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2010 Income Tax Return

Federal Return
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1040
P R I N T C L E A R L Y

Form

Department of the TreasuryInternal Revenue Service

U.S. Individual Income Tax Return CHARLES E

2010

(99)

IRS Use OnlyDo not write or staple in this space.

Name, Address, and SSN


See separate instructions.

For the year Jan. 1Dec. 31, 2010, or other tax year beginning Last name Your first name and initial If a joint return, spouses first name and initial

, 2010, ending

, 20

OMB No. 1545-0074 Your social security number Spouses social security number

PAVLICK
Last name Apt. no.

458 04 0892

Home address (number and street). If you have a P.O. box, see instructions.

1701 MARY LANE


City, town or post office, state, and ZIP code. If you have a foreign address, see instructions.

Make sure the SSN(s) above and on line 6c are correct.

Presidential Election Campaign

WICHITA FALLS, TX

76302
. . . . 4

Checking a box below will not change your tax or refund.

Check here if you, or your spouse if filing jointly, want $3 to go to this fund 1 2 3 6a b c

You

Spouse

Filing Status
Check only one box.

Single Married filing jointly (even if only one had income) Married filing separately. Enter spouses SSN above and full name here.

Head of household (with qualifying person). (See instructions.) If the qualifying person is a child but not your dependent, enter this childs name here.

5 . . . .

Qualifying widow(er) with dependent child

Exemptions

Yourself. If someone can claim you as a dependent, do not check box 6a . . . . . . . . . . . . . . . .


(2) Dependents social security number (3) Dependents relationship to you

. .

. .

. .

. .

Spouse . Dependents:

(1) First name

Last name

(4) if child under age 17 qualifying for child tax credit (see page 15)

Boxes checked on 6a and 6b No. of children on 6c who: lived with you


did not live with you due to divorce or separation (see instructions) Dependents on 6c not entered above

If more than four dependents, see instructions and check here d Total number of exemptions claimed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 8a 9a 10 11 12 13 14 15b 16b 17 18 19 20b 21 22

Add numbers on lines above

Income
Attach Form(s) W-2 here. Also attach Forms W-2G and 1099-R if tax was withheld.

7 8a b 9a b 10 11 12 13 14 15a 16a 17 18 19 20a 21 22 23 24 25 26 27 28 29 30 31a 32 33 34 35 36 37

Wages, salaries, tips, etc. Attach Form(s) W-2 . Taxable interest. Attach Schedule B if required . Tax-exempt interest. Do not include on line 8a . Ordinary dividends. Attach Schedule B if required

. . 8b . .

1 43,073. 81.

Qualified dividends . . . . . . . . . . . 9b Taxable refunds, credits, or offsets of state and local income taxes Alimony received . . . . . . . . . . . . . . .

If you did not get a W-2, see page 20. Enclose, but do not attach, any payment. Also, please use Form 1040-V.

Business income or (loss). Attach Schedule C or C-EZ . . . . . . . . . Capital gain or (loss). Attach Schedule D if required. If not required, check here Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . .

IRA distributions . 15a b Taxable amount . . . Pensions and annuities 16a b Taxable amount . . . Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E Farm income or (loss). Attach Schedule F . Unemployment compensation . . . . Social security benefits 20a . . . . . . . . . . . . . . . . . . . . b Taxable amount . . . . . . . . .

Other income. List type and amount Combine the amounts in the far right column for lines 7 through 21. This is your total income Educator expenses . . . . . . . . . . 23 24 25 26 27 28 29 30 31a 32 33 34 . . . . . . . . . . Certain business expenses of reservists, performing artists, and fee-basis government officials. Attach Form 2106 or 2106-EZ Health savings account deduction. Attach Form 8889 Moving expenses. Attach Form 3903 . . . . . One-half of self-employment tax. Attach Schedule SE Self-employed SEP, SIMPLE, and qualified plans . Self-employed health insurance deduction . . . Penalty on early withdrawal of savings . Alimony paid b Recipients SSN IRA deduction . . . . . .

43,154.

Adjusted Gross Income

. . . . . . . . .

2,400.

. . . .

. . . .

. . . .

. . . .

. Student loan interest deduction . . Tuition and fees. Attach Form 8917 .

. . .

Domestic production activities deduction. Attach Form 8903 35 Add lines 23 through 31a and 32 through 35 . . . . . . . Subtract line 36 from line 22. This is your adjusted gross income

36 37
Form

2,400. 40,754.
1040
(2010)

For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. CDA

Cat. No. 11320B

Form 1040 (2010)

CHARLES E PAVLICK
38 39a b 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 Amount from line 37 (adjusted gross income) Check if:

Tax and Credits

You were born before January 2, 1946, Spouse was born before January 2, 1946,

Blind. Blind.

Page 2 458-04-0892 38 40,754.

Total boxes checked 39a 40 41 42 43 44 45 46

39b Itemized deductions (from Schedule A) or your standard deduction (see instructions) . . Subtract line 40 from line 38 . . . . . . . . Exemptions. Multiply $3,650 by the number on line 6d . . . . . . . . . . . . . . . . . . . . . . . .

If your spouse itemizes on a separate return or you were a dual-status alien, check here

Taxable income. Subtract line 42 from line 41. If line 42 is more than line 41, enter -0- . Tax (see instructions). Check if any tax is from: a Form(s) 8814 Alternative minimum tax (see instructions). Attach Form 6251 . . Add lines 44 and 45 . . . . . . . . . . . . . . . Foreign tax credit. Attach Form 1116 if required . . . .
Credit for child and dependent care expenses. Attach Form 2441

b . . . .

Form 4972 . . . . . . . . . .

5,700. 35,054. 3,650. 31,404. 4,295. 4,295.

47 48 49 50 51

Education credits from Form 8863, line 23 . . . . . Retirement savings contributions credit. Attach Form 8880 Child tax credit (see instructions) . . . . . . . .

Residential energy credits. Attach Form 5695 . . . . 52 3800 b 8801 c Other credits from Form: a 53 Add lines 47 through 53. These are your total credits . . . . . Subtract line 54 from line 46. If line 54 is more than line 46, enter -0Self-employment tax. Attach Schedule SE . . . . Unreported social security and Medicare tax from Form: a Form(s) W-2, box 9 b Schedule H Add lines 55 through 59. This is your total tax . c . . . . . . . a 4137

. . .

. . . b

. . .

. .

. .

. . . .
.

54 55 56 57 58 59 60

0. 4,295.

Other Taxes

56 57 58 59 60 61 62 63 64a b 65 66 67 68 69 70 71 72

. . 8919 . . . .

. .
.

Additional tax on IRAs, other qualified retirement plans, etc. Attach Form 5329 if required

Form 5405, line 16 . . . . . . 61 62 63 64a 65 66 67 68

. .

4,295.

Payments
If you have a qualifying child, attach Schedule EIC.

Federal income tax withheld from Forms W-2 and 1099 . . 2010 estimated tax payments and amount applied from 2009 return Making work pay credit. Attach Schedule M . . . . . . . Earned income credit (EIC) . . . . Nontaxable combat pay election 64b Additional child tax credit. Attach Form 8812 . .

4,972. 400.

NO . .
. .

. .

. . . . .

. . . . .

American opportunity credit from Form 8863, line 14 . First-time homebuyer credit from Form 5405, line 10 . Amount paid with request for extension to file . . .
Excess social security and tier 1 RRTA tax withheld

. . . . 69 Credit for federal tax on fuels. Attach Form 4136 . . . . 70 Credits from Form: a 2439 b 8839 c 8801 d 8885 71 Add lines 61, 62, 63, 64a, and 65 through 71. These are your total payments .

Refund

73

If line 72 is more than line 60, subtract line 60 from line 72. This is the amount you overpaid Amount of line 73 you want refunded to you. If Form 8888 is attached, check here . Routing number 3 1 1 9 9 0 3 9 1 c Type: Checking X Savings Account number 5 2 0 1 2 2 5 Amount of line 73 you want applied to your 2011 estimated tax 75 Amount you owe. Subtract line 72 from line 60. For details on how to pay, see instructions

72 73 74a

Direct deposit? See instructions.

74a b d 75 76

5,372. 1,077. 1,077.

Amount You Owe

76

0. X
No

Third Party Designee

77 77 Estimated tax penalty (see instructions) . . . . . . . Do you want to allow another person to discuss this return with the IRS (see instructions)?
Designees name Phone no.

Yes. Complete below.

Sign Here
Joint return? See page 12. Keep a copy for your records.

Personal identification number (PIN)

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 complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Your signature

Date

Your occupation

Daytime phone number

IT MANAGER
Date Spouses occupation Date Preparers signature

940-761-8632
PTIN

Spouses signature. If a joint return, both must sign.

Paid Preparer Use Only

Print/Type preparers name

SELF-PREPARED
Firms name Firms address

Check if self-employed Firm's EIN Phone no.

Form 1040 (2010)

CDA

Form

8889
Attach

Health Savings Accounts (HSAs)


to Form 1040 or Form 1040NR.
See

OMB No. 1545-0074

Department of the Treasury Internal Revenue Service

separate instructions.

Name(s) shown on Form 1040 or Form 1040NR

CHARLES E PAVLICK
Part I

Social security number of HSA beneficiary. If both spouses have HSAs, see instructions

Attachment Sequence No. 53

2010

458-04-0892

Before you begin: Complete Form 8853, Archer MSAs and Long-Term Care Insurance Contracts, if required. 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 2

Check the box to indicate your coverage under a high-deductible health plan (HDHP) during 2010 (see instructions). . . . . . . . . . . . . . . . . . . . . . . . HSA contributions you made for 2010 (or those made on your behalf), including those made from January 1, 2011, through April 18, 2011, that were for 2010. Do not include employer contributions, contributions through a cafeteria plan, or rollovers (see instructions) . . . . . If you were under age 55 at the end of 2010, and on the first day of every month during 2010, you were, or were considered, an eligible individual with the same coverage, enter $3,050 ($6,150 for family coverage). All others, see the instructions for the amount to enter . . . . Enter the amount you and your employer contributed to your Archer MSAs for 2010 from Form 8853, lines 1 and 2. If you or your spouse had family coverage under an HDHP at any time during 2010, also include any amount contributed to your spouses Archer MSAs . . . . . Subtract line 4 from line 3. If zero or less, enter -0- . . . . . . . . . . . . . . . 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 2010, see the instructions for the amount to enter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . If you were age 55 or older at the end of 2010, married, and you or your spouse had family coverage under an HDHP at any time during 2010, enter your additional contribution amount (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . Add lines 6 and 7 . . . . . . . . . . . . . . . . . . . . . . . . . . Employer contributions made to your HSAs for 2010 . . . . 9 Qualified HSA funding distributions . . . . . . . . . . 10 Add lines 9 and 10 . . . . . . . . . . . . . . . . . . . . . . . . . . Subtract line 11 from line 8. If zero or less, enter -0- . . . . . . . . . . . . . . . HSA deduction. Enter the smaller of line 2 or line 12 here and on Form 1040, line 25, or Form 1040NR, line 25 . . . . . . . . . . . . . . . . . . . . . . . . . . . Caution: If line 2 is more than line 13, you may have to pay an additional tax (see page 5 of the instructions).

X
2

Self-only

Family

2,400. 4,050.

5 6

4 5

4,050. 4,050.

8 9 10 11 12 13

7 8

4,050.

11 12 13

4,050. 2,400.

Part II
14a

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 2010 from all HSAs (see instructions)

2,400.

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) . . . . . . . . . . . . c Subtract line 14b from line 14a . . . . . . . . . . . . . . . . . . . . . . 15 Unreimbursed qualified medical expenses (see instructions) . . . . . . . . . . . . 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 . . . . . . . . . . . . . . . . If any of the distributions included on line 16 meet any of the Exceptions to the Additional 10% Tax (see instructions), check here . . . . . . . . . . . . . . . . .

14b 14c 15

2,400. 2,400.

16

17a

b Additional 10% tax (see instructions). Enter 10% (.10) of the distributions included on line 16 that are subject to the additional 10% tax. Also include this amount in the total on Form 1040, line 60, or Form 1040NR, line 59. On the dotted line next to Form 1040, line 60, or Form 1040NR, line 59, enter HSA and the amount . . . . . . . . . . . . . . . . .
For Paperwork Reduction Act Notice, see your tax return instructions.
Cat. No. 37621P

17b
Form 8889 (2010)

CDA

SCHEDULE M (Form 1040A or 1040)


Department of the Treasury Internal Revenue Service (99) Name(s) shown on return

Making Work Pay Credit


Attach to Form 1040A or 1040. See separate instructions.

OMB No. 1545-0074

Attachment Sequence No.

2010
166

Your social security number

CHARLES E PAVLICK

458-04-0892

!
CAUTION

To take the making work pay credit, you must include your social security number (if filing a joint return, the number of either you or your spouse) on your tax return. A social security number does not include an identification number issued by the IRS. Only the Social Security Administration issues social security numbers.

!
CAUTION

You cannot take the making work pay credit if you can be claimed as someone else's dependent or if you are a nonresident alien.

Important: Check the No box on line 1a and see the instructions if: (a) You have a net loss from a business, (b) You received a taxable scholarship or fellowship grant not reported on a Form W-2, (c) Your wages include pay for work performed while an inmate in a penal institution, (d) You received a pension or annuity from a nonqualified deferred compensation plan or a nongovernmental section 457 plan, or (e) You are filing Form 2555 or 2555-EZ. 1a Do you (and your spouse if filing jointly) have 2010 wages of more than $6,451 ($12,903 if married filing jointly)? X Yes. Skip lines 1a through 3. Enter $400 ($800 if married filing jointly) on line 4 and go to line 5. No. Enter your earned income (see instructions) . . . . . . . 1a

b Nontaxable combat pay included on line 1a (see instructions) . . . . . . . . . 2 3 4 5 6 7 Multiply line 1a by 6.2% (.062) . . . . . . . .

1b . . . . . . . . . . . . . . . . 2 3 . 5 6 . . . . . . . 4

Enter $400 ($800 if married filing jointly) .

Enter the smaller of line 2 or line 3 (unless you checked Yes on line 1a) . Enter the amount from Form 1040, line 38*, or Form 1040A, line 22 . Enter $75,000 ($150,000 if married filing jointly) . . . . . . . . .

400.

40,754. 75,000.

Is the amount on line 5 more than the amount on line 6? X No. Skip line 8. Enter the amount from line 4 on line 9 below. Yes. Subtract line 6 from line 5 . . . . . . . . . . . Multiply line 7 by 2% (.02) . . . . . . . . . . . . . . . . . . . .

. . . . .

7 . . . . . . . . . . . . . . . . 8 9

8 9 10

Subtract line 8 from line 4. If zero or less, enter -0-

400.

Did you (or your spouse, if filing jointly) receive an economic recovery payment in 2010? You may have received this payment in 2010 if you did not receive an economic recovery payment in 2009 but you received social security benefits, supplemental security income, railroad retirement benefits, or veterans disability compensation or pension benefits in November 2008, December 2008, or January 2009 (see instructions).

No. Enter -0- on line 10 and go to line 11. Yes. Enter the total of the payments you (and your spouse, if filing jointly) received in 2010. Do not enter more than $250 ($500 if married filing jointly) . . . . . . . . . . . .

10

11

Making work pay credit. Subtract line 10 from line 9. If zero or less, enter -0-. Enter the result here and on Form 1040, line 63; or Form 1040A, line 40 . . . . . . . . . . . . . .
*If you are filing Form 2555, 2555-EZ, or 4563 or you are excluding income from Puerto Rico, see instructions.
Cat. No. 52903Q

11

400.

For Paperwork Reduction Act Notice, see your tax return instructions.

Schedule M (Form 1040A or 1040) 2010

CDA