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Department of the TreasuryInternal Revenue Service

Form Income Tax Return for Single and


1040EZ Joint Filers With No Dependents (99) 2015 OMB No. 1545-0074
Your first name and initial Last name Your social security number
JUNELLY C COZAR MORON 280 53 4621
If a joint return, spouses first name and initial Last name Spouses social security number

Home address (number and street). If you have a P.O. box, see instructions. Apt. no.

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c Make sure the SSN(s)
2160 S 1200 W above are correct.
City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions). Presidential Election Campaign
West Haven UT 84401 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

Income 1 Wages, salaries, and tips. This should be shown in box 1 of your Form(s) W-2.
Attach your Form(s) W-2. 1 3,649.
Attach
Form(s) W-2
here. 2 Taxable interest. If the total is over $1,500, you cannot use Form 1040EZ. 2
Enclose, but do
not attach, any 3 Unemployment compensation and Alaska Permanent Fund dividends (see instructions). 3
payment.
4 Add lines 1, 2, and 3. This is your adjusted gross income. 4 3,649.
5 If someone can claim you (or your spouse if a joint return) as a dependent, check
the applicable box(es) below and enter the amount from the worksheet on back.
You Spouse
If no one can claim you (or your spouse if a joint return), enter $10,300 if single;
$20,600 if married filing jointly. See back for explanation. 5 10,300.
6 Subtract line 5 from line 4. If line 5 is larger than line 4, enter -0-.
This is your taxable income. a 6 0.
7 Federal income tax withheld from Form(s) W-2 and 1099. 7 312.
Payments, 8a Earned income credit (EIC) (see instructions) 8a
No
Credits, b Nontaxable combat pay election. 8b

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and Tax 9 Add lines 7 and 8a. These are your total payments and credits. a 9 312.
10 Tax. Use the amount on line 6 above to find your tax in the tax table in the
instructions. Then, enter the tax from the table on this line. 10 0.
11 Health care: individual responsibility (see instructions) Full-year coverage 11
12 Add lines 10 and 11. This is your total tax. 12 0.
Refund 13a If line 9 is larger than line 12, subtract line 12 from line 9. This is your refund.
If Form 8888 is attached, check here a 13a 312.
Have it directly
deposited! See
instructions and a b Routing number 1 0 2 0 0 0 0 7 6 ac Type: Checking Savings
fill in 13b, 13c,
and 13d, or
Form 8888. a d Account number 2 5 7 3 4 0 2 3 4 0
Amount 14 If line 12 is larger than line 9, subtract line 9 from line 12. This is
You Owe the amount you owe. For details on how to pay, see instructions. a 14
Do you want to allow another person to discuss this return with the IRS (see instructions)? Yes. Complete below. No
Third Party
Designee Designees Phone Personal identification
name a no. a number (PIN) a

Sign 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
accurately lists all amounts and sources of income I received during the tax year. Declaration of preparer (other than the taxpayer) is based
Here on all information of which the preparer has any knowledge.
Your signature Date Your occupation Daytime phone number
F

Joint return? See


instructions. Lodge Attendant (970)331-2725
Keep a copy for Spouses signature. If a joint return, both must sign. Date Spouses occupation If the IRS sent you an Identity Protection
your records. PIN, enter it
here (see inst.)

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Print/Type preparers name Preparers signature Date PTIN
Paid Check if
self-employed
Preparer
Firms name a Self-Prepared Firms EIN a
Use Only
Firms address a Phone no.
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see instructions. BAA REV 12/30/15 Intuit.cg.cfp.sp
Form 1040EZ (2015)
8965
OMB No. 1545-0074
Health Coverage Exemptions
Form

Department of the Treasury


a Attach to Form 1040, Form 1040A, or Form 1040EZ. 2015
a Information about Form 8965 and its separate instructions is at www.irs.gov/form8965. Attachment
Internal Revenue Service Sequence No. 75
Name as shown on return Your social security number
JUNELLY C COZAR MORON 280-53-4621
Complete this form if you have a Marketplace-granted coverage exemption or you are claiming a coverage exemption

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on your return.
Marketplace-Granted Coverage Exemptions for Individuals. If you and/or a member of your tax household
Part I
have an exemption granted by the Marketplace, complete Part I.
(a) (b) (c)
Name of Individual SSN Exemption Certificate Number

6
Part II

7a

b
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Coverage Exemptions Claimed on Your Return for Your Household

Are you claiming an exemption because your household income is below the filing threshold? .

Are you claiming a hardship exemption because your gross income is below the filing threshold?
. .

.
.

.
.

.
.

.
Yes

Yes
No

No
Coverage Exemptions Claimed on Your Return for Individuals. If you and/or a member of your tax
Part III
household are claiming an exemption on your return, complete Part III.
(c) (d)
(a) (b) (e) (f) (g) (h) (i) (j) (k) (l) (m) (n) (o) (p)
Exemption Full
Name of Individual SSN Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
Type Year

8 JUNELLY COZAR MORO 280-53-4621 G

10

11

12

13
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For Privacy Act and Paperwork Reduction Act Notice, see your tax return instructions. BA REV 12/09/15 Intui Form 8965 (2015)
ELECTRONIC POSTMARK - CERTIFICATION OF ELECTRONIC FILING

Taxpayer: JUNELLY C COZAR MORON


Primary SSN: 280-53-4621

Federal Return Submitted: February 29, 2016 06:42 AM PST

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Federal Return Acceptance Date:

Your return was electronically transmitted on 02/29/2016

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
information should be kept on file with your tax return and other tax-related documentation.

There are two important aspects of the Intuit Electronic Postmark:

1. THE INTUIT ELECTRONIC POSTMARK.


The electronic postmark shows the date and time Intuit received the federal return, and is deemed the
filing date if the date of the electronic postmark is on or before the date prescribed for filing of the
federal individual income tax return.

TIMELY FILING:
For your federal return to be considered filed on time, your return must be postmarked on or before
midnight April 18, 2016. Intuits electronic postmark is issued in the Pacific Time (PT) zone. If you are
not filing in the PT zone, you will need to add or subtract hours from the Intuit Electronic Postmark time
to determine your local postmark time. For example, if you are filing in the Eastern Time (ET) zone and
you electronically file your return at 9 AM on April 18, 2016, your Intuit electronic postmark will indicate
April 18, 2016, 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 18, 2016, and a corrected return is submitted and accepted

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before April 23, 2016. If your return is submitted after April 23, 2016, a new time stamp is issued to
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 17, 2016 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 17, 2016, and the corrected return is submitted and
accepted by October 20, 2015.

2. THE ACCEPTANCE DATE.


Once the IRS accepts the electronically filed return, the acceptance date will be provided by the Intuit
Electronic Filing Center. This date is proof that the IRS accepted the electronically filed return.

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Utah State Tax Commission 2015
40501 Utah Individual Income Tax Return TC-40
All State Income Tax Dollars Fund Education INTUIT
1555
Amended Return - enter code: (code 1 - 5 from instructions)
USTC ORIGINAL FORM

Your Social Security No. Your first name Your last name If deceased,
complete

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280534621 JUNELLY COZAR MORON
Spouses Soc. Sec. No. Spouses first name Spouse's last name page 3,
Part 1
Address Telephone number
2160 S 1200 W
City State ZIP+4 Foreign country (if not U.S.)
WEST HAVEN UT 84401
1 Filing Status - enter code 2 Exemptions - enter number 3 Election Campaign Fund - enter code
1 = Single a 1 Yourself* Does not increase your tax or reduce your refund
1 2 = Married filling jointly b Spouse* C = Constitution
3 = Married filing separately c Dependents* D = Democratic Yourself Spouse
4 = Head of household d Dependents with a disability M = Independent American
5 = Qualifying widow(er) e 1 Total exemptions (add a through d) L = Libertarian
If using code 2 or 3, enter spouses name and SSN above * from federal return R = Republican N = No contribution

4 Federal adjusted gross income from federal return 4 3649.


5 Additions to income from TC-40A, Part 1 (attach TC-40A, page 1) 5

6 Total income - add line 4 and line 5 6 3649.


7 State tax refund included on federal form 1040, line 10, if any 7

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Subtractions from income from TC-40A, Part 2 (attach TC-40A, page 1)

Utah taxable income (loss) - subtract the sum of lines 7 and 8 from line 6

10 Utah tax - multiply line 9 by 5% (.05) (not less than zero)


8

10
3649.

182.
11 Exemption amount - multiply line 2e by $3,000 (if line 4 over $154,950, see instr.) 11 3000.
Electronic filing
12 Federal standard or itemized deductions 12 6300. is quick, easy and
free, and will
13 Add line 11 and line 12 13 9300. speed up your refund.

14 State income tax deducted on federal Schedule A, line 5, if any 14 To learn more,
go to
15 Subtract line 14 from line 13 15 9300. taxexpress.utah.gov

16 Initial credit before phase-out - multiply line 15 by 6% (.06) 16 558.


17 Enter: $13,805 (if single or married filing separately); $20,707 (if head 17 13805.
of household); or $27,610 (if married filing jointly or qualifying widower)
18 Income subject to phase-out - subtract line 17 from line 9 (not less than zero) 18 0.
19 Phase-out amount - multiply line 18 by 1.3% (.013) 19

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0.
20 Taxpayer tax credit - subtract line 19 from line 16 (not less than zero) 20 558.
21 If you are a qualified exempt taxpayer, enter X (complete worksheet in instr.) 21 X

22 Utah income tax - subtract line 20 from line 10 (not less than zero) 22 0.
REV 12/03/15 INTUIT.CG.CFP.SP
Utah Individual Income Tax Return (continued) INTUIT TC-40 Pg. 2
40502 SSN 280534621 Last name COZAR MORON 2015
USTC ORIGINAL FORM

23 Enter tax from TC-40, page 1, line 22 23 0.


24 Apportionable nonrefundable credits from TC-40A, Part 3 (attach TC-40A, page 1) 24

25 Full-year resident, subtract line 24 from line 23 (not less than zero) 25

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0.
Non or Part-year resident, enter the tax from TC-40B,line 38
26 Nonapportionable nonrefundable credits from TC-40A, Part 4 (attach TC-40A, page 1) 26

27 Subtract line 26 from line 25 (not less than zero) 27 0.


28 Voluntary contributions from TC-40, page 3, Part 4 (attach TC-40, page 3) 28

29 AMENDED RETURN ONLY - previous refund 29

30 Recapture of low-income housing credit 30

31 Utah use tax 31

32 Total tax, use tax and additions to tax (add lines 27 through 31) 32 0.
33 Utah income tax withheld shown on TC-40W, Part 1 (attach TC-40W, page 1) 33 109.
34 Credit for Utah income taxes prepaid from TC-546 and 2014 refund applied to 2015 34

35 Pass-through entity withholding tax shown on TC-40W, Part 3 (attach TC-40W, page 2) 35

36 Mineral production withholding tax shown on TC-40W, Part 2 (attach TC-40W, page 2) 36

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37 AMENDED RETURN ONLY - previous payments

38 Refundable credits from TC-40A, Part 5 (attach TC-40A,page 2)

39 Total withholding and refundable credits - add lines 33 through 38


37

38

39 109.
40 TAX DUE - subtract line 39 from line 32 (not less than zero) 40
41 Penalty and interest (see instructions) 41
42 TOTAL DUE - PAY THIS AMOUNT - add line 40 and line 41 42

43 REFUND - subtract line 32 from line 39 (not less than zero) 43 109.
44 Amount of refund on line 43 to be applied to your 2016 taxes 44

45 DIRECT DEPOSIT YOUR REFUND - provide account information (see instructions for foreign accounts) checking savings
Routing number 102000076 Account number 2573402340 Account type: X

Under penalties of perjury, I declare to the best of my knowledge and belief, this return and accompanying schedules are true, correct and complete.
SIGN Your signature Date Spouses signature (if filing jointly) Date
HERE
Third Party Name of designee (if any) you authorize to discuss this return Designees telephone number Designee PIN
Designee

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Preparers signature Date Preparers telephone number Preparers PTIN
Paid
Preparers Firms name SELF-PREPARED Preparers EIN
Section and address

Attach TC-40 page 3 if you are filing for a deceased taxpayer, filing a fiscal year return, filed IRS form 8886, are making voluntary contributions, requesting a direct deposit
to be sent to your Utah Educational Savings Plan, requesting a direct deposit to be sent to a foreign account, or are no longer entitled to a homeowners exemption.
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Part 1 - Utah Withholding Tax Schedule INTUIT TC-40W Pg. 1
40509 SSN 280-53-4621 Last name COZAR MORON 2015
USTC ORIGINAL FORM

Line Explanations IMPORTANT

1 Employer/payer ID number from W-2 box b or 1099 Do not send your W-2s or 1099s with your return. Instead enter
2 Utah withholding ID number from W-2 box 15 or 1099 W-2 or 1099 information below, but only if there is Utah withholding

3
4
5
6
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(14 characters, ending in WTH, no hyphens)
Employer/payer name and address from W-2 box c or 1099
Enter X if reporting Utah withholding from form 1099
Employees Social Security number from W-2 box a or 1099
Utah wages or income from W-2 box 16 or 1099
on the form.

Use additional forms TC-40W if you have more than four W-2s and/or
1099s with Utah withholding tax.

7 Utah withholding tax from W-2 box 17 or 1099 Enter mineral production withholding from TC-675R in Part 2 of TC-40W;
enter pass-through entity withholding in Part 3 of TC-40W.

First W-2 or 1099 Second W-2 or 1099


1 203967749 1

2 11904858003WTH (14 characters, no hyphens) 2 (14 characters, no hyphens)

3 SINCLAIR SERVICES COMPANY 3


550 EAST SOUTH TEMPLE
SALT LAKE CITY UT84130
4 4

5 280534621 5

6 6

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3649.
7 109. 7

Third W-2 or 1099 Fourth W-2 or 1099


1 1

2 (14 characters, no hyphens) 2 (14 characters, no hyphens)

3 3

4 4

5 5

6 6

7 7

Enter total Utah withholding tax from all lines 7 here and on TC-40, page 2, line 33:

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109.
Submit page ONLY if data entered.
Attach completed schedule to your Utah Income Tax Return.
Do not attach W-2s or 1099s to your Utah return.

REV 12/03/15 INTUIT.CG.CFP.SP