1040 U.S. Individual Income Tax Return 2015

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1 Form Department of the Treasury - Internal Revenue Service (99) 040 U.S. Individual Income Tax Return OMB No For the year Jan. -Dec. 3,, or other tax year beginning,, ending, 20 Your first name and initial Last name IRS Use Only-Do not write or staple in this space. See separate instructions. Your social security number If a joint return, spouse's first name and initial Last name Spouse's social security number Home address (number and street). 00 DRONE LANE d Total number of exemptions claimed 7 Wages, salaries, tips, etc. Attach Form(s) W Income 8a 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 600 W-2G and 0 Taxable refunds, credits, or offsets of state and local income taxes R if tax Alimony received was withheld. 2 Business income or (loss). Attach Schedule C or C-EZ Capital gain or (loss). Attach Schedule D if required. If not required, check here 3 If you did not get a W-2, 4 Other gains or (losses). Attach Form see instructions. 5a IRA distributions a b Taxable amount b 6a Pensions and annuities.. 6a b Taxable amount b 7 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 2 Other income 2 22 Combine the amounts in the far right column for lines 7 through 2. This is your total income Reserved Certain business expenses of reservists, performing artists, and fee-basis government officials. Attach Form 206 or 206-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 3a 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 instructions. Adjusted Gross Income 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 SAN ANTONIO T 7820 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 Single 4 Head of household (with qualifying person). (See instructions.) 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 7 qualifying social security number relationship to you for child tax credit lived with you () First name Last name (see instructions) did not live with you due to divorce or separation If more than four (see instructions) dependents, see Dependents on 6c instructions and not entered above check here Add numbers on lines above Apt. no ,000 2, ,500 32,900 32,900 Form 040 ()

2 Form 040 () Page 2 38 Amount from line 37 (adjusted gross income) ,900 39a Check You were born before January 2, 95, Blind. Total boxes { } if: Spouse was born before January 2, 95, 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 instructions. All others: Single or Married filing separately, $6,300 Married filing jointly or Qualifying widow(er), $2,600 Head of household, $9,250 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 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 $54,950 or less, multiply $4,000 by the number on line 6d. Otherwise, see instructions Taxable income. Subtract line 42 from line 4. If line 42 is more than line 4, enter Tax (see instructions). Check if any from: a Form(s) 884 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 6 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 882, if required Residential energy credit. Attach Form Other credits from Form: a 3800 b 880 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 437 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 6 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 204 return a Earned income credit (EIC) a 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 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 206 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 040 Prep Lane Phone no.... No Identity Protection PIN (see inst.) PTIN 6,300 26,600 4,000 22,600 2,68 2,68 2, ,070 2,900 Preparer One STORE CLERK Preparer One -24- P0 Franklin, NC Form 040 ()

3 SCHEDULE B (Form 040A or 040) Department of the Treasury Internal Revenue Service (99) Name(s) shown on return Part I Interest Interest and Ordinary Dividends Attach to Form 040A or 040. Information about Schedule B and its instructions is at OMB No Attachment Sequence No. Your social security number List name of payer. If any interest is from a seller-financed mortgage and the Amount buyer used the property as a personal residence, see instructions and list this interest first. Also, show that buyer's social security number and address 08 (See instructions for Form 040A, or Form 040, line 8a.) Note: If you received a Form 099-INT, Form 099-OID, or substitute statement from a brokerage firm, list the firm's name as the payer and enter the total interest shown on that form. Part II Ordinary Dividends (See instructions for Form 040A, or Form 040, line 9a.) QUEEN BEE SECURITIES 2,600 INTEREST SUBTOTAL 2, Add the amounts on line 2 3 Excludable interest on series EE and I U.S. savings bonds issued after 989. Attach Form Subtract line 3 from line 2. Enter the result here and on Form 040A, or Form 040, line 8a Note: If line 4 is over $,500, you must complete Part III. 5 List name of payer 5 Amount 2,600 2,600 HIVE BANK 800 Note: If you received a Form 099-DIV or substitute statement from DIVIDEND SUBTOTAL 800 a brokerage firm, list the firm's name as the payer and enter the ordinary 6 Add the amounts on line 5. Enter the total here and on Form 040A, or Form dividends shown on that form. 040, line 9a Note: If line 6 is over $,500, you must complete Part III. You must complete this part if you (a) had over $,500 of taxable interest or ordinary dividends; (b) had a foreign account; or (c) received a distribution from, or were a grantor of, or a transferor to, a foreign trust. 7a At any time during, did you have a financial interest in or signature authority over a financial account (such as a bank account, securities account, or brokerage account) located in a foreign country? See instructions Part III Foreign Accounts and Trusts (See If "Yes," are you required to file FinCEN Form 4, Report of Foreign Bank and Financial instructions.) Accounts (FBAR), to report that financial interest or signature authority? See FinCEN Form 4 and its instructions for filing requirements and exceptions to those requirements b If you are required to file FinCEN Form 4, enter the name of the foreign country where the financial account is located 8 During, did you receive a distribution from, or were you the grantor of, or transferor to, a foreign trust? If "Yes," you may have to file Form See instructions For Paperwork Reduction Act Notice, see your tax return instructions Yes 800 No Schedule B (Form 040A or 040)

4 SCHEDULE D (Form 040) Department of the Treasury Internal Revenue Service (99) Name(s) shown on return Part I Part II Capital Gains and Losses Short-Term Capital Gains and Losses - Assets Held One Year or Less Long-Term Capital Gains and Losses - Assets Held More Than One Year Attach to Form 040 or Form 040NR. Information about Schedule D and its separate instructions is at Attachment Use Form 8949 to list your transactions for lines b, 2, 3, 8b, 9, and 0. Sequence No. 2 Your social security number See instructions for how to figure the amounts to enter on the lines below. This form may be easier to complete if you round off cents to whole dollars. a Totals for all short-term transactions reported on Form 099-B for which basis was reported to the IRS and for which you have no adjustments (see instructions). However, if you choose to report all these transactions on Form 8949, leave this line blank and go to line b b Totals for all transactions reported on Form(s) 8949 with Box A checked 2 Totals for all transactions reported on Form(s) 8949 with Box B checked 3 Totals for all transactions reported on Form(s) 8949 with Box C checked (d) Proceeds (sales price) (e) Cost (or other basis) 4 Short-term gain from Form 6252 and short-term gain or (loss) from Forms 4684, 678, and Net short-term gain or (loss) from partnerships, S corporations, estates, and trusts from Schedule(s) K Short-term capital loss carryover. Enter the amount, if any, from line 8 of your Capital Loss Carryover Worksheet in the instructions ( ) 7 Net short-term capital gain or (loss). Combine lines a through 6 in column (h). If you have any longterm capital gains or losses, go to Part II below. Otherwise, go to Part III on page See instructions for how to figure the amounts to enter on the lines below. (d) (e) This form may be easier to complete if you round off cents to Proceeds Cost (sales price) (or other basis) whole dollars. 8a Totals for all long-term transactions reported on Form 099-B for which basis was reported to the IRS and for which you have no adjustments (see instructions). However, if you choose to report all these transactions on Form 8949, leave this line blank and go to line 8b 8b Totals for all transactions reported on Form(s) 8949 with Box D checked Totals for all transactions reported on Form(s) 8949 with Box E checked Totals for all transactions reported on Form(s) 8949 with Box F checked Gain from Form 4797, Part I; long-term gain from Forms 2439 and 6252; and long-term gain or (loss) from Forms 4684, 678, and 8824 (g) Adjustments to gain or loss from Form(s) 8949, Part I, line 2, column (g) (g) Adjustments to gain or loss from Form(s) 8949, Part II, line 2, column (g) 2 Net long-term gain or (loss) from partnerships, S corporations, estates, and trusts from Schedule(s) K- 2 3 Capital gain distributions. See the instructions 3 4 Long-term capital loss carryover. Enter the amount, if any, from line 3 of your Capital Loss Carryover Worksheet in the instructions ( ) 5 Net long-term capital gain or (loss). Combine lines 8a through 4 in column (h). Then go to Part III on page ,500 For Paperwork Reduction Act Notice, see your tax return instructions. Schedule D (Form 040) OMB No (h) Gain or (loss) Subtract column (e) from column (d) and combine the result with column (g) (h) Gain or (loss) Subtract column (e) from column (d) and combine the result with column (g) 8,000 6,500,500

5 Schedule D (Form 040) Page 2 Part III Summary Combine lines 7 and 5 and enter the result 6,500 If line 6 is a gain, enter the amount from line 6 on Form 040, line 3, or Form 040NR, line 4. Then go to line 7 below. If line 6 is a loss, skip lines 7 through 20 below. Then go to line 2. Also be sure to complete line 22. If line 6 is zero, skip lines 7 through 2 below and enter -0- on Form 040, line 3, or Form 040NR, line 4. Then go to line Are lines 5 and 6 both gains? Yes. Go to line 8. No. Skip lines 8 through 2, and go to line Enter the amount, if any, from line 7 of the 28% Rate Gain Worksheet in the instructions 8 9 Enter the amount, if any, from line 8 of the Unrecaptured Section 250 Gain Worksheet in the instructions Are lines 8 and 9 both zero or blank? Yes. Complete the Qualified Dividends and Capital Gain Tax Worksheet in the instructions for Form 040, line 44 (or in the instructions for Form 040NR, line 42). Do not complete lines 2 and 22 below. No. Complete the Schedule D Tax Worksheet in the instructions. Do not complete lines 2 and 22 below. 2 If line 6 is a loss, enter here and on Form 040, line 3, or Form 040NR, line 4, the smaller of: The loss on line 6 or 2 ( ) ($3,000), or if married filing separately, ($,500) Note. When figuring which amount is smaller, treat both amounts as positive numbers. 22 Do you have qualified dividends on Form 040, line 9b, or Form 040NR, line 0b? Yes. Complete the Qualified Dividends and Capital Gain Tax Worksheet in the instructions for Form 040, line 44 (or in the instructions for Form 040NR, line 42). No. Complete the rest of Form 040 or Form 040NR. Schedule D (Form 040)

6 Form 8949 () Attachment Sequence No. Page Name(s) shown on return. Name and SSN or taxpayer identification no. not required if shown on other side Before you check Box D, E, or F below, see whether you received any Form(s) 099-B or substitute statement(s) from your broker. A substitute statement will have the same information as Form 099-B. Either will show whether your basis (usually your cost) was reported to the IRS by your broker and may even tell you which box to check. Part II Long-Term. Transactions involving capital assets you held more than year are long term. For short-term transactions, see page. Note: You may aggregate all long-term transactions reported on Form(s) 099-B showing basis was reported to the IRS and for which no adjustments or codes are required. Enter the totals directly on Schedule D, line 8a; you aren't required to report these transactions on Form 8949 (see instructions). You must check Box D, E, or F below. Check only one box. If more than one box applies for your long-term transactions, complete a separate Form 8949, page 2, for each applicable box. If you have more long-term transactions than will fit on this page for one or more of the boxes, complete as many forms with the same box checked as you need. (D) Long-term transactions reported on Form(s) 099-B showing basis was reported to the IRS (see Note above) (E) Long-term transactions reported on Form(s) 099-B showing basis was not reported to the IRS (F) Long-term transactions not reported to you on Form 099-B 2A Social security number or taxpayer identification number Adjustment, if any, to gain or loss. (e) If you enter an amount in column (g), (h) (c) (d) (a) (b) Cost or other basis. enter a code in column (f). Gain or (loss). Date sold or Proceeds Description of property Date acquired See the Note below See the separate instructions. Subtract column (e) disposed of (sales price) (Example: 00 sh. YZ Co.) (Mo., day, yr.) and see Column (e) from column (d) and (Mo., day, yr.) (see instructions) in the separate (f) (g) combine the result instructions Code(s) from Amount of with column (g) instructions adjustment 2 YZ CORPORATION VARIOUS ,000 6,500,500 2 Totals. Add the amounts in columns (d), (e), (g), and (h) (subtract negative amounts). Enter each total here and include on your Schedule D, line 8b (if Box D above is checked), line 9 (if Box E above is checked), or line 0 (if Box F above is checked) 8,000 6,500,500 Note: If you checked Box D above but the basis reported to the IRS was incorrect, enter in column (e) the basis as reported to the IRS, and enter an adjustment in column (g) to correct the basis. See Column (g) in the separate instructions for how to figure the amount of the adjustment. Form 8949 ()

7 Payment Voucher Filing Instructions Date to file by: Payment: $70 Address to file: Other Instructions: Internal Revenue Service P.O. Box 24 Charlotte, NC 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 040" on your check or money order. To pay by credit card, go to Taxpayer Records: Amount Paid Check Number Date Mailed Form 040-V () Detach Here and Mail With Your Payment and Return Form 040-V Payment Voucher OMB No Department of the Treasury Internal Revenue Service (99) Do not staple or attach this voucher to your payment or return. 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" 70 BUMBLE BEE Internal Revenue Service 00 DRONE LANE P.O. Box 24 SAN ANTONIO, T 7820 Charlotte, NC For Paperwork Reduction Act Notice, see your tax return instructions HP BEE

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