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t A.

(i I \t,{\*

Financial Aid Office


Phone (585) 274-1070
lrar (585) 232-8601

i.r"irlirplqh:rii(ris.lli-igtltq.llgi-qd!1

rd V e ri fi : ati o n Wo rks he e t
Deperudent

2& L5-2A16 V 1- S taffi

q{

i,,,rrs seleeleri ll;,i a review process called Verificatlon The


rvc ma\' :rsk you to conlirnt the intbrmation you and
.t.i,.i.
Federal Regulatory law state.q that belbre au,arding FeCcral Studeni

Your 2015-20.16 Free Application lbr Fedeial Studen'r Arcl (l'Ai::,A)

Music Ftnancial Aid

Ol

ce.

If you

have questions al-roL( reijilci!i.liJli, tll.asc sg11!lict the Easttnan School o1'Music Financial Aid

delay'ed.

A.

Dependent Student's Infoffnation

&eiu\Name

\\\ iy i rM

l'r,st Nanil

Last

rrfS(

'Lqri j7'>20

9eit\,.\0410

Boutnt'j

_skec.[

Ilome -dddress (include apt no

qAza
State

1-lp Lr)ild

0t-\

ll)

-I5@
l)at* ol'flirth

r,en{tl2etr
lrnaii ,\.iriLcss

ag

b*y*i

I,

(itjD 1x-Ltc$L

Aiiernate or Cell Phone Nurnbei

Home Phone Number (include area code)

B.

StLr.lcnt

Dependent Sttrdent's Family Informatiom


Numtler of Household htlembers and Nalxx}:rer im College
List

,
.
.

belorrz the people in the

parents' househqld lncluctre:

The student

if the s;iu'ciei'i1. ijr-.i:sli't livt ir'iiil fhc pitr-ents


iharri.riril'ol'lheirsuppoliliornJulyl,20l5throughJune30Theparents'otherchilclreniftheparentsrviilprovi.i,,,rrore
pior'rrlc
p;iieirtrl
iti[i:; ttilttu'tr ii t]:ut r,vcre completing a ITAFSA for
to
requrred
2016, or if the otlier children would be
The parents (including a stcpparent) cvcn

2015-2C16 inclurle chiidren rvho meet eitirer oith.csr,!Il.ri.iiirds er,,:n il-1iic ohiiciretl cio not iive with the parents.
pror,ide more than half o1'their suppo':t thrur,rgl, ilrne l'-1. ,lt)iir.

qt-rSAfl-h.flflmS in a degree, diploma, or

'viil bt t:nl ollr:rl


certificateprogramatapostseconrlaryeciucationai insliiui:i:liiii',,t';'t-i:e1rrcr:t:"1,;l'i 1.20 l-5andJune30,20l6. Includethe
name o{'the college. lf urore space is neetlerl, attncli i} i1{ij.ii}r'rllc ptage lvith th* stuilent's name and [D number at the top.

l'or

a1y, house

hold rnernirer, exclutlimg y'our p*reutisi"

Name

Age

r.,,i-.n

Will

be Enrolled at

Least Half Time


,fufi;E ,{ana$, ft.at;,;tkp,te), ,

cc

Student's

Name:

SSN or ESM Student

ID:

C. Dependent Student's trncome to Be Verified


Student FederalTax Return Filers
Instructions: Completethrssectioniftircstudent, lr-lc-tli]-i-u,irl lr]ga20l4lRsincometaxreturn
Thebest.utaytoverify
income is b.y using the IRS Datu Retrieva! Too! (f R,l Dtt'i) thut is pttrt of FAFSA
on the lyeb. jn most cases no further
documentation is needed to venfy 2014 li(S incortre tax retlrrn inlbrnration that uas
trar.rsf'erred lnto the student"s FAFSA
using the IRS DRT if that inlorrnation wus not changed.
In most cases, for electronic fllers, 20 i 4 IRS income tax r'0tufn infbr-mation for the IRS DRT
is available rvlthin 3 weeks
after the 2014 electronic IRS income tax return has been accepted by the IRS Generally,
for fllers of 2014 paper IRS
income tax returns, the 20l1lRS income tiix return inforr-nation is available fbr the
IRS DRT within g weeks after the 2014
paper IRS income tax returtr has been reccived bv tlre Ii{.1

Important Notc: If tht student fi!*d,

on

will file, *n ar4encle d 20 t4 IRS incomc tax return, the student must contact

a financial aid counselor treforc completing this srctiorr.

,\l:!

the box that applics:

ln'.stirclent h4!-q$d the IR.S DIt'l rtr I]AFSA on ther Web to transfbr 2014 IRS income tax return inlbrmation into

W
' ,t

studenl's I'AFSA

the

The student haurglJgl-uEd the III S DR]- in ]",qi- S A c,il the Web, but wr ll use
the tool to transfbr 2014 iRS income tax
return information into the student.s t'AirSA onee the 2Ci,1 Ilds tax return has been
filed. The Eastman Schorl of Music
Financial Aicl Office cannot pt'ocee(l vlith lhe t'eriJic*tion pror:ess tmtil the IRS' information
has been transferrei inro
the FAFSA.

El

'rne student is
ltnable or chooses r]qlto use the II{S Lllll' in ITAFSA on the Web, and instead
will provide the Eastman
School of Music Financial Aid oifice a 20i4 IRS'Fax Rrturn t'ranscript.
To obtain a 2014 IRS Truu Return'l'runscrfiit, go to ytvty,-!8Slgpv and
click on the "Get Transcript of your Tax

Records"linkorcalll-800-908-9946 A,{akesurelurequestilte"lRST'oxReturn'li.anscript"aruJnotthe,,tRSTax
Account Transcrtpt."-{,)9e 7,o1xy 5551, dat<z of blrth a*i}
1,611y crc]tfi-ess o4.file y,ith the IRS (nirntalll, rhistvill be rhe
address used on the 2011 tRS tax relvrn). lr lul,e'.v tq' ro
elecn'onic filers ond up to eight vtee lt.; for
Tsctpe r./ilirs.

B
f]

titte

.,rrelis

for

IRS

income tax injornrutian to be available


for

Check l"rere if the stu<-lent's 20 t-+ IRS Tax f{eiurir 'i'ranscript is proviilecl.

Checkhercilthestudent's20i'1 IRST'a.xlieturnl'r.lnscriptwillbe providedlater.Verificationcannotbe

completed until the IRS Tax Rclurn 'l'riLnscript Iurs L ,re n rcceivecl bythe Eastman
Schooi of Music Financial Atd

Office.

Student Nontax Filers


CdrnpJcte this scction if tl.re student:y-{l

trlrlnlg iurti rs.g9_!eq}ged to file

a 20

l4 income

ta;c.re{i.un u,ith the IRS

Check thb.bpx that applies:

The student

The student was

not ernpioyed and had no incomc c:i,irned fiorn rvor

'14.

in 20 1 4 ancl has listed bciow thc


of all employers, the amount earned from each
employer in2014, and
her an IRS W-2 or l()99
is attached. Provide copies of all 2014IRS W-2 and/or 1099
forms issued to the student
c';ci'y e ntplo_ver
ir il'tlrc entplol,er dicl not provide an IRS W-2 or 1099 form
Provide a signed statement explai
the
if unable to obtain an IRS w-2 or 1099 form for income earned

employer. If more space is needed,


Erpl-g.i

s,rtijiAtqA:8oi{

ffiiniid

from

a separafe page

with the student,s name and ID number at the top.


2014 Amount Earned

Student's Name:

SSN ar HSM Student

ID:

D. Parent's Income Infcrmation to Be Verifi*d


Parent Federa! Tax Return Filers -'l'he instruriic;ns brxow apply r* rach parent inrluded
in the household in
Section B' Notify tlre Eastman Financial r\itl Office if thr panenii lilcd nepa*"to IRS income
tax returns for2014 or
had a changc in marital status after the end of the Ztit4 lax ycar om Drcrm5er 31,2014.
Instructions: Complete this section tllhc parents lilqc!-q,r.r'ril ii1.9a2()i4litll incorne rax return The
best.tvay to vertfy
income is hy tr,sing the lRS Data Relriet,al Tot;l ([tt,\ D{77'i thct is
1:ttrt q't;.,i1--.SA on the Llreb.
most cases, fbr electronic frlers, 20 l4 IRS incorne tax rellrin infoilnation lirr the IRS
DRT rs available within 3 weeks
a{terthe20l4electroniclRsincoittetaxreturnha:;beenacceptecl by,theII{S Cerierail'r,, lbrlllersof
20 l4paperIRS
incoite e 1ax returns. the 2014lRS income tax reiu:-n inibrrnalrOn is avaii;LtiiC f.\r the III-S nif'f ivithin g
weeks aiier the
20lr4 paper IRS inconre tar return has been recerved b1, the iRtl
trn

Important Note: If the parents filed, or will file, an i-mgl]dgd 2i!1,f


contact a financial aid counsetror before cornplctiug tlris secfiu*.

lIlS

irrcome tax rcturn, the parents must

Check the bor that applies:

f}

'fire parents
hayg-gseil the IRS DRT rn FAITSA on tire Web lo translcr:ti)14 IRS incrrme tax return iniormation into the
student's FAF'SA.

f]

Tireparentshaye-qalyslusedthelRSDRl inirAFs.q.nihoweir.br-it

r,r'iil uselherool

totransl.er20l4lRSincomerax

return information inl.o the parent's ITAFSA once i,h* 20 i ,:i IRS tax re{Lrrrr l.ras bce n filed. 't'he
Eastnrun School of futusic
liinancial AitlOffice cannot complete the t,et.ificLtriot?
ll.t.o.,t,r,; until tl.tt !RS infcrmution has been transferred into the
FAF-SA.

parerts are unable el_clLqore l19t jo use thr: lF.S I.;R I in f AFljA erii lhe \,Vcb and insteacl
School olMusic Irinancia] Ai,j OI'llce a2Al4 iR.S Tar f,{eiurrr ?'ransrrilit(s).

H"t'l',e

will provicie the Eastman

7'o obtain a 201 4 IRS Ta:c Return Trtnscript, go io


)!)!\v ll:!:\]gpt uilci click on the " Get -l'ranscript of your Tax
Recot'ds" littk or call l-8{}0-908-9946. A.folie sure to rtqlri,st tie " ttll' 'l-r;x lleturn Trartscript"
antl nit the ..IRS Tax
AccowntT-ranscript " Use the SSI'| anddote a.j'hirtlt cirhe
.first;tersor ii.ster! on the 20t4 IRS income taxretunt, and
the qddress onJile with the IRS (normalll; tlti.s v'il! bt: rhc tifulriss usetl t:rt the 2Al l IRS
income tax rettffn). lt takes up
to lhree v'eeksfor !RS income tax in;forntation lo he at,uilultle.[t;r elecrt^ottic.filers anil up
to eight weeksJ:or paper
Jilers.

If the parents lile separafe 20I4 IRS incorne tilx re{urns.2014 lRii-i'ax I{rturn Transcripts must
for br;th.

lK
n

be provided

check here rra 2014 iR.s rax R.eturn Transcripr(s) is pri:vicled.


Check here if a 20 l4 iRS I'ax Return T'ransoripiis) rvjll be pior,ii.lr:d laicr Vcrification cannot be
completecl until the
IRS far Rcturn T'ranscript(s) has been submjllcd tti tnc llilsiliili:r Sr:irool of Music Iiinancial Aid Otfiie.

Parent NonTax Filers - These instructions apply to ear[r parr:nt inclurir,,l in the househok.l in Section B.
Cornplete this

se

ction if the parent(s) u'rll not lile ai:.j qg,liilrrltrg]ryrl trl f rl,- :r ,lu 1l iile t,me tax return rvith the IRS

Check the box that applies:

fl
fJ

Neither parent was ernployctl and hacl no incomr eanrr-t! liopr rvori< i5 :fj

i.i

One or both parents were employed in 20l4 ancl have lrsteii beior,i,rlic rranies of'a.ll t:mployers, the amount
earne6 1]om

eachemployerin20ll.andwhetheranlRSW-2or1099 lorrnisattar:hed Pror,,iCecopicsofall 20l4IRSW-2and/or


l099fbrmsissuedtoilrcparents. Llstevrrr-ycrnployerr:r,cnrfiitectrlii(iveididnotprovrdeaplR.SW-2fbrmor1099

lbrm

Frovide a signcd statemcnt erplarning thc iearlorr ii'unabie ro rrl:iain an lliS W*2 or 1099 fbrm for income
earned
from employ'er' If more space is needed, attach a separale page rvith the student's name and ID number
at the top.
Employer's Nante

Amount Earned

IRS W-2 or 1099


Attached?

Jr:.:::::ir;;iali:i:itri

b2

" ij{}{). $i},

{qxeaiple)

f,gs.{exanipl

Student's Name:

SSN or ESM Student

E. Supplemental Nutrition
fI

ID:

Assistance Program (SNAP) Benefits

ttre parents cer1i1)'that.


a membcr o1'the parents' household (listed in Section B) received
benefits l'rom the Suppiententai
Nutrition Ass;istance Frogram or SNAP ({brrnerly known as the Food Stamp Program)
-sometimeduring20l3or20l4. Sl.lAPma.r, lteknorvnb5ranothernarneinsomestates. Forassistanceindeterminingthe
name used in a state. please cali l-ti(10-4FED-:\lii ( I -8A+43-3243) ,{ copy of the benefits staternent must be
included with this workshcet.

F.

Child Support Paid

[-

Oneoftheparents,inciirdedinthehor-rseirold(lisler.lrn-{tctionB),orthestr-rdentpaidchrldsupportin2014 Listbelorv
the names of tlre persorrs rlho paid the child suilpot-t. rhe narnes of the persons to whom the child support was paid, the
names o1'1he children I'br whom thc r:hild sr-ippoi-t rvas paid. and the total annual amount of child support that was paid in
2014 for each child I1'asked b.1 the Eastmau School o1'N,fusic Financial Aid Offrce, documentation of the payment of
child support may need to be provided. If rnore space is needed, attach a separate page that includes the student's
narne and ID nurnbrr at the top.

Narne of Person Wlro Paicl

Nanie ui- Petson

Whorn Child
Suppcrr.t *'as Paiil

Clrild Support

1o

.r

Cfl, t,i fu-rli t

"n-.7
Support

u,

Was Paid

Amount c'l Child


Support Paid in
2At4

:fuIafu:Ja-fidl

W;;ii,\*;n;i:i#i;l;i;il

G. Certification and Signature

: T.e.r.;.Ytrt J,g.qes ,,;,

Each person signing tl-ris wclrksheot cerlrircs that all oi t.ltt:


intormation rcporled cln it is completc a;rl ,-:orrcct.

'Ihe student
and one parcnt whose infor;rra,iiorr rvas repor{ed
on the FAFSA must sign and dare.

WARNING: lf you purposely glve false or misleading


information on this worksheet, you may be fined, be
sentenced to jail, or both.

244377 ZO

Student"s ESM ID

-tl.L;LhL--

Date

Date

Submit this worksheet tu the Eastmsn School of Music Financiat Aid Office.
26 Gibbs Street, Rochester, NY 14604

ph

585.274.1070

fux

585.232.8601

Jinanciahiil@esrn-rochester.edu

waeandrax

Fom
Copy C

W-Z
EMPLOYEE'S

2014

Control No

RECORDS (see Notice to


For
on back of CoPY B.)

Emploier's mmq addrqi-ls and ZP code

VALLEY CENTER*PAUMA UNTFIED

28751 COLE GRAPE

ROAD

VALLEY CENTER CA 92082


e Employee's name, atrd

BENJAMfN JAMES READ

5888

BOUNTY STREET

SAN DIEGO CA 92L20

ffiiirtemal
r""rr"a i" tt"
imn'os-.d

rorm
c_ory

\f!/-!

Scnice ll

you arc

aEI

TEcoRos (::e Ndrce b Emeloye on the back of copy B.)

9.:.F,:.r.:IrplL-oyjEls,

Emproyets

Statement

Wage and Tax

Rcrcnue

a tax rct"um, a ncgligencc penehl or other sanct ion may be


on vou i[ this income i. ta\ahlc and you fail lo repon [.

iIh-6JTJEGEEIFIiE

ABS ENTEBTAINMENT GROUP,


LLC
2600 W. OLIVE AVE. sTH FLOOR
BURBANK, CA 91505

S N4eaimrerege;;;G;
1o Dependenrcare

trrilproyee s name. address, and Zlp


code

BENJAMIN

"

sAN DTEGO

See instructions

" READ.

CA

t,piE

ta LomtwassJ6G

lnternal Revenue Service


tnent of tlie Treas
COPY B To Be Filed With Employee's FEDERAL Tax Return

OMB No. 1515-0008

and Tax Statement 2014

Conhol number
t66279113

Enrployer's name, address and zip

Mccarthy Building Companies, Inc.


1341 North Rock Hilf Road
st Louis MO 63124
init

A11en P
5BBB Bounty St
San Diego CA 92L20

Last

Na)ne

Zll'

securiry tax u,itlihcld

Medicare wages and tips


)26510.66

Suffix

Medicare tax rvithheld

835.27

10 Dependent care be

12a

AA

12

13

statutory

Emptoyee
PLn

Third'prrry sick
code
State wages, tips etc.
126570.66

Read

Errployer's State lD number


i088 I 25,10000000

Federal income tax withheld

3 Social security wages


I 1 7000.00

Rclrrernent

Errployee's address and

Wages, tips, other compensation

)265'/0.66

551-4 r -5183

Allocated tips
Ernployee's ilrst narne and

bEilE

foibiilT

92120_2919

16 Statewagei

Form W-2 W

FederatincometaiiiEEt

7 State incorne tax


68I 3.30

8 Local q,ages, tips etc.

I llro'ntt

I v.J o..nr,t
L osnt

pry L_l I '

9 Local incornc tax

20 Locality nane

2560.8r

/r

tJ 4l

lrrltr r^

ffi

fnternal Revenue Service


Unitcd $tntcs l)cpanment

of th* Treasury

This Product Contains Sensitive Taxpayen

Data

Request Date: 05-I0-20I5


Response Date: 06-10-2015

Trackins

Number

L00251469?64

Tax Return Transcript

r.* p""i33*.il1x;1"0;"11,;i: l,liz


The following items reflect the amount as shown on the retunn (pR), and
the amount as adjusted.(PC), if applicable. ihev do not-show
=rL="qu".rt
activity on the account.
0207 60

NAME(S) SHOWN 0N RETURN, BENJAMIN


ADDRESS: 5888 B0UNTY

SSN:
SPOUSE SSN:

READ

6q6-32-9075

ST

sAN DIEGo, CA 92L20-2919-889

FILING

STATUS:
FORM NUMBER:

Single

I040EZ
015I9 0 5
Apr. 15 , 20L5
$0.00

CYCLE POSTED:
RECEIVED DATE:

REMITTANCE:

EXEMPTION NUMBER:

PTIN:

PREPARER EIN:

Income

!49F!:_s4"l,4BIE9r
TAXABLE INTEREST

Erc:....
IIf9,
INC0ME:....

...$6,087.00

.....$0.00
.....$0.00

INTEREST:...
UNEHPL0YMENT C0MPENSATI0N:....
TAX-EXEMPT

...$0.00

Adjustments to Income
ADJUSTED GR0SS INC0ME:....

ADJUSTED GROSS INCOME PER C0MPUTER r


DEPENDENT ON ANOTHER TP: . .
FORM lO4()EZ DEDUCTION AND iiEMifi oN PER COMPUTER

....$5,087.00
YUrvvr.vu
$5,087 . 00
......YES

$5,200 . 00

Tax and Credits


TAXABLE INC0ME!....
TAXABLE INCOME PER COMPUTER:

0ther

$0.00

Taxes

T0TAL TAX LIABILITY TP FIGURES: . . . .


TOTAL TAX LIABILITY TP FIGURES PER COMPUTER
Payments
FEDERAL INC0ME TAX WITHHELD:.
OTHER PAYMENT CREDIT AM0UNT:....
EARNED INC0ME CREDIT:....

..$472.97
.$0.00

...50.00

PAY:....:.
gl[E,-,I]'prylpyA!^sElrglslP_rlllyi.....::::.

EARNED INCOME CREDIT NONTAXABLE COMBAT

ll-El!_M

SMALL EMPLOYER HEALTH INSURANCE PER COMPUTER:

:::

::

::

:::::

::

....$().O()

::.:::: : ...$0.00
:.:l:
.....0
.
.

$0.00

: : : . : : : : : : : . . : . : : : : : '.'.'.;eir'.6i

Trackins

Number

Refund or Amount 0wed


REFUND AM0UNT:....

z L00257459264

'ii'iio'iii'iouiutEi;

3AL DUE,/OVER PYMT USING


. : : : : : : : : : : : : : : : : . : : : : : :'.'.t:!,17']rl
BAL DUE/OVER PYMT USING C0I'IPUTER FIGURES:....
+-472.97
FORM 8888 TOTAL REFUND PER C0MPUTER:.
.$0.00

Third Party Designee


THIRD PARTY DESIGNEE ID NUMBER!....
AUTH0RIZATI0N INDICAT0R:....
THIRD PARTY DESIGNEE NAHE:

This Product Contains Sensitive Taxpayer Data

........0

ffi

Internal Revenue Service

Unitcd States l)cpartment of thr Trrnsutgr

This Product Contains Sensitive Taxpayen Data


Request Date: 05-Il-2015
Response Date: 05-1I-20L5
Tracking Number t 100?5755994L

Tax Return Transcript


SSN

Fi'.'-#

E}E

Providedr 554-41-5483

Tax Period Ending: Dec. 31, ?0L4


The following items reflect the amount as shown on the return (PR), and
the amount as adjusted (PC), if applicable. They do not show subsequent
activity on the account.

079625

NAME(S) SHOI.,N ON RETURN: ALLEN P & KIMBERLY R


ADDRESS: 5888 BOUNTY

SPOUSE

SSN: 554-41-5485
SSN: 449-?l-0864

READ

ST

sAN DrEGo, CA 92L2O-2919-889

Married Filing Joint

FILING

STATUS:
FORM NUMBER I

201512t2
Apr.15 , ?0L5
$0.00

CYCLE POSTED:
RECEIVED DATE:
REMITTANCE:

EXEMPTION NUHBER:
DEPENDENT
DEPENDENT
DEPENDENT
DEPENDENT
DEPENDENT
DEPENDENT
DEPENDENT
DEPENDENT

PTIN:

I NAME CTRL:
1 SSN:
2 NAME CTRL:
2 SSN:
3 NAME CTRL:
3 SSN I
4 NAME CTRL:
4 SSN:

READ

547

-Lq-3264

READ

646-?."-6668

READ

545-32-9075

READ

546-52-2488

PREPARER EIN:

fncome

ttAGES, SALARIES, TIPS, ETC:....


TAXABLE INTEREST INCOME: SCH B: . .

INTEREST:...
QUALIFIED DIVIDENDS:....

TAX-EXEMPT

0RDTNARY DIVIDEND INC0ME: SCH

B:. "

Rrruuns oF srATE/LocAL TAXES:....


ALIM0NY RECEIVED:....
BUSINESS INC0ME 0R L0SS (Schedule C):..
BUSINESS INC0ME 0R LOSS: SCH C PER C0MPUTER:....
CAPITAL GAIN 0R L0SS: (Schedule D)r..
CAPITAL GAINS 0R L0SS: SCH D PER C0MPUTER:....
OTi-i5R GAillS SR LCSSES (Form 4797>:....
TOTAL IRA DISTRIBUTI0NS:....
TAXABLE IRA DISTRIBUTI0NS:....

T0TAL PENSI0NS AND ANNUITIES:


TAXABLE PENSI0N,/ANNUITY AMOUNT:....

RENT/R0YALTY,/PARTNERSHIP,/ESTATE (Schedu1e E) r..


RENT,/R0YALTY,/PARTNERSHIP,/ESTATE (Schedu1e E) PER C0MPUTER:.'..
RENT,/R0YALTY INC0ME,/LOSS PER C0MPUTER:.
ESTATE,/TRUST INC0ME./L0SS PER C0MPUTER:.
PARTNERSHIP,/S-C0RP INCOME,/L0SS PER C0MPUTER:....
FARM INC0ME 0R L0SS (Schedule F) : . .
FARM INCOME 0R LOSS (Schedule F) PER C0MPUTER:....
UNEMPLOYMENT C0MPENSATI0N:. '..
TOTAL S0CIAL SECURITY BENEFITS:....
TAXABLE SOCIAL SECURITY BENEFITS:....

.$126f571.00
. $I24. O()
$0.00

" '$IL'57(t'00
$9,442.00
...$411.00
..$0.00

....$0.00
....$0.00

.$4'232.00
.$4,232.00

..'$0.00
...S0.00

$0.00

. . . $0.00

..$0.00
.$0'00
.$0.00

....$0.00
..'.$0.00
.....$0'00
. . $0.00
...$0'00
'..$0.00
...$0.00
$0.00

Tracking

L0025755994L

TAXABLE SOCIAL SECURITY BENEFITS PER C0}'IPUTER:


0THER INC0ME!....
SCHEDULE EIC SE INC0I'IE PER COHPUTER: '

'iI'99
'tu'uu

'

cor'tFurER:.
coNFurrn:....

SciiE[[LE Eii rAnfiEn-irlcblrE FEn


5cii-Eic-ni50uALiFrEu-ir,rc

ibfai'irlE6uE;:::'.:::.:'::.::'.".:::..
r^TAr
DED nnMprrrtrp.
ilifiilE'iiiliouiiiiR:::::::...
+[ili rrrrn..E
to Income
EDUCAT0R EXPENSES:....
EDUCATOR EXPENSES'PER COHPUTER:....

'$0'00
' '$0'00
$0'00
a1 a-a
nan
ll
"...$1431012.00
's143,01?'gs

"$]43,012'00

Adjustments

ExPENSE:....
DaD0dirou:....
...
M0VING EXPENSES: F5903!....
sElF"ruFto?r,tgNr rhi- uEnucrr0N:
SELF EMPL0YIIENT iAx DEb[eiiou rrn coMPurER:....
[EobHTSeF-conrnriiifrolr-nen[cirou:....
SEIF--EMF HEALTH i[s-nEnuctrolt,
Sa[ine5 prrualrv:....

nE5Eiivisr-nuD ornrir-iiuiingss
iiEartu-Savluos AC-i
iiEarrii Savir.reS accr nEbucriolt PER coMPTR:

Ean'rv-i,iirnunAnAl-iiF

ALIH0NY PAID SSN:....


ALIM0NY PAID:

?nn"il'roub?i-on;::...
ih';i DEDUarroH prn coMPUTER 2....

nrnucrroN:....
PER coMPUTER:.
i[Iitoi'i ar'rDPAYrrrs
DEDUCTI0N:
JURY DUTY
poi'irsric pnouucf rol AcirvrrrEs DEDUcrr0N:
StijnEnl-ioAr'r rnfEnE5t

SilnEiir ronr'r iHrEiiESi DEDucrioN PER coMPUTER:.


iuitirir.r aHn rrrs DEDUCTT0N:....
pEbucrior'r

ADJUSTMENTS:..
ARCHER MSA DEDUCTI0N:
ARCHER MSA DEDuitioii'pin coNpurER: .
T0TAL ADJUSTMENTS:..
T0TAL ADJUSTMENTS PER C0MPUTER:....
oTHER

A[iij5rrD-enoSS rNcoME:....
a[Ju5rEb enoss ii.icoME'rrn coMPUTER:....
Tax and Credits

55-0R-0VER:...
BLIND:....
SP0USE 55-0R-0VER:...
SP0USE

BLIND:.. '.

coMPurER:....
STANDAiiU.DEPUCTIOII FTN CO}IPUTER.....

T[X-iABtE-rNC0ME"i;En-col,rFuTER,.
i'rri ioururER:.
rxEr.rFtiop aMour'ri
?iixiibiE-iucot'tr:....
ilixABLE iucoMr pER coupurER:

"$0'00

"" "$0'00
"$0'00
$0'00
'

' $0 ' 00

'$0'00
'$0'00
' $0 ' 00
'$0'00

""
$0 ' 00
" '$o'oo
'$0 '00
" '$0'00
'$0'00

's0'00

"$0'00
$0 00

" " $0 ' 00


'' '
"'IX'X:
' ' tu ' uu
" $0 ' 00
.''tu'uu
" '$0'00
a^

6d

a6

n6

'$145,012'09

"'$143,012'00

"""'N0 ltn
" "1;X
""I;X
"

5raftnAnn-nrnucrion'iiR

ADDITIONAL

'$0'00
"$(]'O()

..$87

'r'Ie

"$0'00
.$().OO

'?1e.90"$51,508'gq

" '$ss '64e


. . "s55,6!e'99
.
'$143'012'00
tiitirr-Fo5iirvr lr,rdollr-'prn-CoNpurER:.
".. '$5'38e'qg
iEHtArlvr-TAX:
'$5,3q9'gg
iElirnrivr rAX pER coupurER3....
$0'00
ioHM daia auorriiiruAt rAx-Ar'roUNr: .
coHPurER:....
PER
'$0'00
rtldollE
'
r-ESS"Soc"5rC
ini"ox-rlrcoNr
...':
" "$0'00
riiiiu-CzEi ALrenflir[n-uiuipr[M raxi. "..
F0RM5251ALTERNATIVEMINIMUMTAx.PERc0MPUTER:
'roii'ereN-inx-cneprr:....
" '$154'00
$134'00
FoiiErGi.i iAX aREDii'iliR'c0MPUTER:....
$0'00
FoRETGN TNCoME Excrirsiot'r-prn coMpurrR:....
"$0'00
FoiiEicli iHcoMr EXaL[sioN rAx prn c0MPUTER:....
...$O.OO
EXCESS ADVANCE FI{EMIIM-TAX CNENTT_RTPAVMTNT AMOUNT'....
....1q'qq
AMouNr:....
vERTFTED
REPAYHENT
cnrnir
rAx
i,iiEMrui,
auvAncr
ExcESS
""'$0'00
ciiirD-a"DrerHDgHr cARE cREDrr:..
' " '$0'00
aiiilD a brpEnDri.it cAHE cnrnir PER coMPUTER:.
" ' $0 ' 00
ciiEurr-rbn ELnriiiv-iil'iD nf SAstrp '
coMPUTER:
PER
uiSastro
"$0'00
Ai'ib
e[nriili
ron
aiiEDii
'$1,500'gg
EDucArlolr cRrnrr:....
$1,500'00
Enucariolr cnEuri'PiR coMPUTER:....
corqrurER:.
cR05S'EnucAtiolr'cirEbli-pen

's0

"$1,s00'00

Trackins

Numben

L00257559941

RETIREMENT SAVINGS CNTRB CREDIT:....


RETIREMENT SAVINGS CNTRB CREDIT PER C0MPUTER:

.$0.00

PRIM RET SAV CNTRB: F8880 LN6A:


SEC RET SAV CNTRB: F8880 LN5B:
T0TAL RETIREMENT SAVINGS CONTRIBUTI0N: F8880 CMPTR:....
RESIDENTIAL ENERGY CREDIT:....
RESIDENTIAL ENERGY CREDIT PER C0MPUTER: .
CHILD TAX CREDIT:...
CHILD TAX CREDIT PER C0MPUTER:....
ADOPTI0N CREDIT: F8839:....
AD0PTI0N CREDIT PER COMPUTER, .
DC lST TIME HOMEBUYERS CREDIT:....
DC 1ST TIME H0MEBUYERS CREDIT PER COMPUTER: .
F0RM 8595 M0RTGAGE CERTIFICATE CREDIT:....
F0RM 8395 M0RTGAGE CERTIFICATE CREDIT PER COMPUTER:.
F3800, F8801 AND 0THER CREDIT AM0UNT:....

3800 GENERAL BUSINESS CREDITS!....


5800 GENERAL BUSINESS CREDITS PER C0MPUTER: .
PRI0R YR MIN TAX CREDIT: F880I:....
PRI0R YR MIN TAX CREDIT: F8801 PER COMPUTER:.
F8854 ELECTRIC VEHICLE CREDIT AM0UNT:....
F8955 ELECTRIC M0T0R VEHICLE CREDIT AM0UNT:....
F8910 ALTERNATIVE M0T0R VEHICLE CREDIT AM0UNT!....
F0RM
F0RM

019625

OTHER

CREDITS:.....

T0TA[ CREDITS:....

T0TAL CREDITS PER C0MPUTER: .


INC0ME TAX AFTER CREDITS PER

. . $0.00

..$0.00
...$0.00
. . . $0.00

.$220.00
. $220.0t)

...$1,300.00
$I,500.00

.....$0.00
. . $0.00
...$0.00
. . . $0.00

.$0.00
$0.00

..$0.00
...$0.00
. . . $0.00
..$0.00
..$0.00
..$0.00
.....$0.00
..$0.00
....$0.00

.$3,154.00
. $5,154.00
S2'235.00

C0MPUTER:.

Other Taxes
SE TAX:.....
....$0.00
SE TAX PER C0MPUTER:.
.....50.00
SOCIAL SECURITY AND MEDICARE TAX 0N UNREP0RTED TIPS: . . . .
. . $0.00
SOCIAL SECURITY AND MEDICARE TAX 0N UNREP0RTED TIPS PER C0MPUTER:.
.$0.00
TAX 0N QUALIFIED PLANS F5329 (PR):
..$0.00
TAX 0N QUALIFIED PLANS F5329 PER C0MPUTER: .
. . . . . $0.00
IRAF TAX PER C0MPUTER:.
....$0.00
TP TAX FIGURES (REDUCED BY IRAF) PER C0MPUTER:.
..$2,255.00
IMF TOTAL TAX (REDUCED BY IRAF) PER C0MPUTER:.
...$2,235.00
OTHER TAXES PER COMPUTER: .
. . $0.00
UNPAID FICA 0N REP0RTED TIPS:
. . $0.00
OTHER TAXES:.....
$0.00
RECAPTURE TAX: F85Il:....
H0USEHOLD EMPL0YMENT TAXES:....
H0USEH0LD EMPL0YMENT TAXES PER COMPUTER:
RECAPTURE TAXES:....
T0TAL ASSESSMENT PER

...$0.00
..$0.00

. . $0.00

. . . . $0.00

C0MPUTER:....

$2,235.00

T0TAL TAX LIABILITY TP FIGURES!....


T0TAL TAX LIABILITY TP FIGURES PER COMPUTER:.

....$2,255.00
....$2,235.00

Payments
FEDERAL INC0ME TAX WITHHELD:.
HEALTH CARE: INDIVIDUAL RESPONSIBILITY:.
HEALTH CARE FULL-YEAR C0VERAGE INDICATOR ! . . .
COBRA PREMIUM SUBSIDY:....
ESTIMATED TAX PAYMENTS: .
OTHER PAYfiENI' CRED]T:

.....
.

CREDIT:....

REFUNDABLE EDUCATION
REFUNDABLE EDUCAT]ON CREDIT PER
REFUNDABLE EDUCATION CREDIT
EARNED INC0HE CREDIT:....
EARNED INC0ME CREDIT PER C0MPUTER: .
EARNED INC0ME CREDIT NONTAXABLE C0HBAT PAY:
SCHEDULE 8812 N0NTAXABLE COMBAT PAY:.

COMPUTER:.
VERIFIED:....

.
EXCESS S0CIAL SECURITY & RRTA TAX IIITHHELD:.
SCHEDULE 8812 T0T SS,/MEDICARE WITHHELD: . .
SCHEDULE 8812 ADDITI0NAL CHILD TAX CREDIT:...
SCHEDULE 8812 ADDITIONAL CHILD TAX CREDIT PER C0MPUTER:....
SCHEDULE 8812 ADDITI0NAL CHILD TAX CREDIT VERIFIED:...
AM0UNT PAID WITH F0RM 48583....
F0RM 2439 REGULATED INVESTHENT C0MPANY CREDIT:....

$8,225.00
$0.00

....1

.....$0.00

$0.00
.s0.00

..$I,000.00
..$1,000.00
..$0.00
$0.00

. . . $0.00
. . . . $0.00

.$0.00

....$0.00
. . $0.00
...$0.00
....S0.00
....$0.00
..$0.00
...$0.00

Tnacking Number t L00?57559941


4155 CREDIT FOR FEDERAL TAX 0N FUELS3.....
4135 CREDIT FOR FEDERAL TAX 0N FUELS PER C0MPUTER:.
HEALTH C0VERAGE TX CR: F8885:....
FORM 8801 REFUNDABLE CREDIT FOR PRI0R YEAR MIN. TAX: . . . . .

....$0.00
..$0.00
...$0.00
$0.00
.....$0.00

FORM
FORM

PREHIUH TAX CREDIT AMOUNT:....


PREMIUH TAX CREDIT VERIFIED AM0UNTI....
PRIMARY NAP FIRST TIME H0ME BUYER INSTALLMENT AMT: . . . .
SEC0NDARY NAP FIRST TIME HOME BUYER INSTALLMENT AMT3....

..$0.00

. . $0.00

$0.00

FIRST TIME HOMEBUYER CREDIT REPAYMENT AM0UNT:....


FORM 5405 TOTAL HOMEBUYERS CREDIT REPAYMENT PER COHPUTER:.
SMALL EMPLOYER HEALTH INSURANCE PER C0MPUTER: .
SMALL EMPLOYER HEALTH INSURANCE PER COMPUTER (2)....
FORM 2459 AND OTHER CREDITS:....

T0TAL PAYMENTS:....
TOTAL PAYMENTS PER C0MPUTER:

...$0.00

....$O.OO
. . . $0.00

.,...$O.O()
....SO.OO
..$9,226.09

.$9 ,225.00

Refund or Amount 0wed


REFUND

AH0UNT:....

..$-5,99\.00
...$0.00
..$0.00
...$0.00
.....$-5,991.00
....$-5,991.00

APPLIED T0 NEXT YEARTS ESTIMATED TAX:.....


ESTIHATED TAX PENALTY:..
TAX 0N INC0ME LESS STATE REFUND PER C0HPUTER:.
BAL DUE,/OVER PYMT USING TP FIG PER C0MPUTER:.
BAL DUE,/0VER PYMT USING C0MPUTER FIGURES:.....
FORH

8888 TOIAL

REFUND PER

CUHPUTER:.

$0.00

Third Party Designee


THIRD PARTY DESIGNEE

AUTH0RIZATI0N

ID NUMBER: . . . . .

INDICAT0R:.....

.......0

THIRD PARTY DESIGNEE NAME:

Schedule A--Itemized Deductions


MEDICAt,/DENTAL

HEDICAL AND DENTAL EXPENSES: . . .

$0.00

ADJUSTED GROSS INCOME PERCENTAGE: . . .


. s0.0u
ADJUSTED GROSS INCOME PERCENTAGE PER COMPUTER 1 0 PERCENT3....
..$14,301.00
ADJUSTED GROSS INCOME PERCENTAGE PER COMPUTER 7 .5 PERCENT:...
..$10,725.09
NET HEDICAL DEDUCTI0N: . . .
NET MEDICAL DEDUCTION PER
: : : : : : : . : : : : . . : : : : : . : . : : : : . : : : . . . : . : . :33:33

ioMiiiii;

TAXES PAID
STATE AND L0CAL INC0ME TAXES:....
INC0HE TAX 0R GENERAL SALES TAX:.
REAL ESTATE TAXES:....

$7,933.00
Income Taxes
$7,675.00
.$855.00
.$0.00

PERS0NAL PR0PERTY TAXES:....


0THER TAXES AM0UNT:....

INTEREST PAID

(FINANCIAL):..
DEDUCTIBLE P0INTS:....
QUALIFIED M0RTGAGE INSURANCE PREHIUMS:....

M0RTGAGE INTEREST

DEDUCTIBLE INVESTHENT INTEREST:


TOTAL INTEREST DEDUCTION:

......i..

.$13,050.00
; -. . . . . . . . $0.00
$0.00

.....$0.00

. . . $0.00
. . . $15,050.00

$15, 050 . oo

CHARITABLE CONTRIBUTIONS
CASH C0NTRIBUTI0NS3.......
0THER THAN CASH: Form 8283:

YEAR:....
C0NTRIBUTIONS:
CONTRIBUTI0NS PER C0MPUTER:.....

CARRY0VER FROM PRI0R

SCH
SCH

A T0TAL
A T0TAL

$1,250. 00

. .$24,998. oo

.$0.00
.$25,?48.00
$26,2q8.00

Trackins Number
CASUALTY AND THEFT LOSS
CASUALTY 0R THEFT

z L00?57559941

L0SS:

. . $0.00

JOBS AND MISCELLANEOUS

AM0UNT:....
EXPENSES:
NET LIMITED MISC DEDUCTI0N:....
NET LIMITED HISC DEDUCTION PER COMPUTER: .
UNREIMBURSED EMPL0YEE EXPENSE

TOTAL LIMITED MISC

.....$0.00
$1,655.00
...$0.00

. . . . $0.00

OTHER MISCELLANEOUS

....50.00
...$0.00

AMOUNT:..
DEDUCTI0NS:....

OTHER THAN GAHBLING

0THER MISC

TOTAL ITEMIZED DEDUCTIONS


079625

TOTAL ITEMIZED DEDUCTI0NS:...


TOTAL ITEMIZED DEDUCTI0NS PER C0MPUTER:....
ELECT ITEMIZED DEDUCTI0N INDICATORi.....
SCH A ITEMIZED PERCENTAGE PER COMPUTER:....

$55,755.00

....S55,763.00

....$0.00

fntenest and Dividends


GR0SS SCHEDULE B INTEREST:...
TAXABLE INTEREST INC0ME:....
EXCLUDABLE SAVINGS FR0M B0ND INT; .
GR0SS SCHEDULE B DIVIDENDS:..
DIVIDEND INC0ME:....
F0REIGN ACCOUNTS IND:.
REQUIRED T0 FILE FINCEN F0RM tl4:..
Schedule D--Capital Gains and Losses

5L24.00
.$124.00
. $0.00
..$ll '674.00
..$11,674.00

.....No

..None

SHORT TERM CAPITAL GAINS AND LOSSES

SH0RT TERM BASIS N0 ADJUSTMENTS SALE

BASIS N0 ADJUSTMENTS C0ST


TERM BASIS SALE AMOUNT!....
TERM BASIS C0ST AH0UNT3....
TERM BASIS ADJUSTMENTS:
TERH N0 BASIS SALE AM0UNT: . .
TERH N0 BASIS C0ST AM0UNT: . .
TERM N0 BASIS ADJUSTMENTS: . .
TERM N0 10998 SALE AM0UNT: . .
TERM N0 10998 COST AM0UNT: . .
TERM N0 10998 ADJUSTMENTS: . .

SHORT TERM

SH0RT
SHORT

SH0RT
SH0RT
SHORT
SHORT
SHORT

SH0RT

AHOUNT:..
AMOUNT:..

$0.00
$0.00
.5205.00
..$195.00
. . $0.00
. $0.00
. $0.00
. . $0.00
. . $0.00
. . $0.00
. 50.00
.50.00

SHORT
SHORT TERH SCHEDULE K-I AMOUNT:....
NET SHORT-TERM GAIN,/L0SS!....

.....$10.00

LONG TERI'I CAPITAL GAINS AND LOSSES

L0NG TERM BASIS


L0NG TERH BASIS
L0NG TERM BASIS
LONG TERM BASIS

N0 ADJUSTMENTS SALE AM0UNT: . .


N0 ADJUSTMENTS COST AMOUNT:..
SALE

. . . . $0.00

....$0.00
.....$103.00

AMOUNT:..
.

$96.00

COST AMOUNT: .

[uilffililiiiii;iliiiluilll

ii:i::::::::::::::::: :::::: :

:,

..

::iH H

TAX COMPUTATION USING MAXIMUM CAPITAL GAINS RATES

282

RATE

GAIN:

...$0.00

Number z 14025755994L
SECT: 1250 GAIN:
SCH D 152 TAX CMPTR:....
CAPITAL GAINS LESS INVEST INC0ME PER C0HPUTER:.
CAP GAINS TENTATIVE AMT PER C0MPUTER (1):.
CAP GAINS TAX AMT PER C0HPUTER (1) r..
CAP GAINS TENTATIVE AMT PER C0MPUTER (2):.
CAP GAINS TAX AMT PER C0HPUTER (5):..
CAP GAINS TAX AMT PER C0MPUTER (5):..
SCHEDULE D TAX PER COMPUTER:.
Form 8853 - Education Cnedits (Hope and Lifetime Leanning Credits)

Trackins

UNRECAPTURED

Part I -

....$0.00
....$0.00

..$4,222.09
.$15,554.00
..$5,589.00
.$13,664.00
.$0.00
.$0.00
$5,389.00

EDUCATION CREDITS

STUDENT I NAHE CNTRL!....


STUDENT I SSN:......
STUDENT 2 NAME CNTRL
STUDENT 2 SSN:....
STUDENT 3 NAME CNTRL:....
STUDENT 5 SSN!....

. . READ

545-22-6668

TENTATIVE CREDIT AHOUNT:


PART

II - LIFETIME LEARNING

CREDITS

TOTL LIFETIM LRNING CR QLFD EXP:.

EDUCATIONAL INSTITUTION FEDERAL ID NUMBER


SECOND EDUCATIONAL INSTITUTION FEDERAL ID
EDUCATIONAL INSTITUTION FEDERAL ID NUMBER
SECOND EDUCATIONAL INSTITUTION FEDERAL ID
EDUCATIONAL INSTITUTION FEDERAL ID NUMBER
SECOND EDUCATIONAL INSTITUTION FEDERAL ID
PRIOR YEAR HOPE SCHOLARSHIP OR AOT CREDIT
ACADEHIC ELIGIBILITY, STUDENT 1:...
P0ST-SEC0NDARY COMPLETE STUDENT 1: . . .
FELONY C0NVICTION STUDENT 1: . . .
PRIOR YEAR H0PE SCH0LARSHIP 0R A0T CREDIT
ACADEMIC ELIGIBILITV STUDENT 2!....
POST-SECONDARY COHPLETE STUDENT 22...
FEL0NY C0NVICTI0N STUDENT 2:...
PRIOR YEAR H0PE SCH0LARSHIP 0R A0T CREDIT
ACADEMIC ELIGIBILITY STUDENT 3I.
P0ST-SEC0NDARY COMPLETE STUDENT 3:...
FELONY C0NVICTI0N STUDENT 3: .

....$0.00
'iiuDiNi 1:.,...
000000000
NUMBER, STUDENT i : . . . . . . . . .000000000
STUDENT 2;.....
000000000
NUMBER STUDENT 2:...
..000000000
STUDENT 3:.....
. .000000000
NUMBER STUDENT 3:...
..000000000
CLAIMEI) STUDENT 1:...
N0
.....YES

CLAIMED STUDENT ?2...

CLAIMED STUDENT

5,...

i'EiiciBii'

III -

.N0NE

...N0NE
..N0NE

VERIFIED NUMBER OF EDUCATION CREDi


STUDENTS:....
TOTL LIFETIM LRNING CR QLFD E XP PE R COMPUTER:
PART

N0
N0

.NONE

......N0NE
.NONE

......NONE
....NoNE

. .00

ALLOWABLE EDUCATION CREDITS

GR0SS EDUCATI0N CR PER C0MPUTER:....


T0TAL EDUCATI0N CREDIT AM0UNT:....
T0TAL EDUCATI0N CREDIT AMOUNT PER C0MPUTER:.

This Product Contains Sensitive Taxpayer Data

...$I,500.00
....$1,500.00
....$1,500.00