1040-V OCR P ayment Voucher

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Date

I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
SCHEDULE 1 (FORM 1040A), PAGE 1 OF 2
MARGINS: TOP 13mm (1⁄ 2 ") (TO BLACK IMAGE), CENTER SIDES. PRINTS: FACE ONLY
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK and PMS 185
FLAT SIZE: 203mm (8") 3 279mm (11")
PERFORATE: (NONE)

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Separation 1 of 2: Ink = Black

Action

Department of the Treasury—Internal Revenue Service

(Form 1040A)

Interest and Ordinary Dividends
for Form 1040A Filers
(99)

O.K. to print
Revised proofs
requested

2006

OMB No. 1545-0074
Your social security number

Name(s) shown on Form 1040A

f
o
s
a
6
t
0
f
0
a
2
r
/
D /08
6
0

Note. If you received a Form 1099-INT, Form 1099-OID, or substitute statement from a
brokerage firm, enter the firm’s name and the total interest shown on that form.

Part I
Interest
1

2
3
4

List name of payer. If any interest is from a seller-financed mortgage
and the buyer used the property as a personal residence, see back of
schedule and list this interest first. Also, show that buyer’s social
security number and address.

Add the amounts on line 1.
Excludable interest on series EE and I U.S. savings bonds issued
after 1989. Attach Form 8815.
Subtract line 3 from line 2. Enter the result here and on Form 1040A,
line 8a.

Amount
1

2
3
4

Note. If you received a Form 1099-DIV or substitute statement from a brokerage firm,
enter the firm’s name and the ordinary dividends shown on that form.

Part II
Ordinary
dividends

Signature

Separation 2 of 2: Ink = PMS 185 (RED).

Schedule 1

(See back
of schedule
and the
instructions
for Form
1040A,
line 8a.)

Date

5

List name of payer.

Amount
5

(See back
of schedule
and the
instructions
for Form
1040A,
line 9a.)

6

Add the amounts on line 5. Enter the total here and on Form 1040A,
line 9a.

For Paperwork Reduction Act Notice, see Form 1040A instructions.

Cat. No. 12075R

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Schedule 1 (Form 1040A) 2006