rte rnin Reeonseven 8) £1040 Gis"inaividua income Tax Return [20 19 | nano. 15864074 173 Use Ony—Do ot new sen i spe Fling Seatus [singe C1 wenicsing ony (J Maric ting spare FS) [Head otneusno HOH C] Guniting wid OW) Nota reckon “Tyouerasd the HFS ba ater hme capes yeu ace he OH or box ore chia ao equaling powon sla but ot our epenert auras and mit Castro ‘Your sci sect rarer FIRST M LAST SSN XX) XXXX Want etry spouse's fate and ia ial taste ‘Spouse's social sear nib (LEAVE BLANK) (LEAVE BLANK) ome aes purber and soe, Fyutave a0, box se rebut Aocmm | Presiden con Conpcin GENERAL DELIVERY, 1234 POST OFFICE ADDRESS erento re senza esp oR pa Fok Ft gla vorrei po eset eens CIty / TOWN, ST 12345 feserire [1 You [pe Ferspn ouny name Foran rowea/aaeaniy Fos 6 | re an ou dept, (if providing one) seceatetorsend tee >] Standard Someone con claim: (] You ssacenendent (] Yur souso asa sopenet Deduction] spouse temses ona spar tun or you ere a chat ttus aon AaerBinness You] Wareborn bets mary 2.1955 CT tebind Spouse: [1] Wat bom bore January2, 1855] te bie Dependents (ee insirveons) eo (0 iar cos race (Festa Late nite" Gear oe eyes o o o o (ZEAVE BLANK) o o o o 1 Wages ean ps le ach Fer 2 ae + [== 2 Tarra ines! z| -0- Toate teen Ser sieges [a man 3a Quatieg vende zx | =0= Ordre noes. Ate son siequies [30 Seteaonte | 4a monotone | =0= Tape eourt 2 saidectired| ¢ porsone an ermutn we | =0= atoaemout 2 2... [as Egy socaisecty beets = |__-0- Taxa anourt se stredtog | a captal gan or ees tach SetedulD reaured naira, check he +w [es [ -o- EEE) ro omereomerom scree 39 SEE ATTACHED 1096 ¢ 1099-010 za |_AMOUNT™ tet Ase 26 26,58 Ti sour tt income ‘AMOUNT# ete | oe sine eco torn Scheie re 22 =0= cHyenctced [_bSubact ine fone 7. Tis aur alse gras income =0= Stora deducton or temized deduction rom Schade ste anes nar deduct Atch Form 895 at Far 85058 Aisne ard 10 Taxable income, Suotctin 1rom ins 27 6rB6, ena-0- =0= Tor Disclosure, Puacy At and Paperwork Reduction Ast Notice, sce separate stuns earn ee Fan 1080 255) *THE AMOUNT SHOULD BE THE TOTAL FOR ALL BILLS BEING REPORTED FOR DISCHARGE. DEFINITIONS FOR FILING STATUSES SINGLE - SINGLE HEAD OF HOUSEHOLD = SINGLE BUT WITH DEPENDENTS (KIDS) WIDOW (2 YEARS OR LESS AFTER DEATH OF SPOUSE) QUALIFYING WIDOWERForm 1040 (2012 Page 2 2a Tax|see inst } Check tany trom Forms: 4 [_] e814 2 [_] 4972 3 [) s2a| (BLANK) LEAVE ts ebiaeatnnrie > [am |_ BEANE 80 Chid tex erect or eect for other dependents sa0| (BLANK) tse i nha =| 11 Sim tent nao rm 1S chrono Swab ‘ te Atm tn os 17 Fadera income tax wahheld from Fors W-2 anci 1099 SEB ATTACHED 1036 6 1999-019 | 47 | AMOUNT* (crmanmon LAS ter parents an refundable cect: Geis os emdeorecene sso|_(BLANK) ‘b Additional child tax erect. Attach Schedule B612 teb| (BLANK) ‘© American opportunity ered trom Form 8863, line 8 - sec] (BLANK) Scheduled, tne 14 sea (BLANK) (© Add lines 18a through 18d, These are your total other payments and refundable credits > | 100 -0- tetas ira to oma a > [Fs aeons Refund tine 19s mote rani 16, abate 1 ose 1. TH isthe mount you eveBai ~. [ao | =0- Amount of ine 20 you wont refunded te you. i Form 8888 9 attached, checkhewe ss. LD | aie = B= Bree ai? outha number OCR [DCL DECC >eTvpe: [Cloneomna C] Savnoe Semmens yg accouncrumber |_| (yuk [rdal [banking |infay 22 Amount of Ine 20 you want applied to your 2020 estimated tax > | ee mi EiRourk snot yon rc io Per Gantt re > [| —o- YouOwe 4 tana py nmin > les] -0- Third Party 09,00 wantto allow anotner person (oer than yourpad preparer to discuss ths rum wth the RS? See natuctions. [_] Yes. Compleie iow. Designee Bn fae oo repel Bim See an ieee (TTT Sign Sees ees eee eee Here “Your signature ae sl erecta deed {the IFS sent you an Icentity Bbaxrs|"""Rithorizeg | feecer tarts etna BY: Fisur Mat GaTE | Representative [rhe ee TR REN RTE eet ene Praneno (XXX) _XXX-XXXX Email accrens email@domain.com tate Seana Soe Sk Tore Paid Cara party Desisnee Prepater aay maa Clearer 30 Only Ee Tae Seromer sco nec Ra ao *THE AMOUNT SHOULD BE THE TOTAL FOR ALL BILLS BEING REPORTED FOR DISCHARGE.