Form 1040 tax return summary

Form
1040 Department of the Treasury—Internal Revenue Service
U.S. Individual Income Tax Return

(99)
2017 OMB No. 1545-0074 IRS Use Only—Do not write or staple in this space.
For the year Jan. 1–Dec. 31, 2017, or other tax year beginning , 2017, ending , 20 See separate instructions.
Your first name and initial Last name Your social security number
Robert T Clarke, Jr 315-04-4786

If a joint return, spouse’s first name and initial Last name Spouse’s social security number
MariRenee Clarke 313-96-8786

Home address (number and street). If you have a P.O. box, see instructions. Apt. no. Make sure the SSN(s) above
c
and on line 6c are correct.
1301 Speer Blvd 710
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 80204 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 instructions.)

Filing Status
2 Married filing jointly (even if only one had income) If the qualifying person is a child but not your dependent, enter this
Check only one 3 Married filing separately. Enter spouse’s SSN above child’s name here. a
box. and full name here. a 5 Qualifying widow(er) (see instructions)
Exemptions 6a
b
Yourself. If someone can claim you as a dependent, do not check box 6a .
Spouse . . . . . . . . . . . . . . . . . . . .
.
.
.
.
.
.
.
.
} Boxes checked
on 6a and 6b
No. of children
2
c Dependents: (2) Dependent’s (3) Dependent’s (4) if child under age 17 on 6c who:
social security number relationship to you qualifying for child tax credit • lived with you
(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 Dependents on 6c
instructions and not entered above
check here a Add numbers on
d Total number of exemptions claimed . . . . . . . . . . . . . . . . . lines above a
2
7 Wages, salaries, tips, etc. Attach Form(s) W-2 . . . . . . . . . . . . 7 106,919.
Income
8a Taxable interest. Attach Schedule B if required . . . . . . . . . . . . 8a 116.
b Tax-exempt interest. Do not include on line 8a . . . 8b
Attach Form(s)
9a Ordinary dividends. Attach Schedule B if required . . . . . . . . . . . 9a
W-2 here. Also
attach Forms b Qualified dividends . . . . . . . . . . . 9b
W-2G and 10 Taxable refunds, credits, or offsets of state and local income taxes . . . . . . 10 680.
1099-R if tax 11 Alimony received . . . . . . . . . . . . . . . . . . . . . 11
was withheld.
12 Business income or (loss). Attach Schedule C or C-EZ . . . . . . . . . . 12
13 Capital gain or (loss). Attach Schedule D if required. If not required, check here a 13
If you did not 14 Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . . . 14
get a W-2,
see instructions. 15a IRA distributions . 15a b Taxable amount . . . 15b
16a Pensions and annuities 16a b Taxable amount . . . 16b
17 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E 17 -3,694.
18 Farm income or (loss). Attach Schedule F . . . . . . . . . . . . . . 18
19 Unemployment compensation . . . . . . . . . . . . . . . . . 19
20a Social security benefits 20a b Taxable amount . . . 20b
21 Other income. List type and amount 21
22 Combine the amounts in the far right column for lines 7 through 21. This is your total income a 22 104,021.
23 Educator expenses . . . . . . . . . . . 23
Adjusted 24 Certain business expenses of reservists, performing artists, and
Gross fee-basis government officials. Attach Form 2106 or 2106-EZ 24
Income 25 Health savings account deduction. Attach Form 8889 . 25
26 Moving expenses. Attach Form 3903 . . . . . . 26
27 Deductible part of self-employment tax. Attach Schedule SE . 27
28 Self-employed SEP, SIMPLE, and qualified plans . . 28
29 Self-employed health insurance deduction . . . . 29
30 Penalty on early withdrawal of savings . . . . . . 30
31a Alimony paid b Recipient’s SSN a 31a
32 IRA deduction . . . . . . . . . . . . . 32
33 Student loan interest deduction . . . . . . . . 33 2,500.
34 Tuition and fees. Attach Form 8917 . . . . . . 34
35 Domestic production activities deduction. Attach Form 8903 35
36 Add lines 23 through 35 . . . . . . . . . . . . . . . . . . . 36 2,500.
37 Subtract line 36 from line 22. This is your adjusted gross income . . . . . a 37 101,521.
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. BAA REV 02/22/18 Intuit.cg.cfp.sp Form 1040 (2017)
Form 1040 (2017) Page 2
38 Amount from line 37 (adjusted gross income) . . . . . . . . . . . . . . 38 101,521.
Tax and
Credits
39a Check
if:
{ You were born before January 2, 1953,
Spouse was born before January 2, 1953,
Blind.
Blind.
} Total boxes
checked a 39a
b If your spouse itemizes on a separate return or you were a dual-status alien, check here a 39b
Standard 40 Itemized deductions (from Schedule A) or your standard deduction (see left margin) . . 40 17,167.
Deduction 84,354.
for— 41 Subtract line 40 from line 38 . . . . . . . . . . . . . . . . . . . 41
• People who 42 Exemptions. If line 38 is $156,900 or less, multiply $4,050 by the number on line 6d. Otherwise, see instructions 42 8,100.
check any
box on line 43 Taxable income. Subtract line 42 from line 41. If line 42 is more than line 41, enter -0- . . 43 76,254.
39a or 39b or 44 Tax (see instructions). Check if any from: a Form(s) 8814 b Form 4972 c 44 10,546.
who can be
claimed as a 45 Alternative minimum tax (see instructions). Attach Form 6251 . . . . . . . . . 45
dependent,
see 46 Excess advance premium tax credit repayment. Attach Form 8962 . . . . . . . . 46
instructions. 47 Add lines 44, 45, and 46 . . . . . . . . . . . . . . . . . . . a 47 10,546.
• All others:
48 Foreign tax credit. Attach Form 1116 if required . . . . 48
Single or
Married filing 49 Credit for child and dependent care expenses. Attach Form 2441 49
separately,
$6,350 50 Education credits from Form 8863, line 19 . . . . . 50
Married filing 51 Retirement savings contributions credit. Attach Form 8880 51
jointly or
Qualifying 52 Child tax credit. Attach Schedule 8812, if required . . . 52
widow(er), 53 Residential energy credits. Attach Form 5695 . . . . 53
$12,700
Head of 54 Other credits from Form: a 3800 b 8801 c 54
household, 55 Add lines 48 through 54. These are your total credits . . . . . . . . . . . . 55
$9,350
56 Subtract line 55 from line 47. If line 55 is more than line 47, enter -0- . . . . . . a 56 10,546.
57 Self-employment tax. Attach Schedule SE . . . . . . . . . . . . . . . 57
Other 58 Unreported social security and Medicare tax from Form: a 4137 b 8919 . . 58
59 Additional tax on IRAs, other qualified retirement plans, etc. Attach Form 5329 if required . . 59
Taxes 60a Household employment taxes from Schedule H . . . . . . . . . . . . . . 60a
b First-time homebuyer credit repayment. Attach Form 5405 if required . . . . . . . . 60b
61 Health care: individual responsibility (see instructions) Full-year coverage . . . . . 61 0.
62 Taxes from: a Form 8959 b Form 8960 c Instructions; enter code(s) 62
63 Add lines 56 through 62. This is your total tax . . . . . . . . . . . . . a 63 10,546.
Payments 64 Federal income tax withheld from Forms W-2 and 1099 . . 64 11,868.
65 2017 estimated tax payments and amount applied from 2016 return 65
If you have a
66a Earned income credit (EIC) . . . . . . .No. . . 66a
qualifying
child, attach b Nontaxable combat pay election 66b
Schedule EIC. 67 Additional child tax credit. Attach Schedule 8812 . . . . . 67
68 American opportunity credit from Form 8863, line 8 . . . 68
69 Net premium tax credit. Attach Form 8962 . . . . . . 69
70 Amount paid with request for extension to file . . . . . 70
71 Excess social security and tier 1 RRTA tax withheld 71 . . . .
72 Credit for federal tax on fuels. Attach Form 4136 72 . . . .
73 Credits from Form: a 2439 b Reserved c 8885 d 73
74 Add lines 64, 65, 66a, and 67 through 73. These are your total payments . . . . . a 74 11,868.
Refund 75 If line 74 is more than line 63, subtract line 63 from line 74. This is the amount you overpaid 75 1,322.
76a Amount of line 75 you want refunded to you. If Form 8888 is attached, check here . a 76a 1,322.
a bRouting number 0 3 1 1 7 6 1 1 0 a c Type: Checking Savings
Direct deposit?
See a dAccount number 1 3 5 8 7 3 4 5 0
instructions.
77 Amount of line 75 you want applied to your 2018 estimated tax a 77
Amount 78 Amount you owe. Subtract line 74 from line 63. For details on how to pay, see instructions a 78
You Owe 79 Estimated tax penalty (see instructions) . . . . . . . 79
Third Party Do you want to allow another person to discuss this return with the IRS (see instructions)? Yes. Complete below. No
Designee’s Phone Personal identification
Designee name a no. a number (PIN) a
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
Sign accurately list all amounts and sources of income I received during the tax year. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Here Your signature Date Your occupation Daytime phone number
F
Joint return? See

instructions. Patent Attorney (312)714-9280
Keep a copy for Spouse’s signature. If a joint return, both must sign. Date Spouse’s occupation If the IRS sent you an Identity Protection
your records. PIN, enter it
Customer Service Agent here (see inst.)
Print/Type preparer’s name Preparer’s signature Date PTIN
Paid Check if
self-employed
Preparer
Use Only Firm’s name a Self-Prepared Firm’s EIN a
Firm’s address a Phone no.

Go to www.irs.gov/Form1040 for instructions and the latest information. REV 02/22/18 Intuit.cg.cfp.sp Form 1040 (2017)
SCHEDULE A Itemized Deductions OMB No. 1545-0074
2017
(Form 1040) a Go to www.irs.gov/ScheduleA for instructions and the latest information.
a Attach to Form 1040.
Department of the Treasury Attachment
Internal Revenue Service (99) Caution: If you are claiming a net qualified disaster loss on Form 4684, see the instructions for line 28. Sequence No. 07
Name(s) shown on Form 1040 Your social security number
Robert T Clarke, Jr & MariRenee Clarke 315-04-4786
Caution: Do not include expenses reimbursed or paid by others.
Medical
and 1 Medical and dental expenses (see instructions) . . . . . 1 0.
2 Enter amount from Form 1040, line 38 2 101,521.
Dental
3 Multiply line 2 by 7.5% (0.075). . . . . . . . . . . . 3 7,614.
Expenses
4 Subtract line 3 from line 1. If line 3 is more than line 1, enter -0- . . . . . . . . 4
Taxes You 5 State and local (check only one box):
Paid a
b
Income taxes, or
General sales taxes } . . . . . . . . . . . 5 3,971.
6 Real estate taxes (see instructions) . . . . . . . . . 6 1,682.

7 Personal property taxes . . . . . . . . . . . . . 7 593.
8 Other taxes. List type and amount a
8
9 Add lines 5 through 8 . . . . . . . . . . . . . . . . . . . . . . 9 6,246.
Interest 10 Home mortgage interest and points reported to you on Form 1098 10 10,504.
You Paid 11 Home mortgage interest not reported to you on Form 1098. If paid
to the person from whom you bought the home, see instructions
Note: and show that person’s name, identifying no., and address a
Your mortgage
interest
deduction may 11
be limited (see 12 Points not reported to you on Form 1098. See instructions for
instructions). special rules . . . . . . . . . . . . . . . . . 12
13 Mortgage insurance premiums (see instructions) . . . . . 13
14 Investment interest. Attach Form 4952 if required. See instructions 14
15 Add lines 10 through 14 . . . . . . . . . . . . . . . . . . . . . 15 10,504.
Gifts to 16 Gifts by cash or check. If you made any gift of $250 or more,
Charity see instructions . . . . . . . . . . . . . . . . 16 200.
If you made a 17 Other than by cash or check. If any gift of $250 or more, see
gift and got a instructions. You must attach Form 8283 if over $500 . . . 17 217.
benefit for it, 18 Carryover from prior year . . . . . . . . . . . . 18
see instructions.
19 Add lines 16 through 18 . . . . . . . . . . . . . . . . . . . . . 19 417.
Casualty and 20 Casualty or theft loss(es) other than net qualified disaster losses. Attach Form 4684 and
Theft Losses enter the amount from line 18 of that form. See instructions . . . . . . . . . 20
Job Expenses 21 Unreimbursed employee expenses—job travel, union dues,
and Certain job education, etc. Attach Form 2106 or 2106-EZ if required.
Miscellaneous See instructions. a Employee business expenses 21 600.
Deductions 22 Tax preparation fees . . . . . . . . . . . . . 22
23 Other expenses—investment, safe deposit box, etc. List type
and amount a
23
24 Add lines 21 through 23 . . . . . . . . . . . . 24 600.
25 Enter amount from Form 1040, line 38 25 101,521.
26 Multiply line 25 by 2% (0.02) . . . . . . . . . . 26 2,030.
27 Subtract line 26 from line 24. If line 26 is more than line 24, enter -0- . . . . . . 27
Other 28 Other—from list in instructions. List type and amount a
Miscellaneous
Deductions 28
Total 29 Is Form 1040, line 38, over $156,900?
}
Itemized No. Your deduction is not limited. Add the amounts in the far right column
Deductions for lines 4 through 28. Also, enter this amount on Form 1040, line 40. . . 29 17,167.
Yes. Your deduction may be limited. See the Itemized Deductions
Worksheet in the instructions to figure the amount to enter.
30 If you elect to itemize deductions even though they are less than your standard
deduction, check here . . . . . . . . . . . . . . . . . . . a
For Paperwork Reduction Act Notice, see the Instructions for Form 1040. REV 02/22/18 Intuit.cg.cfp.sp Schedule A (Form 1040) 2017
BAA
SCHEDULE E Supplemental Income and Loss OMB No. 1545-0074
2017
(Form 1040) (From rental real estate, royalties, partnerships, S corporations, estates, trusts, REMICs, etc.)
a Attach to Form 1040, 1040NR, or Form 1041.
Internal Revenue Service (99) a Go to www.irs.gov/ScheduleE for instructions and the latest information. Sequence No. 13
Name(s) shown on return Your social security number
Part I Income or Loss From Rental Real Estate and Royalties Note: If you are in the business of renting personal property, use
Schedule C or C-EZ (see instructions). If you are an individual, report farm rental income or loss from Form 4835 on page 2, line 40.
A Did you make any payments in 2017 that would require you to file Form(s) 1099? (see instructions) . . . . . Yes No
B If “Yes,” did you or will you file required Forms 1099? . . . . . . . . . . . . . . . . . . . Yes No
1a Physical address of each property (street, city, state, ZIP code)
A 1150 N Lake Shore Dr. 23J Chicago IL 60611
B
C
1b Type of Property 2 For each rental real estate property listed Fair Rental Personal Use
above, report the number of fair rental and QJV
(from list below) Days Days
personal use days. Check the QJV box
A 1 only if you meet the requirements to file as A 365 0
B a qualified joint venture. See instructions. B
C C
Type of Property:
1 Single Family Residence 3 Vacation/Short-Term Rental 5 Land 7 Self-Rental
2 Multi-Family Residence 4 Commercial 6 Royalties 8 Other (describe)
Income: Properties: A B C
3 Rents received . . . . . . . . . . . . . 3 16,500.
4 Royalties received . . . . . . . . . . . . 4
Expenses:
5 Advertising . . . . . . . . . . . . . . 5
6 Auto and travel (see instructions) . . . . . . . 6 2,082.
7 Cleaning and maintenance . . . . . . . . . 7 5,520.
8 Commissions. . . . . . . . . . . . . . 8 100.
9 Insurance . . . . . . . . . . . . . . . 9 98.
10 Legal and other professional fees . . . . . . . 10 170.
11 Management fees . . . . . . . . . . . . 11
12 Mortgage interest paid to banks, etc. (see instructions) 12 3,755.
13 Other interest. . . . . . . . . See . . Stmt
. . . 13
14 Repairs. . . . . . . . . . . . . . . . 14 851.
15 Supplies . . . . . . . . . . . . . . . 15 200.
16 Taxes . . . . . . . . . . . . . . . . 16 2,171.
17 Utilities . . . . . . . . . . . . . . . . 17 100.
18 Depreciation expense or depletion . . . . . . 18 5,147.
19 Other (list) a 19
20 Total expenses. Add lines 5 through 19 . . . . . 20 20,194.
21 Subtract line 20 from line 3 (rents) and/or 4 (royalties). If
result is a (loss), see instructions to find out if you must
file Form 6198 . . . . . . . . . . . . . 21 -3,694.
22 Deductible rental real estate loss after limitation, if any,
on Form 8582 (see instructions) . . . . . . . 22 ( -3,694. ) ( )( )
23a Total of all amounts reported on line 3 for all rental properties . . . . 23a 16,500.
b Total of all amounts reported on line 4 for all royalty properties . . . . 23b
c Total of all amounts reported on line 12 for all properties . . . . . . 23c 3,755.
d Total of all amounts reported on line 18 for all properties . . . . . . 23d 5,147.
e Total of all amounts reported on line 20 for all properties . . . . . . 23e 20,194.
24 Income. Add positive amounts shown on line 21. Do not include any losses . . . . . . . 24
25 Losses. Add royalty losses from line 21 and rental real estate losses from line 22. Enter total losses here . 25 ( 3,694. )
26 Total rental real estate and royalty income or (loss). Combine lines 24 and 25. Enter the result here.
If Parts II, III, IV, and line 40 on page 2 do not apply to you, also enter this amount on Form 1040, line
17, or Form 1040NR, line 18. Otherwise, include this amount in the total on line 41 on page 2 . . . 26 -3,694.
For Paperwork Reduction Act Notice, see the separate instructions. BAA REV 02/13/18 Intuit.cg.cfp.sp Schedule E (Form 1040) 2017
Form 8889 Health Savings Accounts (HSAs)
OMB No. 1545-0074
2017
a Attach to Form 1040 or Form 1040NR.
Internal Revenue Service a Go to www.irs.gov/Form8889 for instructions and the latest information. Sequence No. 52
Name(s) shown on Form 1040 or Form 1040NR Social security number of HSA
beneficiary. If both spouses have
Robert T Clarke, Jr HSAs, see instructions a 315-04-4786
Before you begin: Complete Form 8853, Archer MSAs and Long-Term Care Insurance Contracts, if required.
Part I HSA Contributions and Deduction. See the instructions before completing this part. If you are filing jointly
and both you and your spouse each have separate HSAs, complete a separate Part I for each spouse.
1 Check the box to indicate your coverage under a high-deductible health plan (HDHP) during
2017 (see instructions) . . . . . . . . . . . . . . . . . . . . . . . a Self-only Family
2 HSA contributions you made for 2017 (or those made on your behalf), including those made
from January 1, 2018, through April 17, 2018, that were for 2017. Do not include employer
contributions, contributions through a cafeteria plan, or rollovers (see instructions) . . . . . 2 0.
3 If you were under age 55 at the end of 2017, and on the first day of every month during 2017,
you were, or were considered, an eligible individual with the same coverage, enter $3,400
($6,750 for family coverage). All others, see the instructions for the amount to enter . . . . 3
4 Enter the amount you and your employer contributed to your Archer MSAs for 2017 from Form
8853, lines 1 and 2. If you or your spouse had family coverage under an HDHP at any time
during 2017, also include any amount contributed to your spouse’s Archer MSAs . . . . . 4
5 Subtract line 4 from line 3. If zero or less, enter -0- . . . . . . . . . . . . . . . 5
6 Enter the amount from line 5. But if you and your spouse each have separate HSAs and had
family coverage under an HDHP at any time during 2017, see the instructions for the amount to
enter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
7 If you were age 55 or older at the end of 2017, married, and you or your spouse had family
coverage under an HDHP at any time during 2017, enter your additional contribution amount
(see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . 7 0.
8 Add lines 6 and 7 . . . . . . . . . . . . . . . . . . . . . . . . . . 8 0.
9 Employer contributions made to your HSAs for 2017 . . . . 9
10 Qualified HSA funding distributions . . . . . . . . . . 10
11 Add lines 9 and 10 . . . . . . . . . . . . . . . . . . . . . . . . . . 11
12 Subtract line 11 from line 8. If zero or less, enter -0- . . . . . . . . . . . . . . . 12 0.
13 HSA deduction. Enter the smaller of line 2 or line 12 here and on Form 1040, line 25, or Form
1040NR, line 25 . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 0.
Caution: If line 2 is more than line 13, you may have to pay an additional tax (see instructions).
Part II HSA Distributions. If you are filing jointly and both you and your spouse each have separate HSAs, complete
a separate Part II for each spouse.
14a Total distributions you received in 2017 from all HSAs (see instructions) . . . . . . . . 14a 751.
b Distributions included on line 14a that you rolled over to another HSA. Also include any excess
contributions (and the earnings on those excess contributions) included on line 14a that were
withdrawn by the due date of your return (see instructions) . . . . . . . . . . . . 14b
c Subtract line 14b from line 14a . . . . . . . . . . . . . . . . . . . . . . 14c 751.
15 Qualified medical expenses paid using HSA distributions (see instructions) . . . . . . . 15 751.
16 Taxable HSA distributions. Subtract line 15 from line 14c. If zero or less, enter -0-. Also,
include this amount in the total on Form 1040, line 21, or Form 1040NR, line 21. On the dotted
line next to line 21, enter “HSA” and the amount . . . . . . . . . . . . . . . . 16 0.
17a If any of the distributions included on line 16 meet any of the Exceptions to the Additional
20% Tax (see instructions), check here . . . . . . . . . . . . . . . . . a
b Additional 20% tax (see instructions). Enter 20% (0.20) of the distributions included on line 16
that are subject to the additional 20% tax. Also include this amount in the total on Form 1040,
line 62, or Form 1040NR, line 60. Check box c on Form 1040, line 62, or box b on Form 1040NR,
line 60. Enter “HSA” and the amount on the line next to the box . . . . . . . . . . . 17b
For Paperwork Reduction Act Notice, see your tax return instructions. REV 11/27/17 Intuit.cg.cfp.sp Form 8889 (2017)
BAA
Form 8889 (2017) Page 2
Part III Income and Additional Tax for Failure To Maintain HDHP Coverage. See the instructions before
completing this part. If you are filing jointly and both you and your spouse each have separate HSAs,
complete a separate Part III for each spouse.
18 Last-month rule . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
19 Qualified HSA funding distribution . . . . . . . . . . . . . . . . . . . . . 19

20 Total income. Add lines 18 and 19. Include this amount on Form 1040, line 21, or Form
1040NR, line 21. On the dotted line next to Form 1040, line 21, or Form 1040NR, line 21, enter
“HSA” and the amount . . . . . . . . . . . . . . . . . . . . . . . . 20
21 Additional tax. Multiply line 20 by 10% (0.10). Include this amount in the total on Form 1040,
line 60. Enter “HDHP” and the amount on the line next to the box . . . . . . . . . . 21
REV 11/27/17 Intuit.cg.cfp.sp Form 8889 (2017)
Form 8889 Health Savings Accounts (HSAs)
OMB No. 1545-0074
2017
a Attach to Form 1040 or Form 1040NR.
Internal Revenue Service a Go to www.irs.gov/Form8889 for instructions and the latest information. Sequence No. 52
Name(s) shown on Form 1040 or Form 1040NR Social security number of HSA
beneficiary. If both spouses have
MariRenee Clarke HSAs, see instructions a 313-96-8786
Before you begin: Complete Form 8853, Archer MSAs and Long-Term Care Insurance Contracts, if required.
Part I HSA Contributions and Deduction. See the instructions before completing this part. If you are filing jointly
and both you and your spouse each have separate HSAs, complete a separate Part I for each spouse.
1 Check the box to indicate your coverage under a high-deductible health plan (HDHP) during
2017 (see instructions) . . . . . . . . . . . . . . . . . . . . . . . a Self-only Family
2 HSA contributions you made for 2017 (or those made on your behalf), including those made
from January 1, 2018, through April 17, 2018, that were for 2017. Do not include employer
contributions, contributions through a cafeteria plan, or rollovers (see instructions) . . . . . 2 0.
3 If you were under age 55 at the end of 2017, and on the first day of every month during 2017,
you were, or were considered, an eligible individual with the same coverage, enter $3,400
($6,750 for family coverage). All others, see the instructions for the amount to enter . . . . 3
4 Enter the amount you and your employer contributed to your Archer MSAs for 2017 from Form
8853, lines 1 and 2. If you or your spouse had family coverage under an HDHP at any time
during 2017, also include any amount contributed to your spouse’s Archer MSAs . . . . . 4
5 Subtract line 4 from line 3. If zero or less, enter -0- . . . . . . . . . . . . . . . 5
6 Enter the amount from line 5. But if you and your spouse each have separate HSAs and had
family coverage under an HDHP at any time during 2017, see the instructions for the amount to
enter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
7 If you were age 55 or older at the end of 2017, married, and you or your spouse had family
coverage under an HDHP at any time during 2017, enter your additional contribution amount
(see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . 7 0.
8 Add lines 6 and 7 . . . . . . . . . . . . . . . . . . . . . . . . . . 8 0.
9 Employer contributions made to your HSAs for 2017 . . . . 9
10 Qualified HSA funding distributions . . . . . . . . . . 10
11 Add lines 9 and 10 . . . . . . . . . . . . . . . . . . . . . . . . . . 11
12 Subtract line 11 from line 8. If zero or less, enter -0- . . . . . . . . . . . . . . . 12 0.
13 HSA deduction. Enter the smaller of line 2 or line 12 here and on Form 1040, line 25, or Form
1040NR, line 25 . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 0.
Caution: If line 2 is more than line 13, you may have to pay an additional tax (see instructions).
Part II HSA Distributions. If you are filing jointly and both you and your spouse each have separate HSAs, complete
a separate Part II for each spouse.
14a Total distributions you received in 2017 from all HSAs (see instructions) . . . . . . . . 14a 35.
b Distributions included on line 14a that you rolled over to another HSA. Also include any excess
contributions (and the earnings on those excess contributions) included on line 14a that were
withdrawn by the due date of your return (see instructions) . . . . . . . . . . . . 14b
c Subtract line 14b from line 14a . . . . . . . . . . . . . . . . . . . . . . 14c 35.
15 Qualified medical expenses paid using HSA distributions (see instructions) . . . . . . . 15 35.
16 Taxable HSA distributions. Subtract line 15 from line 14c. If zero or less, enter -0-. Also,
include this amount in the total on Form 1040, line 21, or Form 1040NR, line 21. On the dotted
line next to line 21, enter “HSA” and the amount . . . . . . . . . . . . . . . . 16 0.
17a If any of the distributions included on line 16 meet any of the Exceptions to the Additional
20% Tax (see instructions), check here . . . . . . . . . . . . . . . . . a
b Additional 20% tax (see instructions). Enter 20% (0.20) of the distributions included on line 16
that are subject to the additional 20% tax. Also include this amount in the total on Form 1040,
line 60. Enter “HSA” and the amount on the line next to the box . . . . . . . . . . . 17b
For Paperwork Reduction Act Notice, see your tax return instructions. REV 11/27/17 Intuit.cg.cfp.sp Form 8889 (2017)
BAA
Form 8889 (2017) Page 2
Part III Income and Additional Tax for Failure To Maintain HDHP Coverage. See the instructions before
completing this part. If you are filing jointly and both you and your spouse each have separate HSAs,
complete a separate Part III for each spouse.
18 Last-month rule . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
19 Qualified HSA funding distribution . . . . . . . . . . . . . . . . . . . . . 19

20 Total income. Add lines 18 and 19. Include this amount on Form 1040, line 21, or Form
1040NR, line 21. On the dotted line next to Form 1040, line 21, or Form 1040NR, line 21, enter
“HSA” and the amount . . . . . . . . . . . . . . . . . . . . . . . . 20
21 Additional tax. Multiply line 20 by 10% (0.10). Include this amount in the total on Form 1040,
line 60. Enter “HDHP” and the amount on the line next to the box . . . . . . . . . . 21
Form 8582 Passive Activity Loss Limitations
a See separate instructions.
OMB No. 1545-1008
2017
a Attach
to Form 1040 or Form 1041.
Internal Revenue Service (99) a Go to www.irs.gov/Form8582 for instructions and the latest information. Sequence No. 88
Name(s) shown on return Identifying number
Part I 2017 Passive Activity Loss
Caution: Complete Worksheets 1, 2, and 3 before completing Part I.
Rental Real Estate Activities With Active Participation (For the definition of active participation, see
Special Allowance for Rental Real Estate Activities in the instructions.)
1a Activities with net income (enter the amount from Worksheet 1,
column (a)) . . . . . . . . . . . . . . . . . . 1a 0.
b Activities with net loss (enter the amount from Worksheet 1, column
(b)) . . . . . . . . . . . . . . . . . . . . . 1b ( 3,694. )
c Prior years' unallowed losses (enter the amount from Worksheet 1,
column (c)) . . . . . . . . . . . . . . . . . . 1c ( )
d Combine lines 1a, 1b, and 1c . . . . . . . . . . . . . . . . . . . . . . 1d -3,694.
Commercial Revitalization Deductions From Rental Real Estate Activities
2a Commercial revitalization deductions from Worksheet 2, column (a) . 2a ( )
b Prior year unallowed commercial revitalization deductions from
Worksheet 2, column (b) . . . . . . . . . . . . . . 2b ( )
c Add lines 2a and 2b . . . . . . . . . . . . . . . . . . . . . . . . . 2c ( )
All Other Passive Activities
3a Activities with net income (enter the amount from Worksheet 3,
column (a)) . . . . . . . . . . . . . . . . . . 3a
b Activities with net loss (enter the amount from Worksheet 3, column
(b)) . . . . . . . . . . . . . . . . . . . . . 3b ( )
c Prior years' unallowed losses (enter the amount from Worksheet 3,
column (c)) . . . . . . . . . . . . . . . . . . 3c ( )
d Combine lines 3a, 3b, and 3c . . . . . . . . . . . . . . . . . . . . . . 3d
4 Combine lines 1d, 2c, and 3d. If this line is zero or more, stop here and include this form with
your return; all losses are allowed, including any prior year unallowed losses entered on line 1c,
2b, or 3c. Report the losses on the forms and schedules normally used . . . . . . . . 4 -3,694.
If line 4 is a loss and: • Line 1d is a loss, go to Part II.
• Line 2c is a loss (and line 1d is zero or more), skip Part II and go to Part III.
• Line 3d is a loss (and lines 1d and 2c are zero or more), skip Parts II and III and go to line 15.
Caution: If your filing status is married filing separately and you lived with your spouse at any time during the year, do not complete
Part II or Part III. Instead, go to line 15.
Part II Special Allowance for Rental Real Estate Activities With Active Participation
Note: Enter all numbers in Part II as positive amounts. See instructions for an example.
5 Enter the smaller of the loss on line 1d or the loss on line 4 . . . . . . . . . . . . 5 3,694.
6 Enter $150,000. If married filing separately, see instructions . . 6 150,000.
7 Enter modified adjusted gross income, but not less than zero (see instructions) 7 107,715.
Note: If line 7 is greater than or equal to line 6, skip lines 8 and 9,
enter -0- on line 10. Otherwise, go to line 8.
8 Subtract line 7 from line 6 . . . . . . . . . . . . . 8 42,285.
9 Multiply line 8 by 50% (0.50). Do not enter more than $25,000. If married filing separately, see instructions 9 21,143.
10 Enter the smaller of line 5 or line 9 . . . . . . . . . . . . . . . . . . . . 10 3,694.
If line 2c is a loss, go to Part III. Otherwise, go to line 15.
Part III Special Allowance for Commercial Revitalization Deductions From Rental Real Estate Activities
Note: Enter all numbers in Part III as positive amounts. See the example for Part II in the instructions.
11 Enter $25,000 reduced by the amount, if any, on line 10. If married filing separately, see instructions 11
12 Enter the loss from line 4 . . . . . . . . . . . . . . . . . . . . . . . . 12
13 Reduce line 12 by the amount on line 10 . . . . . . . . . . . . . . . . . . 13
14 Enter the smallest of line 2c (treated as a positive amount), line 11, or line 13 . . . . . . 14
Part IV Total Losses Allowed
15 Add the income, if any, on lines 1a and 3a and enter the total . . . . . . . . . . . . 15 0.
16 Total losses allowed from all passive activities for 2017. Add lines 10, 14, and 15. See
instructions to find out how to report the losses on your tax return . . . . . . . . . . . 16 3,694.
For Paperwork Reduction Act Notice, see instructions. BAA REV 02/13/18 Intuit.cg.cfp.sp Form 8582 (2017)
Form 8582 (2017) Page 2
Caution: The worksheets must be filed with your tax return. Keep a copy for your records.
Worksheet 1—For Form 8582, Lines 1a, 1b, and 1c (See instructions.)
Current year Prior years Overall gain or loss
Name of activity
(a) Net income (b) Net loss (c) Unallowed
(d) Gain (e) Loss
(line 1a) (line 1b) loss (line 1c)
1150 N Lake Shore Dr. 23J 0. 3,694. 3,694.
Total. Enter on Form 8582, lines 1a, 1b,

and 1c . . . . . . . . . . . a 0. 3,694.
Worksheet 2—For Form 8582, Lines 2a and 2b (See instructions.)
(a) Current year (b) Prior year
Name of activity (c) Overall loss
deductions (line 2a) unallowed deductions (line 2b)
Total. Enter on Form 8582, lines 2a and

2b . . . . . . . . . . . . a
Worksheet 3—For Form 8582, Lines 3a, 3b, and 3c (See instructions.)
Current year Prior years Overall gain or loss
Name of activity
(a) Net income (b) Net loss (c) Unallowed
(d) Gain (e) Loss
(line 3a) (line 3b) loss (line 3c)
Total. Enter on Form 8582, lines 3a, 3b,

and 3c . . . . . . . . . . . a
Worksheet 4—Use this worksheet if an amount is shown on Form 8582, line 10 or 14 (See instructions.)
Form or schedule
(d) Subtract
and line number (c) Special
Name of activity (a) Loss (b) Ratio column (c) from
to be reported on allowance
column (a)
(see instructions)
1150 N Lake Shore Dr. 23J E Ln 22 3,694. 1.00000000 3,694. 0.
Total . . . . . . . . . . . . . . . . . a 3,694. 1.00 3,694. 0.

Worksheet 5—Allocation of Unallowed Losses (See instructions.)
Form or schedule
and line number
Name of activity (a) Loss (b) Ratio (c) Unallowed loss
to be reported on
(see instructions)
Total . . . . . . . . . . . . . . . . . . . a 1.00
Tax History Report 2017
G Keep for your records
Name(s) Shown on Return

Robert T Clarke, Jr & MariRenee Clarke
Five Year Tax History:
2013 2014 2015 2016 2017
Filing status MFJ MFJ MFJ MFJ MFJ
Total income 124,343. 95,820. 87,883. 88,600. 104,021.
Adjustments to income 8,626. 7,297. 2,500. 2,500. 2,500.
Adjusted gross income 115,717. 88,523. 85,383. 86,100. 101,521.
Tax expense 3,516. 1,768. 3,502. 5,409. 6,246.
Interest expense 9,864. 10,504.
Contributions 1,140. 353. 300. 2,280. 417.
Miscellaneous
deductions 19,983. 28,066.
Other Itemized
Deductions
Total itemized/
standard deduction 24,639. 30,187. 12,600. 17,553. 17,167.
Exemption amount 7,800. 11,850. 12,000. 12,150. 8,100.
Taxable income 83,278. 46,486. 60,783. 56,397. 76,254.
Tax 12,676. 6,056. 8,194. 7,484. 10,546.
Alternative min tax
Total credits 1,000. 1,000. 1,001.
Other taxes 0. 0.
Payments 17,275. 10,316. 9,168. 10,305. 11,868.
Form 2210 penalty
Amount owed
Applied to next
year’s estimated tax
Refund 4,599. 5,260. 1,974. 3,822. 1,322.
Effective tax rate % 10.95 5.71 8.43 7.53 10.39
**Tax bracket % 25.0 15.0 15.0 15.0 25.0
**Tax bracket % is based on Taxable income.

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The chart below shows the options for filing your tax return (e-file or paper return), the RPS
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proceeds, and costs associated with the various options.
WHAT TYPE WHAT ARE YOUR WHAT IS THE WHAT COSTS DO YOU
OF FILING DISBURSEMENT ESTIMATED TIME TO INCUR IN ADDITION
METHOD? OPTIONS? RECEIVE REFUND? TO TAX PREPARATION
FEES?
PAPER RETURN IRS direct deposit to Approximately No additional cost.

your personal bank 6 to 8 weeks 2
No Refund Processing account.
Service
Check mailed by IRS Approximately
to address on tax 6 to 8 weeks 2
return.
ELECTRONIC IRS direct deposit to Usually within 21 days2 No additional cost.

FILING your personal bank
(E-FILE) account.
No Refund Processing Check mailed by IRS Approximately

Service to address on tax 21 to 28 days 2
return.
ELECTRONIC (a) Direct deposit to Usually within $ 39.99

FILING your personal bank 21 days 2
(E-FILE) account, or
Refund Processing (b) Load to your

Service prepaid card 1.
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is detected. If your return contains Earned Income Tax Credit or Additional Child Tax Credit,
the IRS will issue your refund no earlier than February 15, 2018.
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SBIA1001.SCR 04/30/15
Form 8960 Form 8960 Worksheet 2017
Lines 4b, 5b, 7, 9, 10
Name(s) Shown on Return Your SSN

Line 4b - Adjustment for trade or business income or loss
(a) Activity name (b) Gain or

loss
Enter additional adjustments not included above:
Adjustment for trade or business income not subject to net investment tax
Line 5b - Adjustment for gain or loss on dispositions
(a) Activity name (b) Gain or

loss
Capital loss carryover adjustment from 2016 for net investment tax purposes
Enter additional adjustments not included above and check the box if a capital gain or loss:
Net gain or loss from disposition of property not subject to net investment tax
Capital gain/loss not included in net investment income
(a) Activity name (b) Capital

Gain or Loss
Capital gain or loss from sale of property not subject to net investment income tax
Calculation of line 5b adjustment due to capital loss carryforward
1 Net capital loss not included in net investment income 1 0.

2 Capital loss carryover to next year 2
3 Lesser of line 1 or line 2 (Included as an adjustment on line 5b table above) 3 0.
Line 7 - Other modifications to investment income
1 Casualty and theft losses reported on Schedule A, line 20 1

2 Amounts reported on Form 8814, line 12 2
3 Adjustment for distributions from estates and trusts 3
4 Schedules C and F income/loss included in net investment income 4
5 Substitute interest and dividend payments 5
6 Recovery of a prior year deduction 6 0.
7 7
8 Total other modifications to investment income 8 0.

Robert T Clarke, Jr & MariRenee Clarke 315-04-4786 Page 2
Line 9b - State income tax allocable to net investment income
1 State, local, and foreign income taxes 1 3,971.

2 Investment income 2 -3,578.
3 Total adjusted gross income 3 101,521.
4 Divide line 2 by line 3. Enter result as a decimal amount 4 0.0000
5 State, local and foreign income taxes allocable to investment income 5 0.
Line 10 - Tax preparations fees allocable to net investment income
1 Tax preparations fees 1

2 Investment income 2
3 Total adjusted gross income 3
4 Divide line 2 by line 3. Enter result as a decimal amount 4
5 Tax preparations fees allocable to investment income 5
Lines 9 and 10 - Application of Itemized Deduction Limitations Worksheet
Part I - Application of Section 67 to Deductions Properly Allocable to Investment Income
1 Enter the amount of Miscellaneous Itemized Deductions properly

allocable to investment income before any itemized deductions limitations:
2 Enter the total of all items listed on line 1 2

3 Enter the amount of all Miscellaneous Itemized Deductions after the application
of the section 67 limitation (Schedule A (Form 1040), line 27) 3
4 Enter the lesser of the total reported on line 2 or line 3 4
Part II - Application of Section 67 Limitation to Specific Deductions

(A) (B) (C)
Reenter the amounts and descriptions from Part I, line 1 Fraction Column A
(see Help) times B
x =
x =
x =
x =
Part III - Application of Section 68 to Deductions Properly Allocable to Investment Income
1 Enter the amount of Miscellaneous Itemized Deductions properly

allocable to investment income from Column(C) of Part II:
1
2 Enter the amount of state, local, and foreign income taxes that are properly
allocable to investment income 2 0.
3 Enter the amount of other Itemized Deductions subject to the section 68
limitation and properly allocable to investment income before any itemized
deduction limitation:
3
4 Enter the total deductions properly allocable to investment income subject to
the section 68 limitation. Enter the sum of lines 1 through 3 4 0.
5 Enter the amount of total itemized deductions allowed after the section 68
limitation. Form 1040, line 40 5 17,167.
6 Enter all other itemized deductions allowed but not subject to the section 68
deduction limitation: 6 0.
7 Subtract line 6 from line 5 7 17,167.
8 Enter the lesser of line 7 or line 4 8 0.
Part IV - Reconciliation of Schedule A Deductions to Form 8960 plus additional expenses, lines 9 and 10
(A) (B) (C)
Reenter the amounts and descriptions from Part III, lines 1-3 Fraction Column A
(see Help) times B
Miscellaneous Itemized Deductions properly allocable to Investment
Income reportable on Form 8960, line 9c:
1 x =
x =
x =
x =
Total miscellaneous investment expenses to Form 8960, line 9c
2 State, local, and foreign income taxes x =
Itemized Deductions Subject to Section 68 reportable on Form 8960, line 10:

3 x =
x =
x =
x =
Penalty on early withdrawal of savings
Other modifications:
Total additional modifications to Form 8960, line 10
Calculation of Former Passive Activity Suspended Losses Allowed as Deduction Against NII
1) Former Passive Activity Suspended Losses
(a) Activity name (b) Suspended (c) Suspended (d) Used against (e) Used against
12/31/2016 12/31/2017 activity other passive
2) Former Passive Activity Suspended Losses - Schedule D
3) Former Passive Activity Suspended Losses - Form 4797
Form 8960 Deduction Recoveries Worksheet 2017
Line 7
Name(s) Shown on Return Your SSN

Was the recovery taken into account in computing a section 1411 net operating loss? YES NO X
1 Enter total amount of recovery included in gross income 680.

* Do not include recoveries of items that are included in net
investment income in the year of recovery (included on lines 1-6)
* Do not include recoveries of items if the amount relates to a
deduction taken in a tax year beginning before 2013
* Do not include recoveries of items if the amount relates to a
deduction taken in a tax year beginning after 2012, and you were
not subject to the NIIT solely because your MAGI was below the
applicable threshold.
2 Amount of the recovery that would have been included in gross
income but for the application of the tax benefit rule under
section 111 0.
3 Total amount of the recovery (add lines 1 and 2) 680.
4 Enter as a decimal the percentage of the deduction allocated to
net investment income in the prior year. (If the deduction was not
allocated between investment income and non-investment
income, enter 1.0000) 0.0000
5 Enter the lesser of (a) line 3 mutiplied by line 4, or (b) the total amount deducted
on the prior year Form 8960 attributable to item recovered (after any deduction
limitations imposed by section 67 or 68) 0.
Calculation of recoveries when the deduction is not taken into account in computing your section 1411 NOL
6 Multiply line 5 by .038 0.

7 Enter the amount of net investment income in the year of the
deduction (previous year’s Form 8960, line 12, unless line 12 is
zero, then previous year’s Form 8960, line 8 minus line 11) -8,670.
8 Add the amount of line 5 to line 7 -8,670.
9 Using the previous year’s Form 8960, recalculate the NIIT for the
year of the deduction by replacing the amount reported on line 12
with the amount reported on line 8 of this worksheet (do not use
the net investment income reported on that year’s Form 8960,
line 12). Enter your recalculated NIIT here -329.
10 Enter the NIIT reported for the year of the deduction 0.
11 Subtract line 10 from line 9 0.
12 Enter the smaller of line 6 or line 11 0.
13 Divide line 12 by 3.8%. Enter the result here and include on Form 8960, line 7 0.
Calculation of recoveries when the deduction is taken into account in computing your section 1411 NOL
14 Enter the amount of the section 1411 NOL in the year of the
deduction (entered as a positive number)
15 Enter the amount of the section 1411 NOL in the year of the
deduction recomputed without the amount on line 5 (entered as a
positive number, but not less than zero)
16 Subtract line 15 from line 14.Enter the result here and include on Form 8960, line 7
Form 1040 Other Income Statement 2017
Line 21 Statement L21
Name(s) Shown on Return Social Security Number
(a) (b)
Taxpayer Spouse
1 Child’s investment income, from Form 8814

2 Gambling winnings:
a From Form W-2G
b Winnings (prizes, etc.) from Form 1099-MISC, box 3
c Not reported on Form W-2G or Form 1099-MISC
3 Taxable income from Form 1099-MISC:
a Substitute payments in lieu of interest or dividends
b Other income from box 3
c Alaska Permanent Fund
d Tribal Gaming
e Non-Employee Compensation from Form 1099-MISC box 7
f Rent from personal property from Form 1099-MISC box 1
4 Taxable income from Form 1099-Q or 1099-QA:
a Qualified tuition program distributions
b Coverdell ESA distributions
c ABLE account distributions
5 Taxable income from Form 1099-G:
a Grants
b RTAA payments
6 Foreign earned income and housing exclusion, from Form 2555
7 Net operating loss carryover from a prior year
8 Other income, from Schedule(s) K-1
9 Taxable distribution from:
a Form 8853:
1 Taxable Archer MSA distributions MSA
2 Taxable Medicare Advantage distributions Med MSA
3 Taxable long term care distributions LTC
4 Total Form 8853
b Form 8889, Health Savings Accounts
10 Refunds or reimbursements of deductions claimed
in a prior year:
a Reimbursement for deducted medical expenses
b Refunds of deducted taxes (not state or local income taxes)
Type of Tax State or
Local ID
c Recapture of deducted moving expenses

d Reimbursement for deducted casualty or theft loss
e Reimbursement for deducted employee business expenses
f Other refunds or reimbursements
11 Recoveries of bad debts deducted in a prior year
12 Jury duty pay
13 Bartering income not reported elsewhere
14 Income from the rental of personal property
15 Income from the Cancellation of Debt:
a From Form 1099-C:
1 Amount of debt canceled from box 2
2 Amount of canceled debt excluded from income
3 Taxable amount of canceled debt
b From Schedule(s) K-1
16 Taxable income from Form 1099-K:
a Payment Card/Third Party Network Transactions
17 Income from "not for profit" activities (hobbies):
18 Other taxable income:
a Union unemployment benefits
b Private fund unemployment benefits
c State employee unemployment benefits
d
19 Income from Community Property:

a Positive community property adjustment
b Negative community property adjustment (enter as positive)
20 Total. Add lines 1 through 14, 15a(3), 15b, 16 through 19.

Enter here and on Form 1040 or Form 1040NR, line 21
Charitable Organization Worksheet 2017

Charity Name Planned Parenthood

Address 7155 e 38th ave
City denver State CO ZIP code 80207
Combined Amounts Worksheet

Note: Amounts entered in worksheets below will be summarized in this worksheet.
Ref. No. Date Donation Description Donation Type Donation Amount
1 (not needed) Money 200.00
Total: 200.00
Prior Year Total: 1,700.00
ItsDeductible Item Donations Worksheet

Note: Amounts in this worksheet can only be entered using the interview process.
Ref. No. Donat. Date VM* Item Description High Value Qty. Med. Value Qty. Total Value
* VM, Valuation Method. 1 indicates it has been valued by ItsDeductible, 0 indicates you have created
a custom valuation item.
Charitable Organization Worksheet page 2 2017
Other Item Donations Worksheet

Note: Double-click to enter additional information if needed.
Ref. No. Donated Date Donation Description Donation Cost

Acquired Date Donation Type How Valued
How Acquired Donation Value Donation Allowed
Detail of Money Donations Worksheet
Don.
Ref. No. Donat. Date Each Don. Amt Per Yr Once or Recurring 2017 Amount
1 (not needed) 200.00 1 X Once Recur 200.00

Once Recur
Once Recur
Once Recur
Once Recur
Detail of Mileage and Transportation Costs Worksheet
Ref. No. Donation Date Description of Trip

Miles Per Trip Trips Per Yr Once or Recurring Miles Driven
Other Costs Description of Other Costs Value of Miles Total Donation Value
Once Recur
Once Recur
Once Recur
Detail of Stock Donations Worksheet
Stock
Date of Symbol, Value on Date Stock Donation Value
Ref. No. Donation # shares Donation Date Acquired Original Cost
Charitable Organization Questions
1 Was the entire interest given for all property donated to this charity? X Yes No
2 Were restrictions attached to the charity’s right

to use or dispose of any property donated to this charity? Yes No
3 Did you give to anyone other than this charity the right to income from any
of the donated property or to possession of any of the donated property? Yes No
4 What Type of charitable organization was it? Check one:

X (a) 50% charity (b) Other than 50% charity
Charitable Organization Worksheet 2017

Charity Name GoodWill

Address 2230 W. 93rd Avenue
City merrillville State IN ZIP code 46410
Combined Amounts Worksheet

Note: Amounts entered in worksheets below will be summarized in this worksheet.
Ref. No. Date Donation Description Donation Type Donation Amount
1 10/17/2017 Summary Items - ItsDeductible 217.00
Total: 217.00
Prior Year Total: 300.00
ItsDeductible Item Donations Worksheet

1 10/17/2017 1 Carry On 5.00 3 4.00 0 15.00

1 10/17/2017 1 Fry Pan 11.00 1 8.00 0 11.00
1 10/17/2017 1 Sauce Pan 8.00 1 5.00 0 8.00
1 10/17/2017 1 Saute Pan 14.00 0 10.00 1 10.00
See Detail of Item Donations - Continued 173.00
* VM, Valuation Method. 1 indicates it has been valued by ItsDeductible, 0 indicates you have created
a custom valuation item.
Other Item Donations Worksheet

Note: Double-click to enter additional information if needed.
Ref. No. Donated Date Donation Description Donation Cost

Acquired Date Donation Type How Valued
How Acquired Donation Value Donation Allowed
Detail of Money Donations Worksheet
Don.
Ref. No. Donat. Date Each Don. Amt Per Yr Once or Recurring 2017 Amount
Once Recur
Once Recur
Once Recur
Once Recur
Once Recur
Detail of Mileage and Transportation Costs Worksheet
Ref. No. Donation Date Description of Trip

Miles Per Trip Trips Per Yr Once or Recurring Miles Driven
Other Costs Description of Other Costs Value of Miles Total Donation Value
Once Recur
Once Recur
Once Recur
Detail of Stock Donations Worksheet
Stock
Date of Symbol, Value on Date Stock Donation Value
Ref. No. Donation # shares Donation Date Acquired Original Cost
Charitable Organization Questions
1 Was the entire interest given for all property donated to this charity? X Yes No
2 Were restrictions attached to the charity’s right

to use or dispose of any property donated to this charity? Yes No
3 Did you give to anyone other than this charity the right to income from any
of the donated property or to possession of any of the donated property? Yes No
4 What Type of charitable organization was it? Check one:

X (a) 50% charity (b) Other than 50% charity
Federal Information Worksheet 2017
Part I ' Personal Information
Information in Part I is completely calculated from entries on Personal Information Worksheets.
Taxpayer: Spouse:
First name Robert First name MariRenee
Middle initial T Suffix Jr Middle initial Suffix
Last name Clarke Last name Clarke
Social security no. 315-04-4786 Social security no. 313-96-8786
Occupation Patent Attorney Occupation Customer Service Agent
Date of birth 01/19/1981 (mm/dd/yyyy) Date of birth 07/17/1981 (mm/dd/yyyy)
Age as of 1-1-2018 36 Age as of 1-1-2018 36
Daytime phone (312)714-9280 Ext Daytime phone Ext
Legally blind Legally blind
Date of death Date of death
Dependent of Someone Else: Dependent of Someone Else:
Can taxpayer be claimed as dependent of another Can spouse be claimed as dependent of another
person (such as parent)? Yes X No person (such as parent)? Yes X No
If yes, was taxpayer claimed as dependent on that If yes, was spouse claimed as dependent on that
person’s return? Yes X No person’s return? Yes X No
Credit for the Elderly or Disabled (Schedule R): Credit for the Elderly or Disabled (Schedule R):
Is the taxpayer retired on total Is the spouse retired on total
and permanent disability? Yes No and permanent disability? Yes No
Presidential Election Campaign Fund: Presidential Election Campaign Fund:
Does the taxpayer want $3 to go to the Presidential Does the spouse want $3 to go to the Presidential
Election Campaign Fund? Yes X No Election Campaign Fund? Yes X No
Part II ' Address and Federal Filing Status (enter information in this section)
US Address:
Address 1301 Speer Blvd Apt no. 710
City Denver State CO ZIP code 80204
Foreign Address: Check this box to use foreign address
Address Apt no.
City
Foreign code Foreign country
Foreign province/county Foreign postal code
APO/FPO/DPO address, check if appropriate APO FPO DPO
Home phone
Check to print phone number on Form 1040 Home X Taxpayer daytime Spouse daytime
Federal filing status:
1 Single
X 2 Married filing jointly
3 Married filing separately
Check this box if you did not live with your spouse at any time during the year
Check this box if you are eligible to claim your spouse’s exemption (see Help)
4 Head of household
If the ’qualifying person’ is your child but not your dependent:
Child’s First name MI Last Name Suff
Child’s social security number
5 Qualifying widow(er)
Check the appropriate box for the year your spouse died 2015 2016
Are you a dependent with a qualifying child Yes No
If the ’qualifying person’ is your child but not your dependent:
Child’s First name MI Last Name Suff
Child’s social security number
Part III ' Dependent/Earned Income Credit/Child and Dependent Care Credit Information
Information in Part III is completely calculated from entries on Dependent/Nondependent Info Worksheets.
Date of birth Date of death
(mm/dd/yyyy) (mm/dd/yyyy)
Qualified
Not child/dep Lived
C qual care exps with Educ *
Social security o for incurred E taxpyr Tuitn D
First name MI number d child and paid I in and e
Last name Suff Relationship Age e tax cr 2017 C U.S. Fees p
* "Yes" - qualifies as dependent, "No" - does not qualify as dependent

Part IV ' Earned Income Credit Information (you must answer these questions to calculate EIC)
Is the taxpayer or spouse a qualifying child for EIC for another person? Yes No
Was the taxpayer’s (and spouse’s if married filing jointly) home in the United States
for more than half of 2017? Yes No
If the SSN of the taxpayer, or spouse if married filing jointly, was obtained to
get a federally funded benefit, such as Medicaid, and the Social Security card
contains the legend Not Valid for Employment, check this box (see Help)
Check if you are filing head of household and your spouse is a nonresident alien
and you lived with your spouse during the last six months of 2017
Check if you were notified by the IRS that EIC cannot be claimed in 2017 or
if you are ineligible to claim the EIC in 2017 for any other reason
Part V ' Direct Deposit or Direct Debit Information (not applicable for Form 9465)
Do you want to elect direct deposit of any federal tax refund? X Yes No
Do you want to elect direct debit of federal balance due (Electronic filing only)? Yes No
If you selected either of the options above, fill out the information below:
Name of Financial Institution (optional) Capital One 360
Check the appropriate box Checking X Savings
Routing number 031176110 Account number 135873450
Enter the following information only if you are requesting direct debit of balance due:
Enter the payment date to withdraw from the account above
Balance-due amount from this return
Part VI ' Additional Information for Your Federal Return

Standard Deduction/Itemized Deductions:
Check this box if you are itemizing for state tax or other purposes even though your itemized
deductions are less than your standard deduction
Check this box if you are married filing separately and your spouse itemized deductions
Check this box to take the standard deduction even if less than itemized deductions
Main Form Selection:

Check this box to calculate Form 1040 even if you qualify to use Form 1040A or 1040EZ
Real Estate Professionals:

Do you or your spouse qualify for the special passive activity rules for
taxpayers in real property business? (see Help) Yes X No
Credit for Qualified Retirement Savings Contributions (Form 8880):

Is the taxpayer a full-time student? Yes No
Is the spouse a full-time student? Yes No
American Opportunity and Lifetime Learning Credit, and Tuition and Fees Deduction (Form 8863 and 8917)
For 2017, were you (or your spouse if married) a nonresident alien for any part
of the year, and did not elect to be treated as a resident alien? Yes No
Foreign Tax Credit (Form 1116):

Check this box to file Form 1116 even if you’re not required to file Form 1116
Resident country USA
Excludable Income from Am. Samoa, Guam, Commonwealth of the N. Mariana Islands, or Puerto Rico:
Excludable income of bona fide residents of American Samoa, Guam, or the
Commonwealth of the Northern Mariana Islands
Excludable income from Puerto Rico
Dual Status Alien Return:

Check this box if you are a dual-status alien
Check this box to print ’DUAL-STATUS STATEMENT’ on Form 1040
Third Party Designee:

Caution: Review transferred information for accuracy.
Do you want to allow another person to discuss this return with the IRS? Yes No
If Yes, complete the following:
Third party designee name
Third party designee phone number
Personal Identification number (enter any 5 numbers)
IRS Disaster Tax Relief:

Check if you were affected by a natural disaster in 2017
Part VI ' Additional Information for Your Federal Return - Continued
Personal Representative for deceased taxpayers:

Name of personal representative required for E-filed
returns when Form 1310 is not filed or it is not the
surviving spouse
Part VII ' State Filing Information
Identity Protection PIN:

If the IRS sent the taxpayer an Identity Protection PIN, enter it here
If the IRS sent the spouse an Identity Protection PIN, enter it here
Taxpayer:
Enter the taxpayer’s state of residence as of December 31, 2017 CO
Check the appropriate box:
Taxpayer is a resident of the state above for the entire year X
Taxpayer is a resident of the state above for only part of year
Date the taxpayer established residence in state above
In which state (or foreign country) did the taxpayer reside before this change?
Spouse:
Enter the spouse’s state of residence as of December 31, 2017 CO
Spouse is a resident of the state above for the entire year X
Spouse is a resident of the state above for only part of year
Date the spouse established residence in state above
In which state (or foreign country) did the spouse reside before this change?
Nonresident states:
Nonresident State(s) Taxpayer/Spouse/Joint
IL
Check this box if you are in a Registered Domestic Partnership or a civil union
If you checked the box on the line above, also check the appropriate box below:
Check if this is your individual federal return you are filing with the IRS
Check if this is the joint return created to file joint state tax return (see Help)
Use the PIN that you signed last year’s tax return with.
Taxpayer’s Prior year PIN
Spouse’s Prior year PIN
These signature PINs are chosen by the taxpayer and spouse and used for e-filing your tax return
Taxpayer’s PIN used to sign the return 30024
Spouse’s PIN used to sign the return 83633
Taxpayer:
Drivers license or state ID number 150230639
Issued by what state CO
License or ID license X ID neither decline
Spouse
Drivers license or state ID number 150230646
Issued by what state CO
License or ID license X ID neither decline
Personal Information Worksheet 2017
For the Taxpayer
QuickZoom to another copy of Personal Information Worksheet
QuickZoom to Federal Information Worksheet
Part I ' Taxpayer's Personal Information

First name Robert Middle initial Last name
T Clarke
Suffix Jr
Social security no. 315-04-4786 Member of U.S. Armed Forces in 2017? Yes X No
Date of birth 01/19/1981 (mm/dd/yyyy) age as of 1-1-2018 36

Occupation Patent Attorney Daytime phone (312)714-9280 Ext
Marital status Married

If widowed, check the appropriate box for the year your spouse died:
After 2017 2017 2016 2015 Before 2015
Are you retired on total and permanent disability? (for Schedule R, see Help). Yes No
Check if this person is legally blind Yes X No
If deceased, enter the date of death (mm/dd/yyyy)
Were you under the age of 16 as of 1-1-2018 and this is the first year you
are filing a tax return? Yes No
Do you want $3 to go to Presidential Election Campaign Fund? Yes X No
Part II ' Questions for Individuals Who Could Be Or Are Dependents of Another Taxpayer
1 Can someone (such as your parent) claim you as a dependent? Yes X No
2 If you answered ’Yes’ to question 1, are you actually claimed as a dependent
on that person’s tax return? Yes X No
Questions 3 through 5 are only required for individuals who claim the
American Opportunity Credit.
3 Were you a full-time student during any part of five months during 2017? Yes No
4 Did your earned income exceed one-half of your support? Yes No
5 Was at least one of your parents alive on December 31, 2017? Yes No
Part III ' Taxpayer's State Residency Information

Enter this person’s state of residence as of December 31, 2017 CO
This person is a resident of the state above for the entire year X
This person is a resident of the state above for only part of year
Date this person established residence in state above
In which state (or foreign country) did this person reside before this change?
Part IV ' Dependent Care Expenses

Qualified dependent care expenses incurred and paid for this person in 2017
Unreimbursed medical expenses paid for qualifying person in 2017
Employment taxes paid for dependent care providers in 2017
Full-time student for 5 calendar months during 2017? Yes No
Disabled person who was not physically or mentally capable of self-care? Yes No
This person is a qualifying person for the child and dependent care credit Yes X No
Part VI ' Healthcare Coverage

Does coverage in prior year qualify January and February for eligibility for
short gap exemption? See help for additional details. X Yes No
Prior year covered or exempt other than short gap exemption for November and
December, supports answer to January and February eligible for short gap exemption
above.
Check if covered or exempt (other than short gap) for prior year November X
Check if covered or exempt (other than short gap) for prior year December X
Check the appropriate box below to indicate the healthcare coverage for this person. Select 12 months
if they were covered all year, select the individual months if they were not covered all year and leave
blank if they did not have minimum essential during any month of the year.
12 months Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
X X X X X X X X X X X X X
Enter any Marketplace-granted coverage exemption for this person below:
Exemption Certificate Number Exemption Start Month Exemption End Month
Enter any other insurance coverage exemption requested for this person below:
Exemption Type Check Full Year or Months Exempt for Each Type
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Full Year
Full Year
Full Year
Healthcare coverage information has been completed for this person.

Personal Information Worksheet 2017
For the Spouse
QuickZoom to another copy of Personal Information Worksheet
Part I ' Spouse's Personal Information

First name MariRenee Middle initial Last name Clarke
Suffix
Social security no. 313-96-8786 Member of U.S. Armed Forces in 2017? Yes X No

Occupation Customer Service Agent Daytime phone Ext
Marital status Married

If widowed, check the appropriate box for the year your spouse died:
After 2017 2017 2016 2015 Before 2015
Are you retired on total and permanent disability? (for Schedule R, see Help). Yes No
Check if this person is legally blind Yes X No
If deceased, enter the date of death (mm/dd/yyyy)
Were you under the age of 16 as of 1-1-2018 and this is the first year you
are filing a tax return? Yes No
Do you want $3 to go to Presidential Election Campaign Fund? Yes X No
Part II ' Questions for Individuals Who Could Be Or Are Dependents of Another Taxpayer
1 Can someone (such as your parent) claim you as a dependent? Yes X No
2 If you answered ’Yes’ to question 1, are you actually claimed as a dependent
on that person’s tax return? Yes X No
Questions 3 through 5 are only required for individuals who claim the
American Opportunity Credit.
3 Were you a full-time student during any part of five months during 2017? Yes No
4 Did your earned income exceed one-half of your support? Yes No
5 Was at least one of your parents alive on December 31, 2017? Yes No
Part III ' Spouse's State Residency Information

Enter this person’s state of residence as of December 31, 2017 CO
This person is a resident of the state above for the entire year X
Part IV ' Dependent Care Expenses

Qualified dependent care expenses incurred and paid for this person in 2017
Full-time student for 5 calendar months during 2017? Yes No
Disabled person who was not physically or mentally capable of self-care? Yes No
This person is a qualifying person for the child and dependent care credit Yes X No

above.
X X X X X X X X X X X X X
Full Year
Full Year
Full Year

Dependent and Nondependent Information Worksheet 2017
QuickZoom to another copy of Dependent and Nondependent Information Worksheet

First name Cassidy Middle initial A Last name Clarke

Suffix
Social security no. 307-27-1197

Did this person pass away in 2017 (deceased)? Yes X No Date of death
Relationship to taxpayer or spouse Daughter

CAUTION: If claiming a child other than your own, see Relationship in the Tax Help.
NOTE: The ability to set your answers to being the same as last year for the dependent is only
available in Step-by-Step mode and not in Forms mode.
Are the answers to the questions below for this person, to determine
whether they are your dependent, the same as they were last year? Yes No
Dependency code * X Is not a person in the current tax return
*Dependency code is set based on your selections in the Dependency Exemption/EIC Smart Worksheet
Dependent is disabled
Check this box if:

- The taxpayer filing this return is filing as Qualifying Widow(er)
- This dependency code for this dependent is type X
- This dependent would qualify as a qualifying child for the Qualifying Widow(er) filing status,
except the dependent’s gross income was $4,050 or more, or was filing a married filing joint
return, or the taxpayer could be claimed as a dependent
Part II ' Earned Income Credit and Child Tax Credit
Is this person a U.S. citizen, U.S. national, or a U.S. resident? X Yes No

Is this person a resident of Canada or Mexico? Yes X No
This person is adopted and you are a U.S. citizen or U.S. national
TurboTax Web Only:
Was the adoption final as of December 31, 2017? Yes No
Was the person placed with you for adoption after 2017, or was the adoption
final in 2017 or later? Yes No
The adopted child lived with you all year Yes No
*If the child is adopted, you are a U.S. citizen or U.S. national and they lived with you
all year, they are considered to meet the citizen test and the U.S. citizen box will
automatically be checked yes.
Child is a potentially qualifying child for earned income credit Yes X No

Child is a nondependent, but may qualify for earned income credit Yes X No
You, and no one else, is claiming this nondependent for the earned income credit Yes No
Months lived with taxpayer in the United States 2
Qualifying for the earned income credit * N Non-qualifying person
*EIC code is set based on your selections in the Dependency Exemption/EIC Smart Worksheet
Check if this person is not a qualifying child for the child tax credit X
If this dependent has an ITIN issued by the IRS instead of a Dependent has ITIN
social security number issued by the social security administration,
did they meet the substantial presence test? (see Schedule 8812 Instructions) Yes No
Dependent name Cassidy A Clarke Page 2
Part III ' Dependent Care Expenses
Qualified child or dependent care expenses incurred and paid in 2017

Child or dependent is a qualifying person for the child and dependent care credit Yes X No
Child is a nondependent, but may qualify for the child and dependent care credit Yes X No
Part V ' Dependent’s State Residency Information
Enter this person’s state of residence as of December 31, 2017

This person is a resident of the state above for the entire year
above.
X X X X X X X X X X X X

Full Year
Full Year
Full Year
Part VI ' Identity Protection Pin
If the IRS sent an Identity Protection PIN for this dependent, enter it here
Form 1040 Forms W-2 & W-2G Summary 2017

Form W-2 Summary
Box No. Description Taxpayer Spouse Total
1 Total wages, tips and compensation:

Non-statutory & statutory wages not on Sch C 97,580. 9,339. 106,919.
Statutory wages reported on Schedule C
Foreign wages included in total wages
Unreported tips 0. 0. 0.
2 Total federal tax withheld 11,685. 183. 11,868.
3 & 7 Total social security wages/tips 102,893. 9,339. 112,232.
4 Total social security tax withheld 6,379. 579. 6,958.
5 Total Medicare wages and tips 102,893. 9,339. 112,232.
6 Total Medicare tax withheld 1,492. 135. 1,627.
8 Total allocated tips
9 Not used
10 a Total dependent care benefits
b Offsite dependent care benefits
c Onsite dependent care benefits
11 Total distributions from nonqualified plans
12 a Total from Box 12 22,910. 490. 23,400.
b Elective deferrals to qualified plans 5,313. 5,313.
c Roth contrib. to 401(k), 403(b), 457(b) plans 490. 490.
d Deferrals to government 457 plans
e Deferrals to non-government 457 plans
f Deferrals 409A nonqual deferred comp plan
g Income 409A nonqual deferred comp plan
h Uncollected Medicare tax
i Uncollected social security and RRTA tier 1
j Uncollected RRTA tier 2
k Income from nonstatutory stock options
l Non-taxable combat pay
m QSEHRA benefits
n Total other items from box 12 17,597. 17,597.
14 a Total deductible mandatory state tax
b Total deductible charitable contributions
c This line does not apply to TurboTax
d Total RR Compensation
e Total RR Tier 1 tax
f Total RR Tier 2 tax
g Total RR Medicare tax
h Total RR Additional Medicare tax
i Total RRTA tips
j Total other items from box 14 4,702. 4,702.
16 Total state wages and tips 97,580. 9,339. 106,919.
17 Total state tax withheld 3,680. 85. 3,765.
19 Total local tax withheld 69. 69.
Form W-2 Wage and Tax Statement 2017
Name Social Security Number

X Spouse’s W-2 Military: Complete Part VI on Page 2 below

Do not transfer this W-2 to next year
a Employee’s social security No 313-96-8786 1 Wages, tips, other 2 Federal income

b Employer’s ID number 87-0426325 compensation tax withheld
c Employer’s name, address, and ZIP code 9,339.00 183.00
SKYWEST AIRLINES INC 3 Social security wages 4 Social security tax withheld
9,339.00 579.00
Street 444 S River Rd 5 Medicare wages and tips 6 Medicare tax withheld
City St George 9,339.00 135.00
State UT ZIP Code 84790 7 Social security tips 8 Allocated tips
Foreign Province A Enter unreported tips in Part VII on Page 2 below.

Foreign Postal Code
Foreign Country
Verification Code 10 Dependent care benefits
d Control number 2327-e850-575e-9c43
11 Nonqualified plans Distributions from sect. 457
X Transfer employee information from and nonqualified plans
the Federal Information Worksheet (Important, see Help)
e Employee’s name 12 Enter box 12 below
First MariRenee M.I.
Last Clarke Suff. 13 Statutory employee
f Employee’s address and ZIP code X Retirement plan
Street 1301 Speer Blvd #710 Third-party sick pay
City Denver
State CO ZIP Code 80204 14 Enter box 14 below after entering boxes 18, 19, and 20.
Foreign Province NOTE: Enter box 15 before entering box 14.
Foreign Postal Code
Foreign Country
Box 12 Box 12 If Box 12 code is:

Code Amount A: Enter amount attributable to RRTA Tier 2 tax
AA 490.00 M: Enter amount attributable to RRTA Tier 2 tax
P: Double click to link to Form 3903, line 4
R: Enter MSA contribution for Taxpayer
Spouse
W: Enter HSA contribution for Taxpayer
Spouse
G: Employer is not a state or local government
Box 15 Box 16 Box 17

State Employer’s state I.D. no. State wages, tips, etc. State income tax
CO 8046404 9,339.00 85.00
I confirm that the state withholding identification number(s) are accurate X
Box 20 Box 18 Box 19 Associated

Locality name Local wages, tips, etc. Local income tax State
Box 14 TurboTax Identification of Description or Code

Description or Code (Identify this item by selecting the identification from
on Actual Form W-2 Amount the drop down list. If not on the list, select Other).
Form W-2 Wage and Tax Statement 2017

Spouse’s W-2 Military: Complete Part VI on Page 2 below

Do not transfer this W-2 to next year
a Employee’s social security No 315-04-4786 1 Wages, tips, other 2 Federal income

b Employer’s ID number 72-0564834 compensation tax withheld
c Employer’s name, address, and ZIP code 97,580.00 11,685.00
NATIONAL FINANCE CENTER 3 Social security wages 4 Social security tax withheld
102,893.00 6,379.00
Street PO BOX 60000 5 Medicare wages and tips 6 Medicare tax withheld
City NEW ORLEANS 102,893.00 1,492.00
State LA ZIP Code 70160 7 Social security tips 8 Allocated tips
Foreign Province A Enter unreported tips in Part VII on Page 2 below.

Foreign Postal Code
Foreign Country
Verification Code 10 Dependent care benefits
d Control number
11 Nonqualified plans Distributions from sect. 457
X Transfer employee information from and nonqualified plans
the Federal Information Worksheet (Important, see Help)
e Employee’s name 12 Enter box 12 below
First Robert M.I. T
Last Clarke Suff. Jr 13 Statutory employee
f Employee’s address and ZIP code X Retirement plan
Street 1301 SPEER BLVD Third-party sick pay
City DENVER
State CO ZIP Code 80204 14 Enter box 14 below after entering boxes 18, 19, and 20.
Foreign Province NOTE: Enter box 15 before entering box 14.
Foreign Postal Code
Foreign Country
Box 12 Box 12 If Box 12 code is:

Code Amount A: Enter amount attributable to RRTA Tier 2 tax
D 5,313.00 M: Enter amount attributable to RRTA Tier 2 tax
DD 17,597.00 P: Double click to link to Form 3903, line 4
R: Enter MSA contribution for Taxpayer
Spouse
W: Enter HSA contribution for Taxpayer
Spouse
G: Employer is not a state or local government
Box 15 Box 16 Box 17

State Employer’s state I.D. no. State wages, tips, etc. State income tax
CO 08007337 97,580.00 3,680.00
I confirm that the state withholding identification number(s) are accurate X
Box 20 Box 18 Box 19 Associated

Locality name Local wages, tips, etc. Local income tax State
DENVER CO 284846030048 69.00 CO
Box 14 TurboTax Identification of Description or Code

Description or Code (Identify this item by selecting the identification from
on Actual Form W-2 Amount the drop down list. If not on the list, select Other).
NT HEALTH BENEFITS 4,702.00 Other (not classified)
Healthcare Entry Sheet 2017
The forms associated with healthcare (8965, 8962, 1095-A, 1095-B, 1095-C, and this Healthcare Entry Sheet) all interact with
information from the information worksheet. Be sure to enter all personal information including dependents listed on the return
before using this sheet to track health insurance coverage.
Yes No/Partial
Everyone on the tax return was covered by health insurance all year.
If everyone on the return was covered and there was no Market Place coverage (Form 1095-A) then check the YES box
above - no other action is required. The 1095-B or 1095-C can be used to verify coverage but you do not need to enter
the information if everyone on the return was covered.
Health Insurance Coverage for Individuals: Use this form to report healthcare coverage for individuals for months:
? not reported on 1095-A, 1095-B or 1095-C
? not covered by employer
? months not covered by an exemption
Note: The 1095-A information must be entered on Form 1095-A in order to correctly calculate any Premium Tax Credit. The 1095-B
or the 1095-C months can be entered directly in the table below.
If applicable enter information on form 1095-A, Health Insurance Marketplace Statement
Note: The IRS is not requiring the 1095-B or 1095-C be filed with the returns. To track the months covered you can either enter
on the 1095-B and/or 1095-C or check the boxes below
If applicable enter information on form 1095-B, Health Coverage
If applicable enter information on form 1095-C, Employer-Provided Health Insurance Offer and Coverage
If applicable enter Market Place exemptions (ECNs) or Request exemptions on form 8965
Note: Do not enter the name, SSN, or date of birth directly on the table below. Instead, enter the information at the bottom of the
Personal Information Worksheet or Dependent and Nondependent Information Worksheet.
Or if you check the box at the top "Yes" that "Everyone on the tax return was covered by health insurance all year." the covered
all 12 months box will be marked for all the individuals below regardless of what is entered on the Personal Information or
Dependent and Nondependent Information Worksheet.
Short Gap
Eligible*
Yes No
a. Name of covered individual(s) Covered all
b. SSN c. DOB 12 months Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
1 Robert Clarke Short gap: X Yes No
315-04-4786 01/19/81 X X X X X X X X X X X X X T
2 MariRenee Clarke Short gap: X Yes No
313-96-8786 07/17/81 X X X X X X X X X X X X X S
3 Short gap: Yes No
4 Short gap: Yes No
5 Short gap: Yes No
6 Short gap: Yes No
* See help for explanation of short gap Yes/No box function. It affects the calculation of short gap coverage for January and
February based on answer, which indicates whether coverage at end of prior year qualify months for short gap eligibility.
To review the detail of each person listed on the return (covered, not covered, exempt) and to see any penalty calculation go to the
Health Care Individual Responsibility Smart Worksheet on Form 8965
Completion checkbox:
X Check this box once you are finished with all the healthcare related entries.
Form 1099-SA Distributions from an HSA, Archer MSA or 2017
Medicare Advantage MSA

Check if for spouse See below for additional distribution information Corrected amount
Payer’s name, street address, city, state, and Zip code

HSA BAnk, a division of Webster BAnk, N.A.
506 N 8th street STE 320

Sheboygan WI 53081
Payer’s Recipient’s 1 Gross distribution 2 Earnings on excess

Federal identification No. identification No. contributions
06-0273620 315-04-4786 $ 750.68 $
Check to transfer Recipient’s information 3 Distribution code 4 FMV on date of death

from Federal Information Worksheet 1 $
Recipient’s Name
Robert T Clarke, Jr 5 HSA X
Street address (including apartment number)
1301 Speer Blvd, Apt. 710 Archer MSA
City State ZIP Code
Denver CO 80204 Advantage MSA
Account number (optional)
Additional Distribution Information
Recipient’s Age
A Check this box if the recipient was age 65 or over at time of distribution
Medical Expenses See Help for important information
B Check this box if the entire amount in box 1 was used to pay qualified medical expenses
and can be treated as tax free X
C If less than the amount in box 1 was used to pay medical expenses, enter the amount
that was used to pay qualified medical expenses and can be treated tax free
Rollover
D Enter the amount in box 1 that was rolled over
Return of Excess Contribution
E Check this box if this is the return of excess contributions made by the employer (See Help)
Death Distribution (Box 3 - Code 4)
F Was the MSA or HSA inherited from a spouse who died? Yes No
QuickZoom to Form 8853, p1

QuickZoom to Form 8889T
QuickZoom to Form 8889S
Form 1099-SA Distributions from an HSA, Archer MSA or 2017
Medicare Advantage MSA

Check if for spouse X See below for additional distribution information Corrected amount
Payer’s name, street address, city, state, and Zip code

HSA BAnk, a division of Webster Bank, N.A.
605 n 8th street STE 320

Sheboygan WI 53081
Payer’s Recipient’s 1 Gross distribution 2 Earnings on excess

Federal identification No. identification No. contributions
06-0273620 313-96-8786 $ 35.00 $
Check to transfer Recipient’s information 3 Distribution code 4 FMV on date of death

from Federal Information Worksheet 1 $
Recipient’s Name
MariRenee Clarke 5 HSA X
Street address (including apartment number)
1301 Speer Blvd, Apt. 710 Archer MSA
City State ZIP Code
Denver CO 80204 Advantage MSA
Account number (optional)
Additional Distribution Information
Recipient’s Age
A Check this box if the recipient was age 65 or over at time of distribution
Medical Expenses See Help for important information
B Check this box if the entire amount in box 1 was used to pay qualified medical expenses
and can be treated as tax free X
C If less than the amount in box 1 was used to pay medical expenses, enter the amount
that was used to pay qualified medical expenses and can be treated tax free
Rollover
D Enter the amount in box 1 that was rolled over
Return of Excess Contribution
E Check this box if this is the return of excess contributions made by the employer (See Help)
Death Distribution (Box 3 - Code 4)
F Was the MSA or HSA inherited from a spouse who died? Yes No
QuickZoom to Form 8853, p1

QuickZoom to Form 8889T
QuickZoom to Form 8889S
Wages, Salaries, & Tips Worksheet 2017

The following amounts are included in the total entered on line 7 of Form 1040 (or Form 1040A), on line 1
of Form 1040EZ, on line 8 of Form 1040NR:
Taxpayer Spouse Total
1 Wages, from Form W-2 97,580. 9,339. 106,919.

2 Miscellaneous income, from Form 8919
3 Items from Form 1099-R:
a Disability before minimum retirement age
b Return of contributions
4 Excess reimbursement, from Form 2106
5a Taxable tips, from Form 4137
b Noncash tips
6 Excess moving expense reimbursement,
from Form 3903
7 Wages earned as a household employee (if
less than $2,000 and without a Form W-2)
8 Items not on Form W-2 or Form 1099-R:
a Sick pay or disability payments
b Total foreign source income
c Check this box if the amount on line 8b is
eligible for the foreign exclusion/deduction
d Ordinary income from employer stock
transactions not reported on Form W-2
9 Other earned income:
a Non-gov unemployment received/repaid 2017
b
10 Subtotal.
Add lines 1 through 9 97,580. 9,339. 106,919.
11 Taxable employer-provided dependent care
benefits, from Form 2441
12 Taxable employer-provided adoption benefits
less any excluded benefits from Form 8839
13 Scholarship/fellowship income not on
Form W-2
14 Other non-earned income:
15 Total of lines 10 through 14 97,580. 9,339. 106,919.

Form 1040 Child Tax Credit Worksheet 2017
Line 52 G Keep for your records
Name as Shown on Return Social Security No.
Note: ? To be a qualifying child for the child tax credit, the child must be under age 17 at the end of 2017
and meet the other requirements listed in the instructions for Form 1040 or 1040A.
? If applicable, first complete Form 2555, Foreign Earned Income and enter any exclusion of
income from U.S. Possessions on the Federal Information Worksheet.
Part 1
1 Number of qualifying children: X $1,000. Enter the result 1
2 Enter the amount from Form 1040, line 38, or
Form 1040A, line 22 2
3 1040 filers: enter the total of any '
? Exclusion of income from Puerto Rico, and
? Amounts from Form 2555, lines 45 and 50;
Form 2555-EZ, line 18; and Form 4563, 3
line 15.
1040A filers: Enter -0-.
4 Add lines 2 and 3. Enter the total 4
5 Enter the amount shown below for your filing status.
? Married filing jointly ' $110,000
? Single, head of household, or
qualifying widow(er) ' $75,000 5
? Married filing separately ' $55,000
6 Is the amount on line 4 more than the amount on
line 5?
No. Leave line 6 blank. Enter -0- on line 7.
Yes. Subtract line 5 from line 4 6
If the result is not a multiple of $1,000,
increase it to the next multiple of $1,000.
For example, increase $425 to $1,000,
increase $1,025 to $2,000, etc.
7 Multiply the amount on line 6 by 5% (.05). Enter the result 7
8 Is the amount on line 1 more than the amount on line 7?
No. Stop.
You cannot take the child tax credit on Form 1040, line 52, or
Form 1040A, line 35. You also cannot take the additional child tax
credit on Form 1040, line 67, or Form 1040A, line 43. Complete the
rest of your Form 1040 or 1040A.
Yes. Subtract line 7 from line 1. Enter the result. Go to Part 2 8
Part 2
9 Enter the amount from Form 1040, line 47, or Form 1040A, line 30 9
10 Add the amounts from '
Form 1040, line 48
Form 1040, line 49, or Form 1040A, line 31 +
Form 5695, line 30 +
Schedule R, line 22 +
Enter the total 10
11 Are you claiming any of the following credits?
? Mortgage interest credit, Form 8396
? Adoption Credit, Form 8839
? Residential energy efficient property credit, Form 5695, Part I
? District of Columbia first-time homebuyer credit, Form 8859
No. Enter the amount from line 10
Yes. If you are filing Form 2555, enter the amount from 11
line 10. Otherwise, Complete the Line 11 Worksheet below to
figure the amount to enter here.
12 Subtract line 11 from line 9. Enter the result. 12
13 Is the amount on line 8 of this worksheet more than the amount on line 12?
No. Enter the amount from line 8
Yes. Enter the amount from line 12. This is your child
See the TIP below. tax credit 13
Enter this amount on
Form 1040, line 52, or
Form 1040A, line 35.
TIP: You may be able to take the additional child tax credit on Form 1040, line 67, or Form 1040A,
line 43, only if you answered ’Yes’ on line 13.
? First, complete your Form 1040 through line 66a (also complete line 71), or Form 1040A through
line 42a.
? Then, use Parts II through IV of Schedule 8812 to figure any additional child tax credit.
Child Tax Credit (2017) Line 11 Worksheet Page 2
Caution: Use this worksheet only if you answered ’Yes’ on line 11 of the Child Tax Credit Worksheet above.
1 Enter the amount from line 8 of the Child Tax Credit Worksheet above 1
2 Enter earned income from the Earned Income Worksheet that applies to you 2
3 Is the amount on line 2 more than $3,000?
No. Leave line 3 blank, enter -0- on line 4, and go to line 5.
Yes. Subtract $3,000 from the amount on line 2. Enter the result 3
4 Multiply the amount on line 3 by 15% (.15) and enter the result 4
5 Is the amount on line 1 of the Child Tax Credit Worksheet $3,000 or more?
No. If line 4 above is:
? Zero, enter the amount from line 1 above on line 12 of this
worksheet. Do not complete the rest of this worksheet. Instead,
go back to the Child Tax Credit Worksheet and do the following.
Enter the amount from line 10, on line 11 and complete lines 12 and 13.
? More than zero, leave lines 6 through 9 blank, enter -0- on line 10,
and go to line 11 below.
Yes. If line 4 above is equal to or more than line 1 above, leave lines 6
through 9 blank, enter -0- on line 10, and go to line 11 below.
Otherwise, complete lines 58, 66a, and 71 of your return if
they apply to you and then go to line 6.
If married filing jointly, include your spouse’s amounts with yours when
completing lines 6 and 7.
6 Enter the total of the following amounts from
Form(s) W-2:
? Social security taxes from box 4, and
? Medicare taxes from box 6. 6 8,585.
Railroad employees, see Note below.
7 1040 filers: Enter the total of any '
? Amounts from Form 1040, line 27 and
58, and
? Any taxes that you identified using code 7
"UT" and entered on
line 62.
1040A filers: Enter -0-.
9 1040 filers: Enter the total of the amounts
from Form 1040, lines 66a and 71.
9
1040A filers: Enter the total of any '
? Amount from Form 1040A, line 42a, and
? Excess social security and tier 1 RRTA
taxes withheld that you entered to the
left of Form 1040A, line 46.
10 Subtract line 9 from line 8. If zero or less, enter -0- 10
11 Enter the larger of line 4 or line 10 11
12 Is the amount on line 11 of this worksheet more than the amount on line 1?
No. Subtract line 11 from line 1. Enter the result
12
Yes. Enter -0-.
Next, figure the amount of any of the following credits that you are claiming.
? Mortgage interest credit, Form 8396
? Adoption Credit, Form 8839
? Residential energy efficient property credit, Form 5695, Part I
? District of Columbia first-time homebuyer credit, Form 8859
Then, go to line 13.
13 Enter the total of the amounts from '
? Form 8396, line 9, and

? Form 8839, line 16 and
? Form 5695, line 15, and
? Form 8859, line 3. 13
14 Enter the amount from line 10 of the Child Tax Credit Worksheet 14
Enter this amount on

line 11 of the Child
Tax Credit Worksheet.
Note: Railroad Employees
Include the following taxes in the total on line 6 of the Line 11 Worksheet:
? Tier 1 tax withheld from your pay. This tax should be shown in box 14 of your W-2 form(s) and
identified as ’Tier 1 tax.’
? If you were an employee rep., 50% of the total Tier 1 tax and Tier 1 Medicare tax you paid for 2017.
Schedule D Unrecaptured Section 1250 Gain Worksheet 2017

Regular Alternative
Tax Minimum Tax
If you are not reporting a gain on Form 4797, line 7, skip lines 1
through 9 and go to line 10.
1 If you have a section 1250 property in Part III of Form 4797 for
which you made an entry in Part I of Form 4797 (but not Form
6252), enter the smaller of line 22 or line 24 of Form 4797 for that
property. If you did not have any such property, go to line 4. 1
2 Enter the amount from Form 4797, line 26g, for the property for
which you made an entry on line 1 2
3 Subtract line 2 from line 1 3
4 Enter the total unrecaptured section 1250 gain included on lines
26 or 37 of Form(s) 6252 from installment sales of trade or
business property held more than one year 4
5 Enter the total of any amounts reported on a Schedule K-1 from a
partnership or an S corporation as "unrecaptured section 1250
gain". 5
6 Add lines 3 through 5 6
7 Enter the smaller of line 6 or the gain from Form
4797, line 7 7
8 Enter the amount, if any, from Form 4797, line 8 8
10 Enter the amount of any gain from sale of an interest in a
partnership attributable to unrecaptured section 1250 gain 10
11 Enter the total of any amounts reported to you as "unrecaptured
section 1250 gain" from an estate, trust, real estate investment
trust or mutual fund
Regular AMT
a On Form 1099-DIV
b On Form 2439
c On Schedule(s) K-1
d On Form 1099-R
e From Form 8814
f Other
Total 11
12 Enter the total of any unrecaptured section 1250 gain from sales
(including installment sales) or other dispositions of section 1250
property held more than 1 year for which you did not make
an entry in Part I of Form 4797 for the year of sale 12
13 Add lines 9 through 12 13
14 If you had any section 1202 gain or collectibles gain or (loss),
enter the total of lines 1 thru 4 of the 28% Rate Gain Worksheet.
Otherwise, enter -0- 14 0. 0.
15 Enter the (loss), if any, from Schedule D, line 7. If Schedule D, line
7, is zero or a gain, enter -0- 15 0. 0.
16 Enter your long-term capital loss carryovers from Schedule D, line
14, and Schedule K-1 (Form 1041), line 11, code C 16
a Enter your capital gain excess, if you are filing Form 2555 a 0.
17 Combine lines 14 through 16a. If the result is a (loss), enter it as a
positive amount. If the result is zero or a gain, enter -0- 17 0. 0.
18 Unrecaptured section 1250 gain. Subtract line 17 from line 13. If
zero or less, enter -0-. If more than zero, enter the result here and
on Schedule D, line 19 18
Schedule D 28% Rate Gain Worksheet 2017

Regular Alternative
Tax Minimum Tax
1 Enter the total of all collectibles gain or (loss) from items you
reported on Form 8949, Part II 1
2 Enter as a positive number the amount of any section 1202
exclusion you reported in column (g) of Form 8949, Part II, with
code "Q" in column (f), that is 50% of the gain, plus 2/3 of any
section 1202 exclusion you reported in column (g) of Form
8949, Part II, with code "Q" in column (f), that is 60% of the
gain, plus 1/3 of any section 1202 exclusion you reported in
column (g) of Form 8949, Part II, with code "Q" in column (f),
that is 75% of the gain.
50 % 60 % 75%
Exclusion Exclusion Exclusion
a Schedule D
b Form 8814
c Schedule B
d Form 6252
e Form 2439
f Other
Total 2
3 Enter the total of all collectibles gain or (loss) from:
Regular AMT
a Form 4684, line 4 (but only
if line 15 is more than zero)
b Form 6252
c Form 6781, Part II
d Form 8824
Total 3
4 Enter the total of any collectibles gain reported to you on:
Regular AMT
a Form 1099-DIV, box 2d
b Form 2439, box 1d
c Schedule K-1 from a
partnership, S corporation,
estate, or trust
d Disposition of interest in
partnership or S corporation
e Other
Total 4
5 Enter your long-term capital loss carryovers from Schedule D,
line 14, and Schedule K-1 (Form 1041), line 11, code C 5
6 If Schedule D, line 7, is a (loss), enter that (loss) here.
Otherwise, enter -0-. 6
7 Combine lines 1 through 6. If zero or less, enter -0-. If more
than zero, also enter this amount on Schedule D, line 18 7
8 Enter the amount of any capital gain excess 8 0.
9 Subtract line 8 from line 7. If zero or less, enter -0-.
Enter this amount on Schedule D Tax Worksheet, line 11a 9 0. 0.
Form 1040 Schedule D Tax Worksheet 2017

1 a Enter your taxable income from Form 1040, line 43 1a 76,254.

b Enter the amount from your (and your spouse’s) Form 2555, line 45 b
c Add lines 1a and 1b 1c 76,254.
2 a Enter your qualified dividends
from Form 1040, line 9b 2a
b Enter any capital gain excess
attributable to qualified dividends b
c Subtract line 2b from line 2a 2c
3 Amount from Form 4952, line 4g 3
4 a Amount from Form 4952, line 4e 4 a
b Amount from the dotted line
next to Form 4952, line 4e b
c Line 4b, if applicable, 4a, if not c
5 Subtract line 4c from line 3. 5 0.
6 Subtract line 5 from line 2c. If zero or less, enter -0- 6 0.
7 a Enter line 15 of Schedule D 7a
b Enter line 16 of Schedule D b
c Enter the smaller of line 7a or line 7b 7c 0.
8 Enter the smaller of line 3 or line 4c 8
9 a Subtract line 8 from line 7. 9a 0.
b Enter any capital gain excess attributable to
capital gains b
c Subtract line 9b from line 9a 9c 0.
10 Add lines 6 and 9c 10 0.
11 a Enter the amount from Schedule D, line 18 11 a 0.
b Enter the amount from Schedule D, line 19 b
c Add lines 11a and 11b 11 c 0.
12 Enter the smaller of line 9c or line 11c 12 0.
13 Subtract line 12 from line 10 13 0.
14 Subtract line 13 from line 1c. If zero or less, enter -0- 14 76,254.
15 Enter:
? $37,950 if single or married filing separately;
? $75,900 if married filing jointly or qualifying widow(er); or 15 75,900.
? $50,800 if head of household.
16 Enter the smaller of line 1c or line 15 16 75,900.
17 Enter the smaller of line 14 or line 16 17 75,900.
18 Subtr ln 10 from ln 1c. If zero or less, enter -0- 18 76,254.
19 Enter the larger of line 17 or line 18 19 76,254.
20 Subtract line 17 from line 16. This amount is taxed at 0% 20 0.
If lines 1c and 16 are the same, skip lines 21 through 41
and go to line 42. Otherwise, go to line 21.
21 Enter the smaller of line 1c or line 13 21 0.
22 Enter the amount from line 20 (if line 20 is blank, enter -0-) 22 0.
23 Subtract line 22 from line 21. If zero or less, enter -0- 23 0.
24 Enter:
? $418,400 if single,
? $235,350 if married filing separately, 24 470,700.
? $470,700 if married filing jointly or qualifying widow(er),
? $444,550 if head of household.
25 Enter the smaller of line 1c or line 24 25 76,254.
26 Add lines 19 and 20 26 76,254.
28 Enter the smaller of line 23 or line 27 28 0.
29 Multiply line 28 by 15% (.15) 29 0.
30 Add lines 22 and 28 30 0.
31 Subtract line 30 from line 21 31 0.
32 Multiply line 31 by 20% (.20) 32 0.
If Schedule D, line 19, is zero or blank, skip lines 33 through 38

33 Enter the smaller of line 9c above or Schedule D, line 19 33
34 Add lines 10 and 19 34
35 Enter the amount from line 1c above 35
38 Multiply line 37 by 25% (.25) 38
If Schedule D, line 18, is zero or blank, skip lines 39 through 41
39 Add lines 19, 20, 28, 31, and 37 39
40 Subtract line 39 from line 1c 40
42 Figure the tax on the amount on line 19. If the amount on line 19 is less than $100,000,
use the Tax Table to figure this tax. If the amount on line 19 is $100,000 or more,
use the Tax Computation Worksheet 42 10,546.
43 Add lines 29, 32, 38, 41, and 42 43 10,546.
44 Figure the tax on the amount on line 1c. If the amount on line 1c is less than $100,000,
use the Tax Table to figure this tax. If the amount on line 1c is $100,000 or more,
use the Tax Computation Worksheet 44 10,546.
45 Tax on all taxable income (including capital gains and qualified dividends).
Enter the smaller of line 43 or line 44. Also include this amount on Form 1040, line 44 45 10,546.
Form 1040 Qualified Dividends and Capital Gain Tax Worksheet 2017

1 Enter the amount from Form 1040, line 43 1

2 Enter the amount from Form
1040, line 9b 2
3 Are you filing Schedule D?
Yes. Enter the smaller of line 15
or 16 of Schedule D. If
either line 15 or 16 is blank
or loss, enter -0- 3
No. Enter the amount from Form
1040, line 13.
5 If filing Form 4952 (used to figure
investment interest expense
deduction), enter any amount from line
4g of that form. Otherwise, enter -0-. 5
8 Enter:
$37,950 if single or married filing separately,
$75,900 if married filing jointly or qualifying widow(er), 8
$50,800 if head of household.
9 Enter the smaller of line 1 or line 8 9
11 Subtract line 10 from line 9 (this amount taxed at 0%) 11
13 Enter the amount from line 11 13
14 Subtract line 13 from line 12. 14
15 Enter:
$418,400 if single,
$235,350 if married filing separately, 15
$470,700 if married filing jointly or qualifying widow(er),
$444,550 if head of household.
24 Figure the tax on the amount on line 7. If the amount on line 7 is less than
$100,000, use the Tax Table to figure the tax. If the amount on line 7 is
$100,000 or more, use the Tax Computation Worksheet 24
25 Add lines 20, 23, and 24 25
26 Figure the tax on the amount on line 1. If the amount on line 1 is less than
$100,000, use the Tax Table to figure this tax. If the amount on line 1 is
$100,000 or more, use the Tax Computation Worksheet 26
27 Tax on all taxable income. Enter the smaller of line 25 or line 26 here and on
Form 1040, line 44. 27
IRA Contributions Worksheet 2017

Traditional IRA Contributions
Regular Traditional IRA Contributions Taxpayer Spouse
1 Enter traditional IRA contributions made for 2017, including

any made between 1/1/2018 and 4/17/2018, any amounts
later recharacterized to a Roth IRA, and any excess
contributions, but not including any rollovers. Also include any
contributions to deemed IRAs under an employer plan
2 Contributions recharacterized from a Roth IRA (from line 24)
3 Traditional IRA contributions, from Schedule(s) K-1
4 Contributions recharacterized (not converted) to a Roth IRA
A If there is a recharacterization indicated on line 4, an
explanation must be attached to the tax return.
5 Traditional IRA contributions. Combine lines 1 through 4
6 Enter any contribution included on line 5 withdrawn before
the due date of the tax return. See Help
7 Excess traditional IRA contribution credit
8 Repayments of qualified reservist distributions
9 Total traditional IRA contributions.
Additional Traditional IRA Contribution Information Taxpayer Spouse
10 Check if covered by a retirement plan at work. If married filing

a separate return, check box in spouse column, if applicable X X
11 Enter any contributions included on line 9 that were made
during 1/1/2018 to 4/17/2018 (See Help)
12 Age 70-1/2 or older in tax year
Deductible and Non-deductible Traditional IRA Contributions Taxpayer Spouse
13 Deductible traditional IRA contributions from worksheet

14 Nondeductible traditional IRA contributions from worksheet
QuickZoom to worksheet indicated by the check:

IRA deduction worksheet
Worksheet for social security recipients
15 Amount on line 13 you elect to make nondeductible

16 Excess traditional IRA contributions, to Form 5329, line 15
Note: You may avoid a penalty by withdrawing the amount
on line 16 before due date of return, including extensions.
17 Deductible traditional IRA contributions, to Form 1040, line 32

18 Qualified reservist repayments
19 Nondeductible traditional IRA contributions, to Form 8606, ln 1
IRA Contributions Worksheet 2017
Roth IRA Contributions
Regular Roth IRA Contributions Taxpayer Spouse
20 Enter regular Roth IRA contributions made for 2017, including

any made between 1/1/2018 and 4/17/2018, any amounts
later recharacterized to a traditional IRA, and any excess
contributions, but not including any rollovers or conversions.
Also include any contributions to deemed Roth IRAs under an
employer plan
21 Contributions recharacterized from a traditional IRA, (from ln 4)
22 Roth IRA contributions, from Schedule(s) K-1
23 Enter contributions recharacterized to a traditional IRA
A If there is a recharacterization indicated on line 23, an
explanation must be attached to the tax return.
24 Disallowed Roth IRA conversions
25 Roth IRA contributions. Combine lines 20 through 24
26 Enter any contribution included on line 25 withdrawn before
the due date of the tax return. See Help
27 Excess Roth IRA contribution credit
28 Total Roth IRA contributions
29 Repayments of qualified Roth reservist distributions
Roth IRA Contributions After Limitations Taxpayer Spouse
30 Roth IRA contributions after limitation

31 Excess Roth IRA contributions, to Form(s) 5329, line 23
Note: You may avoid a penalty by withdrawing the amount

on line 31 before due date of return, including extensions.
Coverdell Education Savings Account (Education IRA) Contributions
Excess Coverdell Education Savings Account Contributions Taxpayer Spouse
32 Enter any excess contributions made to Coverdell Education

Savings Accounts (ESAs) of which you are the beneficiary
Note: You do not need to report any Coverdell ESA

contributions which are not excess contributions..
Schedule A Medical Expenses Worksheet 2017

1 Prescription medications 1
2 Health insurance premiums:
a Premiums other than self-employed health insurance or reported on a 1095-A 2a
b From Form(s) 1095-A - net of adjustments b
Taxpayer’s portion of 1095-A premiums (total less spouse)
Spouse’s portion of 1095-A premiums, enter the amount
for the spouse, the remaining goes to the taxpayer
c Medicare premiums c
d From Form(s) 1099-R d
NOTE: If LTC premiums are associated with a specific business activity,
enter them directly on the applicable Self-Employed Health and Long-Term
Care Insurance Deduction Worksheet, not on lines 2e - 2j below.
e Taxpayer’s gross long-term care premiums 2e
f Taxpayer’s allowable long-term care premiums f
g Spouse’s gross long-term care premiums g
h Spouse’s allowable long-term care premiums h
i Dep or child under 27 gross long-term care premiums i
j Dep or child under 27 allowable long-term care prem. j
k Total allowable long-term care premiums, sum of lines 2f, 2h, and 2j k
l Taxpayer’s long-term care premiums not deducted as an adjustment to income l
m Spouse’s long-term care premiums not deducted as an adjustment to income m
n Dependent’s long-term care premiums not deducted as an adj to income n
o Other self-employed health insurance not deducted as an adj to income o
3 Fees for doctors, dentists, etc 3
4 Fees for hospitals, clinics, etc 4
5 Lab and x-ray fees 5
6 Expenses for qualified long-term care 6
7 Eyeglasses and contact lenses 7
8 Medical equipment and supplies 8
9 Medical transportation expenses:
a Medical miles driven 9a
b Multiply the number of miles on line 9a by 17 cents
per mile b
c Other medical transportation costs not included above
for example: ambulance fees c
d Total medical transportation expenses (add lines 9b and 9c) 9d
10 Lodging for medical purposes (up to $50 per night per person) 10
11 Other medical and dental expenses:
a 11 a
b b
c c
d d
e e
f f
g g
h h
i i
j j
12 Total of medical and dental expenses (add lines 1 through 11j) 12
13 a Less: insurance reimbursement for any expenses listed 13 a
b Less: medical savings account (MSA) or health savings account (HSA)
distributions b 786.
14 Total deductible medical and dental expenses. Subtract lines 13a plus 13b
from line 12 (to Schedule A, line 1) 14 0.
Tax Payments Worksheet 2017

Estimated Tax Payments for 2017 (If more than 4 payments for any state or locality, see Tax Help)
Federal State Local
Date Amount Date Amount ID Date Amount ID
1 04/18/17 04/18/17 04/18/17
2 06/15/17 06/15/17 06/15/17
3 09/15/17 09/15/17 09/15/17
4 01/16/18 01/16/18 01/16/18
Tot Estimated
Payments
Tax Payments Other Than Withholding Federal State ID Local ID

(If multiple states, see Tax Help)
6 Overpayments applied to 2017

7 Credited by estates and trusts
8 Totals Lines 1 through 7
9 2017 extensions
Taxes Withheld From: Federal State Local
10 Forms W-2 11,868. 3,765. 69.

11 Forms W-2G
12 Forms 1099-R
13 Forms 1099-MISC, 1099-K and 1099-G
14 Schedules K-1
15 Forms 1099-INT, DIV and OID
16 Social Security and Railroad Benefits
17 Form 1099-B St Loc
18 a Other withholding St Loc
b Other withholding St Loc
c Other withholding St Loc
d Positive Adjustment St Loc
e Negative Adjustment St Loc
f Additional Medicare Tax
19 Total Withholding Lines 10 through 18f
11,868. 3,765. 69.
20 Total Tax Payments for 2017 11,868. 3,765. 69.
Prior Year Taxes Paid In 2017 State ID Local ID

(If multiple states or localities, see Tax Help)
21 Tax paid with 2016 extensions

22 2016 estimated tax paid after 12/31/2016
23 Balance due paid with 2016 return 137. IL
24 Other (amended returns, installment payments, etc)
Schedule A Tax and Interest Deduction Worksheet 2017
Lines 5 - 12 G Keep for your records

Tax Deductions
1 State and local taxes:

Optional Sales Tax Tables
a Available Income:
(1) Income from Form 1040, line 38 101,521.
(2) Nontaxable income entered elsewhere on return
(3) Available income: 2016 refundable credits in excess of tax 0.
(4) Enter any additional nontaxable income
(5) Total available income 101,521.
b Sales Tax Per State of Residence:
Enter state in column (1), then enter total (combined) state and local sales tax rate in column (4).
Arizona, Colorado, Louisiana, Mississippi, New York or South Carolina only:
Double-click in column (4) to select your locality for each state entered.
(1) (2) (3) (4) (5) (6) (7) (8) (9)

S Date Date Enter State Local State Local Prorated
t Lived in Lived in Total Sales Sales Sales Sales or Total
a State State State & Tax Tax Tax Tax Amount
t From To Local Rate Rate (%) Table Amount
e Rate (%) (%) (4) - (5) Amount
c Total general sales tax using tables

d Sales Tax Paid on Specific Items (see help):
(1) (2) (3) (4) (5) (6) (7) (8)

ST Total Description Type Cost Rate if Actual Specific
State & Different Sales Tax Item
Local Amount Deduction
Rate Paid
e Total sales tax deduction on specific items

f Total general sales tax per tables plus sales tax on specific items
g Actual State and Local General Sales Tax:
Actual sales taxes (enter the total sales taxes paid during the year on all items)
h State and Local Income Taxes:
State and Local Income taxes 3,971.00
i State and Local Tax Deduction to Schedule A, line 5:
Greater of line 1f, line 1g, or line 1h (to Schedule A, line 5) 3,971.00
j Check a box to choose to use income taxes paid, sales taxes paid, or whichever
provides the greater deduction:
Income Taxes Sales Taxes Greater amount X
2 Real estate taxes:

a Real estate taxes paid on principal residence not entered on Form 1098 1,682.00
b Real estate taxes paid on principal residence entered on Home Mortgage Int. Wks
c Real estate taxes paid on additional homes or land
Personal portion of real estate taxes from Schedule E Worksheet for:
d Principal residence
e Vacation home
f Less real estate taxes deducted on Form 8829
g Add lines 2a through 2f (to Schedule A, line 6) 1,682.00
3 Personal property taxes:
a Auto registration fees based on the value of the vehicle.
2016 Amount Enter 2017 description:
2017 Subaru FOrester 593.00
b Non-business portion of personal property taxes from Car & Truck Exp Wks
c Other personal property taxes
d Add lines 3a through 3c (to Schedule A, line 7) 593.00
4 Other taxes:
a Other taxes from Schedule(s) K-1
b Foreign taxes from interest and dividends
c Foreign taxes from Schedule(s) K-1
d Other foreign taxes (not used to claim a foreign tax credit)
e Other taxes.
2016 Amount Enter 2017 description:
f Add lines 4a through 4e (to Schedule A, line 8)
Interest Deductions
5 Home mortgage interest and points reported on Form 1098:

a Mortgage interest and points from the Home Mortgage Interest Worksheet 10,504.00
b Qualified mortgage interest from Schedule E Worksheet
c Less home mortgage interest/points deducted on Form 8829
d Less home mortgage interest from Form 8396, line 3
e Add lines 5a through 5d (to Sch A, line 10) or line A2 from above 10,504.00
6 Home mortgage interest not reported on Form 1098:
a Mortgage interest from the Home Mortgage Interest Worksheet
b Less home mortgage interest deducted on Form 8829
c Add lines 6a and 6b (to Sch A, line 11) or line B2 from above
7 Points not reported on Form 1098:
a Amortizable points from the Home Mortgage Interest Worksheet
b Other points not on Form 1098 from the Home Mortgage Interest Worksheet
c Less points deducted on Form 8829
d Add lines 7a through 7c (to Schedule A, line 12) or line C2 from above
Schedule A State and Local Tax Deduction Worksheet 2017

State and Local Income Taxes
State income taxes:

1 State income tax withheld 1 3,765.
2 2017 state estimated taxes paid in 2017 2
3 2016 state estimated taxes paid in 2017 3
4 Amount paid with 2016 state application for extension 4
5 Amount paid with 2016 state income tax return 5 137.
6 Overpayment on 2016 state income tax return applied to 2017 tax 6
7 Other amounts paid in 2017 (amended returns, installment payments, etc.) 7
8 State estimated tax from Schedule(s) K-1 (Form 1041) 8
Local income taxes:
9 Local income tax withheld 9 69.
10 2017 local estimated taxes paid in 2017 10
11 2016 local estimated taxes paid in 2017 11
12 Amount paid with 2016 local application for extension 12
13 Amount paid with 2016 local income tax return 13
14 Overpayment on 2016 local income tax return applied to 2017 tax 14
15 Other amounts paid in 2017 (amended returns, installment payments, etc.) 15
16 Local estimated tax from Schedule(s) K-1 (Form 1041) 16
Other:
17 17
18 Total Add lines 1 through 17 18 3,971.
19 State and local refund allocated to 2017 19
20 Nondeductible state income tax from line 28 20
21 Total reductions Add lines 19 and 20. 21
22 Total state and local income tax deduction Line 18 less line 21 22 3,971.
Nondeductible State Income Tax (Hawaii Only)
23 Nontaxable federal employee cost of living allowance 23

24 Adjusted gross income 24
26 Nondeductible percent. Line 23 divided by line 25 26 %
27 Hawaii state income tax included in line 18 27
28 Nondeductible Hawaii state income tax. Multiply line 26 by line 27. 28
Schedule A Home Mortgage Interest Worksheet 2017
Lines 6 and 10-13 G Keep for your records

Note: Use this worksheet to report home mortgage interest you paid on your main home or second home.
Enter mortgage interest you paid for business property other than a home office on the appropriate
schedule or form for the business activity (Schedule C, Schedule E, etc.).
Mortgage Lender Info:

1 Recipient’s/lender’s name RoundPoint Mortgage Servicing Corporation
2 a Was the mortgage interest reported to you on Form 1098? Yes X No

b Mortgage interest paid on your main home or second home in 2017 10,504.00
3 Outstanding mortgage principal as of 1/1/2017
4 Mortgage origination date 03/07/2016
5 a Did your home loan close after December 31, 2006? Yes No
b Mortgage insurance premiums
6 a Points paid to buy or improve your main home in 2017

b Check if points were reported to you on Form 1098
c Check if points were reported on the HUD-1 loan closing statement, or
my name is not listed first on Form 1098
Computed points reported on Form 1098
Computed points not reported on Form 1098
7 Property taxes
8 Check this box if you refinanced your loan with a different lender, paid off this loan,
or sold the property
9 Did you pay points to this lender which must be spread over the life of the loan, for example:
points you paid on your second home, on a home equity loan, or when you refinanced,
enter the following Yes No X
a Total points originally paid on a loan for which the points must be amortized
b Length of loan (years)
c Points deducted in prior years for this loan
d Amortized points allowable this year
e Amortizable points deducted this year (to Tax and Interest Deduction Wkst., line 7a)
Uncommon Situations:
10 Were you and someone else liable for this mortgage and the other person received the
Form 1098, enter the other person’s name and address Yes No
Name
Address
City State ZIP
11 Did you buy your home from the recipient and did NOT receive a Form 1098, enter the
recipient’s identifying number and address Yes No X
Recipient’s SSN -OR- Recipient’s EIN
Recipient’s address
City State ZIP
12 Did you pay more mortgage interest than what is shown on Form 1098 Yes No
QuickZoom to attach a statement to your return explaining the difference
Schedule A Cash Contributions Worksheet 2017

Cash Contributions
Name of Charitable Organization Type 2017 Amount

Note: Summarized from the Charitable Organization Worksheet.
Enter amounts on the Charitable Organization Worksheet.
1a Planned Parenthood A 200.00
1b From Schedule A ' Cash contributions for qualified

disaster relief allowed against 100% of AGI 1b
2 From Schedule K-1 ' Partnerships and S Corporations 2
3 From Form(s) W-2, Box 14 3
4 Miles driven:
a To perform charitable service 4a
b From Detail of Mileage and
Transportation Costs Worksheet
above 4b
c Add lines 4a and 4b 4c
d Multiply line 4c by 14 cents per mile 4d
5 Parking fees, tolls, and local transportation
a To perform charitable service 5a
b From Charitable Org. Wks 5b
c Add lines 5a and 5b. 5c
6 Add lines 1 thru 5 and enter here (to Schedule A, line 16) 6 200.00
Schedule A Noncash Contributions Worksheet 2017

Part I Name of Charity and Donation Value
1 Name of charity GoodWill

2 a Value of contribution 217.00
Part II Type of Donated Property
3 Check one:
Tangible personal property Intangible property
a X Household items & clothing i Stock, Publicly traded
b Motor vehicle, boat, or airplane j Stock, Other than publicly traded
c Art, Other than self-created k Securities, Other than stock
d Art, Self-created l Intellectual property
e Collectibles m Other
f Business equipment Real property
g Business inventory n Real property, Conservation property
h Other o Real property, Other than conservation
Part III Additional Information

If total noncash contributions are more than $500, complete Part III
4 a Street address of charity 2230 W. 93rd Avenue

b Charity City or Town merrillville State IN ZIP 46410
5 Unique description of donated property Clothing, Footwear, Accessories &
Household items
6 Date of donation (mm/dd/yyyy or Various) 10/17/2017

7 Method used to determine the fair market value Comparative sales
Part IV Acquisition Information

If the value of this contribution is more than $500, complete Part IV
Only enter ’various’ for date acquired, if the property was held more than one year.
8 Date the donated property was acquired (mm/dd/yyyy)

9 How the donated property was acquired
10 Cost or adjusted basis in the donated property
11 If business equipment, enter accumulated depreciation
Part V Deduction
12 Amount claimed as a deduction 217.

A Robert T Clarke, Jr & MariRenee Clarke 315-04-4786 Page 2
Part VI Type of Charitable Organization
13 Check one: X (a) 50% charity (b) Other than 50% charity
Part VII Charity’s Use of Certain Appreciated Property

Complete when value is greater than cost.
14 Is the charity’s use of property related to its exempt purpose? Yes No

Check ’No’ if the charity sold the donated property.
Part VIII Motor vehicle, boat, airplanes
15 a Was a Form 1098-C received? Yes No

b If no, did you receive other written acknowledgment? Yes No
c Vehicle Identification Number
Part IX Additional Information for Contributions of Property More than $5,000

Complete Part IX for a contribution of property that has a value of more than $5,000.
Generally, you must have a written appraisal for these contributions.
16 Was an appraisal required for this property? Yes No

17 Appraiser Information:
a Date of Appraisal
b Appraiser Title
c Appraiser Identifying Number
d Appraiser Business Address (including room or suite number)
e Appraiser City or Town State ZIP Code
18 Charity Information:
a Charity Date of Receipt of Gift
b Charity Representative Title
c Charity Identifying Number
d Charity Street Address (including room or suite number)
e Charity City or Town State ZIP Code
19 Other Information:
a If a group of items were donated, describe any items
which were appraised at $500 or less
b For tangible property, give a brief summary of its overall physical
condition on the date it was donated
c For stock and securities (checkboxes 3i-3j), enter average trading price
d For bargain sales, enter the amount received
Part X Partial Interest Donations

If entire interest in the property was not donated, complete Part X.
Complete Part X for a contribution of property that has a value of $5,000 or less and for
publicly traded stock donations.
20 Was the entire interest donated for this property? X Yes No

If no, complete line 21
21 Partial interest donation information:
a Amount claimed as a deduction on 2017 tax return
b Deduction claimed for this property on prior years’ tax returns
c Location of tangible property donated
d Name of the person, other than the charity on line 1, who has
possession of the donated property
Complete lines 21e through 21g only if different from the charity on line 1:
e If a partial interest in this property was donated to a different charity
in a prior year, enter the name of the charity
f Street address of prior charity
g City of prior charity State ZIP Code
Schedule A Noncash Contributions Worksheet 2017

Part I Name of Charity and Donation Value
1 Name of charity
2 a Value of contribution
Part II Type of Donated Property
3 Check one:
Tangible personal property Intangible property
a Household items & clothing i Stock, Publicly traded
b Motor vehicle, boat, or airplane j Stock, Other than publicly traded
c Art, Other than self-created k Securities, Other than stock
d Art, Self-created l Intellectual property
e Collectibles m Other
f Business equipment Real property
g Business inventory n Real property, Conservation property
h Other o Real property, Other than conservation
Part III Additional Information

If total noncash contributions are more than $500, complete Part III
4 a Street address of charity

b Charity City or Town State ZIP
5 Unique description of donated property
6 Date of donation (mm/dd/yyyy or Various)

7 Method used to determine the fair market value
Part IV Acquisition Information

If the value of this contribution is more than $500, complete Part IV
Only enter ’various’ for date acquired, if the property was held more than one year.
8 Date the donated property was acquired (mm/dd/yyyy)

9 How the donated property was acquired
10 Cost or adjusted basis in the donated property
11 If business equipment, enter accumulated depreciation
Part V Deduction
12 Amount claimed as a deduction

Charitable Deduction Limits Worksheet 2017
For Current Year Contributions

Step 1. List your qualified charitable contributions made during the year.
1 Enter contributions for relief efforts in the Hurricanes Harvey, Irma & Maria disaster areas
that you elect to treat as qualified contributions. Do not include this amount on line 2 below
Step 2. List your other charitable contributions made during the year.
2 Enter your contributions to 50% limit organizations. Do not include contributions of capital
gain property deducted at fair market value. Do not include contributions entered on line 1. 417.
3 Enter your contributions to 50% limit organizations of capital gain property deducted at fair
market value
4 Enter your contributions (other than of capital gain property) to organizations that are not
50% limit organizations
5 Enter your contributions "for the use" of any qualified organization
6 Add lines 4 and 5
7 Enter your contributions of capital gain property to or for the use of any qualified
organization. (But do not enter here any amount entered on line 1 or 2)
Step 3. Figure your deduction for the year and your carryover to the next year.
8 Enter your adjusted gross income 101,521.
9 Multiply line 8 by 0.5. This is your 50% limit. 50,761.
Limits Deduct Carryover

this year to next
Cash and Other Capital gain year
50% Other 50% Other

Org Org
Contributions to 50% limit

organizations
12 Subtract line 10 from line 9 50,344.
Contributions not to 50% limit

organizations
13 Add lines 2 and 3 417.
14 Multiply line 8 by 0.3. This is your 30%
limit. 30,456. 30,456.
16 Enter the smallest of line 6, 14, or 15 0.
Capital gain property to 50% limit

organizations
Capital gain property not to 50% limit

organizations
limit. 20,304.
24 Enter the smaller of line 7, 18, 21, 22,
or 23 0.
26 Add lines 10, 16, 19, and 24.

Amount for Schedule A, Line 19 417.
28 Enter the smaller of line 1 or line 27
here on Schedule A, line 19. 0.
30 Add lines 11, 17, 20, 25 and 29. Carry
to next year. 0.
Charitable Deduction Limits Worksheet 2017
For Carryover Contributions

Step 1. List your qualified charitable contributions made during the year.
1 Enter contributions for relief efforts in the Hurricanes Harvey, Irma & Maria disaster areas
that you elect to treat as qualified contributions. Do not include this amount on line 2 below
Step 2. List your other charitable contributions made during the year.
2 Enter your contributions to 50% limit organizations. Do not include contributions of capital
gain property deducted at fair market value. Do not include contributions entered on line 1.
3 Enter your contributions to 50% limit organizations of capital gain property deducted at fair
market value
4 Enter your contributions (other than of capital gain property) to organizations that are not
50% limit organizations
5 Enter your contributions "for the use" of any qualified organization
6 Add lines 4 and 5
7 Enter your contributions of capital gain property to or for the use of any qualified
organization. (But do not enter here any amount entered on line 1 or 2)
Step 3. Figure your deduction for the year and your carryover to the next year.
8 Enter your adjusted gross income 101,521.
9 Multiply line 8 by 0.5. This is your 50% limit. 50,761. less 417. 50,344.
Limits Deduct Carryover

this year to next
Cash and Other Capital gain year
50% Other 50% Other

Org Org
Contributions to 50% limit

organizations
Contributions not to 50% limit

organizations
13 Add lines 2 and 3 417.
limit. 30,456. 30,456.
Capital gain property to 50% limit

organizations
Capital gain property not to 50% limit

organizations
limit. 20,304.
24 Enter the smaller of line 7, 18, 21, 22,
or 23 0.
26 Add lines 10, 16, 19, and 24.

Amount for Schedule A, Line 19 0.
here on Schedule A, line 19. 0.
30 Add lines 11, 17, 20, 25 and 29. Carry
to next year. 0.
Charitable Contributions Summary 2017
Part I Cash Contributions Summary
(a) (b) (c) (d)
Name of Charitable Organization Total 50% 30% 100%
Limit Limit Limit
Planned Parenthood 200. 200.
Totals: 200. 200.

Part II Non-Cash Contributions Summary
Total Other Property Capital Gain Property
(a) (b) (c) (d) (e)

Name of Charitable Organization Total 50% 30% 30% 20%
Limit Limit Limit Limit
GoodWill 217. 217.
Totals: 217. 217.

Part III Contribution Carryovers to 2018
Total Cash and Other Capital Gain
Non-Capital Gain Property Property
(a) (b) (c) (d) (e) (f)
Total 100% 50% 30% 30% 20%
Limit Limit Limit Limit Limit
1 2017 contributions 417. 417.
2 2017 contributions
allowed 417. 0. 417. 0. 0. 0.
3 Carryovers from:
a 2016 tax year
b 2015 tax year
c 2014 tax year
d 2013 tax year
e 2012 tax year
4 Carryovers
allowed in 2017 0. 0. 0. 0. 0.
5 Carryovers
disallowed in 2017 0. 0. 0. 0. 0.
6 Carryovers to 2018:
a From 2017 0. 0. 0. 0. 0.
b From 2016
c From 2015
d From 2014
e From 2013
f From 2012
Part IV Special Situations in Your Return for Current Year Donations

1 Was the entire interest given for all property donated to all charities? X Yes No
2 Were restrictions attached to any charities’s right
to use or dispose of any property donated to any charity? Yes X No
3 Did you give to anyone other than the charity the right to income from any
of the donated property or to possession of any of the donated property? Yes X No
4 Was any charity other than a 50% charity? Yes X No
Schedule A Miscellaneous Itemized Deductions Worksheet 2017
Lines 21, 23, 28 G Keep for your records

Employee Business Expenses ' Subject to 2% Limitation
1 Deductible expenses from Form 2106, line 10 less deductions for

performing artists and armed forces reservists claimed elsewhere 1 600.
2 a Qualified Educator Expenses (from Educator Expenses Worksheet) 2a
b Educator Expense Deduction (from 1040, line 23) 2b
c Excess Educator Expenses (line 2a less line 2b) 2c
3 Union and professional dues 3
4 Professional subscriptions 4
5 Uniforms and protective clothing 5
6 Job search costs 6
7 Other:
7
8 Combine lines 1 through 7 (to Schedule A, line 21) 8 600.
Miscellaneous Expenses ' Subject to 2% Limitation Investment

Check the box in investment column if an investment expense expense T
9 Depreciation and amortization deductions X 9
10 Casualty/theft losses of property used in services as an employee 10
11 REMIC expenses, from Schedule E X 11
12 Investment expenses related to interest and dividend income X 12
13 Expenses related to portfolio income, from Schedule(s) K-1 X 13
14 Miscellaneous deductions, from Schedule(s) K-1 14
15 Excess deductions on termination, from Schedule(s) K-1 15
16 Investment counsel and advisory fees X 16
17 Certain attorney and accounting fees X 17
18 Safe deposit box rental fees X 18
19 IRA custodial fees X 19
20 Loss incurred from total distribution of all traditional IRAs 20
21 Loss incurred from total distribution of all Roth IRAs 21
22 Loss incurred from final distribution of a QTP investment 22
23 Hobby expense (limited to hobby income) 23
24 Other:
a Prior year government unemployment benefits repaid in 2017 24
b
25 Combine lines 9 through 24 (to Schedule A, line 23) 25
Other Miscellaneous Deductions ' Not Subject to 2% Limitation
26 Expenses related to portfolio income, from Schedule(s) K-1 X 26

27 Federal estate tax paid on decedent’s income reported on this return 27
28 Impairment-related expenses of a handicapped employee, from Form 2106 28
29 Amortizable bond premiums on bonds acquired before 10/23/86 29
30 Gambling losses 30
31 Deduction for repayment of amounts under claim of right if over $3,000 31
32 Casualty/theft losses of income-producing property 32
33 Unrecovered investment in annuity 33
34 Ordinary loss attributable to certain debt instruments 34
35 Net Qualified Disaster Loss 35
36 Combine lines 26 through 35 (to Schedule A, line 28) 36
Schedule A Itemized Deductions Worksheet 2017

1 Add the amounts on Schedule A, lines 4, 9, 15, 19, 20, 27 and 28 1 17,167.
2 Add the amounts on Schedule A, lines 4, 14 and 20, plus any gambling
and casualty or theft losses included on line 28. Also include in the total any
amount included on Schedule A, line 16, that you elected to treat as qualified
contributions for the relief efforts in a Hurricane disaster area. 2 0.
CAUTION: Be sure your total gambling and casualty or theft losses are clearly
identified on the Miscellaneous Itemized Deductions Statement.
3 Is the amount on line 2 less than the amount on line 1?
No. STOP. Your deduction is not limited. Enter the amount from
line 1 above on Schedule A, line 29.
X Yes. Subtract line 2 from line 1 3 17,167.
4 Multiply line 3 by 80% (.80) 4 13,734.
5 Enter the amount from Form 1040, line 38 5 101,521.
6 Enter $261,500 if single; $313,800 if married filing
jointly or qualifying widow(er); $287,650 if head of
household, $156,900 if married filing separately
6 313,800.
7 Is the amount on line 6 less than the amount on
line 5?
X No. STOP. Your deduction is not limited.
Enter the amount from line 1 above on
Schedule A, line 29.
Yes. Subtract line 6 from line 5 7
10 Total itemized deductions. Subtract line 9 from line 1.
(to Schedule A, line 29, or line 15 if filing form 1040NR) 10
Form 1040 Standard Deduction Worksheet for Dependents 2017

Use this worksheet only if someone can claim you, or your spouse if filing jointly, as a dependent.
1 Is your earned income* more than $700?
Yes. Add $350 to your earned income. Enter the total 1
No. Enter $1,050
2 Enter the amount shown below for your filing status.
? Single or married filing separately ' $6,350
? Married filing jointly or Qualifying widow(er) ' $12,700 2 12,700.
? Head of household ' $9,350
3 Standard deduction.
3 a Enter the smaller of line 1 or line 2. If born after January 1, 1953, and not
blind, stop here and enter this amount on Form 1040, line 40. Otherwise go
to line 3b 3a
3 b If born before January 2, 1953, or blind, multiply the number on Form 1040,
line 39a, by $1,250 ($1,550 if single or head of household) 3b
3 c Add lines 3a and 3b. Enter the total here and on Form 1040, line 40 3c
*Earned income includes wages, salaries, tips, professional fees, and other compensation received for
personal services you performed. It also includes any taxable scholarship or fellowship grant. Generally,
your earned income is the total of the amount(s) you reported on Form 1040, lines 7, 12, and 18, minus
the amount, if any, on line 27; or on Form 1040A, line 7.
Form 1040 Deduction for Exemptions Worksheet 2017

1 Multiply $4,050 by the total number of exemptions claimed on Form

1040, line 6d 1 8,100.
2 Enter the amount from Form 1040, line 38 2 101,521.
3 Enter the amount shown below for your filing status:
? Single, enter $261,500
? Married filing jointly or qualifying widow(er), enter $313,800
? Married filing separately, enter $156,900
? Head of household, enter $287,650 3 313,800.
4 Subtract line 3 from line 2. If zero or less, stop; enter the amount from
line 1 above on Form 1040, line 42 4 -212,279.
5 Is line 4 more than $122,500 ($61,250 if married filing separately)?
Yes. You cannot take a deduction for exemptions.
Enter zero here and on Form 1040, line 42.
Do not complete the rest of this worksheet.
No. Divide line 4 by $2,500 ($1,250 if married filing separately). If the
result is not a whole number, increase it to the next whole number
(for example, increase .0004 to 1) 5
6 Multiply line 5 by 2% (.02) and enter the result as a decimal 6
7 Multiply line 1 by line 6 7
8 Deduction for exemptions. Subtract line 7 from line 1. Enter the result here
and on Form 1040, line 42 8
Earned Income Worksheet 2017

Part I ' Earned Income Credit Wks Computation Taxpayer Spouse Total
1 If filing Schedule SE:

a
Net self-employment income
b
Optional Method and Church Employee income
c
Add lines 1a and 1b
d
One-half of self-employment tax
e
Subtract line 1d from line 1c
2 If not required to file Schedule SE:
a Net farm profit or (loss)
b Net nonfarm profit or (loss)
c Add lines 2a and 2b
3 If filing Schedule C or C-EZ as a statutory
employee, enter the amount from line 1
of that Schedule C or C-EZ
4 Add lines 1e, 2c and 3. To EIC Wks, line 5
Part II ' Form 2441 and Standard Deduction Worksheet Computations
5 Net self-employment earnings (line 4 above)

6 Wages, salaries, and tips less distributions
from nonqualified or section 457 plans, etc 97,580. 9,339. 106,919.
7a Taxable employer-provided adoption benefits
b Foreign earned income exclusion
8 Add lines 5 through 7b. To Form 2441, lines 19
and 20 97,580. 9,339. 106,919.
9a Taxable dependent care benefits
b Nontaxable combat pay
10 Add lines 8, 9a & 9b . To Form 2441, lines
4 and 5 97,580. 9,339. 106,919.
11 Scholarship or fellowship income not on W-2
12 SE exempt earnings less nontaxable income
13 Distributions from nonqualified/Sec. 457 plans
14 Add lines 5, 6, 7a, 9a and 11 through 13.
To Standard Deduction Worksheet 97,580. 9,339. 106,919.
Part III ' IRA Deduction Worksheet Computation
15 Net self-employment income or (loss)

16 Wages, salaries, tips, etc 97,580. 9,339. 106,919.
17 Net self-employment loss
18 Alimony received
19 Nontaxable combat pay
20 Foreign earned income exclusion
21 Keogh, SEP or SIMPLE deduction
22 Combine lines 15 through 21. To IRA Wks, ln 2 97,580. 9,339. 106,919.
Part IV ' Schedule 8812 and Child Tax Credit Line 11 Worksheet Computations
23 Self-employed, church and statutory employees

24 Wages, salaries, tips, etc 97,580. 9,339. 106,919.
25 Nontaxable combat pay
26 Combine lines 23 through 25. To Schedule
8812, line 4a & Line 11 Wks, line 2 97,580. 9,339. 106,919.
Form 4952 Investment Interest Expense Worksheet 2017

Investment Interest Expense ( Form 4952, line 1)

1 Investment interest expense, from Schedule K-1 1
2 Investment interest expense from royalties 2
3 Other investment interest expense:
a 3a
b b
c c
d d
4 Total investment interest expense. Add lines 1 through 3. 4
Gross Income from Property Held for Investment (Form 4952, line 4a)
5 Taxable investment income:
a From Schedule B, Interest and Dividend Income 5a 116.
b From Schedules K-1, Partnerships, S Corporations, Estates and Trusts b
c From Form 8814, Parents’ Election to Report Child’s Interest and Dividends c
d Total d 116.
6 Royalty income, from Schedule E 6
7 Net passive income from publicly traded partnerships 7
8 Income from nonpassive trade or business without material participation 8
9 Other investment income:
a 9a
b b
c c
d d
10 Total investment income. Add lines 5d through 9. 10 116.
Net Capital Gain Income (Form 4952, lines 4d and 4e)

Regular Tax Alt Min Tax
11 a Net gains from Schedule D, line 16 11 a

b Less net gains from property not held for investment b
c Net gains from property held for investment. c
12 a Net capital gains from Schedule D, lesser of ln 15 or ln 16 12 a

b Less net capital gains from property not held for investment b
c Net capital gains from property held for investment. c
Investment Expenses (Form 4952, line 5)

13 Royalty expenses 13
14 Investment expenses included as itemized deductions (after the 2% limitation) 14
15 Investment expenses included as itemized deductions (no 2% limitation) 15
16 Expenses from nonpassive trade or business without material participation 16
17 Other investment expenses:
a 17 a
b b
c c
d d
18 Total investment expenses. Add lines 13 through 17. 18
Allocation of Investment Interest Expense (Schedule A, line 14)

Regular Tax Alt Min Tax
19 Allowed investment interest expense, Form 4952, line 8 19

20 Less amount deducted on other forms and schedules: 20
a Deducted on Schedule E, page 2 for passthru entities a
b Deducted on Schedule E, page 1 for royalties b
c Other amounts deducted on other forms and schedules c
d Total amount deducted on other forms and schedules d
21 Investment interest expense. 21
Schedule E Schedule E Worksheet 2017
Name(s) shown on return Social Security No.

General Information:
Property description Chicago Condo LSD
Property type 1 Single Family Residence If type is other, enter a description
Location (street address) 1150 N Lake Shore Dr. 23J
City Chicago State IL ZIP code 60611
If a foreign address: Foreign province or state
Foreign postal code Foreign country
Complete For All Properties:

Did you make any payments that would require you to file Form(s) 1099? Yes No X
If yes, did you or will you file all required Form(s) 1099? Yes No
Complete For All Rental Properties:

Days rented at fair rental value 365 Days of personal use 0
Check All That Apply:

A Owned by spouse B Owned jointly X
C Active participation X D Material participation
E Qualified joint venture F Some investment is not at risk
G Other passive exceptions H Complete taxable disposition - See Help
Trade or business not subject to net investment income tax
I Treat all MACRS assets for this activity as qualified Indian reservation property? Yes No X
J Treat all assets acquired after August 27, 2005 as
qualified GO Zone property? Regular Extension No X
K Treat all assets acquired after May 4, 2007 as
qualified Kansas Disaster Zone property? Yes No X
L Was this activity located in a Qualified Disaster Area? Yes No X
M Reserved for future use
Ownership Percentage:
N Check to allocate income and expenses using ownership percentage
O Enter ownership percentage %
Owner-Occupied Rentals:
P Check to allocate personal use items to Schedule A
Q Percentage of rental use %
Vacation Home or Property with Personal Use Days:

R Check to allocate interest and taxes using the Tax Court Method
S Number of days property owned if less than the entire year
Property Location Page 2
1150 N Lake Shore Dr. 23J, Chicago, IL 60611
Income % if Different Total
3 Enter rental income (not reported elsewhere) 16,500.
Rental income from Form 1099-MISC
Rental income from Form 1099-K
Rental Income from Cancellation of Debt Wks
Total rents received 16,500. 100.000000 16,500.
4 Enter royalties received (not reported elsewhere)
Royalty income from Form 1099-MISC
Royalty income from Form 1099-K
Royalty Income from Cancellation of Debt Wks
Royalty Income from Schedule K-1
Total royalties received
(a) (b) (c) (d) (e)

Expenses Total Enter % Reported On Vacation Allocated to
if not Schedule E Home Loss Personal
100.00 Limitation use
5 Advertising 0. 0.
6a Auto
b Travel 2,082. 2,082.
7 Cleaning and maint 5,520. 5,520.
8 Commissions 100. 100.
9a Mort insur qualified
From Form 1098 import
Total mort insur qual
b Other Insurance 98. 98.
10 Legal & other prof fees 170. 170.
11 Management fees 0. 0.
12 a Mortgage int qualified 3,755.
Total mort int qualified 3,755. 3,755.
b Mort int other
Total mort int other
13 Other interest SEE STMT 0. 0.
14 Repairs 851. 851.
15 Supplies 200. 200.
16 a Real estate taxes 2,171.
Total real estate taxes 2,171. 2,171.
b Other taxes 0. 0.
17 Utilities 100. 100.
18 a Depreciation 5,147. 5,147.
b Depletion
c Depreciation carryover
19 Other expenses
a
b
c
d
e Indirect operating exp
f Operating exp carryover
g Vehicle rental
h Amortization
20 Add lines 5 through 19 20,194. 20,194.
21 Income or (loss) -3,694.
22 Deductible rental real estate loss -3,694.
Form 4562 Depreciation and Amortization Report 2017
Tax Year 2017
Sch E - 1150 N Lake Shore Dr. 23J 315-04-4786
Asset Description * Code Date Cost Land Bus Section Special Depreciable Method/ Prior Current
In Service (Net of Use % 179 Depreciation Basis Life Convention Depreciation Depreciation
Land) Allowance
DEPRECIATION
1150 North Lake Shore Drive 03/11/14 141,533 100.00 141,533 27.5 SL/MM 14,368 5,147
SUBTOTAL PRIOR YEAR 141,533 0 0 0 141,533 14,368 5,147
TOTALS 141,533 0 0 0 141,533 14,368 5,147
* Code: S = Sold, A = Auto, L = Listed, V = Vine with SDA in Year Planted/Grafted, X = Non-depreciated asset, H = Home Office
Page 1 of 1
Form 4562 Alternative Minimum Tax Depreciation Report 2017
Tax Year 2017
Sch E - 1150 N Lake Shore Dr. 23J 315-04-4786
Asset Description * Code Date Cost Land Bus Section Special Depreciable Method/ Prior Current Adjustments
In Service (Net of Use % 179 Depreciation Basis Life Convention Depreciation Depreciation Preferences
Land) Allowance
DEPRECIATION
1150 North Lake Shore Drive 03/11/14 141,533 100.00 141,533 27.5 SL/MM 14,368 5,147 0.
SUBTOTAL PRIOR YEAR 141,533 0 0 0 141,533 14,368 5,147 0.
TOTALS 141,533 0 0 0 141,533 14,368 5,147 0.
* Code: S = Sold, A = Auto, L = Listed, V = Vine with SDA in Year Planted/Grafted, X = Non-depreciated asset H = Home Office
Page 1 of 1
Asset Entry Worksheet 2017
QuickZoom to another copy of Asset Entry Worksheet

Activity: Sch E 1150 N Lake Shore Dr. 23J
Asset Information @ For vehicles, use the Car and Truck Expenses Worksheet
1 Description of asset 1150 North Lake Shore Drive Example: Laser printer
2 Date placed in service 03/11/2014 Example: 06/15/2017
3 Enter the total cost when asset was acquired 141,533. Include land for asset type I, J or M
4 Type of asset I - Residential rental
Range: 1.00 to 100.00
5 Percentage of business use 100.00 % If blank, 100.00% is used.
Applicable for asset type A-G, P, Q.
6 Enter the amount of Sec 179 expense elected Subject to limitation. See Tax Help.
7 Total amount of land included in the cost Applicable for asset type I, J or M
8 a Economic Stimulus - Qualified Property Yes X No

1 If yes, and if placed in service after 9/27/17, was this property
acquired after 9/27/17? Yes No X N/A
2 For post 9/27/17, elect 50% in place of 100% Special Depreciation
Allowance Yes No X N/A
b Qualified Second Generation/Cellulosic Biofuel/Biomass Plant Property Yes X No
c Qualified Disaster Area - Qualified Property Yes X No
d Kansas Disaster Zone - Qualified Property Yes X No
e Gulf Opportunity Zone - Qualified Property Reg Ext X No
f In service in GO Zone Ext bldg within 90 days of bldg in-service date Yes No X N/A
g Percentage for Special Depreciation Allowance 100% & 50% 30% X N/A
h Elect OUT of Special Depreciation Allowance Yes No
i Elect 30% in place of 50% Special Depreciation Allowance Yes No
j QuickZoom to view the Election statements
k Special Depreciation Allowance Deduction
l AMT Special Depreciation Allowance Ded
If blank, prior depreciation from
Asset Life History is used.
9 Prior depreciation 14,368. Required if asset was sold.
10 Depreciation deduction 5,147.
If blank, prior depreciation from
Asset Life History is used.
11 AMT prior depreciation 14,368. Required if asset was sold.
12 AMT depreciation deduction 5,147.
13 AMT adjustment/preference 0. See Tax Help for computation
14 QuickZoom to Asset Life History
15 If a computer or peripheral equipment (asset type A), was asset

used exclusively at your regular business establishment? Yes No
16 If video, photo, or phono equipment (asset type B),
was asset used exclusively at your regular business establishment,
or in connection with your principal trade or business? Yes No
17 If rental appliances, carpeting, or furniture (asset type F), have you
amended a prior year tax return or filed Form 3115 to change
the recovery period to 5 years? Yes No
18 Enter the IRC section under which you amortize
the cost of intangibles (asset type L)
1150 North Lake Shore Drive
Dispositions ' Complete only if you sold, abandoned, or otherwise disposed of the asset in 2017
19 Date sold, given away,

or abandoned in 2017 Example: 12/01/2017
20 Date acquired 03/11/2014 If converted from personal use
21 Asset sales price Enter business portion only
22 Asset expense of sale Enter business portion only
23 Property type
24 Land sales price Enter business portion only
25 Land expense of sale Enter business portion only
26 Section 179 deduction allowed
27 If Section 1250:
a Additional depreciation after 1975
b Applicable percentage %
c Additional depreciation after 1969 and before 1976
28 a Double click to link sale to Form 6252
b Double click to link sale to Home Sale Wks
29 Basis for gain or loss, if different from ln 3 Enter 100% of basis
30 Basis for AMT gain or loss, if diff from ln 53 Enter 100% of basis
31 Gain or loss
32 AMT gain or loss
33 Part of Form 4797 that gain or loss carries to
34 Land gain or loss (if separate) Only applies if line 24 is entered
35 Part of Form 4797 that land gain or loss carries to (if separate)
36 Check to compute personal residence depreciation after May 6, 1997
Regular tax after 5/6/97 AMT after 5/6/97
Detail Asset Information ' This section is calculated for most assets from the data above.
Use Find Next Error feature to check for any required entries.
37 Listed property? Yes X No See Tax Help

38 Subject to automobile limitations? Yes X No
39 Truck or van? Yes X No
40 Electric Passenger Vehicle? Yes X No
41 Heavy SUV? Yes X No
42 Eligible Section 179 property? Yes No Applies to current year assets only
43 Use IRS tables for MACRS property? Yes X No
44 Qualified Indian reservation property? Yes X No
Regular Depreciation
45 Depreciation Type MACRS
46 Asset class R
47 Depreciation Method SL
48 MACRS convention MM
49 QuickZoom to set 2017 convention
50 Recovery period 27.5
51 Year of depreciation 4
52 Depreciable basis 141,533. See Tax Help for computation
Alternative Minimum Tax Depreciation
53 AMT basis, if different from line 3
54 If placed in service before 1987, is asset
55 AMT depreciation method SL
56 AMT recovery period 27.5
57 AMT depreciable basis 141,533.
1150 North Lake Shore Drive
MACRS Property Involved in a Like-kind Exchange or Involuntary Conversion

58 Elect OUT of regs under Sec 1.168(i)-6(i) Yes No X N/A
59 Asset ID (Enter same ID on all related assets)
60 If this asset represents entire basis of replacement property, enter excess basis
61 If this asset represents exchanged basis of replacement property, enter:
a Date placed in service of relinquished property
b Date of disposition of relinquished property
c MACRS convention for relinquished property
d Depreciation claimed on relinquished property in year of disposition
e AMT depreciation claimed on relinquished property in year of disposition
State Depreciation
62 QuickZoom to select or delete states
63 a State (CA info must be entered in CA state return, do not enter here)
b Asset status See State Depreciation Statement
c State cost or basis
d State Section 179 deduction
e State Section 179 deduction allowed (enter for dispositions only)
f State Special Depreciation Allowance
g State asset class
h State depreciation method
i State MACRS convention
j State recovery period
k State depreciable basis
l State prior depreciation
m State depreciation deduction
n If this asset represents entire basis of replacement property, enter excess basis
o If exchanged basis, enter depr on relinquished property in year of disposition
p State gain/loss basis, if different from state cost
q Include asset in state return Yes No
Asset Life History 2017
Yearly Allowable Depreciation

Description: 1150 North Lake Shore Drive Depreciation type: MACRS Asset class: R
Cost/
Basis: 141,533. Depreciable Basis: 141,533. Method: SL Life: 27.50
AMT Cost/ AMT Depreciable AMT AMT
Basis: 141,533. Basis: 141,533. Method: SL Life: 27.50
Tax Prior Deduction AMT Prior AMT Deduction

Year Depreciation for the Year Depreciation for the Year
1 2014 0. 4,074. 0. 4,074.

2 2015 4,074. 5,147. 4,074. 5,147.
3 2016 9,221. 5,147. 9,221. 5,147.
4 2017 14,368. 5,147. 14,368. 5,147.
5 2018 19,515. 5,147. 19,515. 5,147.
6 2019 24,662. 5,147. 24,662. 5,147.
7 2020 29,809. 5,147. 29,809. 5,147.
8 2021 34,956. 5,147. 34,956. 5,147.
9 2022 40,103. 5,147. 40,103. 5,147.
10 2023 45,250. 5,147. 45,250. 5,147.
11 2024 50,397. 5,147. 50,397. 5,147.
12 2025 55,544. 5,146. 55,544. 5,146.
13 2026 60,690. 5,147. 60,690. 5,147.
14 2027 65,837. 5,146. 65,837. 5,146.
15 2028 70,983. 5,147. 70,983. 5,147.
16 2029 76,130. 5,146. 76,130. 5,146.
17 2030 81,276. 5,147. 81,276. 5,147.
18 2031 86,423. 5,146. 86,423. 5,146.
19 2032 91,569. 5,147. 91,569. 5,147.
20 2033 96,716. 5,146. 96,716. 5,146.
21 2034 101,862. 5,147. 101,862. 5,147.
22 2035 107,009. 5,146. 107,009. 5,146.
23 2036 112,155. 5,147. 112,155. 5,147.
24 2037 117,302. 5,146. 117,302. 5,146.
25 2038 122,448. 5,147. 122,448. 5,147.
26 2039 127,595. 5,146. 127,595. 5,146.
27 2040 132,741. 5,147. 132,741. 5,147.
28 2041 137,888. 3,645. 137,888. 3,645.
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
Schedule E Two-Year Comparison 2017

Property Location
1150 N Lake Shore Dr. 23J, Chicago, IL 60611
Note: Transferred data will not be displayed in the prior year column unless you have entered
current year data on the Schedule E Worksheet and are using TurboTax Premier or
Self-Employed.
2016 2016 2017 2017 2016 to 2017

Percent Percent Comparison
of of X as amount
Income* Income* as percent
Income:
1 Rental income 15,275. 100.00 16,500. 100.00 1225.00
2 Royalty income
Expenses:
3 Advertising 0.00
4 Auto
5 Travel 2,532. 16.58 2,082. 12.62 -450.00
6 Cleaning & maintenance 5,417. 35.46 5,520. 33.45 103.00
7 Commissions 100. 0.65 100. 0.61 0.00
8 Insurance:
a Mortgage Insur qualified
b Other insurance 254. 1.66 98. 0.59 -156.00
9 Legal & professional 170. 1.03 170.00
10 Management fees 0.00
11 Mortgage interest:
a Qualified 3,878. 25.39 3,755. 22.76 -123.00
b Other
12 Other interest 0.00
13 Repairs 4,780. 31.29 851. 5.16 -3929.00
14 Supplies 150. 0.98 200. 1.21 50.00
15 a Real estate taxes 1,985. 13.00 2,171. 13.16 186.00
b Other taxes 0.00
16 Utilities 100. 0.65 100. 0.61 0.00
17 a Depreciation 5,147. 33.70 5,147. 31.19 0.00
b Depletion
c Depreciation carryover
18 a Other expenses
b Indirect operating exp
c Operating exp carryover
d Vehicle rental
e Amortization
19 Total expenses 24,343. 159.36 20,194. 122.39 -4149.00
20 Income or (loss) -9,068. -59.36 -3,694. -22.39 5374.00
21 Deductible rental loss -9,068. -3,694. 5374.00
Passive suspended losses:

Schedule E
Form 4797
Schedule D
*Lines 1 through 20 as a percentage of income.

New Rental Property Worksheet 2017

A Property type Residential

B Property location 1150 N Lake Shore Dr. 23J, Chicago, IL 60611
C Was the property placed in service in 2017? Yes
D Did you acquire the rental property in the current year? Yes
E Was this rental property previously your principal residence? Yes
F How was the property acquired? Purchase Like-kind exchange
Inheritance Gift
Other
G Date placed in service
H Date acquired (if different)
Adjusted Basis
1 a Enter the purchase price (or original basis) of the property 1a
b Postponed gain on sale of previous home, from Form 2119 for the year
in which you sold your previous home, if applicable b
c Adjusted purchase price (from previous Form 2119, if applicable) c
Increases to Basis
2 Settlement fees or closing costs. Do not include
amounts previously deducted as moving expenses.
a Abstract and recording fees 2a
b Legal fees (including title search/preparing documents) b
c Surveys c
d Title insurance d
e Transfer or stamp taxes e
f Amounts the seller owed that you agreed to pay, such as back taxes or
interest, recording or mortgage fees, and sales commissions f
3a Repairs to property damaged by casualty or theft 3a
b Insurance reimbursement for casualty or theft losses b
c Deductible casualty losses not covered by insurance c
d Net increase or decrease to basis due to casualties or thefts
(subtract lines 3b and 3c from line 3a) d
4 Cost of capital improvements 4
5 Additions, including costs of materials and labor 5
6 Special tax assessments paid for local improvements 6
7 Other increases to basis 7
8 Total increases to basis (lines 2a through 2f and 3d through 7) 8
Decreases to Basis
9 Seller-paid points (if old home bought after 1990). 9
10 a Depreciation claimed (or allowable) on the property before May 7, 1997 10 a
b Depreciation claimed (or allowable) on the property after May 6, 1997 b
11 Payments received for easement or right-of-way granted 11
12 Residential energy credits claimed 12
13 Energy conservation subsidy excluded from income 13
14 Other decreases to basis 14
15 Total decreases to basis (add lines 9 through 14) 15
16 Adjusted basis. Subtract line 15 from the sum of lines 1c and 8. 16
If Rental Property was Converted from Principal Residence:
17 Fair Market Value 17
18 Lesser of Adjusted Basis or Fair Market Value 18
Allocation between Land and Improvements:

Property Tax Allocated
Statement #’s Percentage Basis
19 Land %
20 Improvements %
21 Total Allocation (Equals line 18 above)
Form 1040 Earned Income Credit Worksheet 2017

QuickZoom to Schedule EIC

QuickZoom to Dependent Information Worksheet to enter qualifying children information
QuickZoom to Wages, Salaries, & Tips Worksheet to enter earned and non-earned income
QuickZoom to page 2 of this worksheet, if credit is not calculated on line 7
1 Enter the amount from Form 1040 or 1040A, line 7, or Form 1040EZ, line 1,
less amounts considered not earned for EIC purposes 1 106,919.
2 Adjustments to line 1 amount:
a Income reported as wages and as self-employment income 2a
b Other income entered as wages that is not considered earned income b
c Distributions from section 457 and other nonqualified plans reported on W-2 c
3 Subtract lines 2a, 2b and 2c from line 1 3 106,919.
4a Taxpayer’s nontaxable combat pay election for EIC 4a
b Spouse’s nontaxable combat pay election for EIC b
c Total nontaxable combat pay election 4c
5 If you were self-employed or used Schedule C or Schedule C-EZ
as a statutory employee, enter the amount from the
Earned Income Worksheet, line 4 5
6 Earned income. Add lines 3, 4, and 5 6 106,919.
7 Enter the credit, from the EIC Table, for the amount on line 6. Be sure to use
the correct column for filing status and number of children 7 0.
If line 7 is zero, stop. You cannot take the credit.

Enter "No" on the dotted line next to Form 1040, line 66a.
8 Enter your AGI from Form 1040, line 38 8

9 If you have:
? No qualifying children, is the amount on line 8 less than $8,350
($13,950 if married filing jointly)?
? 1 or more qualifying children, is the amount on line 8 less than $18,350
($23,950 if married filing jointly)?
X Yes. Go to line 10 now.

No. Enter the credit, from the EIC Table, for the amount on line 8. Be
sure to use the correct column for filing status and number of children 9
10 Earned income credit.
? If ’Yes’ on line 9, enter the amount from line 7
? If ’No’ on line 9, enter the smaller of line 7 or line 9 10
Enter line 10 amount on Form 1040, line 66a, Form 1040A, line 42a, or Form 1040EZ, line 8a.
If one or more of the boxes below are checked, the earned income credit is not allowed.
1 The total taxable earned income (line 6 above) is equal to or more than:
X $15,010 ($20,600 if married filing jointly) without a qualifying child.
$39,617 ($45,207 if married filing jointly) with one qualifying child.
$45,007 ($50,597 if married filing jointly) with two qualifying children.
$48,340 ($53,930 if married filing jointly) with more than two qualifying children.
2 The Adjusted Gross Income (line 8 above) is equal to or more than:

X $15,010 ($20,600 if married filing jointly) without a qualifying child.
$39,617 ($45,207 if married filing jointly) with one qualifying child.
$45,007 ($50,597 if married filing jointly) with two qualifying children.
$48,340 ($53,930 if married filing jointly) with more than two qualifying children.
3 Investment income is more than $3,450.

(Investment Income Smart Worksheet, item H above)
4 The married filing separate return status is checked.

(Information Worksheet, Part II)
5 Taxpayer (or spouse if filing joint) is a qualifying child of another person.

(Information Worksheet, Part IV)
6 Without a qualifying child, and your (or your spouse’s, if married filing jointly)
main home is in the U.S. less than half the year.
7 Without a qualifying child, and taxpayer (and spouse if filing joint) are under age 25
or over age 64.
(Information Worksheet, Part I)
8 Without a qualifying child, and taxpayer (or spouse if filing joint) is eligible to be claimed
as a dependent on someone else’s return.
9 Social Security Number is invalid for EIC purposes, for taxpayer, (or spouse,
if married filing joint).
10 Have qualifying children, but all are either

a qualifying children of another person, or
b invalid social security numbers for EIC purposes.
(Information Worksheet, Part III)
11 Disallowed by IRS to claim Earned Income Credit in 2017.

12 Filing Form 2555, Foreign Earned Income.
13 Not a citizen or resident alien for the entire year, claiming dual status.
(Information Worksheet, Part VI)
14 Head of household filing status and lived with nonresident alien spouse during the last six
months of the year.
Compliance and Due Diligence Information
1 Is this how long your dependents lived with you in the U.S in 2017?
Yes, all of the above is correct.

No, I’ll go back and review my dependent information.
The IRS may ask you for documents to prove you lived with anyone you’re claiming for the Earned
Income Credit.
Is this where you lived with your dependents the longest in 2017?
2 Yes, my dependents lived with me at this address.

No, I’d like to add an additional address where I lived with my dependents. Use the Interview to
add an additional address where you lived with your dependents the longest in 2017.
Compliance and Due Diligence Indicator X

Disqualified from Earned Income Credit X Yes No
Potential qualifying child count 0

Non dependent potential qualifying child count 0
Qualifying child count (max 3) 0
Schedule SE Adjustments Worksheet 2017

(a) Taxpayer (b) Spouse
QuickZoom to the Short Schedule SE (Schedule SE, page 1)

QuickZoom to the Long Schedule SE (Schedule SE, page 2)
A Use Long Schedule SE, even if qualified to use Short Schedule SE

B Approved Form 4029. Exempt from SE tax on all income
C Chapter 11 bankruptcy net profit or loss for Schedule SE, line 3
D QuickZoom to the Explanation statement for any adjustment to
SE income/loss shown on a partnership K-1. (See Help)
Part I Farm Profit or (Loss) Schedule SE, line 1

1 Total Schedules F
2 Farm partnerships, Schedules K-1
3 Other SE farm profit or (loss) (See Help)
4 Less SE exempt farm profit or (loss) (See Help)
5 Total for Schedule SE, line 1
6 Conservation Reserve Program payments not subject to self-
employment tax reported on:
a Schedule F, line 4b
b Schedule K-1 (Form 1065), box 20, code Z
c Total CRP payments not subject to SE tax
Part II Nonfarm Profit or (Loss) Schedule SE, line 2

1a Total Schedules C
b Less SE exempt Schedules C (approved Form 4361)
2 Nonfarm partnerships, Schedules K-1
3 Forms 6781
4 Other SE income reported as income on Form 1040, line 7
5a Clergy Form W-2 wages
b Clergy housing allowance
c Less clergy business deductions
d QuickZoom to the Explanation statement for entry on line 5c
6 Other SE nonfarm profit or (loss) (See Help)
7 Less other SE exempt nonfarm profit or (loss) (See Help)
8 Total for Schedule SE, line 2
9 Exempt Notary Public income for Schedule SE, line 3 (See Help)
Part III Farm Optional Method Schedule SE, page 2, Part II

1 Use Farm Optional Method
2 Gross farm income from Schedules F
3 Gross farming or fishing income from partnership Schedules K-1
4 Other gross farming or fishing self-employment income
5 Total gross income for Farm Optional Method
Part IV Nonfarm Optional Method Schedule SE, page 2, Part II

1 Use Nonfarm Optional Method (Must have had net SE earnings
of $400 or more in 2 of prior 3 years and used the
Nonfarm Optional Method less than 5 times)
2 Gross nonfarm income from Schedules C
3 Gross nonfarm income from partnership Schedules K-1
4 Other gross nonfarm self-employment income
5 Total gross income for Nonfarm Optional Method
Form 1040 Student Loan Interest Deduction Worksheet 2017

Part I Information from Form(s) 1098-E, Student Loan Interest Statement
(a) (b) (c) (d) (e)

Lender’s name Borrower Borrower’s Prior Year Student loan
(Taxpayer, social security Student Loan interest
Spouse) number Interest (Box 1)
Nelnet Taxpayer 315-04-4786 1,009. 926.

Firstmark Taxpayer 315-04-4786 2,692. 2,752.
Total student loan interest 3,678.
Part II Computation of Student Loan Interest Deduction
1 Enter the total interest you paid in 2017 on qualified student loans 1 3,678.
(see Form 1040 instructions).
2 Enter the smaller of line 1 or $2,500 2 2,500.
3 Modified AGI 3 104,021.
Note: If line 3 is $80,000 or more if single, head of household, or qualifying
widow(er) or $165,000 or more if married filing jointly, stop here. You cannot
take the deduction.
4 Enter: $65,000 if single, head of household, or qualifying widow(er);
$135,000 if married filing jointly 4 135,000.
5 Subtract line 4 from line 3. If zero or less, enter -0- here and on line 7, skip
line 6, and go on to line 8 5 0.
6 Divide line 5 by $15,000 or $30,000 if married filing jointly.
Enter the result as a decimal (rounded to at least three places) 6 0.0000
7 Multiply line 2 by line 6 7 0.
8 Student loan interest deduction. Subtract line 7 from line 2. Enter the result
here and on Form 1040, line 33. Do not include this amount in figuring any
other deduction on your return (such as on Schedule A, C, E, etc.) 8 2,500.
* Modified AGI is the amount from Form 1040, line 22, increased by any excludable income from Puerto
Rico, or of bona fide residents of American Samoa, Guam, or the Commonwealth of the Northern
Mariana Islands, and foreign earned income/housing exclusion, and decreased by amounts on
Form 1040, lines 23 through 32 and any write-in amount next to line 36, not including the
Foreign housing deduction on line A of the Other Adjustments to Income Smart Worksheet.
Form 6251 Schedule D Tax Worksheet 2017
Line 37 as refigured for the
Alternative Minimum Tax

(a) (b) (c)

Before Allocation of After
Allocation of Capital Gain Allocation of
Capital Gain Excess * Capital Gain
Excess * Excess
1 Not applicable
2 Enter your total qualified dividends as refigured for
the Alternative Minimum Tax (AMT):
a Total qualified dividends
b Adjustment from Schedules K-1
c Other adjustments to qualified dividends
d Total. Combine lines 2a, 2b, and 2c 0. 0.
3 Enter the amount from Form 4952 for AMT, line 4g
4 Enter the amount from Form 4952 for AMT, line 4e
5 Subtract line 4 from line 3. If zero or less, enter -0- 0. 0.
6 Subtract line 5 from line 2. If zero or less, enter -0- 0. 0.
7 Net long-term capital gain:
a Enter the gain from line 15 of Schedule D
as refigured for the AMT 0.
b Enter the gain from line 16 of Schedule D
c Enter the smaller of line 7a or line 7b 0. 0.
9 Subtract line 8 from line 7c. If zero or less, enter -0- 0. 0. 0.
10 Add lines 6 and 9 0. 0.
A Enter the amount from Form 6251, line 30. 5,420.
B Capital gain excess. Subtract line A from line 10. * 0.
11 Total 28% rate and unrecaptured section 1250 gain:
a Enter the gain from line 18 of Schedule D
b Enter the gain from line 19 of Schedule D
as refigured for the AMT
c Add lines 11a and 11b 0.
12 Enter the smaller of line 9 or line 11c 0.
13 Subtract line 12 from line 10. Also enter this amount
on Form 6251, line 37. 0.
* Capital gain excess applies only if filing Form 2555, Foreign Earned Income.
Form 6251 Alternative Minimum Tax Worksheet 2017
Taxable Income ' Line 1

1 If filing Schedule A (Form 1040), enter the amount from Form 1040, line 41.
Otherwise, enter the amount from Form 1040, line 38. (If less than zero,
enter as a negative amount.) 1 84,354.
2 Additions to income 2
3 Add lines 1 and 2 3 84,354.
4 Subtractions from income 4
5 Subtract line 4 from line 3. Enter on Form 6251, line 1 5 84,354.
Taxes ' Line 3

1 Generation skipping transfer taxes included on Schedule A, line 8 1
Home Mortgage Interest Adjustment ' Line 4

(a) (b) (c)
NOT Total
Deductible Deductible Home
for AMT for AMT Mortgage
Purposes Purposes Interest
1 Attributable to mortgage used to purchase, build, or

improve:
a Main home or second home that is house, apartment,
condominium or non-transient mobile home 10,504.
b Second home that is transient mobile home or boat
c Total 10,504.
2 Attributable to mortgage used to refinance:
a To pay off mortgage
b For other purposes
c Total
3 Attributable to other mortgage deductible for AMT:
a Pre-July 1, 1982 mortgage
4 Total column (a) 10,504.

5 Total column (b). Enter result on Form 6251, line 4.
6 Total mortgage interest from Schedule A 10,504.
Refund of Taxes ' Line 7

1 Taxable refund of state and local income tax 1 680.
2 Amount and description of any refund of state and local personal property
taxes, foreign income or real property taxes deducted after 1986 2
3 Total tax refund adjustment. Enter on Form 6251, line 7 3 680.
Alternative Tax Net Operating Loss Deduction (ATNOLD) ' Line 11
1 Alternative minimum taxable income (AMTI) without ATNOLD 1 89,920.

2 Enter adjustments 2
3 Adjustment for domestic production activities deduction 3
4 Adjusted AMTI without ATNOLD. Add lines 1-3 4 89,920.
5 ATNOLD limitation. Multiply line 4 by 90% 5 80,928.
6 Enter ATNOL carried to 2016 from other year(s) 6
7 Enter ATNOL included above attributable to qualified disaster losses 7
8 ATNOL above not attributable to qualified disaster losses. Line 6 minus 7 8
9 ATNOL deduction other than qualified disaster losses. Lesser of line 5 or 8 9
10 ATNOL Disaster Deduction. Lesser of line 7 or (line 4 minus line 9) 10
11 ATNOLD. Add lines 9 and 10. Enter on Form 6251, line 11, as neg 11
Incentive Stock Options ' Line 14
1 Incentive stock options adjustment from Schedule K-1 worksheets 1

2 Incentive stock options from Employer Stock Transaction Worksheets 2
3 Incentive stock options from Exercise of Stock Options Worksheets 3
4 Other incentive stock options 4
5 Total incentive stock options. Enter on Form 6251, line 14 5
Disposition of Property ' Line 17
Alternative Regular
Minimum Tax Tax Difference
1 Net capital gain or loss (Schedule D)

2 Ordinary gain or loss (Form 4797, Part II)
3 Ordinary income from sale of Incentive Stock
4 Total. Enter on Form 6251, line 17
Post-86 Depreciation ' Line 18
1 From depreciation worksheets 1

2 Plus amount from Schedule K-1 worksheets 2
3 Add lines 1 and 2. 3
4 Any amount relating to an activity for which the partnership interest
basis limits apply, for which you are not at risk, or which is a tax shelter
farm activity. 4
5 Total. Subtract line 4 from line 3. Enter on Form 6251, line 18 5
Passive Activities ' Line 19
1 Adjustment for recomputed income (loss) from passive activities 1 0.

2 Adjustment for recomputed income (loss) from publicly traded partnerships 2
3 Other adjustments to passive activities 3
4 Total. Add lines 1, 2, and 3. Enter on Form 6251, line 19 4 0.
Circulation Costs ' Line 21
1 Circulation costs adjustment from Schedule K-1 Worksheets 1

2 Other circulation costs adjustment 2
3 Total. Add lines 1 and 2. Enter on Form 6251, line 21 3
Mining Costs ' Line 23
1 Mining costs adjustment from Schedule K-1 Worksheets 1

2 Other mining costs adjustment 2
Research and Experimental Costs ' Line 24
1 Research and Experimental costs adjustment from Schedule K-1 Worksheets 1

2 Other research and experimental costs adjustment 2
Intangible Drilling Costs ' Line 26
1 Excess intangible drilling costs 1

2 Net income from oil and gas wells 2
4 Tentative intangible drilling costs preference. Subtract line 3 from line 1 4
5 Independent producers exception amount 5
6 Subtract line 5 from line 4. Enter this amount on Form 6251, line 26 6
Other Adjustments ' Line 27
1 Pre-1987 depreciation from depreciation worksheets 1

2 Plus amount from Schedule K-1 worksheets 2
4 Any amount relating to an activity for which the partnership interest
basis limits apply, for which you are not at risk, or which is a tax shelter
farm activity. 4
6 Enter other adjustments, including income-based related adjustments 6
8 Standard deduction if a qualified disaster loss was added to standard
deduction. 8
9 Total other adjustments. Add lines 7 and 8 and enter on Form 6251, line 27 9
Alternative Minimum Taxable Income ' Line 28
If married filing separately and Form 6251, line 28, is more than $249,450:
1 Alternative minimum taxable income, Form 6251 1
2 Threshold amount 2
5 Smaller of line 4 or $41,900 5
6 Add line 1 and line 5. Enter on Form 6251, line 28 6
Exemption ' Line 29
1 Enter $54,300 if single or head of household, $84,500 if married filing jointly

or qualifying widow(er), $42,250 if married filing separately 1 84,500.
2 Enter your alternative minimum taxable income from Form 6251, line 28 2 89,920.
3 Enter $120,700 if single or head of household, $160,900 if married filing
jointly or qualifying widow(er), $80,450 if married filing separately 3 160,900.
5 Multiply line 4 by 25% (.25) 5 0.
6 Subtract line 5 from line 1. If zero or less, enter -0- 6 84,500.
If any of the three conditions under Certain Children Under Age 24 apply, go
to line 7. Otherwise, enter this amount on Form 6251, line 29.
7 Minimum exemption amount for certain children under age 24 7
8 a Enter the child’s earned income, if any 8a
b Enter any adjustments b
9 Add lines 7, 8a and 8b. If zero or less, enter -0- 9
10 Enter the smaller of line 6 or line 9 here and on Form 6251, line 29. 10
Form 6251 Foreign Earned Income 2017
Line 31 Alternative Minimum Tax Worksheet

1 Enter amount from Form 6251, line 30 1

2 a Enter amount from Form(s) 2555, lines 45 and 50 2a
b Enter the total amount of any itemized deductions or exclusions you could not
claim because they are related to excluded income 2b
c Subtract line 2b from line 2a. If zero or less, enter 0 2c
3 Add line 1 and line 2c. Enter the result here and on Form 6251 line 36 3
4 Tax on amount on line 3
? If you reported capital gain distributions directly on Form 1040, line 13; or
you reported qualified dividends on Form 1040, line 9b; or you had a gain
on both line 15 and 16 of Schedule D (Form 1040), enter the amount from
line 3 of this worksheet on Form 6251, line 36. Complete the rest of Part III
of Form 6251. However, before completing Part III, see Form 2555 to see
if you must complete Part III with certain modifications. Then enter the
amount from Form 6251, line 64 here.
? All Others: If line 3 is $187,800 or less ($93,900 or less if married filing
separately), multiply line 3 by 26% (.26). Otherwise, multiply line 3 by 28%
(.28) and subtract $3,756 ($1,878 if married filing separately) from
the result. 4
5 Tax on amount on line 2c. If line 2c is $187,800 or less ($93,900 or less if
married filing separately), multiply line 2c by 26% (.26). Otherwise, multiply
line 2c by 28% (.28) and subtract $3,756 ($1,878 if married filing separately)
from the result 5
6 Subtract line 5 from line 4. Enter here and on Form 6251, line 31. If zero or
less, enter 0 6
Federal Carryover Worksheet 2017

2016 State and Local Income Tax Information
(a) (b) (c) (d) (e) (f) (g)

State or Paid With Estimates Pd Total With- Paid With Total Over- Applied
Local ID Extension After 12/31 held/Pmts Return payment Amount
IL 137.
CO 3,317. 680.
Totals 3,317. 137. 680.
2016 State Extension Information 2016 Locality Extension Information
(a) (b) (a) (b)

State Paid With Extension Locality Paid With Extension
2016 State Estimates Information 2016 Locality Estimates Information
(a) (c) (a) (c)

State Estimates Paid After 12/31 Locality Estimates Paid After 12/31
2016 State Taxes Due Information 2016 Locality Taxes Due Information
(a) (e) (a) (e)

State Paid With Return Locality Paid With Return
IL 137.
2016 State Refund Applied Information 2016 Locality Refund Applied Information
(a) (g) (a) (g)

State Applied Amount Locality Applied Amount
2016 State Tax Refund Information 2016 Locality Tax Refund Information
(a) (d) (f) (a) (d) (f)

Total Total Total Total
State Withheld/Pmts Overpayment Locality Withheld/Pmts Overpayment
CO 3,317. 680.
Federal Carryover Worksheet page 2 2017
Other Tax and Income Information 2016 2017
1 Filing status 1 2 MFJ 2 MFJ

2 Number of exemptions for blind or over 65 (0 - 4) 2
3 Itemized deductions 3 17,553. 17,167.
4 Check box if required to itemize deductions 4
5 Adjusted gross income 5 86,100. 101,521.
6 Tax liability for Form 2210 or Form 2210-F 6 6,483. 10,546.
7 Alternative minimum tax 7
8 Federal overpayment applied to next year estimated tax 8
QuickZoom to the IRA Information Worksheet for IRA information
Excess Contributions 2016 2017
9a Taxpayer’s excess Archer MSA contributions as of 12/31 9a

b Spouse’s excess Archer MSA contributions as of 12/31 b
10 a Taxpayer’s excess Coverdell ESA contributions as of 12/31 10 a
b Spouse’s excess Coverdell ESA contributions as of 12/31 b
11 a Taxpayer’s excess HSA contributions as of 12/31 11 a
b Spouse’s excess HSA contributions as of 12/31 b
Loss and Expense Carryovers 2016 2017

Note: Enter all entries as a positive amount
12 a Short-term capital loss 12 a

b AMT Short-term capital loss b
13 a Long-term capital loss 13 a
b AMT Long-term capital loss b
14 a Net operating loss available to carry forward 14 a
b AMT Net operating loss available to carry forward b
15 a Investment interest expense disallowed 15 a
b AMT Investment interest expense disallowed b
16 Nonrecaptured net Section 1231 losses from: a 2017 16 a
b 2016 b
c 2015 c
d 2014 d
e 2013 e
f 2012 f
17 AMT Nonrecap’d net Sec 1231 losses from: a 2017 17 a
b 2016 b
c 2015 c
d 2014 d
e 2013 e
f 2012 f
Federal Carryover Worksheet page 3 2017
Credit Carryovers 2016 2017
18 General business credit 18

19 Adoption credit from: a 2017 19 a
b 2016 b
c 2015 c
d 2014 d
e 2013 e
f 2012 f
20 Mortgage interest credit from: a 2017 20 a
b 2016 b
c 2015 c
d 2014 d
21 Credit for prior year minimum tax 21
22 District of Columbia first-time homebuyer credit 22
23 Residential energy efficient property credit 23
Other Carryovers 2016 2017
24 Section 179 expense deduction disallowed 24 0.

25 Excess a Taxpayer (Form 2555, line 46) 25 a
foreign b Taxpayer (Form 2555, line 48) b
housing c Spouse (Form 2555, line 46) c
deduction: d Spouse (Form 2555, line 48) d
Charitable Contribution Carryovers
26 2016 Carryover of Other Property Capital Gain

charitable contributions
from: (a) 50% (b) 30% (c) 30% (d) 20%
a 2016
b 2015
c 2014
d 2013
e 2012
27 2017 Carryover of Other Property Capital Gain

charitable contributions
from: (a) 50% (b) 30% (c) 30% (d) 20%
a 2017
b 2016
c 2015
d 2014
e 2013
28 Amount overpaid less earned income credit 3,822.
2016 State Capital Loss Carryovers (For users not transferring from the prior year)
State Short-term AMT Short-term Long-term AMT Long-term Capital Loss AMT Capital Loss
ID Capital Loss Capital Loss Capital Loss Capital Loss (combined) (combined)
for State for State for State for State for State for State
IRA Information Worksheet 2017

Part I Traditional IRA Taxpayer Spouse
Basis and Value

1 Total basis in traditional IRAs
2 Year-end value on 12/31/2017
3 Basis carryover as of 12/31/2017
Excess Contributions
4 Excess contributions as of 12/31/2016
5 Carryover of excess contributions to 2018
Part II Roth IRA Taxpayer Spouse
Basis (Contribution and Conversion History)

6 Basis in Roth IRA contributions
7 Basis in Roth IRA conversions
8 Contribution basis carryover as of 12/31/2017
9 Conversion basis carryover as of 12/31/2017
Excess Contributions
10 Excess contributions as of 12/31/2016
11 Carryover of excess contributions to 2018
Part III Traditional IRA Basis Detail Taxpayer Spouse
12 Basis for 2016 and earlier years

13 Adjustment due to return of excess contributions
14 Rollover of nontaxable portion of a qualified retirement plan
15 Basis received from former spouse due to divorce or inherited
16 Basis transferred to former spouse due to divorce
17 Adjusted total basis in Traditional IRAs
Part IV Traditional IRA Year-end Value Detail Taxpayer Spouse
18 Enter the combined value of all traditional IRAs

(including SIMPLE IRAs) on 12/31/2017 (See Help)
19 If any amounts were recharacterized either to or from any
traditional IRA, enter the net amounts recharacterized after
12/31/2017.
qualified charitable distributions (QCD) made in Jan. 2018
to be treated as made in December 2017 (See Help).
20 Enter the total amount of any traditional IRA distributions
that you rolled over, or intend to roll over, to another traditional
IRA, but the rollover was (or will be) made after 12/31/2017
21 Check this box if you converted all of the traditional IRAs you
had in 2017 to Roth IRAs in 2017
G Keep for your records Page 2

Part V Roth IRA Contribution and Conversion Balances Taxpayer Spouse
22 Opened a Roth IRA before 2013 Yes No Yes No
2016 Balances (Basis - Before 2017 Transactions)
23 Cumulative regular Roth IRA contributions, including rollovers

from Roth 401(k) and Roth 403(b)
24 Cumulative pre 2013 conversions - taxable and nontaxable
25 2013 conversion contributions taxable at conversion
26 2013 conversion contributions not taxable at conversion
2017 Transactions - Contributions Taxpayer Spouse
33 Regular Roth IRA contributions

34 Rollover from Roth 401(k) and Roth 403(b)
35 Conversion contributions taxable at conversion
36 Conversion contributions not taxable at conversion
37 Repayments of qualified Roth reservist distributions
2017 Transactions - Distributions
Distributions from regular Roth IRA contributions and from

38 rollovers from Roth 401(k) and Roth 403(b)
39 Distributions from cumulative pre 2013 conversions
40 Distributions from 2013 conversions taxable at conversion
41 Distribs. from 2013 conversions not taxable at conversion
Yes No Yes No
50 Did you have any open Roth IRA accounts on 12/31/2017?
Balance c/over to 2018 (Basis - After 2017 Transactions)
Cumulative regular Roth IRA contributions, including rollovers

51 from Roth 401(k) and Roth 403(b)
G Keep for your records Page 3

Part VI Roth IRA Basis Adjustments Taxpayer Spouse
Received From Former Spouse due to Divorce or Inheritance

Transferred To Former Spouse due to Divorce

Form 8582 Modified Adjusted Gross Income Worksheet 2017

Description Amount
Income
Wages 106,919.
Interest income before Series EE bond exclusion 116.
Dividend income
Tax refund 680.
Alimony received
Nonpassive business income or loss
Royalty and nonpassive rental activities income or loss
Nonpassive partnership income or loss
Nonpassive S corporation income or loss
Nonpassive farm rental income or loss
Nonpassive farm income or loss
Nonpassive estate and trust income or loss
Real estate mortgage investment conduits
Business gains and losses from nonpassive activities
Capital gains and losses
Taxable IRA distributions
Taxable pension distributions
Unemployment compensation
Other income
Total income 107,715.
Adjustments
Educator expenses
Certain business expenses of reservists, performing artists, and government officials
Health savings account deduction
Moving expenses
Self-employed SEP, SIMPLE, and qualified plans
Self-employed health insurance deduction
Penalty on early withdrawals of savings
Alimony paid
Other adjustments
Total adjustments
Modified adjusted gross income 107,715.

Depreciation Options 2017

MACRS Convention and Computation

X Compute convention (result shown below).
When ’Compute convention’ is checked, the program automatically determines which
convention applies to MACRS personal property assets placed in service in 2017, and checks the
appropriate box below. If ’Compute Convention’ is unchecked, the program uses the ’Half-year convention’
unless you check ’Mid-quarter convention.’
1 X Half-year convention
2 Mid-quarter convention
3 Use IRS tables for all MACRS property placed in service this year? Yes X No
Federal Section 179 Information

If more than one business activity is claiming a Section 179 expense deduction, the limitation must
be computed on a separate copy of Form 4562, per the IRS instructions. This is the copy that
appears on the menu as Form 4562:Section 179 Limitation. Please review Tax Help for instructions
on allocating the allowable Section 179 back to the individual activities when the deduction is limited.
If only one business activity is claiming a Section 179 expense deduction, the limitation will be
computed on the Form 4562 for that activity.
1a Elect to treat Qualified Real Property as "Section 179 Property" 1a Yes X No

b Calculated "Total cost of Section 179 property placed in service" b 300.
c Additions or subtractions to calculated total on line 1a c
2 If Married Filing Separately, enter:
a Total cost of eligible property placed in service this year by spouse 2a
b Allocation percentage elected for your return, if other than 50% b %
c Section 179 elected on Qualified Real Property this year by spouse c
3a Taxable income computed for the Section 179 limitation 3a 106,919.
b Additions or subtractions to taxable income b
State Depreciation
Enter the State ID of all states for which you want depreciation computed. A corresponding state record
will be created on all assets and vehicles in the Federal return.
Note: Only supported states may be selected. Not applicable to California. California depreciation data
must be entered in the state return.
To delete or change a state:
@ Check the "Yes" box for "Delete this state’s depreciation data from the Federal file now"
@ Delete the entry in the "State" field, or change it to the desired state
@ Check the "No" box for "Delete this state’s depreciation data from the Federal file now"
States currently entered: CO IL
State CO
Delete this state’s depreciation data from Federal file when transferring to 2018 Yes X No
Delete this state’s depreciation data from the Federal file now Yes X No
State IL
Delete this state’s depreciation data from Federal file when transferring to 2018 Yes X No
Delete this state’s depreciation data from the Federal file now Yes X No
State Section 179 Dollar Limitation

1 State 1
2a Married Filing Separately for state? If Yes, enter: 2a Yes No
b Total cost of state eligible property placed in service this year by spouse b See State Section 179 Statement
c Allocation percentage elected for state return c %
d State Section 179 elected on Qualified Real Property this year by spouse d
3a Elect to treat state Qualified Real Property as "Section 179 Property" 3a Yes No
b Calculated "Total cost of state Section 179 property placed in service" b
c Additions or subtractions to state calculated value c
4 State maximum amount 4
5 State threshold cost of Section 179 property 5
6 Reduction in state limitation (Line 3b less line 5, not less than 0) 6
7 State dollar limitation (Ln 4 less ln 6, not less than 0. MFS, times ln 2d) 7
8 Total state Section 179 elected (Cannot exceed line 7) 8
9 Total state Section 179 elected on Qualified Real Property 9
State Defaults for Economic Stimulus Depreciation Allowance and 2017 Section 179
Note: Only supported states are shown
Check box to reset all state Economic Stimulus defaults shown below
STATE CALC STIMULUS BONUS DEPRECIATION 2017 SECTION 179
State F/S conformity 1st yr Stimulus start Stimulus end 1st yr Maximum Threshold
AL State Full 12/31/2008 12/31/2020Full 510,000. 2,030,000.
AZ State Full 12/31/2012 12/31/2020Part 510,000. 2,030,000.
AR State N/A N/A N/AFull 25,000. 200,000.
See State 2009 Economic Stimulus Default Statement
State Defaults for Qualified Disaster Area Depreciation Allowance and Section 179
Check box to reset all state Qualified Disaster Area defaults shown below
STATE CALC DISASTER AREA BONUS DEPRECIATION DISASTER AREA SECTION 179
State F/S conformity 1st yr Disaster Area start Disaster Area end 1st yr Maximum Increase Threshold Increase
AL None N/A N/A N/AN/A 0. 0.
AZ State N/A 12/31/2007 12/31/2013Part 100,000. 600,000.
AR None N/A N/A N/AN/A 0. 0.
See State Qualified Disaster Area Default Statement
State Defaults for Kansas Disaster Zone Depreciation Allowance and Section 179
Check box to reset all state Kansas Disaster Zone defaults shown below
STATE CALC KANSAS ZONE BONUS DEPRECIATION KANSAS ZONE SECTION 179
State F/S conformity 1st yr Kansas Zone start Kansas Zone end 1st yr Maximum Increase Threshold Increase
AL None N/A N/A N/AN/A 0. 0.
AZ State N/A 05/04/2007 12/31/2009Part 100,000. 600,000.
See State Kansas Disaster Zone Default Statement
State Defaults for Cellulosic Biomass Ethanol Plant Property (CBEPP)

Check box to reset all state CBEPP defaults shown below
STATE CALC CBEPP BONUS DEPRECIATION
State F/S conformity 1st yr CBEPP start CBEPP end
AL Federal Full 12/20/2006 12/31/2017
AZ Federal Full 12/20/2006 12/31/2017
AR None N/A N/A N/A
See State CBEPP Default Statement
Page 3
State Defaults for GO Zone Depreciation Allowance and GO Zone Section 179
Check box to reset all state GO Zone defaults shown below
STATE CALC GO ZONE BONUS DEPRECIATION GO ZONE SECTION 179
State F/S conformity 1st yr GO Zone start GO Zone end 1st yr Maximum Increase Threshold Increase
AL Federal Full 08/28/2005 03/30/2012Full 100,000. 600,000.
AZ State Full 08/28/2005 03/30/2012Part 100,000. 600,000.
See State GO Zone Default Statement
State Defaults for Pre-2006 Special Depreciation Allowance (SDA), and Trucks/Vans
Check box to reset all state SDA & Truck/Van defaults shown below
STATE CALC PRE-2006 SPECIAL DEPRECIATION ALLOWANCE Truck
State F/S calc SDA % 1st yr 30% start 30% end 50% start 50% end /Van
AL Fed 50, 30Full 09/11/200112/31/200505/06/200312/31/2005Y

AZ State None N/A N/A N/A N/A N/AY
AR State None N/A N/A N/A N/A N/AN
See State Pre-2005 SDA Default Statement
State Defaults for Sec 179 on Computer Software & Qualified Real Property
Check box to reset all state Sec 179 defaults shown below
STATE CALC COMPUTER SOFTWARE STATE CALC QUALIFIED REAL PROPERTY
State F/S conformity Start End F/S conformity Start End
AL Federal TY2003 PERMANENTFederal TY2010 PERMANENT
AZ Federal TY2003 PERMANENTFederal TY2010 PERMANENT
AR Federal TY2003 PERMANENTNone N/A N/A
See State Software/Real Property Sec 179 Default Statement
State Defaults for Asset Class on Qualified Real Property & Farm Machinery/Equipment
Check box to reset all state Asset Class defaults shown below
STATE CALC FARM & RETAIL STATE CALC RESTAURANT & LEASEHOLD
AL Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017
AZ Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017
AR Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017
See State Asset Class Default Statement
State Defaults for Taking Economic Stimulus Depreciation Allowance on Fruit/Nut Tree/Vine in Year
Planted/Grafted
Check box to reset defaults shown below
STATE CALC Fruit/Nut Tree/Vine SDA
State F/S conformity 1st yr Start End
AL Federal Full 12/31/15 12/31/20
AZ State Full 12/31/12 12/31/20
AR State N/A N/A N/A
See Fruit/Nut Tree/Vine SDA in Year Planted/Grafted
Section 179 Expense Report 2017
G Keep for your records PAGE 1

Description Business Use Elected

Activity of Cost/Basis Section 179
Property Expense
Computer
From K-1(s): Current year

Prior year carryover
Totals: Current year 300. 300.
Prior year carryover

Two-Year Comparison 2017

Income 2016 2017 Difference %
Wages, salaries, tips, etc 97,863. 106,919. 9,056. 9.25

Interest and dividend income 121. 116. -5. -4.13
State tax refund 0. 680. 680.
Business income (loss) -593. 593. 100.00
Capital and other gains (losses) 277. -277. -100.00
IRA distributions
Pensions and annuities
Rents and royalties -9,068. -3,694. 5,374. 59.26
Partnerships, S Corps, etc
Farm income (loss)
Social security benefits
Income other than the above
Total Income 88,600. 104,021. 15,421. 17.41
Adjustments to Income 2,500. 2,500. 0. 0.00
Adjusted Gross Income 86,100. 101,521. 15,421. 17.91
Itemized Deductions
Medical and dental
Income or sales tax 3,570. 3,971. 401. 11.23
Real estate taxes 1,682. 1,682. 0. 0.00
Personal property and other taxes 157. 593. 436. 277.71
Interest paid 9,864. 10,504. 640. 6.49
Gifts to charity 2,280. 417. -1,863. -81.71
Casualty and theft losses
Miscellaneous
Phaseout of itemized deductions
Total Itemized Deductions 17,553. 17,167. -386. -2.20
Standard or Itemized Deduction 17,553. 17,167. -386. -2.20
Exemption Amount 12,150. 8,100. -4,050. -33.33
Taxable Income 56,397. 76,254. 19,857. 35.21
Income tax 7,484. 10,546. 3,062. 40.91

Additional income taxes
Alternative minimum tax
Total Income Taxes 7,484. 10,546. 3,062. 40.91
Nonbusiness credits 1,001. -1,001. -100.00
Business credits
Total Credits 1,001. -1,001. -100.00
Self-employment tax
Other taxes 0. 0. 0.
Total Tax After Credits 6,483. 10,546. 4,063. 62.67
Withholding 10,305. 11,868. 1,563. 15.17
Estimated and extension payments
Earned income credit
Additional child tax credit
Other payments
Total Payments 10,305. 11,868. 1,563. 15.17
Form 2210 penalty
Applied to next year’s estimated tax
Refund 3,822. 1,322. -2,500. -65.41
Balance Due
Current year effective tax rate 10.39 %

Tax Summary 2017
Name (s)
Total income 104,021.

Adjustments to income 2,500.
Adjusted gross income 101,521.
Itemized/standard deduction 17,167.
Exemption amount 8,100.
Taxable income 76,254.
Tentative tax 10,546.
Additional taxes
Alternative minimum tax
Total credits
Other taxes 0.
Total tax 10,546.
Total payments 11,868.
Estimated tax penalty
Amount Overpaid 1,322.
Refund 1,322.
Amount Applied to Estimate
Balance due 0.
Which Form 1040 to file?

You must use Form 1040 because
you had rental real estate and royalty income (or loss).
Compare to U. S. Averages 2017
Name(s) Shown on Return Social Security No

Your 2017 adjusted gross income (AGI) 101,521.

National adjusted gross income range used below from 100,000. to 199,999.
Note: National average amounts have been adjusted for inflation. See Help for details.
Actual National
Selected Income, Deductions, and Credits Per Return Average
Salaries and wages 106,919. 117,731.

Taxable interest 116. 1,272.
Tax-exempt interest 7,245.
Dividends 6,252.
Business net income 28,383.
Business net loss 7,173.
Net capital gain 13,761.
Net capital loss 2,241.
Taxable IRA 27,188.
Taxable pensions and annuities 41,495.
Rent and royalty net income 12,782.
Rent and royalty net loss -3,694. 8,172.
Partnership and S corporation net income 40,818.
Partnership and S corporation net loss 10,623.
Taxable social security benefits 23,596.
Medical and dental expenses deduction 11,596.

Taxes paid deduction 6,246. 11,336.
Interest paid deduction 10,504. 9,134.
Charitable contributions deduction 417. 4,262.
Total itemized deductions 17,167. 25,950.
Child care credit 610.

Education tax credits 1,459.
Child tax credit 1,399.
Retirement savings contributions credit 0.
Earned income credit 0.
Other Information Actual National

Per Return Average
Adjusted gross income 101,521. 138,646.

Taxable income 76,254. 105,114.
Income tax 10,546. 17,628.
Alternative minimum tax 2,377.
Total tax liability 10,546. 18,398.
ELECTRONIC POSTMARK - CERTIFICATION OF ELECTRONIC FILING
Taxpayer: Robert T Clarke, Jr & MariRenee Clarke

Primary SSN: 315-04-4786
Federal Return Submitted: April 01, 2018 12:34 PM PDT

Federal Return Acceptance Date:
Your return was electronically transmitted on 04/01/2018
The Intuit Electronic Postmark shows the date and time Intuit received your federal tax return. The Intuit
Electronic Postmark documents the filing date of your income tax return, and the electronic postmark
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1. THE INTUIT ELECTRONIC POSTMARK.

The electronic postmark shows the date and time Intuit received the federal return, and is deemed the
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For your federal return to be considered filed on time, your return must be postmarked on or before
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you electronically file your return at 9 AM on April 17, 2018, your Intuit electronic postmark will indicate
April 17, 2018, 6 AM. If your federal tax return is rejected, the IRS still considers it filed on time if the
electronic postmark is on or before April 17, 2018, and a corrected return is submitted and accepted
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reflect that your return was submitted after the IRS deadline and, consequently, is no longer considered
to have been filed on time.
If you request an automatic six-month extension, your return must be electronically postmarked by
midnight October 15, 2018 If your federal tax return is rejected, the IRS will still consider it filed on time
if the electronic postmark is on or before October 15, 2018, and the corrected return is submitted and
accepted by October 20, 2018.
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Once the IRS accepts the electronically filed return, the acceptance date will be provided by the Intuit
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The chart below shows the options for filing your tax return (e-file or paper return), the
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WHAT TYPE WHAT ARE YOUR WHAT IS THE WHAT COSTS DO YOU
OF FILING DISBURSEMENT ESTIMATED TIME TO INCUR IN ADDITION
METHOD? OPTIONS? RECEIVE REFUND? TO TAX PREPARATION
FEES?
PAPER RETURN IRS direct deposit to Approximately Free

your personal bank 6 to 8 weeks 3
No Refund Processing account.
Service
Check mailed by IRS Approximately
to address on tax 6 to 8 weeks 3
return.
ELECTRONIC IRS direct deposit to Usually within 21 days Free

FILING your personal bank
(E-FILE) account.
No Refund Processing Check mailed by IRS Approximately

Service to address on tax 21 to 28 days 3
return.
ELECTRONIC (a) Direct deposit to Usually within Free option with your
FILING your personal bank 21 days 3 purchase of TurboTax
(E-FILE) account, or Premium Services or
TurboTax MAX 2
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is detected. If your return contains Earned Income Tax Credit or Additional Child Tax Credit,
Questions? Call 1-877-908-7228

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To agree, enter your name and date in the boxes below.
Robert Clarke

01/18/2018
Date
MariRenee Clarke
First Name - Spouse Last Name - Spouse

01/18/2018
Date
F7216U04 SBIA5004
Pro Delegation Worksheet 2017
Check this box if you are preparing this return as a PRO preparer
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Account statement from financial institution
Utility billing statement
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Finish and File Info:

To indicate a client return download in FnF
fdiv8001.SCR 12/19/17
Robert T Clarke, Jr & MariRenee Clarke 315-04-4786 1
Smart Worksheets from your 2017 Federal Tax Return
SMART WORKSHEET FOR: Form 1040: Individual Tax Return
Tax Smart Worksheet
A Tax 10,546.
Check if from:
1 Tax table X
2 Tax Computation Worksheet (see instructions)
3 Schedule D Tax Worksheet
4 Qualified Dividends and Capital Gain Tax Worksheet
5 Schedule J
6 Form 8615
7 Foreign Earned Income Tax Worksheet
B Additional tax from Form 8814
C Additional tax from Form 4972
D Tax from additional Form(s) 4972
E Recapture tax from Form 8863
F IRC Section 197(f)(9)(B)(ii) election for an additional tax
G Health Coverage Tax Credit Recovery, Form 8885, Line 5, if negative
H Tax. Add lines A through G. Enter the result here and on line 44 10,546.
SMART WORKSHEET FOR: Form 8889: Health Savings Accounts (Taxpayer)
Line 14 Smart Worksheet
A Gross distributions 751.

B Rollovers
C Return of excess contributions
D Subtract lines B and C from line A. 751.
E Taxable earnings on excess contributions
Non-surviving spouse beneficiaries who received no
distribution this year use lines F & G
F FMV of inherited HSA assets if no distribution received
G Qualified medical expenses
SMART WORKSHEET FOR: Form 8889: Health Savings Accounts (Taxpayer)
Check here if failure to maintain HDHP coverage in 2017 was due to death or disability
A 1 Total HSA contribution in 2016 0.

2 Excess contribution in 2016
3 Net HSA contribution in 2016 0.
B Check the box below to indicate the type of coverage you had for each
month of 2016. Select Family for any month that you had self only coverage
and were married to a spouse with family coverage. Select None for any
month you were covered by Medicare.
1 January None Self-only Family
2 February None Self-only Family
3 March None Self-only Family
4 April None Self-only Family
5 May None Self-only Family
6 June None Self-only Family
7 July None Self-only Family
8 August None Self-only Family
9 September None Self-only Family
10 October None Self-only Family
11 November None Self-only Family
12 December X None Self-only Family
C 1 Total maximum allowable contribution for 2016
2 Amount allocated to spouse in 2016
3 Net maximum allowable contribution for 2016
SMART WORKSHEET FOR: Form 8889: Health Savings Accounts (Spouse)
A Gross distributions 35.

B Rollovers
C Return of excess contributions
D Subtract lines B and C from line A. 35.
E Taxable earnings on excess contributions
Non-surviving spouse beneficiaries who received no
distribution this year use lines F & G
F FMV of inherited HSA assets if no distribution received
G Qualified medical expenses
SMART WORKSHEET FOR: Form 8889: Health Savings Accounts (Spouse)
Check here if failure to maintain HDHP coverage in 2017 was due to death or disability
A 1 Total HSA contribution in 2016 0.

2 Excess contribution in 2016
3 Net HSA contribution in 2016 0.
B Check the box below to indicate the type of coverage you had for each
month of 2016. Select Family for any month that you had self only coverage
and were married to a spouse with family coverage. Select None for any
month you were covered by Medicare.
1 January None Self-only Family
2 February None Self-only Family
3 March None Self-only Family
4 April None Self-only Family
5 May None Self-only Family
6 June None Self-only Family
7 July None Self-only Family
8 August None Self-only Family
9 September None Self-only Family
10 October None Self-only Family
11 November None Self-only Family
12 December X None Self-only Family
C 1 Total maximum allowable contribution for 2016
2 Amount allocated to spouse in 2016
3 Net maximum allowable contribution for 2016
SMART WORKSHEET FOR: Form 8960 Deduction Recoveries Worksheet
A Line 3 times line 4 0.

B Amount deducted in prior year attributable to item recovered
C Lesser of line A or line B 0.
SMART WORKSHEET FOR: Form 8960 Deduction Recoveries Worksheet
Line 9 - Recalculated Prior Year Net Investment Income Tax Smart Worksheet
A Prior year Form 8960, line 13, modified adjusted gross income 86,100.
B Prior year Form 8960, line 14, threshold based on filing status 250,000.
C Prior year Form 8960, line 15, Subtract line B from A, not less than zero 0.
D Smaller of line 8 or line C -8,670.
E Recomputed net investment income tax. Multiply line D by 3.8% (.038) -329.
SMART WORKSHEET FOR: Federal Information Worksheet
TurboTax for the Web FIling Status Smart Worksheet
Check this box to override the filing status selected thru Interview
Marital Status
Filing Status Selected
SMART WORKSHEET FOR: Dependent Information Worksheet (Cassidy)
Dependency Exemption/EIC Smart Worksheet

NOTE: It is recommended that you answer the questions below using the Step-by-Step mode.
That will help insure that answers to the questions are not inconsistent.
A How many months did this person live with you? 2

Note: If born or died in current year and lived with you entire time or qualified
missing child select "The whole year". If more than one-half the year select 7
or more
B Who are the parents of this person?
(Used to determine if additional questions are necessary for children of divorced parents.)
Both Taxpayer and spouse
Taxpayer X
Spouse
C Did this person provide more than 1/2 their own support? Yes X No
D Was this person married on December 31, 2017 and filing a joint return
for the year (You may answer no if the only reason the joint return is filed
is to get a refund of tax withheld or estimated tax payments and neither
spouse would have a tax liability on their return if they filed separate
returns)? Yes X No
Detailed answers for this question. This dependent:
- Was married on December 31, 2017 Yes X No
- If married, filed a joint return for the year Yes No
- If filed joint return, only filed to get a refund of
tax withheld or estimated tax payments Yes No
- If filed married filing separate, neither spouse
had a tax liability on their return if they had filed
separately Yes No
E Is this person a Full time student? Yes No
F Is this person’s gross income less than $4,050? Yes No
1 Did you provide over 1/2 the support for this person?
or
Did you provide over 10% of the support for the person and with other
individuals who would be able to claim the person except for the
support test over 1/2 the support and all of you have agreed that you
alone will claim the person and you have filled out the Multiple Support
Declaration, Form 2120, to attach to your return? Yes No
G Is there an agreement with this person’s other parent about who can claim
this person as a dependent? X Yes No
Note: The noncustodial parent claiming the exemption for the child must
attach to their return Form 8332 from the custodial parent releasing the
claim to the exemption for the child
1 TurboTax Web Only:
Is the other parent claiming this dependent per the custody
agreement? X Yes No
Has the other parent waived their legal right so you can claim this
dependent on your tax return? Yes No
H Who will be claiming this person as a dependent as a result of:
- an agreement between the parents
- the rules controlling who can claim a qualifying child when the child meets the
conditions to be a qualifying child of more than one person?
Taxpayer (includes spouse if married filing joint) in this return?
Other parent in different return? X
Someone else in different return?
Child and Dependent Care Expenses, Form 2441, Special Situations Worksheet
Check this box if this person is a qualifying person only for the dependent care
expenses because they were not your dependent but would have been except that:
* They received gross income greater than $4,050 or more or
* They filed a joint return
Child Tax Credit, Special Circumstances Worksheet
If this dependent does not meet the substantial presence test, check if either of these
special circumstances applies to them (see Schedule 8812 Instructions):
* A valid first-year election was made for this child Yes No
* This is your legally adopted child and a member of your household Yes No
SMART WORKSHEET FOR: Form W-2 : Wage & Tax Statement (Copy 1)
Substitute Form W-2 Smart Worksheet
A Treat as substitute W-2 and generate a form 4852

B Linked substitute W-2 Form 4852
C Enter Form 4852, Line 9 information. "How did you determine amounts on line 7 of Form 4852?"
D Form 4852, Line 10 information. "Explain your efforts to obtain Form W-2?"
E QuickZoom to completed Form 4852 for reference

SMART WORKSHEET FOR: Form W-2 : Wage & Tax Statement (Copy 2)
Substitute Form W-2 Smart Worksheet
A Treat as substitute W-2 and generate a form 4852

B Linked substitute W-2 Form 4852
C Enter Form 4852, Line 9 information. "How did you determine amounts on line 7 of Form 4852?"
D Form 4852, Line 10 information. "Explain your efforts to obtain Form W-2?"
E QuickZoom to completed Form 4852 for reference

SMART WORKSHEET FOR: Child Tax Credit Worksheet
If your employer withheld or you paid Additional Medicare Tax or Tier 1 RRTA taxes, use this
worksheet to figure the amount to enter on line 6.
Social security tax, Medicare tax, and Additional Medicare Tax on Wages.
A Enter the social security tax withheld (Form(s) W-2, box 4) 6,958.
B Enter the Medicare tax withheld (Form(s) W-2, box 6). Box 6 includes any
Additional Medicare Tax withheld 1,627.
C Enter the Additional Medicare Tax, if any, on wages (Form 8959, line 7) 0.
D Add line A, B, and C 8,585.
E Enter the Additional Medicare Tax withheld (Form 8959 line 22) 0.
F Subtract line E from line D 8,585.
Additional Medicare Tax on Self-Employment Income.

G Enter one-half of the Additional Medicare Tax, if any, on self-employment
income (one-half of Form 8959, line 13)
Tier 1 RRTA taxes as an employee of a railroad (enter amounts on lines H, I, J, and K) or employee
representative (enter amounts on lines L, M, N, and O). Do not include amounts in Form W-2,
box 14 that are identified as Additional Medicare Tax or Tier 2 tax. Do not include amounts shown
on Form CT-2 on line 3 for Additional Medicare Tax or line 4 for Tier 2 tax.
H Enter the Tier 1 tax (Form(s) W-2, box 14) 0.

I Enter the Medicare Tax (Form(s) W-2, box 14) 0.
J Enter the Additional Medicare Tax, if any, or RRTA compensation as an
employee (Form 8959, line 17). Do not use the same amount from Form 8959,
line 17 for both this line J and line N.
K Add lines H, I, and J 0.
L Enter one-half of Tier 1 tax (one-half of Forms CT-2, line 1 for all 4 quarters
of 2017)
M Enter one-half of Tier 1 Medicare tax (one-half of Forms CT-2, line 2 for all 4
quarters of 2017)
N Enter one-half of the Additional Medicare Tax, if any, on RRTA compensation
as an employee representative (one-half of Form 8959, line 17). Do not use the
the same amount from Form 8959, line 17 for this line N and line J
0 Add line L, M, and N
Line 6 Amount
P Add line F, G, K and O. Enter here and on Line 11 Worksheet, line 6 8,585.
SMART WORKSHEET FOR: Tax and Interest Deduction Worksheet
Mortgage Interest Limited Smart Worksheet

When mortgage interest is limited because the principal amount of the mortgage is over one million
dollars or the home equity debt amount is over one-hundred-thousand dollars, use the Deductible Home
Mortgage Interest Worksheet to determine the amount to be reported on lines A, B, and C below.
QuickZoom to Deductible Home Mortgage Interest Worksheet
Does your mortgage interest need to be limited: Yes No
A Home mortgage interest and points reported on Form 1098:
1 Sum of lines 5a through 5d below 10,504.00
2 Limited amount to report on Sch A, line 10
B Home mortgage interest not reported on Form 1098:
1 Sum of lines 6a and 6b below
C Points not reported on Form 1098:
1 Sum of lines 7a through 7c below
SMART WORKSHEET FOR: Misc Itemized Deductions Wks
Depreciation Smart Worksheet

A Enter Section 179 carryover from prior year
B QuickZoom to the Asset Entry Worksheet
C QuickZoom to the Depreciation/Amortization Reports
D QuickZoom to Form 4562 for Schedule A
E Treat all MACRS assets for activity as qualified Indian reservation property? Yes X No
F Treat all assets acquired after Aug. 27, 2005 as
qualified GO Zone property? Regular Extension X No
G Treat all assets acquired after May 4, 2007 as
qualified Kansas Disaster Zone property? Yes X No
H Was this property located in a Qualified Disaster Area? Yes X No
SMART WORKSHEET FOR: Schedule E Worksheet (1150 N Lake Shore Dr. 23J)
This copy of the Worksheet will be on Schedule E, Page 1, Copy 1, Property A
Mortgage Interest Smart Worksheet
Lender’s Name Amount Qualified Mortgage Interest

Great Lakes Credit Union 3,755. Yes X No
Yes No
Yes No
Yes No
Activity Summary Smart Worksheet

Supporting information provided by program. NO ENTRIES ARE NEEDED.
A Ownership Joint
B At-risk status All
C Passive status Active RE
Regular AMT
Schedule E
D Tentative profit (loss) -3,694. -3,694.
E Other adjustments and preferences
F At-risk disallowed loss
G Passive carryover loss
H Passive disallowed loss
I Net profit (loss) allowed -3,694. -3,694.
Related Disposition
J Tentative profit (loss)
K At-risk disallowed loss
L Passive carryover loss
M Passive disallowed loss
N Net profit (loss) allowed
SMART WORKSHEET FOR: Schedule E Worksheet (1150 N Lake Shore Dr. 23J) -- Asset Entry Worksheet (1150 North Lake Shore Drive)
Trees or Vines Bearing Fruit or Nuts Planted/Grafted After 2015 Smart Worksheet
The PATH act of 2015 added an election allowing the taxpayer to deduct special depreciation
allowance for trees or vines bearing fruit or nuts in the year the tree or vine was planted, rather
than the date placed in service, for years after 12/31/15.
Enter the date the tree or vine was planted or grafted, if the special depreciation
was taken in that year planted or grafted, whether in the year 2017 or earlier
If this tree or vine was planted/grafted prior to 2017, was it placed in

service in 2017? Yes No
SMART WORKSHEET FOR: Earned Income Credit Worksheet
Nontaxable Combat Pay Election Smart Worksheet
QuickZoom to enter nontaxable combat pay on Form W-2

A Taxpayer:
1 Taxpayer, nontaxable combat pay
1a Taxpayer, prior year nontaxable combat pay from 2016
2 Election for earned income credit (EIC):
Elect taxpayer’s nontaxable combat pay as earned income for EIC? Yes No
3 Election for dependent care benefits (DCB):
Elect taxpayer’s nontaxable combat pay as earned income for DCB? Yes No
4 Election for child and dependent care credit:
Elect taxpayer’s nontaxable combat pay as earned income
for child and dependent care credit? Yes No
B Spouse:
1 Spouse, nontaxable combat pay
1a Spouse, prior year nontaxable combat pay from 2016
2 Election for earned income credit (EIC):
Elect spouse’s nontaxable combat pay as earned income for EIC? Yes No
3 Election for dependent care benefits (DCB):
Elect spouse’s nontaxable combat pay as earned income for DCB? Yes No
4 Election for child and dependent care credit:
Elect spouse’s nontaxable combat pay as earned income
for child and dependent care credit? Yes No
C You may compare the tax benefit of electing or not electing by checking a box on line A or
line B and reviewing the overpayment or amount due below:
Overpayment 1,322. Amount due
Eligible Hurricane and Widfire Victims Smart Worksheet

Election to use 2016 earned income for EIC and Additional Child Tax Credit
The "Yes" box must be marked on Line A and Line B for 2016 earned income to be used
for EIC and Additional Child Tax Credit calculations.
A Elect to use 2016 earned income for EIC
and Additional Child Tax Credit Yes X No
B Taxpayer is eligible to elect to use 2016 earned income
(see Publication 4492 for details) Yes No
C Earned income for EIC from your 2016 return 97,270.

D Current year earned income for EIC 106,919.
If Line D is equal to or greater than Line C the taxpayer is not eligible
to use 2016 earned income for EIC and Additional Child Tax Credit
calculations.
E You may compare the tax benefit of electing to use 2016 Earned Income
by checking the boxes on line A and B
Overpayment 1,322. Amount due

Investment Income Smart Worksheet
A Taxable and tax exempt interest 116.

B Dividend income
C Capital gain net income
D Royalty and rental of personal property net income
E Passive activity net income:
1 Rental real estate net income or loss -3,694.
2 Farm rental net income or loss
3 Partnerships and S corporations net income or loss
4 Estates and trusts net income or loss
5 Total of lines 1 through 4 -3,694.
6 Total passive activity net income, line 5 if greater than zero 0.
F Interest and dividends from Forms 8814
G Adjustments
H Total investment income, add lines A through G 116.
Is line H, total investment income over $3,450?

X No. You may take the credit.
Yes. Stop. You cannot take the credit.
Additional information from your 2017 Federal Tax Return
Schedule E: Supplemental Income and Loss

Income Or Loss From Rental Real Estate And Royalties (1)
Line 13: Property Explanation Statement
Form 1098 Name/Address
Name Address City ST ZipCode
Daniel Francis Sluce 8301 Pine Island Drive CROWN POINT IN 46307
Charitable Organization (GoodWill)

Detail of Item Donations - Continued Continuation Statement
1 10/17/2017 1 Wok 22.00 1 15.00 0 22.00

1 10/17/2017 1 Men's Pants: Cargo 15.00 3 10.00 0 45.00
1 10/17/2017 1 Men's Pants: Dress Slacks 9.00 2 6.00 0 18.00
1 10/17/2017 1 Men's Pants: Jeans/Denim 20.00 3 12.00 0 60.00
1 10/17/2017 1 Men's Pants: Sweatpants/Fleece 14.00 2 9.00 0 28.00
Total 173.00
Schedule E Worksheet (1150 N Lake Shore Dr. 23J) -- Asset Entry Worksheet (1150 North Lake Shore Drive)
State Depreciation Statement Continuation Statement
63 a State (CA info must be entered in CA state return, do not enter here) CO
b Asset status Federal amounts used - no basis/class difference, no 179/SDA/truck/van deductions
c State cost or basis 141,533.
g State asset class R
h State depreciation method SL
i State MACRS convention MM
j State recovery period 27.5
k State depreciable basis 141,533.
l State prior depreciation 14,368.
m State depreciation deduction 5,147.
q Include asset in state return X Yes No
63 a State (CA info must be entered in CA state return, do not enter here) IL
b Asset status Federal amounts used - no basis/class difference, no 179/SDA/truck/van deductions
c State cost or basis 141,533.
g State asset class R
h State depreciation method SL
i State MACRS convention MM
j State recovery period 27.5
k State depreciable basis 141,533.
l State prior depreciation 14,368.
m State depreciation deduction 5,147.
q Include asset in state return X Yes No
Form 4562 Depreciation Options

State Section 179 Statement Continuation Statement
1 State 1 CO
b Total cost of state eligible property placed in service this year by spouse b
3a Elect to treat state Qualified Real Property as "Section 179 Property" 3a Yes X No
b Calculated "Total cost of state Section 179 property placed in service" b 300.
4 State maximum amount 4 510,000.
5 State threshold cost of Section 179 property 5 2,030,000.
6 Reduction in state limitation (Line 3b less line 5, not less than 0) 6 0.
7 State dollar limitation (Ln 4 less ln 6, not less than 0. MFS, times ln 2d) 7 510,000.
8 Total state Section 179 elected (Cannot exceed line 7) 8 300.
1 State 1 IL
b Total cost of state eligible property placed in service this year by spouse b
3a Elect to treat state Qualified Real Property as "Section 179 Property" 3a Yes X No
b Calculated "Total cost of state Section 179 property placed in service" b 300.
4 State maximum amount 4 510,000.
5 State threshold cost of Section 179 property 5 2,030,000.
6 Reduction in state limitation (Line 3b less line 5, not less than 0) 6 0.
7 State dollar limitation (Ln 4 less ln 6, not less than 0. MFS, times ln 2d) 7 510,000.
8 Total state Section 179 elected (Cannot exceed line 7) 8 300.

State 2009 Economic Stimulus Default Statement Continuation Statement
CO Federal Full 12/31/2007 12/31/2020Full 510,000. 2,030,000.
CT Federal Full 12/31/2007 12/31/2020Full 510,000. 2,030,000.
DE Federal Full 12/31/2007 12/31/2020Full 510,000. 2,030,000.
DC State N/A N/A N/AFull 25,000. 200,000.
GA State N/A N/A N/AFull 510,000. 2,030,000.
HI State N/A N/A N/AFull 25,000. 200,000.
ID State Full 12/31/2007 12/31/2009Full 510,000. 2,030,000.
IL Federal Part 12/31/2007 12/31/2020Full 510,000. 2,030,000.
IN State N/A N/A N/AFull 25,000. 2,030,000.
IA State N/A N/A N/AFull 25,000. 200,000.
KS Federal Full 12/31/2007 12/31/2020Full 510,000. 2,030,000.
KY State N/A N/A N/AFull 25,000. 200,000.
LA Federal Full 12/31/2007 12/31/2020Full 510,000. 2,030,000.
ME State N/A N/A N/AFull 510,000. 2,030,000.
MD State N/A N/A N/AFull 25,000. 200,000.
MA State N/A N/A N/AFull 510,000. 2,030,000.
MI Federal Full 12/31/2007 12/31/2020Full 510,000. 2,030,000.
MN Federal Part 12/31/2007 12/31/2020Part 510,000. 2,030,000.
MS State N/A N/A N/AFull 510,000. 2,030,000.

State 2009 Economic Stimulus Default Statement Continuation Statement
MO Federal Full 12/31/2007 12/31/2020Full 510,000. 2,030,000.
MT Federal Full 12/31/2007 12/31/2020Full 510,000. 2,030,000.
NE Federal Full 12/31/2007 12/31/2020Full 510,000. 2,030,000.
NH State N/A N/A N/AFull 100,000. 2,000,000.
NJ State N/A N/A N/AFull 25,000. 200,000.
NM Federal Full 12/31/2007 12/31/2020Full 510,000. 2,030,000.
NY State N/A N/A N/AFull 510,000. 2,030,000.
NC Federal Part 12/31/2007 12/31/2020Part 510,000. 2,030,000.
ND Federal Full 12/31/2007 12/31/2020Full 510,000. 2,030,000.
OH Federal Part 12/31/2007 12/31/2020Part 510,000. 2,030,000.
OK Federal Full 12/31/2007 12/31/2020Full 510,000. 2,030,000.
OR State Full 12/31/2007 12/31/2020Full 510,000. 2,030,000.
PA State N/A N/A N/AFull 25,000. 200,000.
RI State N/A N/A N/AFull 510,000. 2,030,000.
SC State N/A N/A N/AFull 510,000. 2,030,000.
UT Federal Full 12/31/2007 12/31/2020Full 510,000. 2,030,000.
VT State N/A N/A N/AFull 510,000. 2,030,000.
VA State N/A N/A N/AFull 510,000. 2,030,000.
WV State Full 12/31/2007 12/31/2020Full 510,000. 2,030,000.
WI State Full 12/31/2007 12/31/2013Full 510,000. 2,030,000.

State Qualified Disaster Area Default Statement Continuation Statement
CO Federal Full 12/31/2007 12/31/2013Full 100,000. 600,000.
CT Federal Full 12/31/2007 12/31/2013Full 100,000. 600,000.
DE Federal Full 12/31/2007 12/31/2013Full 100,000. 600,000.
DC None N/A N/A N/AN/A 0. 0.
GA None N/A N/A N/AN/A 0. 0.
HI None N/A N/A N/AN/A 0. 0.
ID State Full 12/31/2008 12/31/2013Full 100,000. 600,000.
IL Federal Full 12/31/2007 12/31/2013Full 100,000. 600,000.
IN None N/A N/A N/AN/A 0. 0.
IA None N/A N/A N/AN/A 0. 0.
KS Federal Full 12/31/2007 12/31/2013Full 100,000. 600,000.
KY None N/A N/A N/AN/A 0. 0.
LA Federal Full 12/31/2007 12/31/2013Full 100,000. 600,000.
ME State N/A 12/31/2010 12/31/2013Full 100,000. 600,000.
MD State Full 12/31/2007 12/31/2013N/A 0. 0.
MA None N/A N/A N/AN/A 0. 0.
MI Federal Full 12/31/2007 12/31/2013Full 100,000. 600,000.
MN Federal Part 12/31/2007 12/31/2013Part 100,000. 600,000.
MS State N/A 12/31/2007 12/31/2013Full 100,000. 600,000.
MO Federal Full 12/31/2007 12/31/2013Full 100,000. 600,000.
MT Federal Full 12/31/2007 12/31/2013Full 100,000. 600,000.
NE Federal Full 12/31/2007 12/31/2013Full 100,000. 600,000.
NH None N/A N/A N/AN/A 0. 0.
NJ None N/A N/A N/AN/A 0. 0.
NM Federal Full 12/31/2007 12/31/2013Full 100,000. 600,000.
NY State N/A 12/31/2007 12/31/2013Full 100,000. 600,000.

State Qualified Disaster Area Default Statement Continuation Statement
NC Federal Part 12/31/2007 12/31/2013Full 100,000. 600,000.
ND Federal Full 12/31/2007 12/31/2013Full 100,000. 600,000.
OH Federal Full 12/31/2007 12/31/2013Full 100,000. 600,000.
OK Federal Full 12/31/2007 12/31/2013Full 100,000. 600,000.
OR Federal Full 12/31/2007 12/31/2013Full 100,000. 600,000.
PA None N/A N/A N/AN/A 0. 0.
RI None N/A N/A N/AN/A 0. 0.
SC State N/A 12/31/2007 12/31/2013Full 100,000. 600,000.
UT Federal Full 12/31/2007 12/31/2013Full 100,000. 600,000.
VT None N/A N/A N/AN/A 0. 0.
VA Federal Full 12/31/2007 12/31/2013Full 100,000. 600,000.
WV Federal Full 12/31/2007 12/31/2013Full 100,000. 600,000.
WI Federal Full 12/31/2007 12/31/2013Full 100,000. 600,000.

State Kansas Disaster Zone Default Statement Continuation Statement
DC None N/A N/A N/AN/A 0. 0.
ID State Full 12/31/2008 12/31/2009Full 100,000. 600,000.
IA None N/A N/A N/AN/A 0. 0.
ME None N/A N/A N/AN/A 0. 0.
MD State Full 05/04/2007 12/31/2009N/A 0. 0.
MS State N/A 05/04/2007 12/31/2009Full 100,000. 600,000.
NY State N/A 05/04/2007 12/31/2009Full 100,000. 600,000.
NC Federal Part 05/04/2007 12/31/2009Full 100,000. 600,000.
OH Federal Full 05/04/2007 12/31/2009Part 100,000. 600,000.
OK State Full 05/04/2007 12/31/2009Full 100,000. 600,000.

State Kansas Disaster Zone Default Statement Continuation Statement
SC None N/A N/A N/AN/A 0. 0.
VT None N/A N/A N/AN/A 0. 0.
VA None N/A N/A N/AN/A 0. 0.

State CBEPP Default Statement Continuation Statement
STATE CALC CBEPP BONUS DEPRECIATION
State F/S conformity 1st yr CBEPP start CBEPP end
CO Federal Full 12/20/2006 12/31/2017
CT Federal Full 12/20/2006 12/31/2017
DE Federal Full 12/20/2006 12/31/2017
DC None N/A N/A N/A
GA Federal Full 12/20/2006 12/31/2017
HI Federal Full 12/20/2006 12/31/2017
ID Federal Full 12/20/2006 12/31/2017
IL Federal Full 12/20/2006 12/31/2017
IN Federal Full 12/20/2006 12/31/2017
IA Federal Full 12/20/2006 12/31/2017
KS Federal Full 12/20/2006 12/31/2017
KY None N/A N/A N/A
LA Federal Full 12/20/2006 12/31/2017
ME State Full 12/20/2006 12/31/2007
MD Federal Full 12/20/2006 12/31/2017
MA Federal Full 12/20/2006 12/31/2017
MI Federal Full 12/20/2006 12/31/2017
MN Federal Full 12/20/2006 12/31/2017
MS None N/A N/A N/A
MO Federal Full 12/20/2006 12/31/2017
MT Federal Full 12/20/2006 12/31/2017
NE None N/A N/A N/A
NH None N/A N/A N/A
NJ None N/A N/A N/A
NM Federal Full 12/20/2006 12/31/2017
NY None N/A N/A N/A
NC Federal Full 12/20/2006 12/31/2017
ND Federal Full 12/20/2006 12/31/2017
OH Federal Full 12/20/2006 12/31/2017
OK Federal Full 12/20/2006 12/31/2017
OR Federal Full 12/20/2006 12/31/2017
PA None N/A N/A N/A
RI None N/A N/A N/A
SC None N/A N/A N/A
UT Federal Full 12/20/2006 12/31/2017
VT Federal Full 12/20/2006 12/31/2017
VA None N/A N/A N/A
WV None N/A N/A N/A
WI State Full 12/20/2006 12/31/2013

State GO Zone Default Statement Continuation Statement
STATE CALC GO ZONE BONUS DEPRECIATION GO ZONE SECTION 179
State F/S conformity 1st yr GO Zone start GO Zone end 1st yr Maximum Increase Threshold Increase
DC Federal Full 08/28/2005 03/30/2012Full 100,000. 600,000.
ID Federal Full 08/28/2005 03/30/2012Full 100,000. 600,000.
IA Federal Full 08/28/2005 03/30/2012Full 100,000. 600,000.
ME State Full 08/28/2005 12/31/2007N/A 0. 0.
MD Federal Full 08/28/2005 03/30/2012Full 100,000. 600,000.
MS State N/A 08/28/2005 03/30/2012Full 100,000. 600,000.
NY Federal Full 08/28/2005 03/30/2012Full 100,000. 600,000.
NC Federal Full 08/28/2005 03/30/2012Full 100,000. 600,000.
OH Federal Full 08/28/2005 03/30/2012Part 100,000. 600,000.
OK Federal Full 08/28/2005 03/30/2012Full 100,000. 600,000.
SC State Full 08/28/2005 05/06/2009Full 100,000. 600,000.
VT Federal Full 08/28/2005 03/30/2012Full 100,000. 600,000.
VA None N/A N/A N/AN/A 0. 0.

State Pre-2005 SDA Default Statement Continuation Statement
CO Fed 50, 30Full 09/11/200112/31/200505/06/200312/31/2005Y

CT Fed 50, 30Part 09/11/200112/31/200505/06/200312/31/2005Y
DE Fed 50, 30Full 09/11/200112/31/200505/06/200312/31/2005Y
DC State None N/A N/A N/A N/A N/AY
GA State None N/A N/A N/A N/A N/AY
HI State None N/A N/A N/A N/A N/AY
ID State None N/A N/A N/A N/A N/AY

State Pre-2005 SDA Default Statement Continuation Statement
IL Fed 50, 30Part 09/11/200112/31/200505/06/200312/31/2005Y

IN State None N/A N/A N/A N/A N/AY
IA Both 50 Full N/A N/A05/06/200312/31/2004Y
KS Fed 50, 30Full 09/11/200112/31/200505/06/200312/31/2005Y
KY State None N/A N/A N/A N/A N/AY
LA Fed 50, 30Full 09/11/200112/31/200505/06/200312/31/2005Y
ME Both 50, 30Full 09/11/200112/31/200101/01/200612/31/2006Y
MD State None N/A N/A N/A N/A N/AY
MA State None N/A N/A N/A N/A N/AY
MI Fed 50, 30Full 09/11/200112/31/200505/06/200312/31/2005Y
MN Fed 50, 30Part 09/11/200112/31/200505/06/200312/31/2005Y
MS State None N/A N/A N/A N/A N/AY
MO Both 50, 30Full 09/11/200106/30/200205/06/200312/31/2006Y
MT Fed 50, 30Full 09/11/200112/31/200505/06/200312/31/2005Y
NE Fed 50, 30Full 09/11/200112/31/200505/06/200312/31/2005Y
NH State None N/A N/A N/A N/A N/AN
NJ Both 50, 30Full 09/11/200112/31/200505/06/200312/31/2003Y
NM Fed 50, 30Full 09/11/200112/31/200505/06/200312/31/2005Y
NY Both 50, 30Full 09/11/200105/31/200305/06/200305/31/2003Y
NC Fed 50, 30Part 09/11/200112/31/200505/06/200312/31/2005Y
ND Fed 50, 30Full 09/11/200112/31/200505/06/200312/31/2005Y
OH Fed 50, 30Part 09/11/200112/31/200505/06/200312/31/2005Y
OK Fed 50, 30Full 09/11/200112/31/200505/06/200312/31/2005Y
OR Fed 50, 30Full 09/11/200112/31/200505/06/200312/31/2005Y
PA State None N/A N/A N/A N/A N/AY
RI State None N/A N/A N/A N/A N/AY
SC State None N/A N/A N/A N/A N/AY
UT Fed 50, 30Full 09/11/200112/31/200505/06/200312/31/2005Y
VT Fed 50, 30Full 09/11/200112/31/200505/06/200312/31/2005Y
VA State None N/A N/A N/A N/A N/AY
WV Fed 50, 30Full 09/11/200112/31/200505/06/200312/31/2005Y
WI Fed 50, 30Full 09/11/200112/31/200505/06/200312/31/2005Y

State Software/Real Property Sec 179 Default Statement Continuation Statement
CO Federal TY2003 PERMANENTFederal TY2010 PERMANENT
CT Federal TY2003 PERMANENTFederal TY2010 PERMANENT
DE Federal TY2003 PERMANENTFederal TY2010 PERMANENT
DC Federal TY2003 PERMANENTFederal TY2010 PERMANENT
GA Federal TY2003 PERMANENTNone N/A N/A
HI None N/A N/ANone N/A N/A
ID Federal TY2003 PERMANENTState TY2010 PERMANENT
IL Federal TY2003 PERMANENTFederal TY2010 PERMANENT
IN Federal TY2003 PERMANENTState TY2010 PERMANENT
IA None N/A N/ANone N/A N/A
KS Federal TY2003 PERMANENTFederal TY2010 PERMANENT
KY None N/A N/ANone N/A N/A
LA Federal TY2003 PERMANENTFederal TY2010 PERMANENT
ME State TY2011 PERMANENTState TY2011 PERMANENT

State Software/Real Property Sec 179 Default Statement Continuation Statement
MD None N/A N/ANone N/A N/A
MA Federal TY2003 PERMANENTFederal TY2010 PERMANENT
MI Federal TY2003 PERMANENTFederal TY2010 PERMANENT
MN None N/A N/ANone N/A N/A
MS Federal TY2003 PERMANENTFederal TY2010 PERMANENT
MO Federal TY2003 PERMANENTFederal TY2010 PERMANENT
MT Federal TY2003 PERMANENTFederal TY2010 PERMANENT
NE Federal TY2003 PERMANENTFederal TY2010 PERMANENT
NH None N/A N/ANone N/A N/A
NJ None N/A N/ANone N/A N/A
NM Federal TY2003 PERMANENTFederal TY2010 PERMANENT
NY Federal TY2003 PERMANENTFederal TY2010 PERMANENT
NC Federal TY2003 PERMANENTFederal TY2010 PERMANENT
ND Federal TY2003 PERMANENTFederal TY2010 PERMANENT
OH Federal TY2003 PERMANENTFederal TY2010 PERMANENT
OK Federal TY2003 PERMANENTFederal TY2010 PERMANENT
OR Federal TY2003 PERMANENTState TY2011 PERMANENT
PA None N/A N/ANone N/A N/A
RI State TY2014 PERMANENTState TY2014 PERMANENT
SC Federal TY2003 PERMANENTState TY2010 PERMANENT
UT Federal TY2003 PERMANENTFederal TY2010 PERMANENT
VT Federal TY2003 PERMANENTFederal TY2010 PERMANENT
VA Federal TY2003 PERMANENTFederal TY2010 PERMANENT
WV Federal TY2003 PERMANENTState TY2010 TY2011
WI Federal TY2003 PERMANENTFederal TY2010 PERMANENT

State Asset Class Default Statement Continuation Statement
CO Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017
CT Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017
DE Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017
DC Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017
GA None N/A N/AFederal 10/22/2004 12/31/2017
HI Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017
ID Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017
IL Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017
IN Federal 12/31/2008 12/31/2017State 12/31/2011 12/31/2017
IA None N/A N/ANone N/A N/A
KS Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017
KY None N/A N/ANone N/A N/A
LA Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017
ME Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017
MD None N/A N/ANone N/A N/A
MA Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017
MI Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017
MN Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017
MS Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017
MO Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017
MT Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017

State Asset Class Default Statement Continuation Statement
NE Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017
NH None N/A N/ANone N/A N/A
NJ None N/A N/ANone N/A N/A
NM Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017
NY Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017
NC Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017
ND Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017
OH Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017
OK Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017
OR State 12/31/2008 12/31/2017State 10/22/2004 12/31/2017
PA Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017
RI State 12/31/2013 12/31/2017State 12/31/2013 12/31/2017
SC State 12/31/2008 12/31/2009State 12/31/2014 12/31/2017
UT Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017
VT Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017
VA Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017
WV Federal 12/31/2008 12/31/2017Federal 10/22/2004 12/31/2017
WI State 12/31/2008 12/31/2013State 10/22/2004 12/31/2013

Fruit/Nut Tree/Vine SDA in Year Planted/Grafted Continuation Statement
CO Federal Full 12/31/15 12/31/20
CT Federal Full 12/31/15 12/31/20
DE Federal Full 12/31/15 12/31/20
DC State N/A N/A N/A
GA State N/A N/A N/A
HI State N/A N/A N/A
ID State N/A N/A N/A
IL Federal Part 12/31/15 12/31/20
IN State N/A N/A N/A
IA State N/A N/A N/A
KS Federal Full 12/31/15 12/31/20
KY State N/A N/A N/A
LA Federal Full 12/31/15 12/31/20
ME State N/A N/A N/A
MD State N/A N/A N/A
MA State N/A N/A N/A
MI Federal N/A 12/31/15 12/31/20
MN Federal Part 12/31/15 12/31/20
MS State N/A N/A N/A
MO Federal Full 12/31/15 12/31/20
MT Federal Full 12/31/15 12/31/20
NE Federal Full 12/31/15 12/31/20
NH State N/A N/A N/A
NJ State N/A N/A N/A
NM Federal Full 12/31/15 12/31/20
NY State N/A N/A N/A
NC Federal Part 12/31/15 12/31/20
ND Federal Full 12/31/15 12/31/20

Fruit/Nut Tree/Vine SDA in Year Planted/Grafted Continuation Statement
OH Federal Part 12/31/15 12/31/20
OK Federal Full 12/31/15 12/31/20
OR Federal Full 12/31/15 12/31/20
PA State N/A N/A N/A
RI State N/A N/A N/A
SC State N/A N/A N/A
UT Federal Full 12/31/15 12/31/20
VT State N/A N/A N/A
VA State N/A N/A N/A
WV Federal Full 12/31/15 12/31/20
WI State Full 12/31/15 12/31/13
DR 8453 (10/12/17)
COLORADO DEPARTMENT OF REVENUE
Denver, CO 80261-0005
178453 11555 Colorado.gov/Tax
State of Colorado Individual Income Tax Declaration for Electronic Filing

Do not mail this form to the IRS or the Colorado Department of Revenue Retain with your records
Taxpayer SSN Spouse SSN (If Joint Return) Submission ID
315-04-4786 313-96-8786
Taxpayer Last Name Taxpayer First Name Middle Initial
CLARKE ROBERT T
Spouse Last Name (If Joint Return) Spouse First Name (If Joint Return)
CLARKE MARIRENEE
Street Address Phone Number
1301 SPEER BLVD APT 710 (312)714-9280

City State Zip
DENVER CO 80204
Part I — Tax Return Information
Total Income, line 22 from your federal form 1040, line 15 on form 1040A,
or line 4 on form 1040EZ 1 $ 104021
Taxable Income, line 43 on federal form 1040, line 27 on form 1040A,
line 6 on form 1040EZ 2 $ 76254
Colorado Tax, Line 15 on Colorado form 104 3 $ 3286
Colorado Tax Withheld, Line 16 on Colorado form 104 4 $ 3765
Refund, Line 30 Colorado form 104 5 $ 479
Amount You Owe, Line 35 on Colorado form 104 6 $

Part II — Declaration of Tax Payer
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with the amounts shown on my 2017 Federal/Colorado income tax returns, and that said tax returns, statements, schedules and attachments
are true, correct, and complete to the best of my knowledge and belief. I understand that I (or my Electronic Return Originator (ERO) if
applicable) may be required to provide paper copies of this declaration, my returns, withholding statements, schedules, and attachments
upon request by the Colorado Department of Revenue at any time during the period covered by the Colorado statute of limitations.
Signature Date Spouse's Signature (If Joint Return, Both Must Sign) Date
Part III — Declaration of ERO/Preparer/Transmitter

If the transmitter did not prepare the tax return, check here X
If I am not the preparer, I declare only that the amounts shown in Part I above agree with the amounts shown on the taxpayer's 2017 Federal/
Colorado income tax returns. If I am the preparer, under penalties of perjury I declare that I have reviewed the above taxpayer's 2017 Federal/
Colorado income tax returns and that the information provided to me by the taxpayer and the amounts shown in Part I above agree with the
amounts shown on said tax returns, and that said tax returns, statements, schedules, and attachments are true, correct, and complete to the
EHVWRIP\NQRZOHGJHDQGEHOLHI$VSUHSDUHU,IXUWKHUGHFODUHWKDW,KDYHREWDLQHGWKHWD[SD\HU
VVLJQDWXUHRQWKLVIRUPDWWKHWLPHRI¿OLQJDQG
KDYHSURYLGHGWKHWD[SD\HUZLWKFRSLHVRIDOOIRUPVDQGLQIRUPDWLRQ¿OHG,DOVRDJUHHWRPDLQWDLQWKLVVLJQHG)RUP'5IRUWKHSHULRG
covered by the Colorado statute of limitations, and to provide paper copies of this declaration, said returns, withholding statements, schedules
and attachments upon request by the Colorado Department of Revenue at any time during this period.
ERO's Signature 3UHSDUHU,GHQWL¿FDWLRQ1XPEHURU<RXU661
SELF-PREPARED
Date (MM/DD/YY)
Check if also Preparer
REV 11/13/17 INTUIT.CG.CFP.SP

DR 1778 (06/12/17)
Denver, CO 80261-0006
171778 11555 Colorado.gov/Tax
e-Filer Attachment Form

Instructions for DR 1778
The Department strongly recommends that you submit Mail to:
these documents using the e-Filer Attachment option Colorado Department of Revenue
at Colorado.gov/RevenueOnline, which eliminates the Denver, CO 80261-0006
requirement to mail this form. Failure to timely submit You must resubmit your supporting documentation if you
required documentation will result in denial of the related ¿OHDQDPHQGHGUHWXUQDO NOT return this form in lieu
credit. Revenue Online e-Filer Attachment provides you RIDSD\PHQWYRXFKHURULI\RXDUH¿OLQJDSDSHUUHWXUQ.
ZLWK D FRQ¿UPDWLRQ QXPEHU DQG ZLOO EH DYDLODEOH WR WKH 7KLVIRUPLV21/<UHTXLUHGLI\RXUWD[HVZHUHH¿OHGDQG
Department immediately. your software or preparer was unable to attach the required
Otherwise, complete this form, package it with your documentation electronically.
documentation and mail to the Department. Using this form
can extend return processing time up to 6 weeks.
For Tax Year (MM/DD/YY) RU¿VFDO\HDUEHJLQQLQJMM/DD/YY)

2017
Tax Type X Individual Income C-Corp Income Partnership Income S-Corp Income LLC Income
LP Income LLP Income LLLP Income Association Income 1RQ3UR¿W,QFRPH
Please print or type

Taxpayer Last Name First Name Middle Initial
CLARKE ROBERT T
Spouse’s Last Name (if applicable) First Name Middle Initial
CLARKE MARIRENEE
Taxpayer SSN Spouse SSN (if applicable) FEIN
315-04-4786 313-96-8786
Taxpayer address City State Zip
1301 SPEER BLVD APT 710 DENVER CO 80204
Mark the box for the documents submitted. See the Colorado Department of Revenue, Taxation Division website at
Colorado.gov/Tax for more information about these credits.
X Other state(s) income tax return(s) Colorado Source Capital Gain Subtraction:
DR 1316
Enterprise Zone Credit: DR 1366 and any -RE*URZWK,QFHQWLYH7D[&UHGLW&HUWL¿FDWLRQ
DSSOLFDEOHFHUWL¿FDWLRQIRUPVIURPWKH=RQH letter from the Colorado Department Commission.
Administrator
Gross Conservation Easement: DR 1303, DR 1304 /RZ,QFRPH+RXVLQJ&UHGLW&+)$FHUWL¿FDWLRQ
and/or DR 1305 and supplemental documentation. letter
Aircraft Manufacturer New Employee Credit: Nonresident Partner, Shareholder or Members

DR 0085 and/or DR 0086 Agreement: DR 0107
Innovative Motor Vehicle Credit: Vehicle registration Plastic Recycling Credit: Required documentation
and the purchase invoice or bill of sale. to substantiate credit (receipts, bills, etc)
Child Care Contribution Credit: DR 1317 School-to-Career Investment Credit:
&HUWL¿FDWLRQOHWWHU
Claim for refund on behalf of deceased taxpayer: Other documentation for credits/subtractions
'5GHDWKFHUWL¿FDWH claimed (mark the Other box below and enter
details)
Other Explain
Signature of Taxpayer or Preparer Date (MM/DD/YY)

SELF PREPARED
170104 11555
DR 0104 (06/30/17)
Colorado.gov/Tax
(0013)
2017 Colorado Individual Income Tax Return

X Full-Year Part-Year or Nonresident (or resident, part-year, Mark if Abroad on due date – see instructions
non-resident combination)
*Must attach DR 0104PN
Your Last Name Your First Name Middle Initial
CLARKE, JR ROBERT T
Deceased Date of Birth (MM/DD/YYYY) SSN
If checked and claiming a refund, you must
VXEPLWWKH'5ZLWK\RXUUHWXUQ 01/19/1981 315-04-4786
State of Issue Last 4 characters of ID number Date of Issuance
(QWHUWKHIROORZLQJLQIRUPDWLRQIURP\RXUFXUUHQWGULYHU
OLFHQVHRUVWDWHLGHQWL¿FDWLRQFDUG CO 0639 04/13/17
If Joint, Spouse’s Last Name Spouse’s First Name Middle Initial
CLARKE MARIRENEE
Deceased Spouse’s Date of Birth (MM/DD/YYYY) Spouse’s SSN
If checked and claiming a refund, you must
VXEPLWWKH'5ZLWK\RXUUHWXUQ 07/17/1981 313-96-8786
State of Issue Last 4 characters of ID number Date of Issuance
(QWHUWKHIROORZLQJLQIRUPDWLRQIURP\RXUVSRXVH¶V
FXUUHQWGULYHUOLFHQVHRUVWDWHLGHQWL¿FDWLRQFDUG CO 0646 01/23/15
Mailing Address Phone Number
1301 SPEER BLVD APT 710 (312)714-9280

City State Zip Code Foreign Country (if applicable)
DENVER CO 80204
Round To The Next Dollar
1. Enter Federal Taxable Income from your federal income tax form: 1040EZ
line 6, 1040A line 27, 1040 line 43 1 76254 0 0
6WDSOH:VDQGVZLWK&2ZLWKKROGLQJKHUH.
Additions to Federal Taxable Income

2. State Addback, enter the state income tax deduction from your federal form
1040 schedule A, line 5 (see instructions) 2 3902 0 0
3. Other Additions, explain (see instructions) 3 00

Explain:

DR 0104 (06/30/17)
Colorado.gov/Tax
170104 21555
Name SSN
ROBERT T CLARKE, JR & MARIRENEE CLARKE 315-04-4786
4. Subtotal, sum of lines 1 through 3 4 80156 0 0

5. Subtractions from the DR 0104AD Schedule, line 18, you must submit the
'5$'VFKHGXOHZLWK\RXUUHWXUQ 5 1067 0 0
6. Colorado Taxable Income, subtract line 5 from line 4 6 79089 0 0

Tax, Prepayments and Credits: full-year residents use DR 0104CR and part-year and nonresidents use DR 0104PN
7. Colorado Tax from tax table or the DR 0104PN line 36, you must submit
WKH'531ZLWK\RXUUHWXUQLIDSSOLFDEOH 7 3662 0 0
8. Alternative Minimum Tax from the DR 0104AMT, you must submit the
'5$07ZLWK\RXUUHWXUQ 8 00
9. Recapture of prior year credits 9 00

11. Nonrefundable Credits from the DR 0104CR line 39, the sum of lines 11 and 12
FDQQRWH[FHHGOLQH\RXPXVWVXEPLWWKH'5&5ZLWK\RXUUHWXUQ 11 376 0 0
12. Total Nonrefundable Enterprise Zone credits used – as calculated,
or from the DR 1366 line 87, the sum of lines 11 and 12 cannot exceed line 10,
\RXPXVWVXEPLWWKH'5ZLWK\RXUUHWXUQ 12 00
13. Net Income Tax, sum of lines 11 and 12. Subtract that sum from line 10. 13 3286 0 0
14. Use Tax reported on the DR 0104US schedule line 7, you must submit
WKH'586ZLWK\RXUUHWXUQ 14 00
15. Net Colorado Tax, sum of lines 13 and 14 15 3286 0 0

16. CO Income Tax Withheld from W-2s and 1099s, you must submit the W-2s
DQGRUVFODLPLQJ&RORUDGRZLWKKROGLQJZLWK\RXUUHWXUQ 16 3765 0 0
17. 3ULRU\HDU(VWLPDWHG7D[&DUU\IRUZDUG 17 00
18. Estimated Tax Payments, enter the sum of the quarterly payments
remitted for this tax year 18 00
19. ([WHQVLRQ3D\PHQWUHPLWWHGZLWKWKH'5, 19 00
20. Other Prepayments: DR 0104BEP DR 0108 DR 1079 20

00
21. Gross Conservation Easement Credit from the DR 1305G line 33, you must
VXEPLWWKH'5*ZLWK\RXUUHWXUQ 21 00
22. Innovative Motor Vehicle Credit from the DR 0617, you must submit each
'5ZLWK\RXUUHWXUQ 22 0 00
23. Refundable Credits from the DR 0104CR line 8, you must submit the
'5&5ZLWK\RXUUHWXUQ 23 00

25. Federal Adjusted Gross Income from your federal income tax form:
(=OLQH$OLQHOLQH 25 101521 0 0
26. Overpayment, if line 24 is greater than line 15 then subtract line 15 from line 24 26 479 0 0
27. (VWLPDWHG7D[&UHGLW&DUU\IRUZDUGWR¿UVWTXDUWHULIDQ\ 27 00

DR 0104 (06/30/17)
Colorado.gov/Tax
170104 31555
Name SSN

28. Voluntary Contributions elected on the DR 0104CH schedule line 21, you must
VXEPLWWKH'5&+ZLWK\RXUUHWXUQ 28 00
29. Subtotal, add lines 27 and 28 29 00
30. Refund, subtract line 29 from line 26 (see instructions) 30 479 0 0
Routing Number 0 3 1 1 7 6 1 1 0 Type: X Checking Savings CollegeInvest 529

Direct
Deposit Account Number 1 3 5 8 7 3 4 5 0
For questions regarding CollegeInvest direct deposit or to open an account, visit CollegeInvest.org or call 800-448-2424.
31. Net Tax Due, subtract line 24 from line 15, then add line 28 31 00
32. Delinquent Payment Penalty (see instructions) 32 00
33. Delinquent Payment Interest (see instructions) 33 00

34. (VWLPDWHG7D[3HQDOW\\RXPXVWVXEPLWWKH'5ZLWK\RXUUHWXUQ
(see instructions) 34 00
35. $PRXQW<RX2ZHVXPRIOLQHVWKURXJK 35
7KH6WDWHPD\FRQYHUW\RXUFKHFNWRDRQHWLPHHOHFWURQLFEDQNLQJWUDQVDFWLRQ<RXUEDQNDFFRXQWPD\EHGHELWHGDVHDUO\DVWKHVDPHGD\UHFHLYHGE\WKH6WDWH,IFRQYHUWHG\RXUFKHFNZLOO
QRWEHUHWXUQHG,I\RXUFKHFNLVUHMHFWHGGXHWRLQVXI¿FLHQWRUXQFROOHFWHGIXQGVWKH'HSDUWPHQWRI5HYHQXHPD\FROOHFWWKHSD\PHQWDPRXQWGLUHFWO\IURP\RXUEDQNDFFRXQWHOHFWURQLFDOO\
Third Party Designee

'R\RXZDQWWRDOORZDQRWKHUSHUVRQWRGLVFXVVWKLV
return and any other information related to this return No <HV&RPSOHWHWKHIROORZLQJ
ZLWKWKH&RORUDGR'HSDUWPHQWRI5HYHQXH"
Designee’s Name Phone Number
Sign Below 8QGHUSHQDOWLHVRISHUMXU\,GHFODUHWKDWWRWKHEHVWRIP\NQRZOHGJHDQGEHOLHIWKLVUHWXUQLVWUXHFRUUHFWDQGFRPSOHWH

Your Signature Date (MM/DD/YY)
Spouse’s Signature. If joint return, BOTH must sign. Date (MM/DD/YY)
Paid Preparer’s Name Paid Preparer’s Phone

SELF PREPARED
Paid Preparer’s Address City State Zip
,I\RXDUH¿OLQJWKLVUHWXUQwith a check or ,I\RXDUH¿OLQJWKLVUHWXUQwithout a check or

payment, please mail the return to: payment, please mail the return to:
COLORADO DEPARTMENT OF REVENUE COLORADO DEPARTMENT OF REVENUE
Denver, CO 80261-0006 Denver, CO 80261-0005
These addresses and zip codes are exclusive to the Colorado Department of Revenue, so a street address is not required.
170104AD11555
DR 0104AD (06/30/17)
Colorado.gov/Tax
Subtractions from Income Schedule

If claiming a subtraction, you must submit this schedule with your return.
8VHWKLVVFKHGXOHWRUHSRUWDQ\VXEWUDFWLRQVIURP\RXU)HGHUDO7D[DEOH,QFRPH7KHVHVXEWUDFWLRQVZLOOFKDQJH\RXU
Colorado Taxable Income from the amount of Federal Taxable Income. See instructions in the income tax booklet for
DGGLWLRQDOJXLGDQFHRQFRPSOHWLQJWKLVVFKHGXOH'RQRWHQWHUQHJDWLYHDPRXQWV<RXPXVWVXEPLWWKLVIRUPDORQJZLWK
the DR 0104 if claiming any subtractions.
Name SSN
ROBERT T CLARKE 315-04-4786

Subtractions from Federal Taxable Income
1. State Income Tax Refund from IHGHUDOLQFRPHWD[IRUPOLQH
HQWHULI¿OLQJ$RU(= 1 680 0 0
2. U.S. Government Interest 2 00

Deceased SSN
3. Primary Taxpayer Pension/Annuity Income 3 00

Deceased SSN
4. Spouse Pension/Annuity Income 4 00
5. &RORUDGR6RXUFH&DSLWDO*DLQ\HDUDVVHWVDFTXLUHGRQRUDIWHU 5 00
2ZQHUV661
6. Tuition Program Contribution:
(see instructions) 6 387 0 0
Total Contribution 2ZQHU¶V1DPH
Total Contribution
7. Qualifying Charitable Contribution $ 7 00
8. 4XDOL¿HG5HVHUYDWLRQ,QFRPH 8 00
9. PERA/DPSRS Subtraction, for PERA contributions made in 1984–1986 or
DPSRS contributions made in 1986 9 00
10. 5DLOURDG%HQH¿W6XEWUDFWLRQWLHU,RU,,RQO\ 10 00
11. :LOG¿UH0LWLJDWLRQ0HDVXUHV6XEWUDFWLRQ 11 00
12. Colorado Marijuana Business Deduction 12 00
13. Non-Resident Disaster Relief Worker Subtraction 13 00

DR 0104AD (06/30/17)
Colorado.gov/Tax
170104AD21555
Name SSN
ROBERT T CLARKE 315-04-4786
14. Active Duty Military Colorado HOME Subtraction 14 00

15. Agricultural Asset Lease Deduction. &$'$&HUWL¿FDWH1XPEHU
(QWHU&$'$FHUWL¿FDWHQXPEHUDQGVXEPLW
DFRS\RI\RXUFHUWL¿FDWHZLWK\RXUUHWXUQ 15 00
16. First Time Home Buyer Savings Account Deduction, you must submit
WKH'5ZLWK\RXUUHWXUQ 16 00
17. 2WKHU6XEWUDFWLRQVH[SODLQEHORZ 17 00
Explain
18. Subtotal, add lines 1 through 17, transfer the amount to line 5
on the DR 0104 18 1067 0 0
170104CR11555
DR 0104CR (10/23/17)
Colorado.gov/Tax
Form 104CR
Individual Credit Schedule 2017
Taxpayer’s Last Name First Name Middle Initial SSN
CLARKE ROBERT T 315-04-4786

Use this schedule to calculate your income tax credits. For best results, visit Colorado.gov/Tax to research eligibility
UHTXLUHPHQWVDQGRWKHULQIRUPDWLRQDERXWWKHVHFUHGLWVEHIRUHIROORZLQJWKHOLQHE\OLQHLQVWUXFWLRQVFRQWDLQHGEHORZ
• Be sure to submit the required supporting documentation as indicated for each credit.
• 0RVWH¿OHVRIWZDUHDQGWD[SUHSDUHUVKDYHWKHDELOLW\WRVXEPLWWKLVVFKHGXOHDQGDWWDFKPHQWVHOHFWURQLFDOO\+RZHYHU
5HYHQXH2QOLQHFDQDOVREHXVHGWR¿OH\RXUUHWXUQDQGDWWDFKPHQWVHOHFWURQLFDOO\2WKHUZLVHDWWDFKDOOUHTXLUHG
documents to your paper return.
• If you received any of these credits from a pass-through entity, be sure to provide the entity’s name and account
QXPEHUDQG\RXURZQHUVKLSSHUFHQWDJHZKHUHUHTXLUHG,IFUHGLWVZHUHSDVVHGWKURXJKIURPPXOWLSOHHQWLWLHVDWWDFK
WR\RXUUHWXUQDZULWWHQVWDWHPHQWWKDWLQFOXGHVDOOUHOHYDQWLQIRUPDWLRQ
• 'ROODUDPRXQWVVKDOOEHURXQGHGWRWKHQHDUHVWZKROHGROODU&DOFXODWHSHUFHQWDJHVWRWKHIRXUWKGHFLPDOSODFH5RXQG
WRIRXUVLJQL¿FDQWGLJLWVHJ[[[[[[[
Part I — Refundable Credits

1. Child Care Expenses Credit from the DR 0347, you must submit the DR 0347
ZLWK\RXUUHWXUQ 1 00
(DUQHG,QFRPH7D[&UHGLW(,7&IXOORUSDUW\HDU&RORUDGRUHVLGHQWVZKRFODLPWKHIHGHUDO(,7&DUHDOORZHGDQHDUQHG
income tax credit against their income tax. Complete the table for each qualifying child. Read the instructions in the
ERRNDQG)<,,QFRPHIRUDGGLWLRQDOJXLGDQFHRQFRPSOHWLQJWKLVVHFWLRQ2QO\FKHFNWKH³'HFHDVHG´ER[IRUD
TXDOLI\LQJFKLOGLIWKHFKLOGZDVERUQDQGGLHGLQDQGZDVQRWDVVLJQHGDQ661\RXPXVWVXEPLWDFRS\RIWKHFKLOG¶V
ELUWKFHUWL¿FDWHGHDWKFHUWL¿FDWHRUKRVSLWDOUHFRUGVVKRZLQJDOLYHELUWKZLWK\RXUUHWXUQ
2. Enter the amount of Earned Income calculated for your federal return. 2 00
3. The federal EITC you claimed. 3 00

Qualifying Child’s Last Name Qualifying Child’s First Name Year of Birth SSN Deceased*
&KHFNRQO\LIFKLOGZDVGHFHDVHGEHIRUH661ZDVDVVLJQHGLQVHHLQVWUXFWLRQV
4. COEITC, multiply line 3 by 10% (.1) 4 00

DR 0104CR (10/23/17)
Colorado.gov/Tax
170104CR21555
Name SSN

5. Part-year residents only, multiply line 4 by the percentage on line 34
of the DR 0104PN (If the percentage exceeds 100%, use 100%.) 5 00
6. Business Personal Property Credit:8VHWKHZRUNVKHHWLQWKH%RRNLQVWUXFWLRQV
WRFDOFXODWH\RXPXVWVXEPLWFRS\RIWKHDVVHVVRU¶VVWDWHPHQWZLWK\RXUUHWXUQ 6 00
7. 5HIXQGDEOH5HQHZDEOH(QHUJ\7D[&UHGLWIURPOLQHRIWKH'5
<RXPXVWVXEPLWWKH'5ZLWK\RXUUHWXUQ 7 0 00
8. Total Refundable Credits, add lines 1, 4 (or 5), 6, and 7.
Enter the sum on the DR 0104 line 23. 8 00
Part II — Credit for Tax Paid to Another State
• Colorado nonresidents do not qualify for this credit.
• Part-year residents generally do not qualify for this credit.
,I\RXKDYHLQFRPHDQGRUORVVHVIURPWZRRUPRUHVWDWHV\RXPXVWVHSDUDWHO\FDOFXODWHOLQHV10 through 16
IRUHDFKVWDWHUHJDUGOHVVRIZKHWKHUDQ\WD[ZDVSDLGRQVXFKLQFRPH,I\RXGRQRW¿OHHOHFWURQLFDOO\\RX
must submit the DR 0104&5IRUHDFKVWDWH7KHQHQWHU³&RPELQHG´RQOLQH9 and complete lines 10 through
16 to disclose the combined total for each line. A summary schedule is not acceptable. The Department
VWURQJO\UHFRPPHQGVHOHFWURQLF¿OLQJIRUWD[SD\HUVZLWKFUHGLWVIRUPRUHWKDQRQHVWDWH)DLOXUHWR¿OH
electronically may result in delays processing your return.
6XEPLWDFRS\RIWKHWD[UHWXUQIRUHDFKRWKHUVWDWHZKHQFODLPLQJWKLVFUHGLW7KHSRUWLRQRIWKHUHWXUQVXEPLWWHGPXVWLQFOXGHWKH
DGMXVWHGJURVVLQFRPHFDOFXODWLRQDQ\GLVDOORZHGIHGHUDOGHGXFWLRQVE\WKDWVWDWHDQGWKHWD[FDOFXODWLRQIRUWKHRWKHUVWDWH
9. Name of other state: IL
10. Total of lines 7 and 8 Form 104 10 3662 00

11. 0RGL¿HG&RORUDGRDGMXVWHGJURVVLQFRPHIURPVRXUFHVLQWKHRWKHUVWDWH
see FYI Income 17. 11 10306 00
12. 7RWDOPRGL¿HG&RORUDGRDGMXVWHGJURVVLQFRPH 12 100454 00
13. 'LYLGHOLQHE\OLQH5RXQGWRIRXUVLJQL¿FDQWGLJLWVHJ[[[[[[[ 13 10.2594 %
14. Multiply line 10 by the percentage on line 13 14 376 00
15. Tax liability to the other state 15 429 00
16. Allowable credit, the smaller of lines 14 or 15 16 376 00

Part III — Other Credits
Visit Colorado.gov/TaxIRUOLPLWDWLRQVWKDWDUHVSHFL¿FWRHDFKFUHGLW7RUHSRUWWKLVSURSHUO\XVHWKH¿UVWFROXPQWR
UHSRUWWKHWRWDOFUHGLWWKDWLVDYDLODEOHWKHDPRXQWJHQHUDWHGWKLV\HDUSOXVDQ\SULRU\HDUFDUU\IRUZDUG7KHQXVHWKH
second column to report the amount you are using this year to offset your tax liability.
Available Credit Credit Used
Column (A) Column (B)
17. Plastic recycling investment credit, you must submit
UHTXLUHGUHFHLSWVZLWK\RXUUHWXUQ 17 00 00
3ODVWLFUHF\FOLQJQHWH[SHQGLWXUHVDPRXQW¿OOEHORZ
18. Colorado Minimum Tax Credit 18 00 00

)HGHUDO0LQLPXP7D[&UHGLW¿OOEHORZ

DR 0104CR (10/23/17)
Colorado.gov/Tax
170104CR31555
Name SSN

Available Credit Credit Used
Column (A) Column (B)
19. Historic Property Preservation credit, you must
VXEPLWWKHFHUWL¿FDWLRQZLWK\RXUUHWXUQ 19 00 00
20. Child Care Center Investment credit, you must submit
a copy of your facility license and a list of depreciable
WDQJLEOHSHUVRQDOSURSHUW\ZLWK\RXUUHWXUQ 20 00 00
21. Employer Child Care Facility Investment credit, you must
submit a copy of your facility license and a list of depreciable
WDQJLEOHSHUVRQDOSURSHUW\ZLWK\RXUUHWXUQ 21 00 00
22. School-to-Career Investment credit, you must
VXEPLWDFRS\RIWKHFHUWL¿FDWLRQZLWK\RXUUHWXUQ 22 00 00
23. Colorado Works Program credit, you must submit a
copy of the letter from the county Department of
6RFLDO+XPDQ6HUYLFHVZLWK\RXUUHWXUQ 23 00 00
24. Child Care Contribution credit, you must submit
HDFK'5ZLWK\RXUUHWXUQ 24 00 00
25. Long-term Care Insurance credit, you must
VXEPLWD\HDUHQGVWDWHPHQWWRVKRZSUHPLXPV
SDLGZLWK\RXUUHWXUQ6HH)<,,QFRPH 25 0 00 00
26. $LUFUDIW0DQXIDFWXUHU1HZ(PSOR\HHFUHGLW\RXPXVW
VXEPLWWKH'5DQG'5ZLWK\RXUUHWXUQ 26 00 00
27. Credit for Environmental Remediation of Contaminated
Land, you must submit a copy of the CDPHE
FHUWL¿FDWLRQZLWK\RXUUHWXUQ 27 00 00
28. &RORUDGR-RE*URZWK,QFHQWLYHFUHGLW\RXPXVW
VXEPLWFHUWL¿FDWLRQIURP2(',7ZLWK\RXUUHWXUQ 28 00 00
29. &HUWL¿HG$XFWLRQ*URXS/LFHQVH)HHFUHGLW\RXPXVW
30. Advanced Industry Investment credit, you must
31. /RZLQFRPH+RXVLQJFUHGLW\RXPXVWVXEPLW
&+)$FHUWL¿FDWLRQZLWK\RXUUHWXUQ 31 00 00
32. Credit for Food Contributed to Hunger-Relief
Charitable Organizations, you must submit each
'5ZLWK\RXUUHWXUQ 32 00 00
33. Preservation of Historic Structures credit carried
IRUZDUGIURPDSULRU\HDU 33 00 00
34. Preservation of Historic Structures credit, you
PXVWVXEPLWWKHFHUWL¿FDWHIURP2I¿FHRI(FRQRPLF
'HYHORSPHQWZLWK\RXUUHWXUQ 34 00 00
35. If you are claiming the Preservation of Historic Structures credit enter your credit
FHUWL¿FDWHQXPEHULVVXHGE\2(',7 35
36. Rural Jump–Start Zone credit , you must submit
FHUWL¿FDWHIURP2I¿FHRI(FRQRPLF'HYHORSPHQW
$1'WKH'5ZLWK\RXUUHWXUQ 36 00 00
37. 5XUDO )URQWLHU+HDOWK&DUH3UHFHSWRUFUHGLW\RX
PXVWVXEPLW\RXUFHUWL¿FDWLRQZLWK\RXUUHWXUQ 37 00 00
38. Total of column A lines 17 through 37
H[FOXGHOLQHFHUWL¿FDWHQXPEHU 38 0 00
39. Nonrefundable Credits Used, total of column B plus any amount from
line H[FOXGHOLQHFHUWL¿FDWHQXPEHU. Also enter this amount on
the DR 0104 line 11. Credit used cannot exceed credit available. 39 376 00

Colorado Nonrefundable Credit Worksheet 2017
Use this worksheet to calculate all nonrefundable credits flowing to Form 104CR. Keep for your records
Maximum nonrefundable Credits from Form 104, lines 7 + 8 3,662.
Credit for Taxes Paid to Other States
State Item Amount Amount if Different
IL Adjusted Gross Income from other state 10,306.

Tax paid to other state 429.
10 . Total of lines 7 and 8, Form 104 3,662.
11 . CO MAGI from other state sources 10,306. 14 . Line 10 multiplied by line 13 376.
12 . Total Colorado MAGI 100,454. 15 . Tax liability to the other state 429.
13 . Line 11 divided by line 12 10.2594 16 . Credit, smaller of lines 14 or 15 376.
Adjusted Gross Income from other state
Tax paid to other state
10 . Total of lines 7 and 8, Form 104
11 . CO MAGI from other state sources 14 . Line 10 multiplied by line 13
12 . Total Colorado MAGI 15 . Tax liability to the other state
13 . Line 11 divided by line 12 16 . Credit, smaller of lines 14 or 15
Total gross credit for taxes paid to other states 376.
Nonrefundable Credit Worksheet (Form 104CR)
Carryover Current Net Balance of Credit

from prior credit credit available carryover
year available used credit to next year
? Total other state tax credit 376. 376. 3,286.
Other Personal Credits

17. Plastic Recycling Investment
Credit
a. Expenditures
18. Colorado Minimum Tax Credit
a. 2017 Fed Credit
19. Historic Property Preservation
a. Name of reviewing agency
b. Date Signed
c. Reserved
20. Child Care Center Investment
21. Employer Child Care Facility
Investment Credit
22. School-to-Career Investment
a. Certifying organization
b. Date signed
23. Colorado Works Program
24. Child Care Contribution Credit
a. 2017 Credit Available
b. Donation Date
c. Amount carried over
from 2016
25. Long Term Care Ins Credit 0.
Colorado Long-Term Care Insurance Credit Worksheet
See help for rules and income limits
Enter total premiums paid If joint return, enter number Gross available credit
for each individual policy of individuals covered before credit limits
26. Aircraft manufacturer new

employee credit
27. Environmental Remediation
of Contaminated Land
a. Project name
b. Date signed
28. Job growth incentive tax credit
29. Certified auction group credit
30. Advanced industry
investment tax credit
31. Low-income Housing credit
32. Credit for Food Contributed
to Hunger-Relief Charitable
Organization
33. Historic Structures Credit
Transferred From Prior Year
34. Historic Structures Credit
35. Certificate number & amount
HPTC-
Amount
36. Rural Jump-Start Zone Credit
37. Rural & Frontier Health Care
Preceptor Credit
? Total personal credits
? Total Nonrefundable Credits
Nonrefundable Credit Worksheet (Form 104)

21. Gross conservation easement
credit
Innovative Motor Vehicle Credit Worksheet 2017
Enter the information on this worksheet to claim the innovative motor vehicle credit.
Please reference FYI Income 69 before completing this worksheet.
Did you assign your motor vehicle tax credit to a financing entity? Yes X No
**Note: By assigning your tax credit to a financing entity, you forfeit the right to claim
the motor vehicle tax credit on your personal tax return.
MakeSubaru Year 2017 Model Forester

Date purchased, leased, or converted
VIN #
Check whether this vehicle was:

X Purchased New Leased
Converted
Qualifying Vehicle Type:

X Passenger Vehicles
Light Duty Truck
Medium Duty Truck
Heavy Duty Truck or a Trailer
Qualifying Credit Type:

Electric or plug-in hybrid electric motor car
Electric or plug-in hybrid electric motor truck Weight:
CNG, LPG, LNG, or hydrogen motor car
CNG, LPG, LNG, or hydrogen motor truck Weight:
Hydraulic Hybrid Conversion
Idling Reduction Technology
Aerodynamic Technologies
Clean Fuel Refrigerated Trailer
None Applicable
Vehicle Worksheet for DR617 Part 2 And 3 Credit

1. Cost incurred for the trailer or technology 1.
2. Federal credits this vehicle is eligible for 2.
3. Grants, credits, or rebates available for this vehicle 3.
4. Line 2 plus line 3, all available credits, grants and rebates 4.
5. Line 1 minus line 4 5.
6. Credit percentage (from DR617, Table 2) 6. %
7. Tentative tax credit (line 5 multiplied by line 6) 7.
8. Maximum allowable credit (from DR617, Table 2) 8.
9. Allowable credit 9.
Colorado Information Worksheet 2017
Part I 'Personal Information
Taxpayer: Spouse:
Last Name Clarke Last Name Clarke
First Name Robert First Name MariRenee
Middle Initial T Suffix Jr Middle Initial Suffix
Social Security No. 315-04-4786 Social Security No. 313-96-8786
Date of Birth 01/19/1981 Date of Birth 07/17/1981

Date of Death Date of Death
Work Phone (312)714-9280 * X Work Phone *

Home Phone *
*Check one of these boxes to print daytime phone number on government forms.
Address 1301 Speer Blvd Apt No. 710
City Denver State CO ZIP Code 80204
Foreign Province/County Foreign Postal Code
Foreign Country
Check to confirm address information is correct X
Part II ' Main Form
X Form 104: Resident Filing

Form 104: Part-Year Resident Filing
Form 104: Nonresident Filing
Complete Form 104PN, Part-Year Resident/Nonresident Tax Calculation Schedule
Resident military service persons who served more than 305 days outside the U.S.
may now file as a nonresident on their Colorado income tax return. See Tax Help.
Part III ' Filing Status
Single
X Married filing jointly
Married filing separately
Head of household
Qualifying widow(er)
Part IV ' Other Information
2017 Federal Adjusted gross income 101,521.

2016 Colorado tax liability 2,637.
Underpayment Penalty Calculation:

2016 Federal adjusted gross income (for Form 204) 86,100.
2016 Colorado filing status (for Form 204) 2
Check this box if you do not want to file Form 204 and want the Colorado Department
of Revenue to figure the underpayment penalty (see Tax Help for additional information)
Third Party Designee:

Yes No
Do you want to allow another person to discuss your return with the CO Department of Revenue?
If yes, enter the folowing:
Designee’s Name
Designee’s Phone Number
Farmer / Fisherman Calculation:

Yes No
X Check Yes to calculate estimated taxes for the farmer/fisherman option.
Will the farmer/fisherman filer file and pay the full amount of tax on or before March 1?
Supporting Document Information:

If supporting documentation is required, How will it be submitted to the Revenue Department?
Submitting via mail with Form DR 1778
X Uploading documents via the Colorado Revenue website
The state return will be filed electronically.
Part V ' Direct Deposit and Electronic Funds Withdrawal Information
Yes No
X Do you want to elect direct deposit of state tax refund?
Use direct debit of state tax payment (Electronic Filing Only)?
If you selected direct deposit, fill out the information below:

Name of Financial Institution Capital One 360
Account type Checking X Savings CollegeInvest 529
Routing number 031176110
Account number 135873450
Enter the payment date to withdraw the account above
Enter the amount to withdraw from the account above
International ACH Transactions

Yes No
X Will the funds for this refund (or payment) go to (or come from) an account outside the U.S.?
Part VI ' Extension Status
If the Colorado tax return can’t be filed by April 17, a 6-month automatic extension of time to file is allowed.
Yes No
X Will the tax return be filed after April 17?
Extended due date
Note: An extension of time to file is not an extension of time to pay.
If the Colorado tax return can’t be filed by April 17, will the taxpayer(s) be traveling abroad on April 17?
Yes No
If yes, the automatic due date is June 15.
QuickZoom to the DR 158-I, Extension Payment Voucher Worksheet
Robert T Clarke, Jr 315-04-4786 Page 3
Part VII ' Amended Return
Check this box if you are filing a Colorado amended return.

Enter the tax year you are amending
Previous Colorado payment made
Previous Colorado refund received
QuickZoom to the Form 104X: Amended Income Tax Return
QuickZoom to the Form 104: Individual Income Tax Return
COIW1202.SCR 12/05/17
Form Estimated Tax Worksheet 2018
104-EP G Keep for your records
Name(s) Shown on Return Your Social Security Number

Part I 2018 Estimated Tax Amount Options
1 Select One of Six Ways to Calculate the Required Annual Payment for 2018 Estimates:
a 100% (110%) of 2017 taxes (default, see Tax Help) X 3,286.
b 100% of tax less credits on 2018 estimated taxable income 3,286.
c 70% of tax less credits on 2018 estimated taxable income 2,301.
d 50% of tax less credits on 2018 estimated taxable income (farmers and
fishermen) 1,643.
e Equal to 100% of overpayment (no vouchers needed) 479.
f Enter total amount you want to use for estimates and check box
2 Selected estimated tax amount:
a 2018 Required Annual Payment based on your choice above 3,286.
b Estimated 2018 state income and/or nonresident real estate tax withholding 3,765.
c Total of estimated tax payments required for 2018 (line 2a less line 2b) 0.
3 Select Estimated Tax Payment option:
a Calculate estimates if $1,000 or more (default) X
b Calculate estimates if (specify amount) or more
c Calculate estimates regardless of amount
d Do not calculate estimates
Part II Overpayment Application Options
1 Amount of overpayment available 479.

2 Select Overpayment Application Amount Option:
a Apply none (refund entire overpayment) X
b Apply all (increase estimate if required)
c Apply to extent of total estimated tax and refund excess
d Apply to extent of first quarter amount and refund excess
e Enter amount you want to apply
f Amount applied to 2018 estimated tax 0.
g Overpayment to be refunded (line 1 less line 2f) 479.
Part III Rounding and Printing Options
1 Select Rounding Option:

a X H Round up to b H Round up to c H Round up to d H Round to
next $1 next $10 next $100 nearest $1
2 Select Voucher Printing Option:
a X H Print (per Part I, lines 3a - c) b H Print only name, etc. c H Do not print vouchers
Part IV Estimated Tax Payment Summary
1 2 3 4 Total
4/17/2018 6/15/2018 9/17/2018 1/15/2019
1 If you have already

made payments,
enter amounts
2 Indicate which payment is
due next. (e.g. if it is now
April 25, 2018, check col. 2) X
3 Required Payment
4 Overpayment applied
5 Net payment due
6 Voucher amounts
Part V Changes to Income, Deductions and Withholding for 2018
2017 income and deductions are shown in the "2017 Actual" column below.
*Caution: For each line in the "2018 Estimated" column, enter the estimated 2018 amount if different
from 2017 Otherwise, the "2017 Actual" amount will be used for that line. If zero, you must enter zero.
2017 Actual * 2018 Estimated

1 Taxable income 79,089.
2 Alternative minimum tax
3 Recapture of prior year credits
4 Form 104CR credits 376.
5 Colorado tax withholding 3,765.
Part VI 2018 Estimated Taxable Income and Tax
1 Estimated 2018 Colorado taxable income 1 79,089.

2 Estimated 2018 Colorado income tax ' 4.63% of line 1 2 3,662.
3 Estimated 2018 Colorado alternative minimum tax 3
4 Estimated 2018 recapture of prior year credits 4
5 Total of lines 2, 3, and 4 5 3,662.
6 All credits other than withholding, estimated payment and the State Sales Tax
Refund 6 376.
7 Net estimated tax, line 5 minus line 6. This is your 2018 tax based on your
estimate of 2018 income 7 3,286.
COIW1412.SCR 09/20/17
Line 2 State Income Tax Addback Worksheet 2017
Name as Shown on Return Social Security Number

Line 2 ' State Income Tax Deduction Addback
A 1 State income tax deduction from line 5, Schedule A, federal Form 1040 A1 3,902.
A 2 Total itemized deductions from line 29, Schedule A, federal Form 1040 A2 17,167.
A 3 The amount of federal standard deduction you could have claimed
(See line 40, federal Form 1040 for allowable federal standard deductions). A3 12,700.
A 4 Line A2 minus line A3 A4 4,467.
A 5 Enter the smaller of line A1 or line A4 here and on Form 104, line 2 A5 3,902.
Special Computation for Taxpayers With High Income
C 1 Enter amount from line 9 of the federal itemized deduction worksheet C1

C 2 Enter amount from line 3 of the federal itemized deduction worksheet C2
C 3 Amount of line C1 divided by amount on line C2 C3 %
C 4 Amount of state income tax entered on line 5 of federal Schedule A C4
C 5 Amount of line C4 multiplied by percentage on line C3 C5
C 6 Amount on line C4 minus amount on line C5 C6
C 7 Total itemized deductions from line 29 of federal Schedule A C7
C 8 Federal standard deduction for your status (1040, line 40 instructions) C8
C 9 Subtract the C8 amount from the C7 amount, but not less than $0 C9
C 10 Enter the smaller of C6 or C9 onto line 2 of the Colorado income tax return C 10
This worksheet is derived from page 4 of the government instructions and publication FYI Income 4.
coiw1001.SCR 11/15/17
Interest Worksheet 2017

Line 6 ' United States Government Interest
1 US government interest 1
2 Less: US Treasury Int/Div from mutual funds not 100% exempt 2 ( )
3 Other (itemize):
a 3 a
b b
c c
d d
Total to Form 104, line 6 0.
COIW0801.SCR 10/17/16
Penalty and Interest Worksheet 2017

1 Date return is to be filed and balance paid 1

2 Underpaid tax 2
3 Delinquent payment penalty 3
4 Interest on balance due 4
5 Underpayment penalty from Form 204 5
COIW0601.SCR 04/30/15

Tax Payments for the Current Year
State
Date Payment
1 First Payment
2 Second Payment
3 Third Payment
4 Fourth Payment
Additional Payments
5 Payment
Payment
Payment
Payment
Payment
6 Overpayment from previous year applied to current year 6

7 Amount paid with current year extension 7
8 Total tax payments 8
Income Taxes Withheld for the Current Year
9 State withholding on Forms W-2 9 3,765.

10 State withholding on Forms W-2G 10
11 State withholding on Forms 1099-R 11
12 a State withholding on Forms 1099-MISC 12 a
b State withholding on Forms 1099-G b
c State withholding on Forms 1099-K c
13 Other state tax withholding 13
14 Total income tax withheld 14 3,765.
15 Date return will be filed and balance paid 15
OTHV0301.SCR 11/28/16
Tax Summary 2017
Name(s)
Federal Taxable Income 76,254.

Additions to Federal Income 3,902.
Subtractions from Federal Income 1,067.
Colorado Taxable Income 79,089.
Colorado Tax 3,662.
Alternative Minimum Tax
Recapture of Prior Year Credits
Enterprise Zone Credits
Use Tax
Nonrefundable Credits 376.
Total Colorado Tax: 3,286.
Refundable Credits
Income Tax
Withheld & Estimated Tax Payments 3,765.
Total Colorado Credits and Payments 4,141.
Overpayment 855.
Voluntary Contributions & Amount Applied
Penalty & Interest
Amount Due
Refund 479.
Illinois Department of Revenue
2017 Form IL-1040
Individual Income Tax Return or for fiscal year ending /
Over 80% of taxpayers file electronically. It is easy and you will get your refund faster. Visit tax.illinois.gov.
Step 1: Personal Information

315-04-4786 313-96-8786

Robert T Clarke, Jr
MariRenee Clarke

1301 Speer Blvd 710

Denver CO 80204

C

Filing status (see instructions)
Single or head of household
Married filing jointly Married filing separately Widowed
Step 2: 1 Federal adjusted gross income from your federal Form 1040, Line 37; 1040A, Line 21; or (Whole dollars only)
Income 1040EZ, Line 4 1 101,521 .00

2 Federally tax-exempt interest and dividend income from your federal Form 1040 or 1040A,
Line 8b; or federal Form 1040EZ 2 .00
Staple W-2 and 1099 forms here
3 Other additions. Attach Schedule M. 3 .00

4 Total income. Add Lines 1 through 3. 4 101,521 .00
Step 3: 5 Social Security benefits and certain retirement plan income
Base received if included in Line 1. Attach Page 1 of federal return. 5 .00
6Income Illinois Income Tax overpayment included in federal Form 1040, Line 10 6 .00
7 Other subtractions. Attach Schedule M. 7 680 .00
Check if Line 7 includes any amount from Schedule 1299-C.
8 Add Lines 5, 6, and 7. This is the total of your subtractions. 8 680 .00
9 Illinois base income. Subtract Line 8 from Line 4. 9 100,841 .00
Step 4: See instructions before completing Step 4.
10 a Number of exemptions from your federal return 2 x $2,175 a 4,350 .00
Exemptions
b If someone can claim you as a dependent, see instructions. x $2,175 b .00
c Check if 65 or older: You + Spouse = x $1,000 c .00
d Check if legally blind: You + Spouse = x $1,000 d .00
Exemption allowance. Add Lines a through d. 10 4,350 .00
Step 5:
11 Residents: Net income. Subtract Line 10 from Line 9. Skip Line 12. 11 .00
Net 12 Nonresidents and part-year residents:
Staple your check and IL-1040-V

Income Check the box that applies to you during 2017 Nonresident Part-year resident, and
enter the Illinois base income from Schedule NR. Attach Schedule NR. 12
10,306 .00
Step
6: 13 Residents: Multiply Line 11 by 4.3549% (.043549). Cannot be less than zero.
Tax Nonresidents and part-year residents: Enter the tax from Schedule NR.
Check if you completed Schedule SA to calculate your income tax. Attach Schedule SA. 13 429 .00
14 Recapture of investment tax credits. Attach Schedule 4255. 14 .00
15 Income tax. Add Lines 13 and 14. Cannot be less than zero. 15 429 .00
Step 7: 16 Income tax paid to another state while an Illinois resident.
Attach Schedule CR. 16 .00
Tax After 17 Property tax and K-12 education expense credit amount from
Non- Schedule ICR. Attach Schedule ICR. 17 .00
refundable
18 Credit amount from Schedule 1299-C. Attach Schedule 1299-C. 18 .00
Credits 19 Add Lines 16, 17, and 18. This is the total of your credits. Cannot
exceed the tax amount on Line 15. 19 0 .00
20 Tax after nonrefundable credits. Subtract Line 19 from Line 15. 20 429 .00
ID: 3WM REV 08/23/18 Intuit.cg.cfp.sp This form is authorized as outlined under the Illinois Income Tax Act. Disclosure of
IL-1040 Front (R-12/17) this information is required. Failure to provide information could result in a penalty.
21 Tax after nonrefundable credits from Page 1, Line 20 21 429.00
Step 8: 22 Household employment tax. See instructions. 22 .00
Other 23 Use tax on internet, mail order, or other out-of-state purchases from
Taxes UT Worksheet or UT Table in the instructions. Do not leave blank. 23 0.00
24 Compassionate Use of Medical Cannabis Pilot Program Act Surcharge 24 .00
25 Total Tax. Add Lines 21, 22, 23, and 24. 25 429.00
9:
Step 26 Illinois Income Tax withheld. Attach all W-2 and 1099 forms. 26 .00
Payments 27 Estimated payments from Forms IL-1040-ES and IL-505-I,

and including any overpayment applied from a prior year return 27 .00

Refundable 28 Pass-through withholding payments. Attach Schedule K-1-P or K-1-T. 28 .00
Credit
29 Earned Income Credit from Schedule IL-EIC. Attach Schedule IL-EIC. 29 .00
30 Total payments and refundable credit. Add Lines 26 through 29. 30 .00
Step
10: 31 If Line 30 is greater than Line 25, subtract Line 25 from Line 30. 31 .00
Total 32 If Line 25 is greater than Line 30, subtract Line 30 from Line 25. 32 429.00
11:
Step Only complete this step for late-payment penalty for underpayment
of estimated tax or to make a voluntary charitable donation.
Underpayment 33 Late-payment penalty for underpayment of estimated tax 33 .00
of Estimated

Tax Penalty a Check if at least two-thirds of your federal gross income is from farming.
and
b Check if you or your spouse are 65 or older and permanently
Donations
living in a nursing home.
c Check if your income was not received evenly during the year and
you annualized your income on Form IL-2210. Attach Form IL-2210.
d Check if you were not required to file an Illinois Individual Income Tax
return in the previous tax year.
34 Voluntary charitable donations. Attach Schedule G. 34 .00
35 Total penalty and donations. Add Lines 33 and 34. 35 .00
Step 12: 36 If you have an amount on Line 31 and this amount is greater than
Line 35, subtract Line 35 from Line 31. This is your overpayment. 36 .00
Refund 37 Amount from Line 36 you want refunded to you. Check one box on Line 38. See instructions. 37 .00
38 I choose to receive my refund by
a direct deposit - Complete the information below if you check this box.
Routing number
Checking or Savings

Account number
b Illinois Individual Income Tax refund debit card

c paper check
39 Amount to be credited forward. Subtract Line 37 from Line 36. See instructions. 39 .00
Step 13: 40 If you have an amount on Line 32, add Lines 32 and 35. - or -
Amount If you have an amount on Line 31 and this amount is less than Line 35,
You Owe subtract Line 31 from Line 35. This is the amount you owe. See instructions. 40 429.00
Step 14: If this is a joint return, both you and your spouse must sign below.
Under penalties of perjury, I state that I have examined this return and, to the best of my knowledge, it is true, correct, and complete.
Sign (312)714-9280
Here Your signature Date (mm/dd/yyyy) Spouse’s signature Date (mm/dd/yyyy) Daytime phone number
Self-Prepared Check if
Paid Print/Type paid preparer’s name Paid preparer’s signature Date (mm/dd/yyyy) self-employed Paid Preparer’s PTIN
Preparer
Firm’s name Firm’s FEIN
Use Only
Firm’s address Firm’s phone
Third Check if the Department may
Party discuss this return with the third
Designee Designee’s name (please print) Designee’s phone number party designee shown in this step.
If no payment enclosed, mail to: If payment enclosed, mail to:
ILLINOIS DEPARTMENT OF REVENUE ILLINOIS DEPARTMENT OF REVENUE
ID: 3WM SPRINGFIELD IL 62719-0001 SPRINGFIELD IL 62726-0001

IL-1040
Back (R-12/17) REV 08/23/18 Intuit.cg.cfp.sp DR AP RR DC IR
2017 Schedule M Other Additions and Subtractions for Individuals
Attach to your Form IL-1040 IL Attachment No. 15
Read this information first

Complete this schedule if you are required to add certain income on Form IL-1040, Line 3, or if you are entitled to take subtractions on
Form IL-1040, Line 7.
If you are required to complete Schedule 1299-C, Schedule F, or Form IL-4562, you must do so before you complete this schedule.
Step 1: Provide the following information

R T Clarke, Jr & M Clarke 3 1 5 – 0 4 – 4 7 8 6
Your name as shown on Form IL-1040 Your Social Security number
Step 2: Figure your additions for Form IL-1040, Line 3

Enter the amount of (Whole dollars only)
1 Your child’s federally tax-exempt interest and dividend income as reported on federal Form 8814. 1 ______________ 00
2 Distributive share of additions you received from a partnership, S corporation, trust, or estate.
Attach Illinois Schedule K-1-P or Schedule K-1-T. 2 ______________ 00
3 Lloyd’s plan of operation loss, if reported on your behalf on Form IL-1065 and included in
your adjusted gross income. 3 ______________ 00
4 Earnings distributed from IRC Section 529 college savings and tuition programs if not included
in your adjusted gross income. (Do not include distributions from “Bright Start,” “Bright Directions,” or
“College Illinois” programs or other college savings and tuition programs that meet certain disclosure
requirements. See instructions.) 4 ______________ 00
5 Illinois special depreciation addition amount from Form IL-4562, Step 2, Line 4. Attach Form IL-4562. 5 ______________ 00
6 Business expense recapture (nonresidents only). 6 ______________ 00
7 Recapture of deductions for contributions to Illinois college savings plans transferred to an out-of-state plan. 7 ______________ 00
8 Student-Assistance Contribution Credit taken on Schedule 1299-C. 8 ______________ 00
9 Recapture of deductions for contributions to college savings plans withdrawn for nonqualified expenses
or refunded. 9 ______________ 00
10 Income attributable to domestic production activities under IRC Section 199. Attach Page 1 of federal Form 1040. 10 ______________ 00
11 Other income - Identify each item. _______________________________________________ 11 ______________ 00
12 Total Additions. Add Lines 1 through 11. Enter the amount here and on Form IL-1040, Line 3. 12 ______________ 00
Step 3: Figure your subtractions for Form IL-1040, Line 7

Enter the amount of
13 Contributions made to the following college savings plans:
a “Bright Start” College Savings Pool 13a ______________ 00
b “College Illinois” Prepaid Tuition Program 13b ______________ 00
c “Bright Directions” College Savings Pool 13c ______________ 00
14 Distributive share of subtractions from a partnership, S corporation, trust, or estate. (Do not claim these
same subtractions on any other line of this schedule. See instructions.) Attach Illinois Schedule K-1-P or
K-1-T identifying you as the partner, shareholder, or beneficiary and listing your Social Security number. 14 ______________ 00
15 Restoration of amounts held under claim of right under IRC Section 1341. 15 ______________ 00
16 Contributions to a job training project. 16 ______________ 00
17 Expenses related to federal credits or federally tax-exempt income. 17 ______________ 00
18 Interest earned on investments through the Home Ownership Made Easy Program. 18 ______________ 00
19 Illinois special depreciation subtraction amount from Form IL-4562, Step 3, Line 10. Attach Form IL-4562. 19 ______________ 00
Enter the following only if included in Form IL-1040, Lines 1, 2, or 3:
20 Military pay earned. Attach military W-2. 20 ______________ 00
21 U.S. Treasury bonds, bills, notes, savings bonds, and U.S. agency interest from federal Form 1040A or 1040.
Attach a copy of federal Form 1040A or 1040, Schedule B, if required federally. 21 ______________ 00
22 August 1, 1969, valuation limitation amount from your Schedule F, Line 17. Attach Schedule F and
required federal forms. 22 ______________ 00
23 River edge redevelopment zone and high impact business dividend subtraction amount from your
Schedule 1299-C, Step 2, Line 7. Attach Schedule 1299-C. 23 ______________ 00
24 Add Lines 13a through 23 and enter the amount here and on Page 2, Line 25. 24 ______________ 00
This form is authorized as outlined under the Illinois Income Tax Act. Disclosure of
ID: 3WM REV 01/23/18 Intuit.cg.cfp.sp
this information is required. Failure to provide information could result in a penalty.
IL-1040 Schedule M Front (R-12/17)
Step 3: Continued
25 Enter the amount from Page 1, Line 24. 25 ______________ 00
26 Recovery of items previously deducted on federal Form 1040, Schedule A (including refunds of any state and
local income taxes, other than Illinois). Attach a copy of federal Form 1040, Page 1, and required federal forms. 26 ______________
680 00
27 Ridesharing money and other benefits. 27 ______________ 00
28 Payment of life insurance, endowment, or annuity benefits received. 28 ______________ 00
29 Lloyd’s plan of operation income if reported on your behalf on Form IL-1065. 29 ______________ 00
30 Income from Illinois pre-need funeral, burial, and cemetery trusts. 30 ______________ 00
31 Education loan repayments made for primary care physicians who agree to practice in designated
shortage areas under the Family Practice Residency Act. 31 ______________ 00
32 Reparations or other amounts received as a victim of persecution by Nazi Germany. 32 ______________ 00
33 Interest on the following tax-exempt obligations of Illinois state and local government. Do not include
interest you received indirectly through owning shares in a mutual fund.
a Illinois Housing Development Authority bonds and notes (except housing-related commercial
facilities bonds and notes) 33a ______________ 00
b Tri-County River Valley Development Authority bonds 33b ______________ 00
c Illinois Development Finance Authority bonds, notes, and other obligations (venture fund and
infrastructure bonds only) 33c ______________ 00
d Quad Cities Regional Economic Development Authority bonds and notes (if declared to be exempt
from taxation by the Authority) 33d ______________ 00
e College savings bonds issued under the General Obligation Bond Act in accordance with the
Baccalaureate Savings Act 33e ______________ 00
f Illinois Sports Facilities Authority bonds 33f ______________ 00
g Higher Education Student Assistance Act bonds 33g ______________ 00
h Illinois Development Finance Authority bonds issued under the Illinois Development Finance Authority
Act, Sections 7.80 through 7.87 33h ______________ 00
i Rural Bond Bank Act bonds and notes 33i ______________ 00
j Illinois Development Finance Authority bonds issued under the Asbestos Abatement Finance Act 33j ______________ 00
k Quad Cities Interstate Metropolitan Authority bonds 33k ______________ 00
l Southwestern Illinois Development Authority bonds 33l ______________ 00
m Illinois Finance Authority bonds issued under the Illinois Finance Authority Act, Sections 820.60 and
825.55, or the Asbestos Abatement Finance Act 33m ______________ 00
n Illinois Power Agency bonds issued by the Illinois Finance Authority 33n ______________ 00
o Central Illinois Economic Development Authority bonds 33o ______________ 00
p Eastern Illinois Economic Development Authority bonds 33p ______________ 00
q Southeastern Illinois Economic Development Authority bonds 33q ______________ 00
r Southern Illinois Economic Development Authority bonds 33r ______________ 00
s Illinois Urban Development Authority bonds 33s ______________ 00
t Downstate Illinois Sports Facilities Authority bonds 33t ______________ 00
u Western Illinois Economic Development Authority bonds 33u ______________ 00
v Upper Illinois River Valley Development Authority Act bonds 33v ______________ 00
w Will-Kankakee Regional Development Authority bonds 33w ______________ 00
x Export Development Act of 1983 bonds 33x ______________ 00
34 Interest on the following non-U.S. government bonds.
a Bonds issued by the government of Guam 34a ______________ 00
b Bonds issued by the government of Puerto Rico 34b ______________ 00
c Bonds issued by the government of the Virgin Islands 34c ______________ 00
d Bonds issued by the government of American Samoa 34d ______________ 00
e Bonds issued by the government of the Northern Mariana Islands 34e ______________ 00
f Mutual mortgage insurance fund bonds 34f ______________ 00
35 Amount of your child’s interest from U.S. Treasury and U.S. agency obligations or from sources in Line 21,
33, or 34 as reported on federal Form 8814. 35 ______________ 00
36 Railroad sick pay and unemployment income. Attach Form 1099-G or W-2 and a copy of your federal return. 36 ______________ 00
37 Unjust imprisonment compensation awarded by Illinois Court of Claims. 37 ______________ 00
38 Distributions from “Bright Start,” “College Illinois,” and “Bright Directions” college savings plans if included
in Line 1 because you claimed a federal American Opportunity Credit or Lifetime Learning Credit. 38 ______________ 00
39 Total Subtractions. Add Lines 25 through 38. Enter the amount here and on Form IL-1040, Line 7. 39 ______________
680 00
IL-1040 Schedule M Back (R-12/17)

Nonresident and Part-Year Resident
2017 Schedule NR Computation of Illinois Tax
R T Clarke, Jr & M Clarke 3 1 5 - 0 4 - 4 7 8 6

Your name as shown on your Form IL-1040 Your Social Security number

1 Were you, or your spouse if “married filing jointly,” a full-year resident of Illinois during the tax year?
Yes No If you answered “Yes,” you cannot use this form (see instructions).
2 If you, or your spouse if “married filing jointly,” were a part-year resident during the tax year, tell us your residency dates for 2017.
a I lived in Illinois from / / 1 7 to / /1 7 I lived in from / / 1 7 to / / 1 7
Month Day Year Month Day Year State Month Day Year Month
Day Year
b My spouse lived in Illinois from / / 1 7 to / / 1 7 , and from / / 1 7 to / /1 7

Month Day Year Month Day Year State Month Day Year Month Day Year
3 If you were a resident of any of the states listed below during the tax year or if you were in Illinois only to accompany your spouse who
was in the military, check the appropriate box.
Iowa Kentucky Michigan Wisconsin Military Spouse
4 If you earned income or filed a tax return for the tax year in a state other than those listed above, enter the two-letter abbreviation of that state.
_______
CO _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______
Step 2: Complete Form IL-1040

Complete Lines 1 through 10 of your Form IL-1040, Individual Income Tax Return, as if you were a full-year Illinois resident. Then, complete
the remainder of this schedule following the instructions for your residency. Attach Schedule NR to your Form IL-1040.
Step 3: Figure the Illinois portion of your federal adjusted gross income
Enter the amounts from your federal return in Column A. Before completing Column B, read the Column B instructions.
Column A Column B
Federal Total Illinois Portion
5 Wages, salaries, tips, etc. (federal Form 1040 or 1040A, Line 7; 1040EZ, Line 1) 5 106,919 .00 16,500.00
6 Taxable interest (federal Form 1040 or 1040A, Line 8a; 1040EZ, Line 2) 6 116 .00 0.00
7 Ordinary dividends (federal Form 1040 or 1040A, Line 9a) 7 .00 .00
8 Taxable refunds, credits, or offsets of state and local income taxes
(federal Form 1040, Line 10) 8 680 .00 0.00
9 Alimony received (federal Form 1040, Line 11) 9 .00 .00
10 Business income or loss (federal Form 1040, Line 12) 10 .00 .00
11 Capital gain or loss (federal Form 1040, Line 13 or 1040A, Line 10) 11 .00 .00
12 Other gains or losses (federal Form 1040, Line 14) 12 .00 .00
13 Taxable IRA distributions (federal Form 1040, Line 15b; or 1040A, Line 11b) 13 .00 .00
Income
14 Taxable pensions and annuities (federal Form 1040, Line 16b; or 1040A, Line 12b) 14 .00 .00
15 Rental real estate, royalties, partnerships, S corporations, trusts, etc.
(federal Form 1040, Line 17) 15 -3,694 .00 -3,694.00
16 Farm income or loss (federal Form 1040, Line 18) 16 .00 .00
17 Unemployment compensation and Alaska Permanent Fund dividends
(federal Form 1040, Line 19; 1040A, Line 13; 1040EZ, Line 3) 17 .00 .00
18 Taxable Social Security benefits (federal Form 1040, Line 20b; or 1040A, Line 14b) 18 .00 .00
19 Other income. See instructions. (federal Form 1040, Line 21)
Include winnings from the Illinois State Lottery as Illinois income in Column B. 19 .00 .00
20 Add Column B, Lines 5 through 19. This is the Illinois portion of your federal total income. 20 12,806.00

IL–1040 Schedule NR Front (R-02/18)
Continue with Step 3 on Page 2
Printed by authority of the State of Illinois - Web only
Schedule NR – Page 2
Step 3: Continued Column A Column B
21 12,806 .00
22 .00 .00
23 .00 .00
24 .00 .00
Adjustments to Income
25 .00 .00
26 .00 .00
27 .00 .00
28 .00 .00
29 .00 .00
30 .00 .00
31 .00 .00
32 2,500 .00 2,500 .00
33 .00 .00
34 .00 .00
35 .00 .00
36 2,500 .00
37 101,521 .00
38 Subtract Line 36 from Line 21. This is the Illinois portion of your federal adjusted gross income. 38 10,306 .00
Step 4: Figure your Illinois additions and subtractions

In Column A, enter the total amounts from your Form IL-1040. You must read Column A Column B
the instructions for Column B to properly complete this step. Form IL-1040 Total Illinois Portion
39 Federally tax-exempt interest and dividend income (Form IL-1040, Line 2) 39 .00 .00
Illinois Adjustments
40 Other additions (Form IL-1040, Line 3) 40 .00 .00

41 Add Column B, Lines 38, 39, and 40. This is the Illinois portion of your total income. 41 10,306 .00

42 Federally taxed Social Security and retirement income (Form IL-1040, Line 5) 42 .00 .00
43 Illinois Income Tax overpayment included on your federal Form 1040, Line 10.
(Form IL-1040, Line 6) 43 .00 .00
44 Other subtractions (Form IL-1040, Line 7) 44 680.00 0 .00
45 Add Column B, Lines 42 through 44. This is the total of your Illinois subtractions. 45 0 .00
Step 5: Figure your Illinois income and tax

46 Subtract Line 45 from Line 41. If Line 45 is larger than Line 41, enter zero. This is
your Illinois base income.
Enter this amount on your Form IL-1040, Line 12. 46 10,306 .00
If Line 46 is zero, skip Lines 47 through 51, and enter “0” on Line 52.
Tax Calculations
47 Enter the base income from Form IL-1040, Line 9. 47 .00 100,841
48 Divide Line 46 by Line 47 (carry to three decimal places). Enter the appropriate
decimal. If Line 46 is greater than Line 47, enter 1.000. 48 0.102
49 Enter your exemption allowance from your Form IL-1040, Line 10. 49 .00 4,350
50 Multiply Line 49 by the decimal on Line 48. This is your Illinois exemption
allowance. 50 444 .00
51 Subtract Line 50 from Line 46. This is your Illinois net income. 51 9,862 .00
52 Multiply the amount on Line 51 by 4.3549% (.043549). This amount may not be less than zero.
Enter the amount here and on your Form IL-1040, Line 13.
If you completed Schedule SA, enter the amount from Line 25 of that schedule here and on your Form IL-1040, Line 13.
This is your tax. 52 429 .00

this information is required. Failure to provide information could result in a penalty. IL–1040 Schedule NR Back (R-02/18)
R T Clarke, Jr & M Clarke 315-04-4786 1
Smart Worksheets from your 2017 Colorado Tax Return Attachment
SMART WORKSHEET FOR: Form IL-1040: Illinois Individual Income Tax Return
Use Tax Smart Worksheet
Method 1: Use Tax (UT) Worksheet

Complete this worksheet to report and pay your use tax on Form IL-1040. If your annual use tax
liability is over $600, you must file and pay your use tax with Form ST-44.
Note: Do not include any
- items for which you paid sales tax in another state (but not in another country) of
- 6.25% or more on Line 1a and
- 1% or more on Line 2a
- sales tax you paid in another state, on line 4, for items not included in Lines 1a or 2a
1a Enter the total cost of general merchandise you purchased

to use in Illinois on which you did not pay the required
amount of Illinois Use Tax 1a 0.
1b Multiply Line 1a by 6.25% (.0625). Round the result to whole dollars 1b 0.
2a Enter the total cost of qualifying food, non-prescription drugs
and medical appliances you purchased to use in Illinois on
which you did not pay the required amount of Illinois Use Tax 2a
2b Multiply Line 2a by 1% (.01). Round the result to whole dollars 2b 0.
3 Add Lines 1b and 2b. This is your Use Tax on purchases. 3 0.
4 Enter the amount of sales tax you paid in another state (not in another
country) on the items included on Lines 1a and 2a 4
5 Subtract Line 4 from Line 3. Enter the result here and on Form IL-1040,
Line 23 (if the result is less than zero, enter zero) 5
Method 2: UT Table
If there are no major purchases and do not have receipts to figure purchases, use the table
to estimate annual Illinois Use Tax liability.
AGI (from IL-1040, Line 1) Use Tax

$0 - $10,000 $3
$10,001 - $20,000 $9
$20,001 - $30,000 $15
$30,001 - $40,000 $21
$40,001 - $50,000 $27
$50,001 - $75,000 $38
$75,001 - $100,000 $52
Above $100,000 Multiply AGI by 0.06% (0.0006)
To use UT table calculate Use Tax, check here

Use tax amount based on table above
Keep a copy of this smart worksheet with your records.

SMART WORKSHEET FOR: Schedule NR: Nonresident/Part-Year Resident Tax Computation
Schedule E Income Smart Worksheet
Rental and Royalty Income: State Col A Col B

where Federal Illinois
Rental & Royalty Description located Total Portion
1150 N LAKE SHORE DR. 23J IL -3,694.
K-1 Partnership Income: State of Col A Col B

Income Federal Illinois
Partnership Name Source Total Portion
K-1 S-Corp Income: State of Col A Col B

S-Corp Name Source Total Portion
K-1 Trust Income: State of Col A Col B

Trust Name Source Total Portion
Illinois Self-Employment (ISE) Smart Worksheet

For use in column B, lines 26, 27, and 28 below.
A Self-employment income included in column B, line 20 above

B Total self-employment income (from federal Schedule SE,
Section A, line 3 or Section B, lines 3 and 5a)
C Illinois self-employment (ISE) decimal. Line A divided by line B 0.000
D Deductible portion of self-employment tax (column A, line 26 below)
E Illinois portion. Multiply line D by line C. Enter in column B, line 26 below
F Self-employed health insurance deduction (column A, line 28 below)
G Illinois portion. Multiply line F by line C. Enter in column B, line 28 below
H Keogh and self-employed SEP plans (column A, line 27 below)
I Illinois portion. Multiply line H by line C. Enter in column B, line 27 below
IRA Deduction Smart Worksheet

For use in column B, line 31 below.
A Wages, salaries, tips, and alimony received from Illinois

sources (column B, lines 5 and 9 above) 16,500.
B Wages, salaries, tips, and alimony received from all
sources (column A, lines 5 and 9 above) 106,919.
C Line A divided by line B 0.154
D Total IRA deduction (column A, line 31 below)
E Illinois IRA deduction. Multiply line D by line C.
Enter in column B, line 31 below
2017 Form IL-1040
Individual Income Tax Return or for fiscal year ending /
Over 80% of taxpayers file electronically. It is easy and you will get your refund faster. Visit tax.illinois.gov.
Step 1: Personal Information

315-04-4786 313-96-8786

Robert T Clarke, Jr
MariRenee Clarke

1301 Speer Blvd 710

Denver CO 80204

C

Filing status (see instructions)
Married filing jointly Married filing separately Widowed
Step 2: 1 Federal adjusted gross income from your federal Form 1040, Line 37; 1040A, Line 21; or (Whole dollars only)
Income 1040EZ, Line 4 1 101,521 .00

2 Federally tax-exempt interest and dividend income from your federal Form 1040 or 1040A,
Line 8b; or federal Form 1040EZ 2 .00
Staple W-2 and 1099 forms here
3 Other additions. Attach Schedule M. 3 .00

4 Total income. Add Lines 1 through 3. 4 101,521 .00
Step 3: 5 Social Security benefits and certain retirement plan income
Base received if included in Line 1. Attach Page 1 of federal return. 5 .00
6Income Illinois Income Tax overpayment included in federal Form 1040, Line 10 6 .00
7 Other subtractions. Attach Schedule M. 7 680 .00
Check if Line 7 includes any amount from Schedule 1299-C.
8 Add Lines 5, 6, and 7. This is the total of your subtractions. 8 680 .00
9 Illinois base income. Subtract Line 8 from Line 4. 9 100,841 .00
Step 4: See instructions before completing Step 4.
10 a Number of exemptions from your federal return 2 x $2,175 a 4,350 .00
Exemptions
b If someone can claim you as a dependent, see instructions. x $2,175 b .00
c Check if 65 or older: You + Spouse = x $1,000 c .00
d Check if legally blind: You + Spouse = x $1,000 d .00
Exemption allowance. Add Lines a through d. 10 4,350 .00
Step 5:
11 Residents: Net income. Subtract Line 10 from Line 9. Skip Line 12. 11 .00
Net 12 Nonresidents and part-year residents:
Staple your check and IL-1040-V

Income Check the box that applies to you during 2017 Nonresident Part-year resident, and
enter the Illinois base income from Schedule NR. Attach Schedule NR. 12
10,306 .00
Step
6: 13 Residents: Multiply Line 11 by 4.3549% (.043549). Cannot be less than zero.
Tax Nonresidents and part-year residents: Enter the tax from Schedule NR.
Check if you completed Schedule SA to calculate your income tax. Attach Schedule SA. 13 429 .00
14 Recapture of investment tax credits. Attach Schedule 4255. 14 .00
15 Income tax. Add Lines 13 and 14. Cannot be less than zero. 15 429 .00
Step 7: 16 Income tax paid to another state while an Illinois resident.
Attach Schedule CR. 16 .00
Tax After 17 Property tax and K-12 education expense credit amount from
Non- Schedule ICR. Attach Schedule ICR. 17 .00
refundable
18 Credit amount from Schedule 1299-C. Attach Schedule 1299-C. 18 .00
Credits 19 Add Lines 16, 17, and 18. This is the total of your credits. Cannot
exceed the tax amount on Line 15. 19 0 .00
20 Tax after nonrefundable credits. Subtract Line 19 from Line 15. 20 429 .00
ID: 3WM REV 08/23/18 Intuit.cg.cfp.sp This form is authorized as outlined under the Illinois Income Tax Act. Disclosure of
IL-1040 Front (R-12/17) this information is required. Failure to provide information could result in a penalty.
21 Tax after nonrefundable credits from Page 1, Line 20 21 429.00
Step 8: 22 Household employment tax. See instructions. 22 .00
Other 23 Use tax on internet, mail order, or other out-of-state purchases from
Taxes UT Worksheet or UT Table in the instructions. Do not leave blank. 23 0.00
24 Compassionate Use of Medical Cannabis Pilot Program Act Surcharge 24 .00
25 Total Tax. Add Lines 21, 22, 23, and 24. 25 429.00
9:
Step 26 Illinois Income Tax withheld. Attach all W-2 and 1099 forms. 26 .00
Payments 27 Estimated payments from Forms IL-1040-ES and IL-505-I,

and including any overpayment applied from a prior year return 27 .00

Refundable 28 Pass-through withholding payments. Attach Schedule K-1-P or K-1-T. 28 .00
Credit
29 Earned Income Credit from Schedule IL-EIC. Attach Schedule IL-EIC. 29 .00
30 Total payments and refundable credit. Add Lines 26 through 29. 30 .00
Step
10: 31 If Line 30 is greater than Line 25, subtract Line 25 from Line 30. 31 .00
Total 32 If Line 25 is greater than Line 30, subtract Line 30 from Line 25. 32 429.00
11:
Step Only complete this step for late-payment penalty for underpayment
of estimated tax or to make a voluntary charitable donation.
Underpayment 33 Late-payment penalty for underpayment of estimated tax 33 .00
of Estimated

Tax Penalty a Check if at least two-thirds of your federal gross income is from farming.
and
b Check if you or your spouse are 65 or older and permanently
Donations
living in a nursing home.
c Check if your income was not received evenly during the year and
you annualized your income on Form IL-2210. Attach Form IL-2210.
d Check if you were not required to file an Illinois Individual Income Tax
return in the previous tax year.
34 Voluntary charitable donations. Attach Schedule G. 34 .00
35 Total penalty and donations. Add Lines 33 and 34. 35 .00
Step 12: 36 If you have an amount on Line 31 and this amount is greater than
Line 35, subtract Line 35 from Line 31. This is your overpayment. 36 .00
Refund 37 Amount from Line 36 you want refunded to you. Check one box on Line 38. See instructions. 37 .00
38 I choose to receive my refund by
a direct deposit - Complete the information below if you check this box.
Routing number
Checking or Savings

Account number
b Illinois Individual Income Tax refund debit card

c paper check
39 Amount to be credited forward. Subtract Line 37 from Line 36. See instructions. 39 .00
Step 13: 40 If you have an amount on Line 32, add Lines 32 and 35. - or -
Amount If you have an amount on Line 31 and this amount is less than Line 35,
You Owe subtract Line 31 from Line 35. This is the amount you owe. See instructions. 40 429.00
Step 14: If this is a joint return, both you and your spouse must sign below.
Under penalties of perjury, I state that I have examined this return and, to the best of my knowledge, it is true, correct, and complete.
Sign (312)714-9280
Here Your signature Date (mm/dd/yyyy) Spouse’s signature Date (mm/dd/yyyy) Daytime phone number
Self-Prepared Check if
Paid Print/Type paid preparer’s name Paid preparer’s signature Date (mm/dd/yyyy) self-employed Paid Preparer’s PTIN
Preparer
Firm’s name Firm’s FEIN
Use Only
Firm’s address Firm’s phone
Third Check if the Department may
Party discuss this return with the third
Designee Designee’s name (please print) Designee’s phone number party designee shown in this step.
If no payment enclosed, mail to: If payment enclosed, mail to:
ILLINOIS DEPARTMENT OF REVENUE ILLINOIS DEPARTMENT OF REVENUE
ID: 3WM SPRINGFIELD IL 62719-0001 SPRINGFIELD IL 62726-0001

IL-1040
Back (R-12/17) REV 08/23/18 Intuit.cg.cfp.sp DR AP RR DC IR
2017 Schedule M Other Additions and Subtractions for Individuals
Read this information first

Complete this schedule if you are required to add certain income on Form IL-1040, Line 3, or if you are entitled to take subtractions on
Form IL-1040, Line 7.
If you are required to complete Schedule 1299-C, Schedule F, or Form IL-4562, you must do so before you complete this schedule.

R T Clarke, Jr & M Clarke 3 1 5 – 0 4 – 4 7 8 6
Your name as shown on Form IL-1040 Your Social Security number
Step 2: Figure your additions for Form IL-1040, Line 3

Enter the amount of (Whole dollars only)
1 Your child’s federally tax-exempt interest and dividend income as reported on federal Form 8814. 1 ______________ 00
2 Distributive share of additions you received from a partnership, S corporation, trust, or estate.
Attach Illinois Schedule K-1-P or Schedule K-1-T. 2 ______________ 00
3 Lloyd’s plan of operation loss, if reported on your behalf on Form IL-1065 and included in
your adjusted gross income. 3 ______________ 00
4 Earnings distributed from IRC Section 529 college savings and tuition programs if not included
in your adjusted gross income. (Do not include distributions from “Bright Start,” “Bright Directions,” or
“College Illinois” programs or other college savings and tuition programs that meet certain disclosure
requirements. See instructions.) 4 ______________ 00
5 Illinois special depreciation addition amount from Form IL-4562, Step 2, Line 4. Attach Form IL-4562. 5 ______________ 00
6 Business expense recapture (nonresidents only). 6 ______________ 00
7 Recapture of deductions for contributions to Illinois college savings plans transferred to an out-of-state plan. 7 ______________ 00
8 Student-Assistance Contribution Credit taken on Schedule 1299-C. 8 ______________ 00
9 Recapture of deductions for contributions to college savings plans withdrawn for nonqualified expenses
or refunded. 9 ______________ 00
10 Income attributable to domestic production activities under IRC Section 199. Attach Page 1 of federal Form 1040. 10 ______________ 00
11 Other income - Identify each item. _______________________________________________ 11 ______________ 00
12 Total Additions. Add Lines 1 through 11. Enter the amount here and on Form IL-1040, Line 3. 12 ______________ 00
Step 3: Figure your subtractions for Form IL-1040, Line 7

Enter the amount of
13 Contributions made to the following college savings plans:
a “Bright Start” College Savings Pool 13a ______________ 00
b “College Illinois” Prepaid Tuition Program 13b ______________ 00
c “Bright Directions” College Savings Pool 13c ______________ 00
14 Distributive share of subtractions from a partnership, S corporation, trust, or estate. (Do not claim these
same subtractions on any other line of this schedule. See instructions.) Attach Illinois Schedule K-1-P or
K-1-T identifying you as the partner, shareholder, or beneficiary and listing your Social Security number. 14 ______________ 00
15 Restoration of amounts held under claim of right under IRC Section 1341. 15 ______________ 00
16 Contributions to a job training project. 16 ______________ 00
17 Expenses related to federal credits or federally tax-exempt income. 17 ______________ 00
18 Interest earned on investments through the Home Ownership Made Easy Program. 18 ______________ 00
19 Illinois special depreciation subtraction amount from Form IL-4562, Step 3, Line 10. Attach Form IL-4562. 19 ______________ 00
Enter the following only if included in Form IL-1040, Lines 1, 2, or 3:
20 Military pay earned. Attach military W-2. 20 ______________ 00
21 U.S. Treasury bonds, bills, notes, savings bonds, and U.S. agency interest from federal Form 1040A or 1040.
Attach a copy of federal Form 1040A or 1040, Schedule B, if required federally. 21 ______________ 00
22 August 1, 1969, valuation limitation amount from your Schedule F, Line 17. Attach Schedule F and
required federal forms. 22 ______________ 00
23 River edge redevelopment zone and high impact business dividend subtraction amount from your
Schedule 1299-C, Step 2, Line 7. Attach Schedule 1299-C. 23 ______________ 00
24 Add Lines 13a through 23 and enter the amount here and on Page 2, Line 25. 24 ______________ 00
this information is required. Failure to provide information could result in a penalty.
IL-1040 Schedule M Front (R-12/17)
Step 3: Continued
25 Enter the amount from Page 1, Line 24. 25 ______________ 00
26 Recovery of items previously deducted on federal Form 1040, Schedule A (including refunds of any state and
local income taxes, other than Illinois). Attach a copy of federal Form 1040, Page 1, and required federal forms. 26 ______________
680 00
27 Ridesharing money and other benefits. 27 ______________ 00
28 Payment of life insurance, endowment, or annuity benefits received. 28 ______________ 00
29 Lloyd’s plan of operation income if reported on your behalf on Form IL-1065. 29 ______________ 00
30 Income from Illinois pre-need funeral, burial, and cemetery trusts. 30 ______________ 00
31 Education loan repayments made for primary care physicians who agree to practice in designated
shortage areas under the Family Practice Residency Act. 31 ______________ 00
32 Reparations or other amounts received as a victim of persecution by Nazi Germany. 32 ______________ 00
33 Interest on the following tax-exempt obligations of Illinois state and local government. Do not include
interest you received indirectly through owning shares in a mutual fund.
a Illinois Housing Development Authority bonds and notes (except housing-related commercial
facilities bonds and notes) 33a ______________ 00
b Tri-County River Valley Development Authority bonds 33b ______________ 00
c Illinois Development Finance Authority bonds, notes, and other obligations (venture fund and
infrastructure bonds only) 33c ______________ 00
d Quad Cities Regional Economic Development Authority bonds and notes (if declared to be exempt
from taxation by the Authority) 33d ______________ 00
e College savings bonds issued under the General Obligation Bond Act in accordance with the
Baccalaureate Savings Act 33e ______________ 00
f Illinois Sports Facilities Authority bonds 33f ______________ 00
g Higher Education Student Assistance Act bonds 33g ______________ 00
h Illinois Development Finance Authority bonds issued under the Illinois Development Finance Authority
Act, Sections 7.80 through 7.87 33h ______________ 00
i Rural Bond Bank Act bonds and notes 33i ______________ 00
j Illinois Development Finance Authority bonds issued under the Asbestos Abatement Finance Act 33j ______________ 00
k Quad Cities Interstate Metropolitan Authority bonds 33k ______________ 00
l Southwestern Illinois Development Authority bonds 33l ______________ 00
m Illinois Finance Authority bonds issued under the Illinois Finance Authority Act, Sections 820.60 and
825.55, or the Asbestos Abatement Finance Act 33m ______________ 00
n Illinois Power Agency bonds issued by the Illinois Finance Authority 33n ______________ 00
o Central Illinois Economic Development Authority bonds 33o ______________ 00
p Eastern Illinois Economic Development Authority bonds 33p ______________ 00
q Southeastern Illinois Economic Development Authority bonds 33q ______________ 00
r Southern Illinois Economic Development Authority bonds 33r ______________ 00
s Illinois Urban Development Authority bonds 33s ______________ 00
t Downstate Illinois Sports Facilities Authority bonds 33t ______________ 00
u Western Illinois Economic Development Authority bonds 33u ______________ 00
v Upper Illinois River Valley Development Authority Act bonds 33v ______________ 00
w Will-Kankakee Regional Development Authority bonds 33w ______________ 00
x Export Development Act of 1983 bonds 33x ______________ 00
34 Interest on the following non-U.S. government bonds.
a Bonds issued by the government of Guam 34a ______________ 00
b Bonds issued by the government of Puerto Rico 34b ______________ 00
c Bonds issued by the government of the Virgin Islands 34c ______________ 00
d Bonds issued by the government of American Samoa 34d ______________ 00
e Bonds issued by the government of the Northern Mariana Islands 34e ______________ 00
f Mutual mortgage insurance fund bonds 34f ______________ 00
35 Amount of your child’s interest from U.S. Treasury and U.S. agency obligations or from sources in Line 21,
33, or 34 as reported on federal Form 8814. 35 ______________ 00
36 Railroad sick pay and unemployment income. Attach Form 1099-G or W-2 and a copy of your federal return. 36 ______________ 00
37 Unjust imprisonment compensation awarded by Illinois Court of Claims. 37 ______________ 00
38 Distributions from “Bright Start,” “College Illinois,” and “Bright Directions” college savings plans if included
in Line 1 because you claimed a federal American Opportunity Credit or Lifetime Learning Credit. 38 ______________ 00
39 Total Subtractions. Add Lines 25 through 38. Enter the amount here and on Form IL-1040, Line 7. 39 ______________
680 00
IL-1040 Schedule M Back (R-12/17)

Nonresident and Part-Year Resident
2017 Schedule NR Computation of Illinois Tax
R T Clarke, Jr & M Clarke 3 1 5 - 0 4 - 4 7 8 6

Your name as shown on your Form IL-1040 Your Social Security number

1 Were you, or your spouse if “married filing jointly,” a full-year resident of Illinois during the tax year?
Yes No If you answered “Yes,” you cannot use this form (see instructions).
2 If you, or your spouse if “married filing jointly,” were a part-year resident during the tax year, tell us your residency dates for 2017.
a I lived in Illinois from / / 1 7 to / /1 7 I lived in from / / 1 7 to / / 1 7
Month Day Year Month Day Year State Month Day Year Month
Day Year
b My spouse lived in Illinois from / / 1 7 to / / 1 7 , and from / / 1 7 to / /1 7

Month Day Year Month Day Year State Month Day Year Month Day Year
3 If you were a resident of any of the states listed below during the tax year or if you were in Illinois only to accompany your spouse who
was in the military, check the appropriate box.
Iowa Kentucky Michigan Wisconsin Military Spouse
4 If you earned income or filed a tax return for the tax year in a state other than those listed above, enter the two-letter abbreviation of that state.
_______
CO _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______
Step 2: Complete Form IL-1040

Complete Lines 1 through 10 of your Form IL-1040, Individual Income Tax Return, as if you were a full-year Illinois resident. Then, complete
the remainder of this schedule following the instructions for your residency. Attach Schedule NR to your Form IL-1040.
Step 3: Figure the Illinois portion of your federal adjusted gross income
Enter the amounts from your federal return in Column A. Before completing Column B, read the Column B instructions.
Column A Column B
5 Wages, salaries, tips, etc. (federal Form 1040 or 1040A, Line 7; 1040EZ, Line 1) 5 106,919 .00 16,500.00
6 Taxable interest (federal Form 1040 or 1040A, Line 8a; 1040EZ, Line 2) 6 116 .00 0.00
7 Ordinary dividends (federal Form 1040 or 1040A, Line 9a) 7 .00 .00
8 Taxable refunds, credits, or offsets of state and local income taxes
(federal Form 1040, Line 10) 8 680 .00 0.00
9 Alimony received (federal Form 1040, Line 11) 9 .00 .00
10 Business income or loss (federal Form 1040, Line 12) 10 .00 .00
11 Capital gain or loss (federal Form 1040, Line 13 or 1040A, Line 10) 11 .00 .00
12 Other gains or losses (federal Form 1040, Line 14) 12 .00 .00
13 Taxable IRA distributions (federal Form 1040, Line 15b; or 1040A, Line 11b) 13 .00 .00
Income
14 Taxable pensions and annuities (federal Form 1040, Line 16b; or 1040A, Line 12b) 14 .00 .00
15 Rental real estate, royalties, partnerships, S corporations, trusts, etc.
(federal Form 1040, Line 17) 15 -3,694 .00 -3,694.00
16 Farm income or loss (federal Form 1040, Line 18) 16 .00 .00
17 Unemployment compensation and Alaska Permanent Fund dividends
(federal Form 1040, Line 19; 1040A, Line 13; 1040EZ, Line 3) 17 .00 .00
18 Taxable Social Security benefits (federal Form 1040, Line 20b; or 1040A, Line 14b) 18 .00 .00
19 Other income. See instructions. (federal Form 1040, Line 21)
Include winnings from the Illinois State Lottery as Illinois income in Column B. 19 .00 .00
20 Add Column B, Lines 5 through 19. This is the Illinois portion of your federal total income. 20 12,806.00

IL–1040 Schedule NR Front (R-02/18)
Continue with Step 3 on Page 2
Printed by authority of the State of Illinois - Web only
Schedule NR – Page 2
Step 3: Continued Column A Column B
21 12,806 .00
22 .00 .00
23 .00 .00
24 .00 .00
Adjustments to Income
25 .00 .00
26 .00 .00
27 .00 .00
28 .00 .00
29 .00 .00
30 .00 .00
31 .00 .00
32 2,500 .00 2,500 .00
33 .00 .00
34 .00 .00
35 .00 .00
36 2,500 .00
37 101,521 .00
38 Subtract Line 36 from Line 21. This is the Illinois portion of your federal adjusted gross income. 38 10,306 .00
Step 4: Figure your Illinois additions and subtractions

In Column A, enter the total amounts from your Form IL-1040. You must read Column A Column B
the instructions for Column B to properly complete this step. Form IL-1040 Total Illinois Portion
39 Federally tax-exempt interest and dividend income (Form IL-1040, Line 2) 39 .00 .00
Illinois Adjustments
40 Other additions (Form IL-1040, Line 3) 40 .00 .00

41 Add Column B, Lines 38, 39, and 40. This is the Illinois portion of your total income. 41 10,306 .00

42 Federally taxed Social Security and retirement income (Form IL-1040, Line 5) 42 .00 .00
43 Illinois Income Tax overpayment included on your federal Form 1040, Line 10.
(Form IL-1040, Line 6) 43 .00 .00
44 Other subtractions (Form IL-1040, Line 7) 44 680.00 0 .00
45 Add Column B, Lines 42 through 44. This is the total of your Illinois subtractions. 45 0 .00
Step 5: Figure your Illinois income and tax

46 Subtract Line 45 from Line 41. If Line 45 is larger than Line 41, enter zero. This is
your Illinois base income.
Enter this amount on your Form IL-1040, Line 12. 46 10,306 .00
If Line 46 is zero, skip Lines 47 through 51, and enter “0” on Line 52.
Tax Calculations
47 Enter the base income from Form IL-1040, Line 9. 47 .00 100,841
48 Divide Line 46 by Line 47 (carry to three decimal places). Enter the appropriate
decimal. If Line 46 is greater than Line 47, enter 1.000. 48 0.102
49 Enter your exemption allowance from your Form IL-1040, Line 10. 49 .00 4,350
50 Multiply Line 49 by the decimal on Line 48. This is your Illinois exemption
allowance. 50 444 .00
51 Subtract Line 50 from Line 46. This is your Illinois net income. 51 9,862 .00
52 Multiply the amount on Line 51 by 4.3549% (.043549). This amount may not be less than zero.
Enter the amount here and on your Form IL-1040, Line 13.
If you completed Schedule SA, enter the amount from Line 25 of that schedule here and on your Form IL-1040, Line 13.
This is your tax. 52 429 .00

this information is required. Failure to provide information could result in a penalty. IL–1040 Schedule NR Back (R-02/18)
Illinois Information Worksheet 2017
G Keep for your own records
Taxpayer: Spouse:
First Name Robert First Name MariRenee
Middle Initial T Middle Initial
Last Name Clarke Last Name Clarke
Suffix Jr Suffix
Social Security No. 315-04-4786 Social Security No. 313-96-8786
Date of Birth 01/19/1981 Date of Birth 07/17/1981
Age 65 or Over Age 65 or Over
Legally Blind Legally Blind
Date of Death Date of Death
Daytime Phone (312)714-9280 * X Daytime Phone *
Home phone *
* Check one of these boxes to print the daytime phone number on the Illinois forms.
Street Address 1301 Speer Blvd Apartment Number 710
City Denver State CO ZIP Code 80204
For foreign address, Illinois Department of Revenue requires the following information:
Foreign City Foreign Province or State
Foreign Country Foreign Postal Code
Part II ' Resident Status
Full-Year Resident
X Nonresident
Part-Year Resident lived in Illinois from to
also lived in from to
QuickZoom here to Form IL-1040
Part III ' Filing Status

X Married filing jointly
Married filing separately
Widowed
Part IV ' Other Information
Form IL-2210 Information:

At least two-thirds of your total federal gross income came from farming
65 or older and permanently living in a nursing home
Check if you were not required to file an Illinois income tax return in 2016
X Check if you do not want to file Illinois Form IL-2210 (see on-line help)
First Time Filer:

Yes No
Have you ever filed a tax return in Illinois?
R T Clarke, Jr & M Clarke 315-04-4786 Page 2
Part V ' Electronic Filing Information
Authenticate Your Return for the On-Line Filing Program
Before transmitting your return to the Intuit Electronic Filing Center and then to the Illinois Department of
Revenue (IDOR), you must first read and authenticate the Illinois "Tax Return Signature/Consent to
Disclosure" presented here. This is a legal statement authorizing Intuit and the IDOR to process your return
electronically.
Tax Return Signature:

"Under penalties of perjury, I declare that I have examined this return and, to the best of my knowledge and
belief, it is true, correct, and complete."
Consent to Disclosure:
I consent to my on-line service provider (OLSP) and/or my transmitter sending my return to the IDOR. I also
consent to the IDOR sending my OLSP and/or transmitter an acknowledgment of receipt of transmission and
an indication of whether or not my return is accepted, and if rejected the reason(s) for the rejection.
I am signing this Tax Return Signature/Consent to Disclosure by entering my IL-PIN (Illinois Personal
Identification Number) below:
Taxpayer’s Illinois Personal Identification Number (IL-PIN)

If you’re filing a joint return:
Spouse’s Illinois Personal Identification Number (IL-PIN) 23204639
Today’s Date 04/01/2018
Optional (see tax help): Taxpayer Spouse

Prior year Adjusted Gross Income, IL-1040, Line 1 86,100.
Illinois Driver’s License or ID Card Number
Illinois Driver’s License or ID Card First Name
Illinois Driver’s License or ID Card Middle Name
Illinois Driver’s License or ID Card Last Name
Illinois Driver’s License or ID Card Suffix
Illinois Driver’s License or ID Card Weight
Direct Deposit Consent:

"I consent that my refund be directly deposited as designated below and declare that the RTN and DAN are
correct. If I have filed a joint return, this is an irrevocable appointment of the other spouse as an agent to
receive the refund."
Electronic Funds Withdrawal Consent:

"I authorize the Illinois Department of Revenue and its designated financial agent to initiate an ACH
electronic funds withdrawal as designated in the electronic portion of my 2017 Illinois income tax return.
I authorize the financial institutions involved in the processing of an electronic overpayment of taxes to
receive confidential information necessary to answer inquiries and resolve issues related to the payment."
Part VI ' Direct Deposit Information or Direct Debit Information
Yes No
X Use direct deposit for state tax refund
Elect to receive a state issued debit card
X Use direct debit for state tax payment (Electronic Filing only)
If you selected direct deposit or direct debit above fill out the information below:
Name of Financial Institution (optional) chase bank
Name on account
Account type Checking X Savings
Routing number 074000010
Account number 689978013
Enter the payment date to withdraw from the account above 04/01/2018
State balance-due amount from this return 429.
International ACH Transactions

Yes No
X Will the funds for this refund (or payment) go to (or come from) an account outside the U.S.?
Part VII ' Third Party Designee Information
Yes No
Do you want to allow another person to discuss your return with the Illinois Dept. of Revenue?
Designee’s name
Designee’s phone number
Part VIII ' Extension Status
Yes No
Tax return due date extended?
X
Extended due date
QuickZoom to Form IL-505-I: Automatic Extension Payment
Part IX ' Amended Return
Check this box if you are filing an Illinois amended return

Enter the tax year you are amending
Previous Illinois payment made (before any penalty or interest)
Previous Illinois overpayment (before contributions or amount applied)
QuickZoom here to Form IL-1040X

R T Clarke, Jr & M Clarke 315-04-4786
Tax Payments for the Current Year
State
Date Payment
1 First Payment
2 Second Payment
3 Third Payment
4 Fourth Payment
Additional Payments
5 Payment
Payment
Payment
Payment
Payment
6 Overpayment from previous year applied to current year 6

7 Amount paid with current year extension 7
8 Total tax payments 8
Income Taxes Withheld for the Current Year
9 State withholding on Forms W-2 9

10 State withholding on Forms W-2G 10
11 State withholding on Forms 1099-R 11
12 a State withholding on Forms 1099-MISC 12 a
b State withholding on Forms 1099-G b
c State withholding on Forms 1099-K c
d State withholding on Forms 1099-INT, 1099-DIV and 1099-OID d
13 Other state tax withholding 13
14 Total income tax withheld 14
15 Date return will be filed and balance paid 15
OTHV0301.SCR 11/28/16
Form IL-1040-ES Estimated Tax Worksheet 2018
Name(s) Shown on Return Your Social Security Number

R T Clarke, Jr & M Clarke 315-04-4786
Part I 2018 Estimated Tax Amount Options
1 Select One of Six Ways to Calculate the Required Annual Payment for 2018 Estimates:
a 100% of 2017 taxes (2017 actual tax exception) (default, see Tax Help) X 429.
b 100% of tax on 2018 estimated taxable income 312.
c 90% of tax on 2018 estimated taxable income 281.
d Taxpayer is a farmer - no estimated payments required
e Equal to 100% of overpayment (no vouchers) 0.
f Enter total amount you want to use for estimates and check box
2 Selected estimated tax amount:
a 2018 Required Annual Payment based on your choice above 429.
b Estimated amount of 2018 state income tax withholding 0.
c Total of estimated tax payments required for 2018 (line 2a less line 2b) 429.
3 Select Estimated Tax Payment option:
a Calculate estimates if more than $500 (default) X
b Calculate estimates if (specify amount) or more
c Calculate estimates regardless of amount
d Do not calculate estimates
Part II Overpayment Application Options
1 Amount of overpayment available (Form IL-1040, line 35) 0.

2 Select Overpayment Application Amount Option:
a Apply none (refund entire overpayment) X
b Apply all (increase estimate if required)
c Apply to extent of total estimated tax and refund excess
d Apply to extent of first quarter amount and refund excess
e Enter amount you want to apply
f Amount applied to 2018 estimated tax 0.
g Overpayment to be refunded (line 1 less line 2f) 0.
3 Select Overpayment Application Sequence:
a X H Consecutively b H Evenly
Part III Rounding and Printing Options
1 Select Rounding Option:

a X H Round up to b H Round up to c H Round up to d H Round to
next $1 next $10 next $100 nearest $1
2 Select Voucher Printing Option:
a X H Print (per Part I, lines 3a - c) b H Print only name, etc. c H Do not print vouchers
Part IV Estimated Tax Payment Summary
1 2 3 4 Total
Apr 17, 2018 Jun 15, 2018 Sep 17, 2018 Jan 15, 2019
1 If you have already made

payments, enter amounts
2 Indicate which payment is
due next. (e.g. if it is now
May 1, 2018, check col. 2) X
3 Required payment
4 Overpayment applied
5 Net payment due
6 Voucher amounts
Part V Changes to Income, Exemptions, Withholding and Credits for 2018
2017 income, exemptions, withholding and credits are shown in the ’2017 Actual’ column below.
*Caution: For each line in the ’2018 Estimated’ column, enter the 2018 estimated amount if different
from 2017. Otherwise, the ’2017 Actual’ amount will be used for that line.If zero, you must enter zero.
2017 Actual *2018 Estimated
1 Illinois base income 10,306.

2 Total number of exemptions 2
3 Check the boxes you expect to apply for 2018.
you will be 65 or older
spouse will be 65 or older
you will be legally blind
spouse will be legally blind
Total number of boxes checked 0
4 Estimated income tax to be withheld from wages or other income
and any pass-through withholding payments paid on your behalf 0.
5 Estimated allowable credits for Illinois property tax paid,
income tax paid to other states, education expenses,
earned income, and tax credits from Schedule 1299-C 0.
6 Do you expect to be a resident of Illinois for all of
tax year 2018? X Yes No
If you check the ’No’ box, enter total base income
Part VI 2018 Estimated Taxable Income and Tax
1 Enter the Illinois base income you expect to receive in the year 2018.
Nonresidents and part-year residents, see Schedule NR, Nonresidents and
Part-Year Residents Computation of Illinois Tax 1 10,306.
2 Figure your expected exemption allowance.
a Enter the total number of exemptions that you expect to claim on your
2018 Illinois income tax return 2 Multiply this number by $2,000 2a 4,000.
b Check the boxes that will apply to you in 2018.
you will be 65 or older
spouse will be 65 or older
you will be legally blind
spouse will be legally blind
Add the number of boxes checked 0 Multiply this number by $1,000 2b 0.
3 Add lines 2a and 2b. This is your total expected exemption allowance.
Nonresidents and part-year residents, see Schedule NR 3 4,000.
4 Subtract line 3 from line 1. This is the Illinois net income expected in 2018 4 6,306.
5 Multiply line 4 by 4.95% (.0495) 5 312.
6 Enter the amount of Compassionate Use of Medical Cannabis Pilot Program
Act Surcharge expected in 2018 6
7 Add lines 5 and 6 7 312.
8 Enter the amount of estimated allowable credits for Illinois property tax paid,
income tax paid to other states, education expenses, earned income and
tax credits from Schedule 1299-C 8 0.
9 Subtract line 8 from line 7. This is your 2018 tax based on your
estimate of 2018 income 9 312.
Tax Summary 2017
Name(s)
R T Clarke, Jr & M Clarke
Federal Adjusted Gross Income 101,521.

Additions to income
Subtractions from income 680.
Base income 100,841.
Exemption amount 4,350.
Taxable net income 9,862.
Illinois income tax 429.
Nonrefundable credits 0.
Tax after nonrefundable credits 429.
Household employment tax
Use tax
Total tax 429.
Withholding, payments, refundable credits
IL-2210 penalty
Voluntary contributions
Overpayment after penalty and contributions
Amount applied to next year’s estimated tax
Refund to you
Balance due 429.
Smart Worksheets from your 2017 Illinois Tax Return
SMART WORKSHEET FOR: Form IL-1040: Illinois Individual Income Tax Return
Use Tax Smart Worksheet
Method 1: Use Tax (UT) Worksheet

Complete this worksheet to report and pay your use tax on Form IL-1040. If your annual use tax
liability is over $600, you must file and pay your use tax with Form ST-44.
Note: Do not include any
- items for which you paid sales tax in another state (but not in another country) of
- 6.25% or more on Line 1a and
- 1% or more on Line 2a
- sales tax you paid in another state, on line 4, for items not included in Lines 1a or 2a
1a Enter the total cost of general merchandise you purchased

to use in Illinois on which you did not pay the required
amount of Illinois Use Tax 1a 0.
1b Multiply Line 1a by 6.25% (.0625). Round the result to whole dollars 1b 0.
2a Enter the total cost of qualifying food, non-prescription drugs
and medical appliances you purchased to use in Illinois on
which you did not pay the required amount of Illinois Use Tax 2a
2b Multiply Line 2a by 1% (.01). Round the result to whole dollars 2b 0.
3 Add Lines 1b and 2b. This is your Use Tax on purchases. 3 0.
4 Enter the amount of sales tax you paid in another state (not in another
country) on the items included on Lines 1a and 2a 4
5 Subtract Line 4 from Line 3. Enter the result here and on Form IL-1040,
Line 23 (if the result is less than zero, enter zero) 5
Method 2: UT Table
If there are no major purchases and do not have receipts to figure purchases, use the table
to estimate annual Illinois Use Tax liability.
AGI (from IL-1040, Line 1) Use Tax

$0 - $10,000 $3
$10,001 - $20,000 $9
$20,001 - $30,000 $15
$30,001 - $40,000 $21
$40,001 - $50,000 $27
$50,001 - $75,000 $38
$75,001 - $100,000 $52
Above $100,000 Multiply AGI by 0.06% (0.0006)
To use UT table calculate Use Tax, check here

Use tax amount based on table above
Keep a copy of this smart worksheet with your records.

Schedule E Income Smart Worksheet
Rental and Royalty Income: State Col A Col B

where Federal Illinois
Rental & Royalty Description located Total Portion
1150 N LAKE SHORE DR. 23J IL -3,694.
K-1 Partnership Income: State of Col A Col B

Partnership Name Source Total Portion
K-1 S-Corp Income: State of Col A Col B

S-Corp Name Source Total Portion
K-1 Trust Income: State of Col A Col B

Trust Name Source Total Portion
Illinois Self-Employment (ISE) Smart Worksheet

For use in column B, lines 26, 27, and 28 below.
A Self-employment income included in column B, line 20 above

B Total self-employment income (from federal Schedule SE,
Section A, line 3 or Section B, lines 3 and 5a)
C Illinois self-employment (ISE) decimal. Line A divided by line B 0.000
D Deductible portion of self-employment tax (column A, line 26 below)
E Illinois portion. Multiply line D by line C. Enter in column B, line 26 below
F Self-employed health insurance deduction (column A, line 28 below)
G Illinois portion. Multiply line F by line C. Enter in column B, line 28 below
H Keogh and self-employed SEP plans (column A, line 27 below)
I Illinois portion. Multiply line H by line C. Enter in column B, line 27 below
IRA Deduction Smart Worksheet

For use in column B, line 31 below.
A Wages, salaries, tips, and alimony received from Illinois

sources (column B, lines 5 and 9 above) 16,500.
B Wages, salaries, tips, and alimony received from all
sources (column A, lines 5 and 9 above) 106,919.
C Line A divided by line B 0.154
D Total IRA deduction (column A, line 31 below)
E Illinois IRA deduction. Multiply line D by line C.
Enter in column B, line 31 below
Form
1040 Department of the Treasury—Internal Revenue Service
U.S. Individual Income Tax Return

(99)
2017 OMB No. 1545-0074 IRS Use Only—Do not write or staple in this space.
For the year Jan. 1–Dec. 31, 2017, or other tax year beginning , 2017, ending , 20 See separate instructions.
Your first name and initial Last name 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). If you have a P.O. box, see instructions. Apt. no. Make sure the SSN(s) above
c
and on line 6c are correct.
1301 Speer Blvd 710
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 80204 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 instructions.)

Filing Status
2 Married filing jointly (even if only one had income) If the qualifying person is a child but not your dependent, enter this
Check only one 3 Married filing separately. Enter spouse’s SSN above child’s name here. a
box. and full name here. a 5 Qualifying widow(er) (see instructions)
Exemptions 6a
b
Yourself. If someone can claim you as a dependent, do not check box 6a .
Spouse . . . . . . . . . . . . . . . . . . . .
.
.
.
.
.
.
.
.
} Boxes checked
on 6a and 6b
No. of children
2
c Dependents: (2) Dependent’s (3) Dependent’s (4) if child under age 17 on 6c who:
social security number relationship to you qualifying for child tax credit • lived with you
(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 Dependents on 6c
instructions and not entered above
check here a Add numbers on
d Total number of exemptions claimed . . . . . . . . . . . . . . . . . lines above a
2
7 Wages, salaries, tips, etc. Attach Form(s) W-2 . . . . . . . . . . . . 7 106,919.
Income
8a Taxable interest. Attach Schedule B if required . . . . . . . . . . . . 8a 116.
b Tax-exempt interest. Do not include on line 8a . . . 8b
Attach Form(s)
9a Ordinary dividends. Attach Schedule B if required . . . . . . . . . . . 9a
W-2 here. Also
attach Forms b Qualified dividends . . . . . . . . . . . 9b
W-2G and 10 Taxable refunds, credits, or offsets of state and local income taxes . . . . . . 10 680.
1099-R if tax 11 Alimony received . . . . . . . . . . . . . . . . . . . . . 11
was withheld.
12 Business income or (loss). Attach Schedule C or C-EZ . . . . . . . . . . 12
13 Capital gain or (loss). Attach Schedule D if required. If not required, check here a 13
If you did not 14 Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . . . 14
get a W-2,
see instructions. 15a IRA distributions . 15a b Taxable amount . . . 15b
16a Pensions and annuities 16a b Taxable amount . . . 16b
17 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E 17 -3,694.
18 Farm income or (loss). Attach Schedule F . . . . . . . . . . . . . . 18
19 Unemployment compensation . . . . . . . . . . . . . . . . . 19
20a Social security benefits 20a b Taxable amount . . . 20b
21 Other income. List type and amount 21
22 Combine the amounts in the far right column for lines 7 through 21. This is your total income a 22 104,021.
23 Educator expenses . . . . . . . . . . . 23
Adjusted 24 Certain business expenses of reservists, performing artists, and
Gross fee-basis government officials. Attach Form 2106 or 2106-EZ 24
Income 25 Health savings account deduction. Attach Form 8889 . 25
26 Moving expenses. Attach Form 3903 . . . . . . 26
27 Deductible part of self-employment tax. Attach Schedule SE . 27
28 Self-employed SEP, SIMPLE, and qualified plans . . 28
29 Self-employed health insurance deduction . . . . 29
30 Penalty on early withdrawal of savings . . . . . . 30
31a Alimony paid b Recipient’s SSN a 31a
32 IRA deduction . . . . . . . . . . . . . 32
33 Student loan interest deduction . . . . . . . . 33 2,500.
34 Tuition and fees. Attach Form 8917 . . . . . . 34
35 Domestic production activities deduction. Attach Form 8903 35
36 Add lines 23 through 35 . . . . . . . . . . . . . . . . . . . 36 2,500.
37 Subtract line 36 from line 22. This is your adjusted gross income . . . . . a 37 101,521.
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. BAA REV 02/22/18 Intuit.cg.cfp.sp Form 1040 (2017)
Form 1040 (2017) Page 2
38 Amount from line 37 (adjusted gross income) . . . . . . . . . . . . . . 38 101,521.
Tax and
Credits
39a Check
if:
{ You were born before January 2, 1953,
Spouse was born before January 2, 1953,
Blind.
Blind.
} Total boxes
checked a 39a
b If your spouse itemizes on a separate return or you were a dual-status alien, check here a 39b
Standard 40 Itemized deductions (from Schedule A) or your standard deduction (see left margin) . . 40 17,167.
Deduction 84,354.
for— 41 Subtract line 40 from line 38 . . . . . . . . . . . . . . . . . . . 41
• People who 42 Exemptions. If line 38 is $156,900 or less, multiply $4,050 by the number on line 6d. Otherwise, see instructions 42 8,100.
check any
box on line 43 Taxable income. Subtract line 42 from line 41. If line 42 is more than line 41, enter -0- . . 43 76,254.
39a or 39b or 44 Tax (see instructions). Check if any from: a Form(s) 8814 b Form 4972 c 44 10,546.
who can be
claimed as a 45 Alternative minimum tax (see instructions). Attach Form 6251 . . . . . . . . . 45
dependent,
see 46 Excess advance premium tax credit repayment. Attach Form 8962 . . . . . . . . 46
instructions. 47 Add lines 44, 45, and 46 . . . . . . . . . . . . . . . . . . . a 47 10,546.
• All others:
48 Foreign tax credit. Attach Form 1116 if required . . . . 48
Single or
Married filing 49 Credit for child and dependent care expenses. Attach Form 2441 49
separately,
$6,350 50 Education credits from Form 8863, line 19 . . . . . 50
Married filing 51 Retirement savings contributions credit. Attach Form 8880 51
jointly or
Qualifying 52 Child tax credit. Attach Schedule 8812, if required . . . 52
widow(er), 53 Residential energy credits. Attach Form 5695 . . . . 53
$12,700
Head of 54 Other credits from Form: a 3800 b 8801 c 54
household, 55 Add lines 48 through 54. These are your total credits . . . . . . . . . . . . 55
$9,350
56 Subtract line 55 from line 47. If line 55 is more than line 47, enter -0- . . . . . . a 56 10,546.
57 Self-employment tax. Attach Schedule SE . . . . . . . . . . . . . . . 57
Other 58 Unreported social security and Medicare tax from Form: a 4137 b 8919 . . 58
59 Additional tax on IRAs, other qualified retirement plans, etc. Attach Form 5329 if required . . 59
Taxes 60a Household employment taxes from Schedule H . . . . . . . . . . . . . . 60a
b First-time homebuyer credit repayment. Attach Form 5405 if required . . . . . . . . 60b
61 Health care: individual responsibility (see instructions) Full-year coverage . . . . . 61 0.
62 Taxes from: a Form 8959 b Form 8960 c Instructions; enter code(s) 62
63 Add lines 56 through 62. This is your total tax . . . . . . . . . . . . . a 63 10,546.
Payments 64 Federal income tax withheld from Forms W-2 and 1099 . . 64 11,868.
65 2017 estimated tax payments and amount applied from 2016 return 65
If you have a
66a Earned income credit (EIC) . . . . . . .No. . . 66a
qualifying
child, attach b Nontaxable combat pay election 66b
Schedule EIC. 67 Additional child tax credit. Attach Schedule 8812 . . . . . 67
68 American opportunity credit from Form 8863, line 8 . . . 68
69 Net premium tax credit. Attach Form 8962 . . . . . . 69
70 Amount paid with request for extension to file . . . . . 70
71 Excess social security and tier 1 RRTA tax withheld 71 . . . .
72 Credit for federal tax on fuels. Attach Form 4136 72 . . . .
73 Credits from Form: a 2439 b Reserved c 8885 d 73
74 Add lines 64, 65, 66a, and 67 through 73. These are your total payments . . . . . a 74 11,868.
Refund 75 If line 74 is more than line 63, subtract line 63 from line 74. This is the amount you overpaid 75 1,322.
76a Amount of line 75 you want refunded to you. If Form 8888 is attached, check here . a 76a 1,322.
a bRouting number 0 3 1 1 7 6 1 1 0 a c Type: Checking Savings
Direct deposit?
See a dAccount number 1 3 5 8 7 3 4 5 0
instructions.
77 Amount of line 75 you want applied to your 2018 estimated tax a 77
Amount 78 Amount you owe. Subtract line 74 from line 63. For details on how to pay, see instructions a 78
You Owe 79 Estimated tax penalty (see instructions) . . . . . . . 79
Third Party Do you want to allow another person to discuss this return with the IRS (see instructions)? Yes. Complete below. No
Designee’s Phone Personal identification
Designee name a no. a number (PIN) a
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
Sign accurately list all amounts and sources of income I received during the tax year. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Here Your signature Date Your occupation Daytime phone number
F
Joint return? See

instructions. Patent Attorney (312)714-9280
Keep a copy for Spouse’s signature. If a joint return, both must sign. Date Spouse’s occupation If the IRS sent you an Identity Protection
your records. PIN, enter it
Customer Service Agent here (see inst.)
Print/Type preparer’s name Preparer’s signature Date PTIN
Paid Check if
self-employed
Preparer
Use Only Firm’s name a Self-Prepared Firm’s EIN a
Firm’s address a Phone no.

Go to www.irs.gov/Form1040 for instructions and the latest information. REV 02/22/18 Intuit.cg.cfp.sp Form 1040 (2017)
Smart Worksheets from your 2017 Illinois Tax Return Attachment
SMART WORKSHEET FOR: Form 1040: Individual Tax Return
Tax Smart Worksheet
A Tax 10,546.
Check if from:
1 Tax table X
2 Tax Computation Worksheet (see instructions)
3 Schedule D Tax Worksheet
4 Qualified Dividends and Capital Gain Tax Worksheet
5 Schedule J
6 Form 8615
7 Foreign Earned Income Tax Worksheet
B Additional tax from Form 8814
C Additional tax from Form 4972
D Tax from additional Form(s) 4972
E Recapture tax from Form 8863
F IRC Section 197(f)(9)(B)(ii) election for an additional tax
G Health Coverage Tax Credit Recovery, Form 8885, Line 5, if negative
H Tax. Add lines A through G. Enter the result here and on line 44 10,546.

Form 1040 tax return summary

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Form

1040 Department of the Treasury—Internal Revenue Service

U.S. Individual Income Tax Return

Robert T Clarke, Jr 315-04-4786

MariRenee Clarke 313-96-8786

1 Single 4 Head of household (with qualifying person). (See instructions.)

Joint return? See

Firm’s address a Phone no.

6 Real estate taxes (see instructions) . . . . . . . . . 6 1,682.

19 Qualified HSA funding distribution . . . . . . . . . . . . . . . . . . . . . 19

19 Qualified HSA funding distribution . . . . . . . . . . . . . . . . . . . . . 19

Total. Enter on Form 8582, lines 1a, 1b,

Total. Enter on Form 8582, lines 2a and

Total. Enter on Form 8582, lines 3a, 3b,

Total . . . . . . . . . . . . . . . . . a 3,694. 1.00 3,694. 0.

Name(s) Shown on Return

Five Year Tax History:

2013 2014 2015 2016 2017

Filing status MFJ MFJ MFJ MFJ MFJ

Total income 124,343. 95,820. 87,883. 88,600. 104,021.

Adjustments to income 8,626. 7,297. 2,500. 2,500. 2,500.

Adjusted gross income 115,717. 88,523. 85,383. 86,100. 101,521.

Tax expense 3,516. 1,768. 3,502. 5,409. 6,246.

Interest expense 9,864. 10,504.

Contributions 1,140. 353. 300. 2,280. 417.

Exemption amount 7,800. 11,850. 12,000. 12,150. 8,100.

Taxable income 83,278. 46,486. 60,783. 56,397. 76,254.

Tax 12,676. 6,056. 8,194. 7,484. 10,546.

Alternative min tax

Total credits 1,000. 1,000. 1,001.

Payments 17,275. 10,316. 9,168. 10,305. 11,868.

Form 2210 penalty

Refund 4,599. 5,260. 1,974. 3,822. 1,322.

Effective tax rate % 10.95 5.71 8.43 7.53 10.39

**Tax bracket % 25.0 15.0 15.0 15.0 25.0

**Tax bracket % is based on Taxable income.

Information regarding low-cost deposit accounts may be available at www.mymoney.gov .

PAPER RETURN IRS direct deposit to Approximately No additional cost.

ELECTRONIC IRS direct deposit to Usually within 21 days2 No additional cost.

No Refund Processing Check mailed by IRS Approximately

ELECTRONIC (a) Direct deposit to Usually within $ 39.99

Refund Processing (b) Load to your

Questions? Call 1-877-908-7228

The following statements apply:

First Name Last Name

Name(s) Shown on Return Your SSN

Line 4b - Adjustment for trade or business income or loss

(a) Activity name (b) Gain or

Enter additional adjustments not included above:

Line 5b - Adjustment for gain or loss on dispositions

(a) Activity name (b) Gain or

Capital gain/loss not included in net investment income

(a) Activity name (b) Capital

Calculation of line 5b adjustment due to capital loss carryforward

1 Net capital loss not included in net investment income 1 0.

Line 7 - Other modifications to investment income

1 Casualty and theft losses reported on Schedule A, line 20 1

8 Total other modifications to investment income 8 0.

Line 9b - State income tax allocable to net investment income

1 State, local, and foreign income taxes 1 3,971.

Line 10 - Tax preparations fees allocable to net investment income

1 Tax preparations fees 1

Lines 9 and 10 - Application of Itemized Deduction Limitations Worksheet