CO Check here if you, or your spouse if filing jointly, want $3 to go to this fund. Checking Foreign country name Foreign province/state/county Foreign postal code a box below will not change your tax or refund. You Spouse 1 Single 4 Head of household (with qualifying person). (See ) If Filing the qualifying person is a child but not your dependent, enter this 2 Married filing jointly (even if only one had income) child's name here. Status 3 Married filing separately. Enter spouse's SSN above Check only one box. and full name here. 5 Qualifying widow(er) with dependent child 6a Yourself. If someone can claim you as a dependent, do not check box 6a Boxes checked Exemptions } on 6a and 6b b Spouse No. of children (4) Chk If child under c Dependents: (3) on 6c who: (2) Dependent's Dependent's age 17 qualifying social security number relationship to you for child tax credit lived with you 2 (1) First name Last name (see instructions) did not live with you due to divorce or separation If more than four (see instructions) dependents, see instructions and check here Apt. no. LIMA BEAN DAUGHTER NAVY BEAN SON Dependents on 6c not entered above Add numbers on lines above 4 116,000 1, , ,216 Form 1040 ()

2 Form 1040 () Page 2 38 Amount from line 37 (adjusted gross income) ,216 39a Check You were born before January 2, 1951, Blind. Total boxes { } if: Spouse was born before January 2, 1951, Blind. checked 39a Tax and Credits Standard Deduction for - People who check any box on line 39a or 39b or who can be claimed as a dependent, see All others: Single or Married filing separately, $6,300 Married filing jointly or Qualifying widow(er), $12,600 Head of household, $9,250 Other Taxes Payments If you have a qualifying child, attach Schedule EIC. Refund Direct deposit? See Amount You Owe Third Party Designee Sign Here Joint return? See Keep a copy for your records. Paid Preparer Use Only GREEN & PINTO BEAN b If your spouse itemizes on a separate return or you were a dual-status alien, check here 39b 40 Itemized deductions (from Schedule A) or your standard deduction (see left margin) Subtract line 40 from line Exemptions. If line 38 is $154,950 or less, multiply $4,000 by the number on line 6d. Otherwise, see instructions Taxable income. Subtract line 42 from line 41. If line 42 is more than line 41, enter Tax (see instructions). Check if any from: a Form(s) 8814 b Form 4972c Alternative minimum tax (see instructions). Attach Form Excess advance premium tax credit repayment. Attach Form Add lines 44, 45, and Foreign tax credit. Attach Form 1116 if required Credit for child and dependent care expenses. Attach Form Education credits from Form 8863, line Retirement savings contributions credit. Attach Form Child tax credit. Attach Schedule 8812, if required Residential energy credit. Attach Form Other credits from Form: a 3800 b 8801 c Add lines 48 through 54. These are your total credits Subtract line 55 from line 47. If line 55 is more than line 47, enter Self-employment tax. Attach Schedule SE Unreported social security and Medicare tax from Form: a 4137 b Additional tax on IRAs, other qualified retirement plans, etc. Attach Form 5329 if required a Household employment taxes from Schedule H a b First-time homebuyer credit repayment. Attach Form 5405 if required b 61 Health care: individual responsibility (see instructions) Full-year coverage Taxes from: a Form 8959 b Form 8960 c Instructions; enter code(s) Add lines 56 through 62. This is your total tax Federal income tax withheld from Forms W-2 and , estimated tax payments and amount applied from 2014 return a Earned income credit (EIC) a CLERGY b Nontaxable combat pay election... 66b 67 Additional child tax credit. Attach Schedule American opportunity credit from Form 8863, line Net premium tax credit. Attach Form Amount paid with request for extension to file Excess social security and tier 1 RRTA tax withheld Credit for federal tax on fuels. Attach Form Credits from Form: a 2439 b Reserved c 8885 d Add lines 64, 65, 66a, and 67 through 73. These are your total payments If line 74 is more than line 63, subtract line 63 from line 74. This is the amount you overpaid 75 76a Amount of line 75 you want refunded to you. If Form 8888 is attached, check here. 76a b Routing number c Type: Checking Savings d Account number 77 Amount of line 75 you want applied to your 2016 estimated tax Amount you owe. Subtract line 74 from line 63. For details on how to pay, see instructions Estimated tax penalty (see instructions) Do you want to allow another person to discuss this return with the IRS (see instructions)? Yes. Complete below. Designee's Phone Personal identification name no. number (PIN) 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. Your signature Date Your occupation Daytime phone number Spouse's signature. If a joint return, both must sign. Date Spouse's occupation Preparer's signature Date Check if self-employed Print/Type preparer's name Preparer One Firm's name The Tax Firm Firm's EIN Firm's address 1040 Prep Lane Phone no.... No Identity Protection PIN (see inst.) PTIN 12, ,616 16,000 88,616 13,744 13, ,144 F ,144 12,315 Preparer One CLERGY NURSE Preparer One P Franklin, NC Form 1040 ()

3 SCHEDULE C (Form 1040) (99) Name of proprietor A C E Part I Profit or Loss From Business (Sole Proprietorship) Information about Schedule C and its separate instructions is at Attach to Form 1040, 1040NR, or 1041; partnerships generally must file Form Principal business or profession, including product or service (see instructions) Business name. If no separate business name, leave blank. Business address (including suite or room no.) City, town or post office, state, and ZIP code Part II Expenses. Enter expenses for business use of your home only on line 30. B 09 D Employer ID number (EIN), (see instr.) F Accounting method: (1) Cash (2) Accrual (3) Other (specify) G Did you "materially participate" in the operation of this business during? If "No," see instructions for limit on losses. Yes No H If you started or acquired this business during, check here I Did you make any payments in that would require you to file Form(s) 1099? (see instructions) Yes No J If "Yes," did you or will you file required Forms 1099? Yes No 1 Gross receipts or sales. See instructions for line 1 and check the box if this income was reported to you on Form W-2 and the "Statutory employee" box on that form was checked Returns and allowances Subtract line 2 from line Cost of goods sold (from line 42) Gross profit. Subtract line 4 from line Other income, including federal and state gasoline or fuel tax credit or refund (see instructions) Gross income. Add lines 5 and Advertising 8 18 Office expense (see instructions) 18 9 Car and truck expenses (see 19 Pension and profit-sharing plans 19 instructions) Rent or lease (see instructions): 10 Commissions and fees a Vehicles, machinery, and equipment. 20a 11 Contract labor (see instructions) 11 b Other business property b 12 Depletion Repairs and maintenance Depreciation and section Supplies (not included in Part III) 22 expense deduction (not 23 Taxes and licenses included in Part III) (see instructions) Travel, meals, and entertainment: 14 Employee benefit programs a Travel a (other than on line 19) b Deductible meals and 15 Insurance (other than health). 15 entertainment (see instructions) 24b 16 Interest: 25 Utilities a Mortgage (paid to banks, etc.). 16a 26 Wages (less employment credits) 26 b Other b 27 a Other expenses (from line 48). 27a 17 Legal and professional services 17 b Reserved for future use... 27b 28 Total expenses before expenses for business use of home. Add lines 8 through 27a Tentative profit or (loss). Subtract line 28 from line Expenses for business use of your home. Do not report these expenses elsewhere. Attach Form 8829 unless using the simplified method (see instructions). Simplified method filers only: enter the total square footage of: (a) your home: and (b) the part of your home used for business:. Use the Simplified Method Worksheet in the instructions to figure the amount to enter on line Net profit or (loss). Subtract line 30 from line 29. If a profit, enter on both Form 1040, line 12 (or Form 1040NR, line 13) and on Schedule SE, line 2. (If you checked the box on line 1, see instructions). Estates and trusts, enter on Form 1041, line If a loss, you must go to line If you have a loss, check the box that describes your investment in this activity (see instructions). If you checked 32a, enter the loss on both Form 1040, line 12, (or Form 1040NR, line 13) and on Schedule SE, line 2. (If you checked the box on line 1, see the line 31 instructions). Estates and 32a 32b trusts, enter on Form 1041, line 3. If you checked 32b, you must attach Form Your loss may be limited. Social security number (SSN) Enter code from instructions MINISTER GREEN BEAN All investment is at risk. Some investment is not For Paperwork Reduction Act Notice, see the separate Schedule C (Form 1040) GARBANZO RD DENVER CO at risk. Attachment Sequence No , ,216 SEE CLERGY ATTACHMENT

4 Form 8965 Name as shown on return Health Coverage Exemptions Attach to Form 1040, Form 1040A, or Form 1040EZ. Information about Form 8965 and its separate instructions is at Your social security number Attachment Sequence No. 75 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 member of your tax household Part I have an exemption granted by the Marketplace, complete Part I. (a) (b) (c) Name of Individual SSN Exemption Certificate Number 1 PENDING 2 PINTO BEAN PENDING 3 LIMA BEAN PENDING 4 NAVY BEAN PENDING 5 6 Part II Part III Coverage Exemptions Claimed on Your Return for Your Household a Are you claiming an exemption because your household income is below the filing threshold? Yes No Coverage Exemptions Claimed on Your Return for Individuals. If you and/or a member of your tax household are claiming an exemption on your return, complete Part III. b Are you claiming a hardship exemption because your gross income is below the filing threshold? Yes No (c) (d) (a) (b) (e) (f) (g) (h) (i) (j) (k) (l) (m) (n) (o) (p) Exemption Full Name of Individual SSN Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Type Year For Privacy Act and Paperwork Reduction Act Notice, see your tax return Form 8965 ()

5 Payment Voucher Filing Instructions Date to file by: Payment: $829 Address to file: Other Instructions: P.O. Box 7704 San Francisco, CA If paper-filing your return, mail the tax return, voucher, and check to the address on the voucher. Do not staple the voucher and payment to the return or to each other. If your return was e-filed, mail the voucher and check to the address on the voucher. Make your check or money order payable to "United States Treasury". Enter your SSN and " Form 1040" on your check or money order. To pay by credit card, go to Taxpayer Records: Amount Paid Check Number Date Mailed Form 1040-V () Detach Here and Mail With Your Payment and Return Form 1040-V Payment Voucher (99) Do not staple or attach this voucher to your payment or return. 1 Your social security number (SSN) 2 If a joint return, SSN shown second 3 Amount you are paying by Dollars Cents on your return check or money order. Make your check or money order payable to "United States Treasury" 829 GREEN & PINTO BEAN GARBANZO RD P.O. Box 7704 DENVER, CO San Francisco, CA For Paperwork Reduction Act Notice, see your tax return VU BEAN

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