1040-SR U.S.

Tax Return for Seniors 2021

Form Department of the Treasury—Internal Revenue Service (99)
OMB No. 1545-0074 IRS Use Only—Do not write or staple in this space.

Filing Single Married filing jointly Married filing separately (MFS)

Status Head of household (HOH) Qualifying widow(er) (QW)
Check only If you checked the MFS box, enter the name of your spouse. If you checked the HOH or QW box, enter the child’s
one box. name if the qualifying person is a child but not your dependent a
Your first name and middle initial Last name Your social security number
Carolyn J Palmer 270-40-5691
If joint return, spouse’s first name and middle initial Last name Spouse’s social security number

Home address (number and street). If you have a P.O. box, see instructions. Apt. no. Presidential Election Campaign
104 Philemon St Check here if you, or your
City, town, or post office. If you have a foreign address, also complete spaces below. State ZIP code spouse if filing jointly, want
$3 to go to this fund.
Del Rio TX 788402652 Checking a box below will
Foreign country name Foreign province/state/county Foreign postal code not change your tax or
refund. You Spouse

At any time during 2021, did you receive, sell, exchange, or otherwise dispose of any
financial interest in any virtual currency? . . . . . . . . . . . . . . . . . . . . a Yes No

Standard Someone can claim: You as a dependent Your spouse as a dependent

Deduction Spouse itemizes on a separate return or you were a dual-status alien

Age/Blindness { You:
Spouse:
Were born before January 2, 1957
Was born before January 2, 1957
Are blind
Is blind
Dependents (2) Social security number (3) Relationship to (4)  if qualifies for (see instructions):
(see instructions): (1) First name Last name you Child tax credit Credit for other dependents

If more than four

dependents, see
instructions and
check here a

1 Wages, salaries, tips, etc. Attach Form(s) W-2 . . . . . . . . . . . 1

Attach
2a Tax-exempt interest . 2a b Taxable interest . . 2b
Schedule B
if required. 3a Qualified dividends . . 3a b Ordinary dividends . 3b
4a IRA distributions . . . 4a b Taxable amount . . 4b
5a Pensions and annuities 5a 22,224. b Taxable amount . . 5b 20,823.
6a Social security benefits . 6a 6,038. b Taxable amount . . 6b 5,132.
7 Capital gain or (loss). Attach Schedule D if required. If not required,
check here . . . . . . . . . . . . . . . . . . . . . . . a 7 13,529.
8 Other income from Schedule 1, line 10 . . . . . . . . . . . . . . 8
9 Add lines 1, 2b, 3b, 4b, 5b, 6b, 7, and 8. This is your total income . . a 9 39,484.
10 Adjustments to income from Schedule 1, line 26 . . . . . . . . . . 10
11 Subtract line 10 from line 9. This is your adjusted gross income . . a 11 39,484.
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. BAA REV 02/16/22 Intuit.cg.cfp.sp Form 1040-SR (2021)
Form 1040-SR (2021) Page 2

Standard 12a Standard deduction or itemized deductions (from

Deduction Schedule A) . . . . . . . . . . . . . . . . . 12a 14,250.
See Standard
Deduction Chart b Charitable contributions if you take the standard
on the last page deduction (see instructions) . . . . . . . . . . . 12b
of this form.
c Add lines 12a and 12b . . . . . . . . . . . . . . . . . . . . . 12c 14,250.
13 Qualified business income deduction from Form 8995 or Form 8995-A . 13
14 Add lines 12c and 13 . . . . . . . . . . . . . . . . . . . . . 14 14,250.
15 Taxable income. Subtract line 14 from line 11. If zero or less, enter -0- . 15 25,234.
16 Tax (see instructions). Check if any from:
1 Form(s) 8814 2 Form 4972 3 . . . . . . . 16 1,208.
17 Amount from Schedule 2, line 3 . . . . . . . . . . . . . . . . . 17
18 Add lines 16 and 17 . . . . . . . . . . . . . . . . . . . . . 18 1,208.
19 Nonrefundable child tax credit or credit for other dependents from
Schedule 8812 . . . . . . . . . . . . . . . . . . . . . . . . 19
20 Amount from Schedule 3, line 8 . . . . . . . . . . . . . . . . . 20
21 Add lines 19 and 20 . . . . . . . . . . . . . . . . . . . . . . 21
22 Subtract line 21 from line 18. If zero or less, enter -0- . . . . . . . . 22 1,208.
23 Other taxes, including self-employment tax, from Schedule 2, line 21 . . 23 0.
24 Add lines 22 and 23. This is your total tax . . . . . . . . . . . a 24 1,208.
25 Federal income tax withheld from:
a Form(s) W-2 . . . . . . . . . . . . . . . . . 25a
b Form(s) 1099 . . . . . . . . . . . . . . . . 25b 1,994.
c Other forms (see instructions) . . . . . . . . . . 25c
d Add lines 25a through 25c . . . . . . . . . . . . . . . . . . . 25d 1,994.
26 2021 estimated tax payments and amount applied from 2020 return . . 26
If you have
a qualifying 27a Earned income credit (EIC) . . . . . . . . . . . 27a
child, attach Check here if you were born after January 1, 1998,
Sch. EIC.
and before January 2, 2004, and you satisfy all the
other requirements for taxpayers who are at least
age 18 to claim the EIC. See instructions . . . a
b Nontaxable combat pay election . 27b
c Prior year (2019) earned income . 27c
28 Refundable child tax credit or additional child tax
credit from Schedule 8812 . . . . . . . . . . . 28
29 American opportunity credit from Form 8863, line 8 . 29
30 Recovery rebate credit. See instructions . . . . . 30
31 Amount from Schedule 3, line 15 . . . . . . . . 31
32 Add lines 27a and 28 through 31. These are your total other payments
and refundable credits . . . . . . . . . . . . . . . . . . . a 32
33 Add lines 25d, 26, and 32. These are your total payments . . . . . a 33 1,994.
Go to www.irs.gov/Form1040SR for instructions and the latest information. BAA REV 02/16/22 Intuit.cg.cfp.sp Form 1040-SR (2021)
Form 1040-SR (2021) Page 3

Refund 34 If line 33 is more than line 24, subtract line 24 from line 33. This is the
amount you overpaid . . . . . . . . . . . . . . . . . . . . . 34 786.
35a Amount of line 34 you want refunded to you. If Form 8888 is attached,
check here . . . . . . . . . . . . . . . . . . . . . . . a 35a 786.
Direct deposit? a b Routing number 1 1 4 9 0 1 3 7 0 a c Type: Checking Savings
See
instructions. ad Account number 3 6 8 9 9 2 1

36 Amount of line 34 you want applied to your 2022

estimated tax . . . . . . . . . . . . . . . a 36
Amount 37 Amount you owe. Subtract line 33 from line 24. For details on how to
You Owe pay, see instructions . . . . . . . . . . . . . . . . . . . . a 37
38 Estimated tax penalty (see instructions) . . . . . a 38
Third Party Do you want to allow another person to discuss this return with the IRS? See
Designee instructions . . . . . . . . . . . . . . . . . . . . . a Yes. Complete below. No
Designee’s Phone Personal identification
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
Sign my knowledge and belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information
Here of which preparer has any knowledge.
Your signature Date Your occupation If the IRS sent you an Identity
Protection PIN, enter it here
F

Joint return? retired (see inst.)

See instructions.
Spouse’s signature. If a joint return, both must sign. Date Spouse’s occupation If the IRS sent your spouse an
Keep a copy for
Identity Protection PIN, enter it here
your records. (see inst.)
Phone no. (830)719-9264 Email address
Preparer’s name Preparer’s signature Date PTIN Check if:
Paid
Self-employed
Preparer
Firm’s name a Self-Prepared Phone no.
Use Only Firm’s address a Firm’s EIN a

Go to www.irs.gov/Form1040SR for instructions and the latest information. BAA REV 02/16/22 Intuit.cg.cfp.sp Form 1040-SR (2021)
Form 1040-SR (2021) Page 4

Standard Deduction Chart*

Add the number of boxes checked in the “Age/Blindness” section of Standard Deduction on page 1 . . . . a

IF your filing AND the number of THEN your standard

status is. . . boxes checked is. . . deduction is. . .
1 $14,250
Single
2 15,950
1 $26,450
Married 2 27,800
filing jointly 3 29,150
4 30,500
Qualifying 1 $26,450
widow(er) 2 27,800
Head of 1 $20,500
household 2 22,200
1 $13,900
Married filing 2 15,250
separately** 3 16,600
4 17,950
* Don’t use this chart if someone can claim you (or your spouse if filing jointly) as a dependent, your spouse itemizes on a
separate return, or you were a dual-status alien. Instead, see instructions.
** You can check the boxes for your spouse if your filing status is married filing separately and your spouse had no
income, isn’t filing a return, and can’t be claimed as a dependent on another person’s return.
Go to www.irs.gov/Form1040SR for instructions and the latest information. BAA REV 02/16/22 Intuit.cg.cfp.sp Form 1040-SR (2021)
SCHEDULE D OMB No. 1545-0074
(Form 1040)
Capital Gains and Losses
a
a Attach to Form 1040, 1040-SR, or 1040-NR.
Go to www.irs.gov/ScheduleD for instructions and the latest information.
2021
Department of the Treasury Attachment
Internal Revenue Service (99) a Use Form 8949 to list your transactions for lines 1b, 2, 3, 8b, 9, and 10. Sequence No. 12

Name(s) shown on return Your social security number

Carolyn J Palmer 270-40-5691
Did you dispose of any investment(s) in a qualified opportunity fund during the tax year? Yes No
If “Yes,” attach Form 8949 and see its instructions for additional requirements for reporting your gain or loss.

Part I Short-Term Capital Gains and Losses—Generally Assets Held One Year or Less (see instructions)
See instructions for how to figure the amounts to enter on the (g) (h) Gain or (loss)
lines below. (d) (e) Adjustments Subtract column (e)
Proceeds Cost to gain or loss from from column (d) and
This form may be easier to complete if you round off cents to (sales price) (or other basis) Form(s) 8949, Part I, combine the result
whole dollars. line 2, column (g) with column (g)

1a Totals for all short-term transactions reported on Form

1099-B for which basis was reported to the IRS and for
which you have no adjustments (see instructions).
However, if you choose to report all these transactions
on Form 8949, leave this line blank and go to line 1b .
1b Totals for all transactions reported on Form(s) 8949 with
Box A checked . . . . . . . . . . . . .
2 Totals for all transactions reported on Form(s) 8949 with
Box B checked . . . . . . . . . . . . .
3 Totals for all transactions reported on Form(s) 8949 with
Box C checked . . . . . . . . . . . . .
4 Short-term gain from Form 6252 and short-term gain or (loss) from Forms 4684, 6781, and 8824 . . 4
5 Net short-term gain or (loss) from partnerships, S corporations, estates, and trusts from
Schedule(s) K-1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
6 Short-term capital loss carryover. Enter the amount, if any, from line 8 of your Capital Loss Carryover
Worksheet in the instructions . . . . . . . . . . . . . . . . . . . . . . . . 6 ( )
7 Net short-term capital gain or (loss). Combine lines 1a through 6 in column (h). If you have any long-
term capital gains or losses, go to Part II below. Otherwise, go to Part III on the back . . . . . . 7
Part II Long-Term Capital Gains and Losses—Generally Assets Held More Than One Year (see instructions)
See instructions for how to figure the amounts to enter on the (g) (h) Gain or (loss)
lines below. (d) (e) Adjustments Subtract column (e)
Proceeds Cost to gain or loss from from column (d) and
This form may be easier to complete if you round off cents to (sales price) (or other basis) Form(s) 8949, Part II, combine the result
whole dollars. line 2, column (g) with column (g)

8a Totals for all long-term transactions reported on Form

1099-B for which basis was reported to the IRS and for
which you have no adjustments (see instructions).
However, if you choose to report all these transactions
on Form 8949, leave this line blank and go to line 8b .
8b Totals for all transactions reported on Form(s) 8949 with
Box D checked . . . . . . . . . . . . .
9 Totals for all transactions reported on Form(s) 8949 with
Box E checked . . . . . . . . . . . . .
10 Totals for all transactions reported on Form(s) 8949 with
Box F checked . . . . . . . . . . . . . . 33,529. 20,000. 13,529.
11 Gain from Form 4797, Part I; long-term gain from Forms 2439 and 6252; and long-term gain or (loss)
from Forms 4684, 6781, and 8824 . . . . . . . . . . . . . . . . . . . . . . . 11
12 Net long-term gain or (loss) from partnerships, S corporations, estates, and trusts from Schedule(s) K-1 12
13 Capital gain distributions. See the instructions . . . . . . . . . . . . . . . . . . . 13
14 Long-term capital loss carryover. Enter the amount, if any, from line 13 of your Capital Loss Carryover
Worksheet in the instructions . . . . . . . . . . . . . . . . . . . . . . . . 14 ( )
15 Net long-term capital gain or (loss). Combine lines 8a through 14 in column (h). Then, go to Part III
on the back . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 13,529.
For Paperwork Reduction Act Notice, see your tax return instructions. BAA REV 02/16/22 Intuit.cg.cfp.sp Schedule D (Form 1040) 2021
Schedule D (Form 1040) 2021 Page 2

Part III Summary

16 Combine lines 7 and 15 and enter the result . . . . . . . . . . . . . . . . . . 16 13,529.

• If line 16 is a gain, enter the amount from line 16 on Form 1040, 1040-SR, or 1040-NR, line 7.
Then, go to line 17 below.
• If line 16 is a loss, skip lines 17 through 20 below. Then, go to line 21. Also be sure to complete
line 22.
• If line 16 is zero, skip lines 17 through 21 below and enter -0- on Form 1040, 1040-SR, or
1040-NR, line 7. Then, go to line 22.

17 Are lines 15 and 16 both gains?

Yes. Go to line 18.
No. Skip lines 18 through 21, and go to line 22.

18 If you are required to complete the 28% Rate Gain Worksheet (see instructions), enter the
amount, if any, from line 7 of that worksheet . . . . . . . . . . . . . . . . . a 18

19 If you are required to complete the Unrecaptured Section 1250 Gain Worksheet (see
instructions), enter the amount, if any, from line 18 of that worksheet . . . . . . . . . a 19

20 Are lines 18 and 19 both zero or blank and are you not filing Form 4952?
Yes. Complete the Qualified Dividends and Capital Gain Tax Worksheet in the instructions
for Forms 1040 and 1040-SR, line 16. Don’t complete lines 21 and 22 below.

No. Complete the Schedule D Tax Worksheet in the instructions. Don’t complete lines 21
and 22 below.

21 If line 16 is a loss, enter here and on Form 1040, 1040-SR, or 1040-NR, line 7, the smaller of:

• The loss on line 16; or

• ($3,000), or if married filing separately, ($1,500) } . . . . . . . . . . . . . . . 21 ( )

Note: When figuring which amount is smaller, treat both amounts as positive numbers.

22 Do you have qualified dividends on Form 1040, 1040-SR, or 1040-NR, line 3a?

Yes. Complete the Qualified Dividends and Capital Gain Tax Worksheet in the instructions
for Forms 1040 and 1040-SR, line 16.

No. Complete the rest of Form 1040, 1040-SR, or 1040-NR.

REV 02/16/22 Intuit.cg.cfp.sp Schedule D (Form 1040) 2021

Form 8949 (2021) Attachment Sequence No. 12A Page 2
Name(s) shown on return. Name and SSN or taxpayer identification no. not required if shown on other side Social security number or taxpayer identification number
Carolyn J Palmer 270-40-5691
Before you check Box D, E, or F below, see whether you received any Form(s) 1099-B or substitute statement(s) from your broker. A substitute
statement will have the same information as Form 1099-B. Either will show whether your basis (usually your cost) was reported to the IRS by your
broker and may even tell you which box to check.
Part II Long-Term. Transactions involving capital assets you held more than 1 year are generally long-term (see
instructions). For short-term transactions, see page 1.
Note: You may aggregate all long-term transactions reported on Form(s) 1099-B showing basis was reported
to the IRS and for which no adjustments or codes are required. Enter the totals directly on Schedule D, line
8a; you aren’t required to report these transactions on Form 8949 (see instructions).
You must check Box D, E, or F below. Check only one box. If more than one box applies for your long-term transactions, complete
a separate Form 8949, page 2, for each applicable box. If you have more long-term transactions than will fit on this page for one or
more of the boxes, complete as many forms with the same box checked as you need.
(D) Long-term transactions reported on Form(s) 1099-B showing basis was reported to the IRS (see Note above)
(E) Long-term transactions reported on Form(s) 1099-B showing basis wasn’t reported to the IRS
(F) Long-term transactions not reported to you on Form 1099-B
Adjustment, if any, to gain or loss.
1 (e) If you enter an amount in column (g), (h)
(c) (d) Cost or other basis. enter a code in column (f). Gain or (loss).
(a) (b) See the separate instructions.
Date sold or Proceeds See the Note below Subtract column (e)
Description of property Date acquired
disposed of (sales price) and see Column (e) from column (d) and
(Example: 100 sh. XYZ Co.) (Mo., day, yr.)
(Mo., day, yr.) (see instructions) in the separate (f) (g) combine the result
instructions Code(s) from Amount of with column (g)
instructions adjustment

Lot Number 11 Salem Point, Val Verde County Texas 08/01/87 05/17/21 33,529. 20,000. 13,529.

2 Totals. Add the amounts in columns (d), (e), (g), and (h) (subtract
negative amounts). Enter each total here and include on your
Schedule D, line 8b (if Box D above is checked), line 9 (if Box E
above is checked), or line 10 (if Box F above is checked) a 33,529. 20,000. 13,529.
Note: If you checked Box D above but the basis reported to the IRS was incorrect, enter in column (e) the basis as reported to the IRS, and enter an
adjustment in column (g) to correct the basis. See Column (g) in the separate instructions for how to figure the amount of the adjustment.

REV 02/16/22 Intuit.cg.cfp.sp Form 8949 (2021)

BAA