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Name, Address, and SSN

See separate instructions.

P R I N T C L E A R L Y

OMB No. 1545-0074 Your rst name and initial If a joint return, spouses rst name and initial Last name Last name Apt. no. Your social security number Spouses social security number

Home address (number and street). If you have a P.O. box, see instructions. City, town or post o ce, state, and ZIP code. If you have a foreign address, see instructions.

Make sure the SSN(s) above and on line 6c are correct.

Presidential Election Campaign

Checking a box below will not change your tax or refund.

Check here if you, or your spouse if ling jointly, want $3 to go to this fund .

You

Spouse

Filing Status
Check only one box.

1 2 3

Single Married ling jointly (even if only one had income) Married ling separately. Enter spouses SSN above and full name here. Yourself. If someone can claim you as a dependent, Spouse Dependents: . . . . . . . . . . . . .
(2) Dependents social security number

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

Qualifying widow(er) with dependent child

Exemptions

6a b c

do not check box 6a . . . . . . . . .


(3) Dependents relationship to you

. .

. .

. .

(1) First name

Last name

(4) if child under age 17 qualifying for child tax credit (see page 15)

Boxes checked on 6a and 6b No. of children on 6c who: lived with you


did not live with you due to divorce or separation (see instructions) Dependents on 6c not entered above

If more than four dependents, see instructions and check here d Total number of exemptions claimed . . . . . . . . . . . . . . . . .

Add numbers on lines above

(FOLD)

YOUR 2014 INCOME


SUBTRACT: Exemptions _____ x $12,500 SUBTRACT: Mortgage Interest SUBTRACT: Charitable Contributions SUBTRACT: State & Local Taxes SUBTRACT: Capital Gains & Dividends YOUR TAXABLE INCOME

$
$ $ $ $ $ =$ x 20%

TAXES OWED

=$

Signature Signature

Date Date