2011 Gillibrand Taxes

Cieparlme<1l f tile T(e"'ury o

Inle mal Re~oue Se",,,'"

Filing Status
Check only

1 2 3 6i1

~Single Married filing loinUy (even If only one had income) Married filing Sl!parately. Enter spouse's SSN aOOVe & full

4

D Head of household gualiNing personperson). (See (with qualifying instructions.) If the is a thlld
but not your dependent, enter this child's

~

Exemptions

c Dependents:

b..J...~====~~~~~~tn~~~~~~~~~~~-~ (3) Dependent's
relationship to you

2 2

If more than tour dependents, see instructions and check here....

D
d Total number of exem tions claimed

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,.. . .. ..

.

_

, ........•.........•..........

Income
Attach Form(s) W·2 here. Also a ttaeh Forms W·2G and 1099·R if tax was withheld.

7 Wages, salaries, tips, etc. Attach Form(s) W·2 ,. . DeB. . 8a Taxable interest. Attach Schedule B if required. . . . . . . . . . . . . . . . . . . . .

.

5., 0,0 0.. 1-7::--1f------=-=~~:-:• _....• ~8_ar-

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b Tax-exempt Interest. Do not include on line 8a ...........•. L_;::.8",b..___ --------1 9a Ordinary dividends. Attach Schedule B rt required. . . .• . .. ,..... . .. , ... _.•. " ....•..... b Qualified dividends , .. ' - -. .."." ..• .___9;;_b:;.l.... 10 12

-r

98

'1 Alimony received. 13 14 15a
16a 17 18

If YQU did not get a W·2, see Instructions.

Enclose, ut do b

not attach, any payment Also, Form 1640· V.
please use

19
20a

Taxable refunds, credits, or offsets of state and local income taxes . "." _". >". . - - .. . . .. . .. .. .. .. .. . .. .. .. . , .. - ,. . Business income or (loss). Attach Schedule C or C·EZ ,.,.......... Capital gain or (loss). Att Sch D if reqd, If 1101eed, ck here r __ - .. Other gains Of (losses). Attach Form 4797. , .........•..................••.... IRA ~istributions ,: b Taxable amount. - - . _. Pensions and annuities _ 16a. _b Taxable amount Rental real estate, royalties, partnerships, S corporations, trusts, etc .. Attach Schedule E. Farm income or (loss). Attach Schedule F., - _., , Unemployment compensation. . .. .. . .. .. .. .. _.. . .. .. . . . . •• . . .. . .. .. . .. SIlCiaJ security renelits _ _ 1 20al I b Taxable amount. •..•........

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22 Combine tI1e aiiio~
23 24-

21 Other irn:M18

in the fa;:- right-c;~nfoflin~ iih-;:O~h2i-:-Thlsls -ur-totaii"n"Co-me-:-_-:-.-:-.-:-.-:-.': -:- ~J...:o:22-o-I-----=1-:6:-:5:-/-6~1""'4-.
t-=23::;_t-1 ~24=-t----_----1 ~25;-r--1

21

Adjusted Gross Income

1-26'5-+---------i J...:o:Z1::--r-------___l 28 Self-employed SEP, SIMPLE, and qualified plans. -., .. , 1-"28.:......,1-- ------1 __ 29 Self-employed hea!lh Insurance deduction. .. . ........•. , ~29-:-t--1 30 Penalty on early withdrawal of savings ..•..... _... - .. , ... - 1----::'30:O--r--11 31 a Alimonypaid b Recipient's SSN. . .. t-:::3'::--a=t-1 32

25 26 Moving expenses. Attach Form 3903 Z1 Deductible of self·employment Attach Schedule SE .,. . part tax.

Educator expenses .. " ..... _....... _... .. . . .. . Certainbusiness expenses of reservists, performing artists,and foo·basis gmfflfnmenl officials. Attach Form 2\(6 or 2100·EZ ,., Health savings account deduction. Attach Form 8889_ ......•

33
34 35

IRA deduction ..............•. " Stu:dentloan interest deduction Tuition and fees. Attach Form 8917

_ -

, ..•...... --

_.•• ~32:o--1f--------___l - . , • J.-.:::334r-------___l t-:::34::-1f----

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35 - ... , .... - . . . . .... 1---36~+-_

36 37

BAA

37

165 614. Form 1040 (2011)

___:;_:o;:__:::_=_70:.._.

Form 1040 (20n)

Kirsten

E. and Jonathan M. Gillibrand

Tax and Credits

38 Amount from line 37 (adjusted gross Income). . . .. . .. .. ...• • • , •.. . . . . . . .. .. ;.;' -+-,3:.:8~ '.;.,' 39a C.heck {DYOU were born before January 2, 1947, Blind. Total boxes ft. Spouse was born before January 2, 1947, Blind. checked" 39al.,-,.

0

8

Pag_e2

-=1:..;6:..;5,-,-6::..1:::....::4..:....

b If your spouse itemizes a separate returnor you were a dual·status aliM, cheek here .•.... on ,. .. 39b Standard Deduction ,---40 ltemiled deductions (from Schedule or your standard deduction (see instructions) . . . . . • •. . •• . A) ':":'" 40 lor41 Subtract line 40 from line 38 .. . . . . .. .. ." .. .. , • , ., . 41 • People who 42 Exemptions, Multiply $3,700 by the number on fine 6d _ . 42 check any box 43 Taxable incOIlH'!. Subtract line 42 from line 41. on line 39a or 43 If line 42 is morethan line 41; enter ·0-. . . . . . . . . . . . . . . . . . . . . . . . .. ,.......... ., ... , .. _ .... ' .. 39b or who can be claimed as a 44 Tax (see instrs), Check if any from: : ~~~~(~~~.1~. _.... ~. eleCtl.~n. dependent, see· 44 instructions. 45 Altemative minimum tax (see instructions). Attach Form 6251 ..•....... ,' .,. _ .••.•..• 45 46 Add lines 44 and 45 ,." , . .. . . . . . . . . .. . •.. . . .. . .. . . . . . . . .. .. . .. 46 • All others: Single or 47 Foreign tax credit. Attach Form 1116 if requIred. ,.•. Married filing 4B 4B Creditfor child and depefllent care expenses. Attac:horm 2441.•.... f separately, $5,800 49 Education credits from Form 8863, line 23.. ,. .. .. 49 Married filing 50 Retirement savings contributions credit Attach Form 888Q .. t-::.50~1___i Jointly. or 51 Child tax credit (see instructions). ," , .. , . . . . . . . . . .. ~5;;':--I1___i Qualifying widow (er) , 52 Residential energy credits. Attach Form 5695 t-='S2~1___i $11,600 Head of 53 Oiller CIS from form: a b 8801 c nL.....JL. __ ~~.....l.;;5~3:....d. ---l household, 54 Add lines 47 through 53. These are your total credits •......... . _. . . . . . . . . . .. .. _ ~54":'_I$8,500 55 Subtract line 54 from line 46. If nne 54 is more than line 46, enter ·0·, _.. . . . .. .. "55 56 Self· employment tax.AttachScttedule SE.. . . . . . .. . . . . . .. , ~56:::--IOther 'S1 Unreported social security and Medicare from Form: a 04137 tax b 8919 .......•........ , 1-::57~1Taxes 58 Additionalax on IRAs, other qualifi¢ retirement plans, ele. Attach Form ~329 if required ..•....•.•• t _ . . . . . .. ~58=-I59a Household employment taxes from Schedule H. . . . .. . .. _ ~59=-a;:+b First-time hornebuyer credit repayment. Attach Form 5405 if required _. .. .. .. ' t-::.S=-9=bl60 Other taxes. Enter code(s) from instructions ~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 60

136

28,948. 14,800.
666,

8

121,866. 22,717. 23
479.:..

9.9.62

187.

0:>800

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23, 187 •
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Payments
Qualifying child, attach Schedule EIC.

61 Atkt lines 55-(~J. is yoor tetanax .. , This . ._ 62 Federal income tax witflheld from Forms W·2 and 1099. ..,

_ 62
63

If you have a

63 2011 estimated tax payments a~d amount
64a Earned Income credit (EIC) b Nootaxable combatpay election
65

'. "~61~----2:::-::-8 27 • 219 .

-, 8~2~8=--.

applied frem 2010 return

,

15 • 517 .
-I

66
67

Additional child tax credit. Attach Form 8812, ... , .......•.. American opportunity credit from Form 8863, line 14...• ,

1L764.:..;b""I!'-:::::-:-::,---

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t-::.65~1-

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First-time homebuyer credit from Form 5405, line 10 •....•.. 68 Amount paid with request for extension to file. .. . .... - .... 69 Excess social security and tier 1 RRTA tax withheld ...•.. , 70 Credit for federal tax on fuels. Attacl1 Form 4136 ,

!-'-66.;._I-r=fU::,-I-------___i r=68~Ij.....::69~1t---:::7~0-+

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Refund
Direct deposit? See instructions.

Creditsfrom Form: a 02439 b 8839 c 8lI11 d 08885. \..-'7:..:''-'72 AddIns 62. 63,643,& 65-71. Theseare ~ur total pmts.. .. .. .. • .. .. .. . . 13 If line 72 is mare than line 61, subtract line 61 from line 72. ThiSIS the amnum you overpaid 74a Amount of line 73 you want refunded to y_ou. If Form 8888' is attached, check here

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0

0

-1 -1 -t

-1
..

.. b Routing number .. d Account number
75

Amount You Owe Third Party Designee

Amount of line 73 you want applied to your 2012 estimated 18K . • . . . •. ... 75 76 Am~unt you owe. Subtract line 72.fromline.61. for details on howto pay see,i!1stru 77 Estimated tax_~nal!y_ (~~e InstructIons) .. ._ ~..........•.. ,__. 71

1 }QQ{XXXXXXX I c Type:n 1XXXXXXXXXXXXXXXXXX}{)0O{XX

Checking

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0 Savings
2 000

D

72 42, 736 • 1-"-73~1-----l~3z...:.:.9_=0""8...:.... 1-=-74..:.;2I=4...;1=1.!.., =.9..:;0.::.8...:.... _

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Do you want to allow anotherperson to discuss this returnwith the IRS (see instructions)?. ,
Designee's

lRl Yes.

,I-<~

Complete below.

~ma

...

Sign

Joint return? See instructions, Keep a copy for your records.

Here

.Under penalties of belief, !tel' are true,
Yovr

.illf13llT11
II j"int both mustsilln. Date

~~~-"-~~~~~-----4~--~~~~~----~--------a ,~wm.
name

Paid Preparer's Use Only

Rutnik
F~m's address'" _

CPA

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.

signature

PC

fDlAOl121

11/07111

(Form 1040)

SCHEDULE A
.. Attach to Form 1040.

Itemized Deductions
.. See Instructions for Schedule A (Form 1040) •

OMS

No, 1545 ·0074

2011

Na "",(s) shown On Form I 04()

Kirsten and
Medical Dental Expenses

E. and Jonathan
, 2

M. -Gill,ibrand

rour

50£101 Sill=,=ily="=um:....b_e_,

_

Caution. Do not include expenses reimbursed or paid byothers. Medical ami dental expenses (see insnuctions) , , . , .... , . , .•. , .. " ..•. f •• I-"""-+-----------l Enter alTlGUnt from Form 1040, line 38.. , I. _;2:::...J1I...... ~-t Multiply line 2 by 7.5% (.075) , . .. .... , ...... , .. , ..•.. I..-.::.3...,L.. Subtract line 3 from line 1. If line 3 is more than line 1, enter .0- .. ,......•. State and local (check onl~one

3
4 5

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4

Taxes You Paid

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6 7

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~:es

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box);

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Real estate taxes (see instructions)

. , , . , .•...........•.....•.

Personal property tax, . .. . " 8 Other taxes. List type and amount >

8 9
Interest You Paid

25,800.

'0
11

Kome mIg interest and points reported to you on Form 109& ' .• .•..

. .....

,f--',..;0-t

----I

Home mortgage intemt not reported to you on Form 1098. If paid to the person from whom you bought the hooie, see instructions and sOOwthat person's name, identifying number, and address ...

Your mortgage

Note.

interest deduction may be limited (see instrs).

______________________________

+1..;_1'--1

-1 ----l --; -l ,... '5

12 p~jnts not reported 10 you on Form 1098. See instrsfor spclrules.. , ...•. ' •.. f--01.;;;2-+ 13 Mortgage insurance premiums (see instructIons) . , .....•. , ... , f--1..::.3-+
'4 15 Investment interest. Attach Form 4952 if required. ,

(See mstrs.) .. ,
Gifts to 16 17

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,

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Add lines 10 through 14 .. " more, see instrs .. _

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Gifts by cash or check. If you made any gift of $250 or

Charity

r--:'..=64

4=-S=O-'-[,

If you made gift and got a benefit for it. see instructions,

a

Other than by cash or check. If any gift of $250 or more. see instructions. You must attach Form 8283 if over $500 .........•...•... , .,', .................•.......... , ' " "., , [--'-'.:..7-+'_'. L...:l.:8~ ,... ., •. . .. . . .. .. .. ....•••..... ---1 _, Carryover from prior year. , ..• ,_, , .. ,

18

19 Add lines 16 through 18 Casualty and Theft Losses Job EXpenses and Certain
Miscellaneous Deductions

19
20

4S0.

20 Casualty or theft lossjes). Attach Form 4684. (Seelnstructions.)
21 Unreimbursed employee expenses - job travel, union dues, job education,etc. Attach Form 2106 or 2106·EZ if required. (See lnstructrons.) ~ ~_

o.

I~
-=-3 .... 0-=-0:-O~. 3...:,_0_1_0--r'

22 Tax preparation fees , _ ......•..•............. 23 Other expenses - investment, safe deposit box, etc. List
type and amount .... ....

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---- - - - - ---

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'-I' ,....;2::..:1--+ , .• ~,22~t-

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Addlines21through23

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,

25 Enter amount Irom Form 1040,line 38. 1 251 " 26 Multiply tine 25 by 2% (.02), 27 Subtract line 26 from line 24. If tine 26 Is more than line 24 enter ·0, •..
Other Miscellaneous Deductions Total Itemized Deductions

+-23=-,. :-+------::-::-:-=--1 24 6,010, 165, 614 . ~~ , .. '. __ ,... 26 3, 312.
_ . _. . .. _ 'Z1

2.698.

28

Other - from Iist in instructions.

List type and amount ....

28 29 Add the amounts in the far right column for lines 4 through 2!il.
Also,

o.

enter

this amount on Form 1040, line 40 .......

, ......

, .. ;. .. .. . . . . . . . . . .. . . . .. . . ...

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FDIA03011 11129111

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BAA For Paperwork Reductlon Act Notk:e', see Form 1040 Instructions.

Schedule A (Form 1040) 2011

SCHEDULE B
(Form 1040A or 1040)

Interest and Ordinary Dividends
~ Attach to Form 1040A or 1040, • See Instructions,

OMBNo, 1545

2011

Name(s)

sr.,wn on renen

Kirsten E, and
ParU, -Intcrest
(See instructions for Form 1040A, or Form 1040, line sa.) 1

J
Ust name of payer. If any interest is from a seller-financed mortgage and IDe buyer used the property as a personal residence, see the instructions and list this interest first. Also, show that buyer's social security number and address ~

~_~~a~~

~1~~~~~~~~ ~~~~eE_~~q®~
y~~5£~~~~

_

_ _
_

~~~---------------------------------------=~~~orm 1099,tNT. Form 1Cl99·0tD. or s.ubsblule stalemenl
from a brokerage firm, I~! the linn's

1

~~.fe,'~~f
Chat form,

interest shown oil

2 3

Add the amounts on line 1 , ,. , ' . ' , .. , . , , , ,' El<cludable interest on series EE and I U.S. savings bonds issued after 1989. Attach Form 8815 , .. " _. _...•.... ", ' , , ,' , , , ..•. '..•. , ' . , .. ' , , , . , _. ".,

~

list llame of payer, ~

_

Part II Ordinary Dividends
(See instructions for Form l040A, or Form 1040, line sa)

~~Form 1099-DIVor subst>tule statement from e broke<"f.Ie rlfm, 1.. 1 !he ijrms name, as I,., payer ordinary dividends sho,"" on Chal form.
and enter !he

5

Part III Foreign Accounts and Trusts
(See Instructions.)

You must complete this part if you (a) had over $1,500 of taxable interest or ordinary dividends; (b) had a foreign account; or (c) received a distributlen from, or were a grantor of. or a transferor to, a foreign trust. 7a At any time during 2011. did you have a financial interest in or signature aVJthorily over a financial account (such as a banK account, securities account, or brokerage account) located in a foreign country? See instructions , ........•....•..•.....•..•..•... , ...•..•. '.', .• , ..••. '.•... " .. ,'. , ...•.......

'1r_,::;i~1;o;_

If 'Yes: are you required to file Form TO F 90-22.1 to report that financial interest or signature authority? S Form TD F 90-22.1 and its instructions for filing requirements and exceptions to those requirements ... - , , ... I--X-rl_--. b If you are required to file Form TO F 90-22.1, enter the name of the foreign country where the financial account is located ~ _U!!-!t;_e.Q._~~q<!..o~ _ 8 During 2011, did you receive a distribution from, or were you the grantor of, or transferor to, a foreign trust? If 'Yes: you ma have to file Form 3520. See insltuctions .. , '" " ,', .
FDtAiJ401L 111151]1

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BAA

For Paperwork Reduction Act Notice, see your tax return Instructions,

Schedule B (Form l040A or 1040) 2011

SCHEDULE 0
(Form 1040)
Depa'lmen!

OMB No, 1545·0074

Capital Gains and Losses
.Attach
(99)

InternalReve"". S.Mce

of tile Treasury

to Form 1040 or Form 1040NR, .See Instructions for Schedule D (Form 1040). • Use Form 8949 to list your transactions lor lines 1, 2, 3, 8, 9, and 10.

2011

I Part I I Short-Term

Capital Gains and Losses - Assets Held One Year or Less
~e) Sales ~ice from (~Cost or other basis rom Form(s) 8949, ormcs) 8 9, line 2, line 2, column (f) column (e)

Complete Form 8949 before completing line 1, 2, or 3. This form may be easier 10 complete if you round off cents to whole dollars 1 short-term tolals from all Forms 8949 with box A checked In Part I ........ , . , , , , •...... box B checked in Part I .... ,.

(91 Adjustments to
gain or loss from Form(s) 8949, line 2, column -(g)

(h) Gain or (loss) Combine columns (e). (f), and (g)

2 Short-term lola Is from all Forms 8949 with

. ... ~ . ~ . - - ~-

3 Shari-term totals from all Forms 8949 with
box C checked in Part I , ..... , , . , ..........

50,086.

58,900.
4 5 6
7

-8,814 '.

4 snort-term gain from Form 6252 and short-term gain or (loss) from Forms 4004, 6781, and 8824 . , ~ ........ 5 Net short-term gain or (loss) from partnerships, S corporations, estates, and trusts from Schedule{s) K·1. ... 6 Short-term capital loss carryover. Enter the amount, if any, from line 8 of your Capital loss Carryover
Worksheet in the instructions. ..• , .... , . , , .. , , . , , ... , .................... , , , .... , ... , .• , .. , . , ... , , .•• , , ..

-26 796.
-35,610.

. mart Ii

7 Net short-leon capital gain or (loss). Combine lines 1 through 6 in column (h). If you have any lonq-terrn capital gains or losses,' go to Part II below. otherwise, go to Part ilion page 2 ... , ....... ", , ........ , . , , ..

I Long-Term

Capital

. GainS

and Losses - Assets Held More Than One Year
~e) Sales ~ice from orrnts) 8 9, line 4, column (e) (f) Cost or otne r basi s from rorm(s) 8949, line 4, column (f) (g) Adjustments to gain or loss from Form(s) 8949. line 4, column (g) Gain or (loss) Com ine columns (e), (f), and (g)

Complete Form 8949 before completing line 8,9, or 10. This form mat be easier to complete if you round off cents to wale dollars

(ht

8 long·term

totals from all Forms 8949 with box A checked in Part II............... _.... box 8 checked In Part

9 Long·term totals from all Forms 8949 with

n, ...........

, , ......
, ....

10 Long·term totals from all Forms 8949 with
box C checked in Partll ....... , , ..•... 11

1,755.
11

-1,755,

Gain from Form 4797, Part I; lonq-terrn galn from Forms 2439 and 6252; and long-term gain or (loss) from Forms 4684, 6781, and 8824 .. , .... _. , ..... , .. , . , ., ._ .. , ....... ,' ., . " .•..... , ............. , ....... ". gain or (Ioss)fmm partners.l1ips, S corporations, , ' ..... , ......................... estates, and trusts from Schedule(s) , , . , .............................. .....

12 Nellong·term

K·' . .. 12
13 14
••

13 Capitalgaindistributions, eeinstrs......... S 14

W~.t;=

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if. ~n~:,f~~~ .Ii~e .1, .~f.:~.u~.~~.~~~I.~.~~~.~~":~v~ ~

page 2 . , ... , ..• , , ................ , BAA For Paperwork Reduction Act Notice, see your tax return mstrucuons.
> ••••••••••••••••••••••••••••• , •

15 Net long-te.rm capital gain or (loss). Combine lines 8 through 14 in column (tI), Then go to Part III on
, , ...... , '" , •••• ,', , • , ' ••• , , • , , ' •• ,

15 -1,755. Schedule D (Form 1040) 2011

FDIA0612L l1n5l11

Schedule 0

2011

Kirsten

and Jonathan M. Gil

Ip~t1111
16

ISummary
16

Combine lines 7 and 15 and enter the result. If line 16 is a gail1,. enter the amount from line 16 on Form 1040, line 13, or form 1040NR, Ifne 14. Then go 10 line 17 below. -llllne16 is a loss, skip lines 17 through 20 below. Then go to line 21. Also be sure to complete line 22. If line 16is Zero, skip llnes 17 through 21 below and enter ·0- on Form 1b40, line 13, or Form l04ONR, line ,4. Then to go hne 22. -

-37,365.

17 Are. lines 15 and 16 both gains?

o o

Yes. Go to line 18. No. Sklp lines 18 through 21, and go to line 22. ..... . ..... ~r::.18=-t_

18 ,9

Enter the amount, if any. from line 7 of the 28% Rate Gain Wo,rksheet in the Instructions.. Enter the amount, if any, from line 18 of the Unrecaplured the instructions _ . .....•...•......... Are lines 18 and 19 both zero or blank?

Section 1 250 Gain Worksheet in .. . ,. __.. , .• • .. _

_.

..

1!;1

20

D D Tax Worksheet 1C4qInstructions. 00 not complete lines through 22 below.Then complete No. Complete FOl,? throug.h line 43, or Form 104{lNR line 41. the 21 and
In

DYes. Complete Form 1040 through line 43, or Form 1O4ONRthrough line 41. Then complete the Qualified Oividends.and Capital Gain Tax Worksheet in .the instructions lor Form 104{l, line 44 (or in the Instructlons for Form 1040NR, line 42) .. 00 not complete lines 21 and 22 below. the Schedule'

21

If line 16 is a loss, enter here and on Form 1040. line 13, or Form I040NR, line 14, ll1e smaller of:

-•
22

The loss on line 160r ($3,000), or if married filing separately, ($1,500)

}

.........•.....•..

r •.

-

_ •••

21

-3. 000.

Note. When figuring whiCh amount is smaller, treat both amounts as oosttlve numbers. Do you have qualffieddividends on Form 1040, line 9b. or Form l040NR, line lOb?

D Yes. Complete Capital1040 through line 43, orinForm instructionsthroughForm 1040, line completein the Quali.fied Form l040NR line 41. Then the DIvidends and Gain Tax Worksheet. the for 44 (or
instructions for Form l040NR, line. 42). . the rest of Form 1040 or Form l040NR. Schedule 0 (Form 1040) 2011

IRI No. Complete

fDIAClSI2l

I IIlS!1 I

Form

8949

OMS No. 1545-0074

Note. You must check one of the boxes below. Complete a separate Form 8949, page

t

for each box that is checked.

*Caution. 00 not complete column (b) or (g) untH you have read the instructions fo( those columns (see Instructions fur Schedule D (Form 1040). Columns (b) and (g) do not apply for m051 transactions and should generally be left blank.

o

(A) Short-term transactions

reported on

D (B)ShorHerm
(Mo. tlay. yr}

transactions reported on Form (d)
Dale sok!

00 (C) snort-term
(I) Cos!

transactionsfor

which

Form 109g,'?_lYith basis rellorted to the IRS (b) (a) DeSctipliOl"l 01 property
(Example: 100 shares 'tYZ Co) lor rolumn

1099·8 but basis not resorted to the IRS (c) Date acqui red
(Mo. day. yr)

vcu.cannot check box A or-B
or olt;e, basis (se.··'nSl't.£I!OllS)

Code. tf aoy.

(g)-

(e) Sales pnce (see i~~trl!Ctlo",,)

(g) Adlustments to qaln Or toss, If any ....

1

5/10/10 35 Ishares FTSE Ch na OpU pns-Expired 2/03)10 15 Abercrombie & F tch - C !?tions ExpiI ,ed 2/05/10 35 Coach Inc- CpU! DS Expi T;ed
6/08/10

5 Ishares FTSE Chi a Optic ps-Expired

1/25/11 1/25/11 1/25/11
1/25/11

O. O.

889. 7,207. 1,611. 1,692, 853. 993. 771.
864.

o. o.
O. O.

SPDR Gold Trust (old - C ptions EX-Pi! ed 5110/10 4 Lululernon Athlet ca - Ot tions Expire d 10/08/10 15 Carnival corp - Options Expired. 10/08/10 5 Deckers Outdoor orp - C ptions ExpiI ad 10/27/10 10 Crox Inc - Opt! ns Expi red 10/27/10
4 11

1/25/11 .' 1/25/11 1/25/11
3/21/11

O.

o.
O.
I

1/25/11
8/17111 11/04/11

966. 2,580. 917, 1,456, 890. 968. 668. 758. 898. 880. 792, 5,903.
872.

Abercrombie

&F

tch

Various 10/19/11

1,522. 2,22.4. 410. O. O. O. 836.
,

9 Abercrombie

s Fi ch

17 Bed Bath & Beya d Inc Various 7 Bed Bath & Beyon Inc-OJ;..ons Expire ~ :i 10/18/11 10 Crox Inc - Opti ns Expi'r"ed 2/01/11 10 Crox Inc - OpU ns Expi red 5/02/11
5 Crox Inc 6/06/11

6/18/:1,.1 11/22/11 3/21/11 6/21/11: 10/03/11 10/05/11

10 Crox Inc 8 Crox Inc 3 Deckers Outdoor

9/09/11

2,732. 5,914. O.

10/18/11 10/17/11 ('orp - C pt tons Expl1ed 2/01/11 3/21/11 70 Deckers Outdoor Corp - Options Expi ~ed Various 6/21/11 2 Deckers Outdoor (orp - C ptians ExpiI ed 6/07/11 9/20/11
Totals. Add the amounts in columns. (e) and (f), Also, combine the amounts in column ~). Eliter here and include on Schedule D, line 1 (if box A above ischec ed), line 2 (if box B above is checked). or line 3 (if box C above jscheckedY. , .. , , . .-. .... . . .. . •.. .. . . .. . . . . . • . . . . ... . . . . .. ~ BAA For Paperwork Reduction Act Notice, see your tax return Instructions. 2

o.
O. 50 086.
FDIAn1 ZL 1111:>111

.

2

58,900.

o.
Form S949 (2011)

Form

8949
OIl

0M8 No_ 1545-0074

Depa<tment of !he Treasury I nternai Revenue Se<vice Name{s, shown relum

... See instrudions' for Schedule ... For more information about Form 8949, ... Attach to Schedule D to list transactions

Sales and Other DisDositions

Note. You must check one of the boxes below. Complete a separate Form 8949, paqe 1, for eat:h box that is checked. ·Caution. Do not complete column (b) or (g) until you have read the instructions for those columns (see Instructions for Schedule D (Form 1040», Columns (b) and (g) do not apply for most transactions and should generally be left blank.

o

(A) Short-term transactions

reported on

Form 1099-8 with basis reported to the-'.[3S (b) (a) Oescrip(loo of properly
(E_!e: 100 .hares)Nl
Co) for colurm

o

(B) short-term
Dale acquired (Mo. day, yr)

transactions reported on F(l(m ~(C)

Short-term transactions for which (I) Cost or other basis
(see inslruct;o.,s)

1099·8 but!l_.asis

not

reoorted to the IRS
(e) Sales price (SC<l instrocllOns)

vou cannot check box A or B (9) AdlustmenlS to gain or loss. If any"

Code, if any, (gJ'

(c)

(d)

Oate sold (Mo, day. yr)

1

( Orp - C ptions Exp1t ed 9/19/11 5 Fossil Inc - Opt ons Exp ired 1/:i,2!11 12 Fossil Inc Various Inc - Opt ons EJqi fired 10/17/11 6 Green Mountain C( ffee-OJ;[tions Expire d 3/10/11 25 Green Mountain (offee-( ptions Exp Lr ed Various 8 Green Mountain Cc ffee-Of:ltions Expire d Various
2 Fossil
1

3 Deckers Outdoor

10/25/11 3/21/11 8/18/11 11/22/11 4/19/11 6/21/11 9/20/11 10/05/11 6/21/11 5/13/11 9/28/11 11/22/11 3/21/11 6/16/11 7/19/11 7/19/11 8/23/11 10/21/11 3/21/11 6/01/11 8/10/11
2
FOIA9212l

O.
O.

972 .. 864. 2,755. 932. 933. 3,559. 1,729. 736. 912.
,

-

3,831. O. O.
O.

O.

B IPath S

Green Mountain C ffee 9/19/11 & P 500 Options Expired 5/03/11 IShares Silver Tl
R R

1,815.
O.

8

5/03/11 9/16/11

3,304. 8,308.
O.

912.

15 IShares Silver
10 IShares

816. 90B. 939. 883'.
589.

Silver 5 Lululemon Athlet 7 Lululemon 8 Lululemon Athlet Athlet

ca

-01:

-10/18/11 ions ExpirE d 2/01/11

O. 237.
O. O. O.

ca 6/10/11 ions Expire d ca - O~ ... 6/22/11 10 Lululemon AthIe ica - C pt.Lons Expir t!d 6/15/11 8 Lululemon Athlet ca - OJ) ions Expired 6/23/11
5 Lululemon

814. 913. 889. 946. 942. 939.

1 Netflix
3

Athiet ca 9/19/11 Inc - Op ions E~ pired 2/01/11 Inc rusises 5/02/11 5/03/11

826.
O.

5 Royal Caribbean

Opentable

3,318. 5 611.

2 Totals. Add the amounts in columns Ce)and (f). Also combine the amounts in column Enter here and include on SchedUle D, line 1 (if

~~~ ~:~ ~ l ~~~k~·.

ffl)'

~i.~~ ~i~.~o~.~. :~.~~~ ~

.i~.~~~~:~i~.~~.~if .~r. ..

BAA For Paperwork Reduction

Act Notice, see your till< return Instruaions.

11115111

Form 8949 (2011)

Form

8949
Oil

OMB No. 1545·0074

Departmenl of the Tre<lSUlY anternal Reve-nue Service
Name(s) shown

.. See instruction !Ifor Schedule D (Form 1 (40). .. For more information about Form 8949, see www.irs.gov/form8949 .. Attach to Schedule D to list transactions for lines 1,2,3,8,9, and 10.

Sales and other DisDositions of Caoital Assets

12A

re!urn

Note. You must check one of the boxes below. Complete a separate Form 8949, page 1, for each box that is checked. 9Caution. Do not complete column (b) or (g) until you have read the instructions fO.( those columns (see Instructions for Schedule 0 (Form 1040». Columns (b) and (g) do not apply for most transactions and should generally be left blank.

o
1

(A) snort-term

transactions

reported on to tile IRS (b)

D(S) sbort-term transactions reported on Form !K](C) Short·term transactions for which
1099·B but basisnot (c) Dale acQuired reoorted I0 the IRS (d) Date wid
(Mo, day, Y'I
Sales pncs (see instruction;.)

Form 1099·.8 with"basisreoorted (a) Desor'lliion '" p<operIY (Example: 100 shares XYZ OJ}

you cannot check b ox A or B (f) Cost or other basis
(see instruction.)

f£~~u~(~j

t"'",. day. yr)

(e)

gain

(g) Adjustments 10
Of

loss, if allY"

4 Royal Caribbean 5

(rllsises
5/05/11 8/18/11 9/28/11 9/16/11

4,579.
4,499.

629.
959.

SPDR Gold Shares

Totals. Add the amounts in columns (e) and (I). Also, combine the amounts in column (g). Enter here and include on Schedule D, line 1 (if box A above is checked), line 2 (if box B above is checked), or line 3 (if box C above is checked) ... _...... _. . • . . . . . . . . . • . . . • . . •• • . . .. . . . . . .. ... BAA For Paperwork Reduction Act Notice, see your tax return instructions.

2

2
FDIA9212L 1II15111

Form 8949 (2011)

Form 89492011)
~I"me(s) shown on return"

00 no! enter

n~"", and .<;<;:ial ",,,,,,my numbe"lf she"", on page 1"

I Part
D(A)

II

I Long·Term

Capital Gains and Losses - Assets Held More Than One Year

Note. You must check. one of me boxes below. Complete a separate Form 8949, page 2, for each box that IS checked.

Cautio"n_ Do not complete column (b) or (g) until you have read the instructions for those columns (see Instructions lor SChedule D (Form 1040». Columns (b) and (g) 'do not apply for most transactions and should generally be left blank.
Long-term transactions reported on Form 1099-8 with basis reported to "the IRS
(a) De<crip~Oll of proll"rt~ (Example: 100 shares XYZ Co)

o

(B) Long-term transachons reported on Form [!j{C) 1099-8 but basis not reported to the IRS (d)
Date sold

Lonq-terrn transactions for which

you cannot check box A or B
Sale. price

(b) Code, il
cot~;,/i~.

(C) D.teacQUi,ed (Mo. oay. y<)

(e)
(:;e.

(I) Cost or 01"" ~aslS
"(""" in""""~,,",,)
to

(g) Adjustments
9"in"or I"" s, ,I any

{Mo. day, y.-j

;nsln>ctiootS)

3 3 Ishares

FTSEChiI a Optioll,s-Expired 1/12/10 5 Abercrombie & Filch - Op ions Expire~ 1/12/10

1/25/11

0, O.

816. 939.

1/25/11

4

Totals. Add the amounts in columns (e) and (f)., Also, combine the amounts in c,?lumn (g). En!er here and include o,n Schedule D, line 8 (if. box A above rs checked), hne 9 (If box B above IS checked), or line 10 (If box C above is checKed) _ , , , .. , .. ", •..• , •. , , .. _. . . . . • ~
FDIA9212L 1111Sill

4

o.

o.
Form 8949 (2011)

e2
name and social security

'---"'-"-.;.;;.__, Income or Loss From Partnerships
27

and S Corporations Note. If you report a loss from an at-risk activity for which any amount is not at risk, you must check the box in column (e) on line 28 and attach Form 6198. See instructions. ~No Ce)Check if any amount is not at ri sk

28 A B C

Are you reporting any loss not allowed in a prior year due to the at-risk or ba'sis limitations, a prior year unallowed loss from a passive activity (if thai loss was not reported on Form 8582). or unreirnbursed partnership expenses?., DYes If you answered 'Yes, see instructions before "Y this section. (b) Enter P (c) Check if (d) Employer for partnership: (a) Name foreign. ldennfication S for S pa rtnersh fp number

Wind Crest LtC'

P

0
Pa sslve Income and loss (f) Passive loss allowed (attach Form 8582 if required) A

1

, Income and Loss (h) Nonpasslve loss from Schedule K·1 e*o~VY~~£§2n

9)Passive income rom Schedule K-1

~~~;~~~~
:

349.

_!! _£
D 29a Totals ....•.... b Totals ..
"-'

......

...

.. ,1

1

'v ,

30 31
32

Add columns (g) and

<D

of line 29a ....

Add columns (I). (h). and (I) of line 29b

349. ~ ... . - ....... - . ............... ~ ~ ~ - .... . .~ ......... ....... ~ ..... .~ . ....... _-_.- ... _. . ................... -... - ~ _, ... ... - --_ ... ......
"

..

.

,

30

,

,

31
32 (b) ...

-349. -349
10 no.

Total partnershic and S corvoration income or (loss). Combine lines 30 and 31. Enter the result here and include in the, to at on line 4 below '.~" ....

I D ...... m

I ''''''VIII'C or Loss From Estates and Trusts

~

AI

(a) Name

81
Passive Income and Loss (c) Passive deduction or loss allowed (attach Fonn 8582 if required) ~) Passive Income om Schedule K-1

II.In"n""";',,,

tncome and Loss (f) Other income from Schedule K· 1

(e) Deduction or loss from Schedule K·l

_M

BI

34a Totals .. , .. . bTotals,.,. , 35 36

. . . .. . .. . ~ .... .. - . - - .....
,,
,

.'"c
• ' ' •• + .... •••

,C)

-,-

', ,.,

. ~ ...... ,

,

,

Add columns (d) and (I) of line 34a ....

~~ ... ....

...

-

.,•• , ..............
"to •••• , ................. ~ ••• _ ••

,.

...

-

-

-

•••

-

+

35

Add columns (c) and (e) of line 34b .. , ..• , .•. , .....

, . , .. , ....

, .•...

, .....

, . ' ...•..••....

• ••••• ·

rr

....

'

.....

__

36

37 Total estate an4n~r:~~~~e~~S~n~( mUll here and
I/;)ii'

_em 41 below, '.. Income or Loss From _~eal Estate ...v. '
(a) Name

lines 35 and 36. Enter the .' . .. .. . . . . . .. . . . . .. . . . n . "........;C!i:1duits (f1:EMICs) - _Residual t Ijne 2c.fsee

Hol~er_
~e)11 Sch from Q,Iine,3b

38 39

(b) Employer Identification number

\~mEx~~~~1~~~ (d}~~[~~~:~?~m~t Sci. I

1b

~P-ifrC'i"f;!;J <:;'1
40

Combine. columns (d) and (e) only. Enter the result here and include in the total on line 41 below. Net farm rental income or (loss) from Form 4835. Also, complete line 42 below ...•.•............ Form 1040, line 17, or Form l040NR, line 18 ................. , ....................................... ,,

39 .... ~ .....
40

41 Total Income or (loss). Combine Ilnes 26, 32, 37, 39, and 40. Enter the result here and on 42 ReconciliatIon
of farming and fishing income. Enter ~our gross farming and fishing income reported on Form 4835, line 7: sc edute K·1 f:orm 1065), box 14, code 8; Schedule K·l (form 11208), box 17, code U; an Schedule K·1 (form 1(41), line 14, code F (see Instructions). ....... , ., ..................... IllStructlo 1040 or

~

41

-349.

43 Reconciliati~!ifi~~estate
professional anywhere on in which you

y4

~l
',"

=
.... jjij ,

;m'

professioniJls. If you were a real estate ~f[~~come or (losS) YGU reported all rental real estate activities •under . passive actIvity loss rules.
FDIZ2302L 10125i11

,
.........

.

431

BM

Schedule E (Form 1040) 2011

Form

2441
/QO

Child and Dependent
\ ~ ...)

Care Expenses

OMBNo.154S'()074

.. Attach to Form 1040, Form 1040A, or Form 1040NR.
Depa'tmenl at tne Treasury Internal Revenue _S"",jre Name(s) shown on return

.. See separate instructions.

(d) Amount paid (see instructions)

7.
8 219.
Did you receive No ----~ Complete only Part II below. Complete Part III on page 2 next.

dependent

care benefits?

Yes ----~

Caution. If the care was provided in your home, you may owe employment taxes. If you do, you cannot file. Form I040A. For details, see the instructions for Form 1040, line 59a, or Form 1O4ONR line 5ea.

(a) Qualifying person's name

(b) Quallifying person's social security number

(c) Qualified expenses you incurred and paid in 2011 for the person listed in column (a)

3 4

Add the amounts in column (c) of tine 2. Do not enter more than $3,000 for one qualifying person or $6,000 for two or more persons. If you completed Part Iii, enter the amount from line 31 " , . Enter your earned Income. See instructions , , .. __ , ......• ' , _ ' . II married filing jointly, enter your spouse's earned income (if your spouse WqS a student or was disabled, see the instructions); all others, enter the amount from line 4. .. _. __

5

6 Enter the smallest of line 3, 4. or 5 _. __.. ,
7

,

,_
'--''--''---------1

Enter the amount from Form 1040, line 38; Form 1040A. line 22; or Form l040NR, line 37. , . _ _ _ _,. _. _, _. - _ _. _...•....... ,"',

8 Enter on line 8 the decimal amount shown below that applies to the amount on line 7 If Hne 7 is: If line 71s: But not Decimal But not Over over ilmount is $0- 15,000 35 $29,000- 31,000 31,000- 33,000 15,000- 17,000 .34 .33 17,000- 19,000 33,000 - 35,000 .32 35,000- 37,000 19,000- 21,000 21,000- 23,000 .31 37,000 ....39,000 23,000- 25,000 .30 39,000- 41,000 41,000- 43,000 25,000- 27,000 .29 43,.000- No limit 27,000- 29,000 .28
9 10

Decimal
.27

is

..26 .25 .24
.23

8

X

,22 ,21
,20 _

Multiply line 6 by the decimal amount on line 8. If you paid 2010 expenses 1n 2011, see the instructions, . . .. ~9~1Tax liability limit. Enter the amount from the Credit Limit Worksheet in the instructions; . .. _. _...... . ..•. _.. , •....... , .... ___ .. . .......••.. '.,. line 46

,._:.10::......J', . , .. , .

1

11

Creditfor

here and on Form 1

child and dellendellt

11
Form 2441 (2011)

FDIA3212L

10/13111

Form

Kirsten E. and Jona
Care Benefits

M. Gillibrand

2

I Part III I Dependent
12

Enter the total amount of dependent care benefit.s you received in 2011. Amounts you received as an employee should be shown in box 10 of your Form(s) W·2. Do not include amounts reported as wages in box 1 of Form(s) W·2. If you were sell-employed or a partner, include amounts you received under a dependent care assistance program from your sole proprietorship or partnership. .•.•..... . ........•... Seeinstruct!ons .....•....•... , _........•....... _ ,. _.. ' _

,. j-.!.12=.' + j-.!.13;:_1----14

....;s::...!...

-=O..::O~O:.;.c. _

13 Enter the amount, if any, you carried over from 2010 and used in 2011 during the grace period.

14

Enter the amount, if any, you forfeited or carried forward to 2012. See instructions .••. , .

15 Combine lines 12 through 14. See instructions .•..... 16

...•.•.••••.

_. _

_..

. . . . . . . . • . .• 1-'.:..::5'-+

....:S'-,-=O---=-O---=-O--=--., '·

Enter the total amount of qualified expenses Incurred in 2011 for the care of the qualifying persort{s). . . .. . _. _ . __, ., Enter the smaller of line 15 or 16

17

__ , , .• , __ , . , ,
.' ".,

,,

,
,

18 Enter your earned Income. See instructrons

19 Enter the amount shown below that applies to you. • If married filing jointly, enter your spouse's earned income (if your
• All others. enter the amount from line 18, 20 21 22 Enter the smallest of line 17, 18. or 19.....

spouse was a student or was disabled. see the instructions for line 5). • If married filing separately, see the instructions.

1
,
. ,-., :::~::

1-1_:__:6=------t~__=2:..:0"'-,'-:3:-:3:-6::--'-i. __

,. J-+-17:__I-

~S~O:..;O:.:.O:....:..;.
---=l""5=---·..:..8_,__,---=8..:;2'"'1~.

" .. 1---'-1..:..8-+

1-'-19=---1-----

-1

.............. ,, .. --..... j-.:2::0~_-------;:°4· 21

Enter $5,000 ($2,500 if married filing separately and you were required to enter your spouse's earned income on line 19) , , ", >, •.••• , •••••• _.. Is any amount on line 12 from your sole proprietorship

5,000,

23 24

E::~

IR1 No. Enter

or partnership?

(form 1040A filers go to line 25).

-0·.
.. ..". .• ::::.::::::::::::.:.

~;;e;;~~o~~~~n~~.er.~:::::::.::

t~··1············5~·606-.r-=22=-----:Ir--::24..:....t-

___;:O'-'.:...

DeductibJe benefits. Enter the smallest of line 20. 21, or 22. Also, include this amount on the appropriate Ilne(s) of your return. See instructions. .. .. . ...........•...••...•. , •.. ' .,. -, , .. ,.....

..;;0....;_.

25

Excluded benefits. Form 1040.and 1040NR fliers: If you ctlecked 'No' on line 22. enter the smaller of line 20 or 21. Otherwise. subtract line 24 from the smaller of line 20 or line 21. If zero or less, enter .0·. Form l040A filers: Enter the smaller of line 20 or line 21 ,. . .- ,, ," r=25=--tTaxable benefits. Form 1040 and l040NR filers: Subtract line 25 from line 23. If zero or less, enter ·0·. Also, Include this amount on Form 1040, line 7; or Form 1040NR. line 8. On the dotted I~ne next to Form lQ40. line 7; or Form 1040NR, line 8, enter'DCB.' Form 1040A filet's: Subtract line 25 from line 15. Also, indude this amount on Form l040A, line 7. In the space to the left of line 7, enter 'DC8' .. '." , , ,

---"O;_:':...

26

26

5,000.

To claim the child and dependent care credit, complete lines 27 through 31 below.
27 Enter $3,000 ($6,000 if Iwo or more qualifying persons) .•.••.......
28 29 30 , ..•
...
, •• , • ~ ••••••••• , ••• r • ~ ....... ~ ...

27
2B

Form 1040 and 1040NR filers: Add llnes 24 and 25. Form 1040A filers: Enter the amount from line 25 . , ... , Subtract line 28 from line 27. If zero or less, stop" You cannot take the credit, Exception. If you paid 2010 expenses in 20n, see the instructions for line 9.. , ............... " ....... " ......... _.. , , .......... ' .. Complete line 2 on page 1 of this form. Do not include in column (c) any benefits shown on line 28 above. Then. add tne amounts in Column (c) and enter the total here ......................... _............... , .. Enter the smaller of line 29 or 30. Also. enter this amount on line 3 on page 1 otfhis form and complete lines 41hrough 11 .....••....... , ....•........................ , ............... , ..... , .......•.

29
30 31 Form 2441 (2011)

31

FDIA3212L

10113111

Form

6251
(~) l040NR shown on Form 1040 or Form

OMS

No. 1545,0074

Alternative Minimum Tax - Individuals
~
~ See separate instructions. Attach to Form 1040 or Form HI40NR.

01 the T reasurv Interllill.R""""". Service
Der>ar1men! Na

met")

I,Part I
1

Kirsten E. and Jonathan M. G1l1ibrand

I Altemative

Minimum Taxable Income JS~e instructions for how to complete each line.)
1

liiiiii
2
• ~

ScquerlCe No_
ber

AHachmerrt

2011
32

If flnng Schedule A (Form 1040), enter the amount from Form 1040, line 41 and go to line 2. Otherwise, enter the amount from Form 1040, line 38, and go to line 7. (If less than zero, enter as a negative arnount.), 38_ II zero or less, enter .0" , ........ _. , , .. , .•...

136,666. 25,800. 2,698. -4,260.
.

2 Medical and dental. Enter the smaller of Schedule A (Form 1040), line 4

2.5% (.025) of Form 1040, line _... , __.. , .. _. ...... , .... ,. .,.... , . ~ , .......... ...
01"

... _ .. --.-- ....... 3 Taxes from Schedule A (Form 1040), line 9.-__••.. ,' -j'4 Enterthe home mmtgage interestadjustment, any, from Hne 6 of the worksheetn the instructions this Hoe, . , ......... - .. ~- . _ ... if i for .. 5 Miscellaneous deductions from Schedule A {Form 1040), line 27. .. ' .. - ... -- , . - - . - -.~... . " .... -_ ...... . .. , .~ ..... - ............ 6 Skip this line. It is reserved for future use , , . _•... , ..... .. .. -- . - ... . ~ ~ ~ ..... ...... , .. - -- .~ ........ 7 Tax refund from Form 1040, line 10 or line 2L .. __ ... -- ... -. ..... . -- . - - ~ - .. - . - ~ 8 Investment interest expense (difference between regular tax and AMT), ..... , ,
f • , •• ••••••••
-F ••• ,

.

3

,

,

,,

4 5
6

.;.

_

,

-•t

.

.01-

-

•••

~

...

-

7
B 9

9 11

Oepletion (difference between regular tax and AMl) Alternative tax net operating loss deduction ..•.....

..

••

,1._,

••

_

"

••

'

••••

~

••

6

••

~

•••

,

••

_

~

-

-

1-

-

-

•~

0"

_

_'

•••

' •••••

-_

10 Net operating loss deduction from Form 1040. line 21. Enter as a positive amount. ....•.....
• , • _ ," ••••

12 13 14 15
16

_ ...... . _ ... ~. - .. - .. - -.-, Interest from specified private activity bonds exempt from the regular tax. ......••........•.•..••.••.....
' ~ L

" .........•..
• _ ••• ~ •••• " __ •

_
_

_.

10 '1 12
13

Qualified small business stock (7% of gain excluded under section 1202)............................... Exercise of incentive stock options (excess of AMT income over regular tax income) .......•..• Estates and trusts (amount from Schedule K·1 (Form 1041), box 12, code A)\ .-•• , •.... Electing large partnerships {amount from Schedule K·1 (Form 1065·8), box 6} ............ _•.... ,_ ..... , ..•.......•.• , .•.........

'"
, , ... , ... ' •. ,. _.. _._
~

14 15
16 17
.

17 Disposition of property (difference between AMT and regular tax gain or loss) ....... 19 Passive activittes (dlHerence between AMT and regular tax income or loss).

_.......•...•......

18 Depreciation on assets placed in service after 1986 {difference between regular tax and AMT) ...•..

--.

_,

~ .. r

••••••

"-'

•~,

•••

t •••••.

,•

20 loss limitations (difference between AMT and regular tax income or loss) .. _. _-'-.rO.. ....... _ 21 Circulation costs (difference between regular tax and AMT) ... , ... , ...... ' ..•....... _, ......... , ....•• ' ......... 22 Long·term contracts (differen-ce between AMT and regular tax income) ......•. 23 Mining costs (difference between regular tax and AMT). _ - ............ , . ...... ,,'. ~ .~ ...... - ... - - -_ ... .. •• ~ , ., • _ 4 • ~ ••••••• , • ~ I

'"

'

•••

¥

,

18 19 20 21
22

.

,

,

24

25 26 27
28

I Riift·JIt!

Research and experimental costs (difference between regular tax and AMT) ....•........•.•... "'" ....... Income from certain installment sales before January 1, 1987. ...........•..•. _....•. _.•. _.. _ -- ........ Intangible drilling costs preference ... , ...........•.. < ••••• --- ... ...... , ... . - _ ......... - .. ..... ..Other adjustments, including income- based related adjustments ..•.............. , ... , . .................. Alternative minimum taxable income. Combine lines 1 through 27. (If married flling separately and line 28 i$ "more than $223,900, see Instructions.). , _...... , . , .......... - .... -.- ... , ............. ,.' ,,, ........... , "
"-

.......

'r·

••

23 24 25 26 27 28

I Alternative JVlJmmumTax (AMT),

...

160,904.

29 Exemption. (It you were under age 24 at the end of 2011, see Instructions.)
IF your filing status is •... Single or head of household .............. , .......
, ,

AND line 28 is not over •••

THEN enter on line 29." •
, ~ r c.~ ~

... . $112,500 ........
150,000 ....... 75,000 _._ ·· ,

$48,450

Married filing joinlly or qualifying widow(er) •.....

,. , __•..

-

~

&

••

74,450

30

37,225 Married filing separately .. , ....... _.. _......... , • _...... .... f-'··'·· If line 28 is over the amount shown above for your filing status, see instructions. Subtract line 29 from line 28. If more than zero, go to llne 31. If zero or less, enter ·0· here and on lines 31, 33 and 35, and go to line 34 .. __' .. , _____....................... __...........•... _...•...•...... , .......
-If you reported capital ~in distributionsdirectlyon Form1040, line 13; youreported qualifieddividends Form on 1040, line 9b; or you hada lrii~ on bothlines 15and 16of Schedule D(Form1040) (as refiguredfor tile AMT,f i necessary), comptete Part II on page 2 and enterthe amountfrom line 54here. - All others: If line 30 ls $175,000 or less ($87,500 or less if married filing separately), mUI~16line 30 bJ 26% (.26). Otherwise, multiply line 30 by 28% (.28) and subtract $3,500 ($1, 5 if marrie filing separately) from the result.

}

- .-

.~ 29

71,724.

31 -If you are filing Form 2555 or 2555-EZ. see instructions for the amount to enter.

}

32 Alternative minimum tax foreign tax credit (see instructions) ................. _".. _•. _.. ' .................. 33 Tentative minimum tax. Subtract line 32 from line 31 ... , ............... , ...... , ................. , .... ' •. 34 Tax from Form 1040, line 44 (minus any tax from Form 4972 and any foreign tax credit from Form 1040,

l
32 33 35

31

30

89,180. 23,187.

~7th:Z? 'U~iXg~~:~~~~~~~;

'il~ tn~~~~~~~l)o~~ ~.~~~~t. .~~:t~.e. . ~r~.~.I.i~e.~. ~~:.~~. ~o:_~~~~~.~~.r:~?~~~~ . 34
, .• ,
FDIA5312t ~2122111

23,187.
22,717.

35

AMT. Subtract line 34 from line 33. If zero or less, enter ·0·. J;:nter here and on Form 1040, line 45 ..... Act Notice, see your tax return instructions.

470.
Form 6251 (2011)

BAA For Paperwork Reduction

SCHEDULE
(Form 1040)

H

Household Employment Taxes
(for Socia! Security. Medicare. Wlthhe!d Income. and Federal Unemployment (FLfTA) Taxes)

OMS

No. t545·1971

Deparl rnent ot

~ntem3_~ReVEIltJe Sensce

t"" T ,eaSlJl)'

.. Attach to Form 1040, l040NR, 1040-55,0,.1041.
.. See separate instructions.

2011

A

Did you pay anyone household employee cash wages of $1.700 or more in 2011.1 (If any household .employee was your spouse, your child under age 21, your parent. or anyone under age 18, see the line A instructions before you answer this question,)

IRI Yes.

o
B

Skip lines Band Cand go to !ine 1. Go to line B.

No.

Did you withhold federal income tax during 2011 for any household. employee?

o o
C

Yes. Skip line C and go to line 5. No.. Go to line C.

Did you pay total cash wages of$l,ooO or more in any calendar quari:er of 2010Qr 2011 to all household employees? (Do notcoun! cash wages paid in 2010 or 2m1 to your spouse, your child under age 21, or your parent)

o
I Part I

No.

Stop. Do not file this schedule. Skip lines 1-7 and go 10 line B. (Calendar year taxpayers having no household employees form for 20 ~1). in 2011 do not have to complete this

D Yes,

1 Social Security, Medicare, and Federal Income Taxes
_.. _.... , ..

1 Total cash wages subject to social security taxes. _.... __....•.....
2 Socia.1security taxes. Multiply line 1 by 10.4% (.104) ... Total cash wages subject to Medicare taxes ..... Medicare taxes. Multiply line 3 by 2.9% (.029) Federal income tax withheld, if any .. _

-l,_,.:...1.__

:;.2.:;:3..!..,-'0:..;8;-._:6:..;.'-l.
. 1---i'2:.." .l--_:;.2_,, _ _:::4--=-O=-1~.

3
" 5 6

. __.. _.... " .• __. ......•..... , .•..............

.... 1 3 1 L_~b, _" ._ .. _ _.. __ _ _

~~~~

23,086.

'1-4.:.. _ .

+-

--=6:..;6:..;9~.

5 6

2,495. 5,565,

Total social Seturity, MediCilre,aml federalincometaxes. Add lines 2, 4, and 5 ....

_.•...

<! .•.

.~ ••

~'~

.•'.~

• ..... rl~j.~-

7

Did you pay totill cash wages. of $1,000 or more in any calendar quarter of 2010 or 2011 to all household emplyoyees? (Do not count cash wages paid in 2010 or 2011 to your spouse, your child under age 21, or your parent.)

o
IKJ

No.

Stop. Include the amount from line 6 above on Form 1040, line 59a. If you are no! required to file Form 1040, see the line 7 instructions. .

Yes. Go to line

8.
Reduction Act Notice,

BAA For Privacy Act and Paperwork

see the Instructions.

SchedUle H (Form 1040) 2011

FOIAS412L

12105111

I Part II I Federal Unemployment (FUTA) Tax
8

Schedule H (Form 1040) 2011

Jonathan M. Gillibrand
Yes to ~n.l: one slate ~ (~f. :o.u. ~a.,~.~O~:~ibut~~~~ ~.~~edi.l.r.ed~~~i~,ri::~~e,_ ::~ .to.

Page 2 No

~~t(~tlg~~ ~~cT~~k~~\c~:tri~.u."~~

9 Did you pay all state unemployment contributions for 2011 by April 17,20127 Fiscal year filers, see Instructions ... , 10 Were all wages that are taxable for FUTA tax also taxable for your state's unemployment tax?,
~.. i _ •• , •• , ••.•
I •• ~,

8 9 10

X
X

X

Next:

If you checked the 'Yes' box on all the lines above, complete Section A. If you checked the "No' box on any of the lines above, skip Section A and complete Section B.

Section A
11 13 Name of the slate where you paid unemployment contributions. paid to your slate unemployment fund ... , ..... Total cash wages subject to FUTA tax. , ..... .•. . _. _....•. .... DC '

12 Conlrlbulions

112

I

322.
13

_.. _._ _. __.. _" .. _

9,932.
76.

Section B
15 COI1}~ete all columns below that apply (if you need more space, see instructipns):
(a) Name of slate (b) Taxable wages (as defined in state act) (c) State experience rate period

I

(d) state experience rate

(e) Multlpl~ column (b) by .054

(I) Multiply column (b) by column (d)

(g) Subtract column (f) from column (e). If zero or less, enter -0·.

(h) Contributions paid to state unemployment fund

From

To

16 Totals .. , - ,- - 17 18 19

- ._ , """ Add columns (g) and (h) of line 16 .. ,

.•..•. _

, ...•........ ,

-.-

,_ ..• , , .. ,

"\ ,."

'I

.1.__';..::6---'-..

-r---rL...--. --I

_

l,---,-1 7'----'J'-

Total cash wages sub~ect to FUTA tax (see the line 13 instructions)

18 19

20
21 22

Multiply the portion of the wages on line 18 paid before July 1 by 6.2% (.062). Multiply the portion of the wages on line 18 paid after June 30 by 6.0% (.060). Enter the sum of those amo~nts or line 19., •. _., ..... Multiply line 18 by 5,4% {.054) , , L..__20==--___.l -; Enler the smaller of line 17 or line 20 , , , _.. _ , _.. _ _ , (Employers in a credit reduction state must use the worksheet and check here). '. - .. ,

0
' •••••

_ 21

lti" Ill, 1Total
24 25

FUTA tax. Subtract nne 21 from line 19. Enter the result here and go to line 23 ..

t ,_,

, _ •••••

_ •••••••••

22

Household Employment Taxes
, ..•....
, . __.. __.... , •. . . _. _.. _.. • , ,. . , ..............•.

23 Enter the amount from line 6. If you checked the 'Yes' box on line C of page 1. enter -0Add line 14 (or line 22) and line 23 .... Are you required to file Form 1040?

_" ... , . 23 '-=-'-'..___ 24

----'---'----=---=_=_

5 565. 5,641.

I!I Yes.

59a. 00 not complete Part IV below.

Stop. Include the amount from line 24 above on Form 1040, tine

Apartrnen1, room, or suite oumber City. town or post office. state, and ZlP code Under penalti@s of peq...-y. I dedare that I have examined this schedule, lrlClu:!ing acc~anying statements. arid to the best of my F<nowledge arid. belief. it is true. cooed. and co"l'le!e. No part of any payment ma,de to a state Ilnemployment fund claimed as a CI&d.1 was, Of IS to be. deducted from tm payments to employee s. Declaration of preparet (olrer than ta.Il")'ef) IS based on allmformation of wtl.ch preparer has any kilowtedge.

~~~~~----------------------------------~~------------------Err.,JoylJ<'s slgnat ...e PrlnVType prepares's name

Paid Preparer Use Only

I

Preparers

signature

loate

Date

Check if self-employed

Firm's name ... Firm"s address ..

nl

PT1N

Firm's ElN ..

Poone no.
fDlA9412l 12/05111

Schedule H (Form 1040) 2011

Kirsten E. and Jonathan
5107112

'M,

Form 1040 Wage Schedule

Statement 1

Taxga~f:I - EmI:!loJL~r United States Senate Dependent Care Benefits (DCB) Grand Total

Federal WLH Nage~ 158,821. 27,219. 5,000. 163,82l. --21,219.

FICA 4,486. 4,486.

MediQgre 2,303. 2,303.

State

WLH

Local

WLH

10,467. 10,467.

o.

2011
5/07112

'.

.Federal Suppl~mental.thJ~tlt1i~lrtiit)
Kirsten A Line 21 Unreimbursed Employee Expenses for Member of US

Form 1040 Schedule Total reflects Senate.

$3,000 IRC 162(a) limit on DC living expenses

New York State Department

of Taxation

aod F:mance

Resident Income Tax Return
New York State. New Yorl< City. Yonkers For help completing your return. see the instructions for Form IT-201. You must enter your date(s)of
Your

2011

IT-201

For the full year January 1, 2011, through December 31, 2011, or fiscal year beginning birth and sodal security number(s) below. Your last name (JoT a joi,,' retum enterspouse's name",,",,~ GILLIBRAND
Spouse's last ""me

firs: ""me and m.adle j",t!al

below)

Your date 01 beth

KIRSTEN
Spouse's firSt name and nndd!e initial

E M

spouse'S date of Illrth

JONATHAN
0' post

GILLIBRAND
01 rural "",Ie)

Mld weel

Apartment m.mbe,
COlI1try (if

City. village.

off"",

Stale

~p cooe

na' I)nili!d stateS)
Aportment

pe~5S(S~.;n..uuClicmS)(numbo~"')

rlumber

City> v'II"9~. or post office

SIa.le

ZIP cocle
Decedent

Taxp!l)'e~.s dale of death

NY
(A) Filing status mark an Xin one box:

,,,""maUon:

-.and ending
, Yew, social security no.
New York Sill!. county of resrdenre School district name

• •

cOO. number

Scmal d,SlriOl

Spouse'. dale at death

1 2 3
X

(D) Single Marned filing join! return
(enter spouse's sod<ll

E·file this return. Most taxpayers must now e-file (.see instructions). (1) Did you or your spouse maintainliving quarters In NYCduring2011(see Instructions)! Yes No X

(E)

sea.riZY number abov,,)

(2) Enter the numberof daysspenlin NYCIn 2011 (any part of a day spent in NYC is considered a day)(F) NYC residents and NYC part-year residents only (see instJvctions); (1) Number of months you lived in NYC In 2011 (2) Number of months your spouse lrved in NYC in 2011

Married filing separate retum
(IHItar spouse's sodaJ security _r above)

or monoy

SI""", check

4

Head of household (with qualifying person) Qualifying widow(er) with dependent child Yes Yes

order here_

5

• • • • • •

(B) (e)

Did you itemize your deductions on your 2011 federal income tax retum? Can you be claimed as a dependent on another taxpayer's federal return?

x

No No

(G) Enter y'our 2.character special condition code If applicable (see instructions)

x

If applicable, also enter your second z-cneracter special condition code

Federal income and adjustments

Only full-year NY Stale residents may file tllis form. For lines 1 through 18 below. enter your income items and total adjustments as they appear on your federal return (see instructions). Also see instructions for showing a loss.
Dol"",

1 2 3 4 5 6 7 8 9 10 11 12 13 14 16 17 18

Wages. salaries. lips, etc Taxable interest income Ordinary dividends Taxable refunds, credits, or offsets of state and local income taxes (also enter on line 25) Alimony received Business income or loss (attach a copy of federal Schedule C or C-EZ, Form HMO) Capital gain or loss (if required, attach a copy of federal Schedule D, Form 1(40) Other gains or losses (attach a copy of federal Form 4797) Taxable amount of IRA distrlbullons. If received as a benefiCiary, mark an X in the box If received as a beneficiary, mark an Xin the box SChedule F, Form 1040) Taxable amount of pensions and annuities.

1.
2.

163,821. 882. 4,260. -3,000.

3.
4,

5. 6. 7. 8. 9.
10. 11.

Rental eal estate, royalties. partnerships. corporations, trusts,etc (attach ropy of federill Schedufs E, Form 1040) r S Farm income or loss (attach a copy offedera/ Unemployment compensation Identify: Identify:

-349.

1213.
14.

Taxable amount of social security benefits (also enter on line 27) Add lines 1 through 15 Total federal adjustments to ifl(()me (see instructions) Federal adjusted
~127/11

15 Other il1Come (see Instrs)

gross income

(subtract line 17 from line 16)

15. 16. 17. 18.

165,614.
165,614 _

NYIAI3121

2011111032 You must file all four pages of this original sC8l"!11ablereturn with the Tax Department

IIRI III 11111 1111III 1 III 11111

Page2of4 19

IT-201 (2011)

~itynumbe'

KIRSTEN
Federal adjus1ed gross income (~ge 1)

E. AND

JONATHAN

M
19.

Dollars

165,614 _

New York additions
20 21 22 23

(see instructions) 20. (see instrs) 21. 22. contributions from your wage and ta~ statements (see Instructions)

Interest Income 00 state and local bonds and obligalions (bull1Ot those of NY stole or its local govemmenls) Public employee 414(h) retirement New York's 529 college savings program distributions

Other (sw instfUetiOllS) Identify: 24 Add lines 19 through 23

23. 24.

165,614.

New York subtractions
25 26 Zl 2B 29 30

(see instructions) taxes (from line 4) 25.

Taxable refunds, credits, or offsets of state and locallnoome Pensions of NYS and local glvernments Taxable amount of social securitybenefits(from line 14) Interest income on U.S. government bonds Pension and annuity mcome exclusion Other

4,260.

and the federal government (see iustrS)

26.
27. 28.

(see instructions)

29.
30.

New York's 529 college savings program deduction I earnings

31
32 33

(see instrs)

Identify

31.
32.

Add Jines 25 through 31 New York adjusted gross Income (subtract

line

32 from line 24)

33.

4,260. 161,354.

Standard deduction or itemized deduction
34 Enter your standard deduction below). Mark an X in the appropriate 35 36 37 box: •

(see instructions)
(from worksheet X Itemized Standard or:

(from table below) or your itemized deduction

34. 35. 36.
37.

18,481. 142,873. 2,OO{).
140,873.

Subtract line 34 from tine 33 (if line 34 is more than line 33, leave blank) Dependent exemptions (not the same as total federal exemptions; see instrl.lctions) Taxable income (subtract line 36 from line 35)

or ~ New York State standard deduction table
a
Filing status (from page 1) Standard deduction (enter on line 34 above) b c d Single and you marked item eYes 1 Single and you marked item C No 2 Married filing joint return 3 Married filing separate return 4 Head of household (with qua.lifying person) 5 Qualifying widow(er) with dependent child
NVIA 1312J. 09127111

New York State itemized deduction worksheet
Medical and dentalexpenses (federal Schf!dule A, line f) Taxes you paid (federal Schedule A, line 9) Interest you paid (federal Scrfledule A line 15)

a.
b.

25,800. 450. 2,698. 28,948. 10,467. 18,481. 18,48l. 18,481.

c.

Gifts to charity (federal Schedule A, line 79) e Casualty and theft losses (federal Sqhedule A, line 20) Job expenses/mise deductions(fed .5ch A, tine 27) Other mise deductions (federal Sch A. line 28) Enter amount from federal SchedUle A, line 29
Slate, local. and foreign income taxes (or general sates IIDI. II

d.
e.
t.

$ 3,000

9 h

g. h.
I. j. k.

7,500 15,000 7,500 k I m n o 10,500

~~~~tsa~~~..'t,;~tractloo

SEE 8T 1

j Subtract tine i from line h
Additionadjustmentssee instts) ( Add lines j and k ItemizOO dedudiouadjustmentsee insttuctians) ( Subtract line m from line I

I. m.
n,

College tuitionitemized deduction (see Farm IT·2J2)
New York State itemized dedl,lction and 0; enter on line 34 above) (add lines n

o. p. 18,481.

p

15,000

2012111032
scannable return with the Tax Department.

You must file all toor pages of this original

IJIII I III III 11111Ifl I III Ilf If

Name(s)

as shown

On

p_ 1

number

IT-2m (2011)

Page 3 of 4

KIRSTEN E. AND JONATHAN M. GILLIBRAND Tax computation, credits, and other taxes
38 39 40 Taxable income (from line 37 on page 2) New York State tax on line 38 amount (see Tax Computation in the instructions) New York Siale household credit (from table I, 2, or 3 in the instructions) 40. 41. credits 42. Resident credit (attilch Form IT·112·R or IT- I 12·C, or both; see instructions) 42 43 44 45 46 Other New York State nonrefundable Add lines 40, 41, and. 42 Subtract line 43 from line 39 (if line 43 is more than lIne 39, leave blank) Net other New York State taxes (from Form IT·201·ATT, line 30; attach form) Total New York State taxes (add lines 44 and 45) (from Form IT·201·ATT, line 7; attach form) (see instructions)
Dollars

3&

39.

140,873. 9,650.

41

43.

44.
45.

9,650. 9,650.

46.

New York City and Yonkers taxes, credits, and tax surcharges
47 48 49 50 51 52 53 54 55 56 57 58 New York City resident tax on line 38 amount (see ins trs) New York City household credit (from table 4, 5,
Of

47. 48. 49, See InstructWns to compute NYC and Yonkers taxes, credits, and tax surcharges,

6

In

instme/iorlS)

Subtract line 48 from line 47 (if line 48 is more than fine 47, leave blank) Part-year New York City resident tax (a/tach Form IT-360.I) other New York City taxes (from Form IT-20I-ATT.line Add lines 49, 50, and 51 New York City nonrefundable line 10; attach form) credits (from Form IT·201·ATT, 34; attach form)

SO.
51. 52. 53. 54. 55. 56. 57.

Subtract I1ne 53 from line 52 (if line 53 is more than fine 52, leave blank) Yonkers resident income tax surcharge (see instructions) Yonkers nonresident earninqs tax (attach Form Y-203)

Part-year Yonkers resident income tax surcharge (aitacl1 Form IT-36o. f)
Total New York City and Yonkers taxes/surcharges

(add lines 54 through 57)

58.
59.

59 Safes or use tax (See the instructions.

Do nof leave fine 59 blank.)

85.

Voluntary
60a

contributions

(whole dollar amounts only; see Instructions) 6Oa. GOb. 6Oc.

Return a Gift to Wildlife Missing/Exploited Alzheimer's Fund Olympic Fund ($2 Of $4; see instructions) 9111 Memorial Volunteer Flrefighting & EMS Recruitment Fund (add lines SOa through 60h) (add lines 46, 58. 59, ;;md 6IJ) Children Fund

GOb GOd
60e

GOc Breast Cancer Research Fund

GOd.
60e.

601 Prostate Cancer Research Fund

60g
60h 60 61

6Of. 6Og.
6Oh. 60.

Total voluntary contributions and voluntary contributions

Total New York State. New York City. and Yonkers taxes, sales or use tax,

61.

9,735.

I'IYIAl334L

01103112

2013111032 all four
pages of

You must tile

this original

scannable return

with Ule

Tax Department,

1111111II

m 1111111111111111

Page 4 of 4 62

IT·20l (2011)

.. Ernel

YOUI'"socIal secunty

nlJtrber

KIRST8N E. AND JONATHAN M. GILLIBRAND
Total New York State, New York City, and Yonkers taxes, sales or use tax, and voluntary contributions (from line 6.1 on page 3) 62.

9,735.

Payments and refundable credits
63

(see instructions)
63.

Empire State child credit (attach Form /T·213)

64
65 66 67

NYSINYCchild and dependent care credit (attachFormIT·216)
NYS earned Income credit (EIG) (attach FormIT-2i5 or IT·209) NYS noncustodial parent EIC (attach Form IT-209) Real property tax credit (attach Form IT-214)

64.
65.

If applicable, complete Forms IT·2, IT·l099-R,

68 College tuition credit (attach Form IT·272) 69 NYC school tax credit (also complete (F) on page J; see ins/rs) 70 NYCearned income credit (attachFormIT.215or IT·2(9) 71 Otller refundable credits. (fram FormIT·20I·AIT, line 18; attachform)
72 73 74 Total Ne'l\' York State tax withheld Total New Yor1! City tax withheld Total Yonkers tax withheld Total estimated tax payments I Amount paId with Form tT·370 Total payments. (add lines 63 through 75) (see instructions)

66. 67. 68.
69. 70. 71. 72. 73. 74, 75. 76. 77.

and/or 1T,1099-UI and attach them to your return (see instructions) Staple them (and any other applicable forms) to the top ofthis page 4. See the instructions for the .properassembly of your four-paqe return and all attachments.

10,467.

75
76

10,467.
732.

Your refund I amount overpaid

n

Amount overpaid (if line 76 is more than line 62, subtract line 62 from line 76)

78 Amount of line 77 to be refunded

Mat1t one rllfund choice:
79

direct

deposit

(fllliflllne82)

• or·

debil

card

• or· X

paper check

78.

732. See Itle instructions lor information about your three refund choices.

Amount of line 77 that you want applied to your 2012 (see instructions) mark thIS box

~~~_~ee~~®~ Amoullt you owe
!lO 81

a
and mark line 82

Amount you o..... (if line 76 is less than line 62, subtract lIne 76 from line 92). e To pay by el!JCtronlc funds withdrawal, Estimated lax penalty (Include this amount in line 80 or reduce ~he overpayment on line 77; see Instruciions.)

so.

81.

Account informallon
S2 Account information for direct deposit or electronic funds withdrawal. See instructions.

If the funds for your payment (or refund) would come from (Of 82a
Routing number

gJ to) an account

outside the U.S~ mar~ an X in tltls box (see fnstroctlons)
Electronic funds withdrawal effective date Checking

• •

82Q Account number

820

AccountType

• •
Personal KI""tmcaj,on numb., (PIN)

Tllird "party desiqnee?

Pnnt des'll" ... 's nerne

(see tnstrs.)
X

JONATHAN F. RUTNIK, CPA
No
!;;-mad:

Yes

, Pilid prepllrcr must complete (see Instructions)
Pre parers 519n.tur~
Dale;

,

, Tllxpayer(s) must slfln here ,
Your sIgnature

.. Preperer's NYTRRIN

F, rm's name (0' )"J!Ks._if self-e"lJloyed)

YourOC¢Jpabon

US SENATOR

RUTNIK & COMPANY,
Address

p.e,

Spc ......'s signature and oecupatw>n (If iO/l!t mturn)

Mark an X If seH.employed

FINANCE MANAGER
Oate I::.",.,il;

, Oayllme phone

number

NYIAI334i. 01/03112

2(114111032

You mt.ls\ lil~ all fcnl.r p~g{ls of this orlgin~1 scannaQI@ re:tum wlt}l

ft\{I Ta~ Qepartl11e~t,

111111111111 1 llll III 1111 11111

New York State

De pa ~rne'" of Taxa!","

and F,nance

Summary of W-2 Statements
New York State. New York City.

2011

IT-2

Yonkers

Do not detach or separate the W·2 Records below. File Form tT·2 as an entire page. See instructions.
Taxpeyers. nrst name al'}j midd.le ultUal

KIRSTEN
S~', f~st ""me and middle ,robal

E GILLIBRAND
Spouse's fast name

JONATHAN

M
aox e Employer's

GILLIBRAND
name and full

.aedress ~indudong ZIP code)

W-2 Record 1
Box b Emplo»er idenlmcalioo

UNITED STATES SENATE HART OFFICE BUILDING
BDlIl2a

WASHINGTON
"Code Bo~'5S_ Bo.16 Bo.11

DC 20510-7104
State "'ayes. trps. etc (lor NYS)

A.rnounl

nton'lbef (ElN)
Box

D
1Zb /I""",nI 'Code

NY

158,821.
New Yor1< Stale Income lax w.thheld

T_
(mar~ an X;n """ bol<)' Spouse Boxl2d Amount Box llc

10,467.
A.rnolJllt 'Code
L«ality a b Box

18

Local "'ages,

tips, etc (s...

instr)

Taxpaye< X
BQxt Wages, bps,

other mmpensation

"Cede

Locality

158,821.
ao~8 Allocated lips Box l.oca~,ly •

130.19

Local ircorre

la, wlthheld

13

Statutory employee AIro~nt

locahty

b Box 20 LocaHlya Locality b locality name

Boxl4a

, DeSCl'lption

10,179.
Bo~'O 11
Dependent care benefits

OTHER
, DeSCripboo

~14b

Amount

5,000.
Box Nonq""lified plans Bo.l4c

Amount

, Desctiption Corrected (W -2C)

Do not detach,

BOll c

Employe(s

name and lull address

(induding

ZIP code)

W-2 Record 2
Box Box b Employer ,denllfocalion nember (Ell'l) Box

1Z> Amount

'Code

Bo.15

State

Box 16
Box

Stale wages, tips, etc (10' NYS)

121>

Amount

11

New York Stale income

tax withheld

Till. W·",lrn<:ord Is 10.
(malk

an X In """ OO)t):
Spouse

Box 12<:

AmotJfll

"Code
locaHIY a

Local wages,

ups.

etc

(see in"tr)

Taxpayer

Box 1 Bo. 8

Wages. tips. other compensation

Box

lld /I"",ul'1l

"0000

Locality b

Box 19
Allocated lips

local

income tax withheld

Box 13
Box 143

Statutory employee Amount Locality a

Box 20

Locality

name

Box 10

De~nd.nl

care oonents

Locality b

Box 11

Nonqualm<>tl plans

B~

14<:

Amount

Corrected ~ -2c)

1021111032
NYIA6601 L 10107111

Please file this original

scannable form with the Tax Department.

11111111111111111111111111111

NEW YO'RK STATEMENTS~~
5/07112

STATEMENT 1 FORM IT-201, ITEMIZED DEDUCTION WORKSHEET, LINE I STATE,lOCAl, FOREIGN TAX, OTHER SUBTRACTIONS STATE, LOCAL, FOREIGN, AND GENERAL SALES TAXES, -"' - _.. ', -. -- -. - -- -. _..." --' -r-.$ __ :c-;10OL'-7-46~7.-=-. TOTAL =$ ===10,=,=,==46=7=.

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