Form 1040 A U.S. Individual Income Tax Return

Form

Department of the Treasury—Internal Revenue Service

1040A
Label
(See page 17.)

Use the
IRS label.
Otherwise,
please print
or type.

U.S. Individual Income Tax Return (99)
Your first name and initial
L
A
B
E
L
H
E
R
E

2009

IRS Use Only—Do not write or staple in this space.

Last name

OMB No. 1545-0074
Your social security number

If a joint return, spouse’s first name and initial

Last name

Spouse’s social security number

Home address (number and street). If you have a P.O. box, see page 17.

Apt. no.

¶

City, town or post office, state, and ZIP code. If you have a foreign address, see page 17.

Presidential
Election Campaign © Check here if you, or your spouse if filing jointly, want $3 to go to this fund (see page 17)

Filing
status
Check only
one box.

Exemptions

You must enter
your SSN(s) above.

¶

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

©

Spouse

1
2
3

4
Single
Head of household (with qualifying person). (See page 18.)
Married filing jointly (even if only one had income)
If the qualifying person is a child but not your dependent,
enter this child’s name here. ©
Married filing separately. Enter spouse’s SSN above and
©
5
Qualifying widow(er) with dependent child (see page 19)
full name here.
Boxes
6a
Yourself. If someone can claim you as a dependent, do not check
checked on
box 6a.
6a and 6b
No. of children
b
Spouse
on 6c who:
c Dependents:
(4) ✓ if qualifying ● lived with

%

(1) First name

If more than six
dependents,
see page 20.

Last name

(2) Dependent’s social
security number

(3) Dependent’s
relationship to you

child for child
tax credit (see
page 20)

you
● did not live
with you due
to divorce or
separation
(see page 21)

Dependents
on 6c not
entered above
Add numbers
on lines
above ©

d Total number of exemptions claimed.

Income
Attach
Form(s) W-2
here. Also
attach
Form(s)
1099-R if tax
was withheld.
If you did not
get a W-2, see
page 24.
Enclose, but do
not attach, any
payment. Also,
please use Form
1040-V.

Adjusted
gross
income

7

Wages, salaries, tips, etc. Attach Form(s) W-2.

7

8a
b
9a
b
10
11a

Taxable interest. Attach Schedule B if required.
Tax-exempt interest. Do not include on line 8a. 8b
Ordinary dividends. Attach Schedule B if required.
Qualified dividends (see page 25).
9b
Capital gain distributions (see page 25).
11b Taxable amount
IRA
distributions.
(see page 25).
11a
12a Pensions and
12b Taxable amount
annuities.
(see page 26).
12a
13 Unemployment compensation in excess of $2,400 per recipient and
Alaska Permanent Fund dividends (see page 28).
14a Social security
14b Taxable amount
benefits.
(see page 28).
14a
15

Add lines 7 through 14b (far right column). This is your total income.

16
17
18

Educator expenses (see page 30).
IRA deduction (see page 30).
Student loan interest deduction (see page 32).

19
20

Tuition and fees deduction. Attach Form 8917.
19
Add lines 16 through 19. These are your total adjustments.

21

Subtract line 20 from line 15. This is your adjusted gross income.

8a
9a
10
11b
12b
13
14b
©

15

16
17
18

For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see page 87.

20
©

Cat. No. 11327A

21
Form 1040A (2009)

Page 2

Form 1040A (2009)

Tax, credits, 22 Enter the amount from line 21 (adjusted gross income).
23a Check
You were born before January 2, 1945,
Blind Total boxes
and
if:
Spouse
was
born
before
January
2,
1945,
Blind checked © 23a
payments

$

Standard
Deduction
for—
● People who
checked any
box on line
23a, 23b, or
24b or who
can be
claimed as a
dependent,
see page 34.
● All others:
Single or
Married filing
separately,
$5,700
Married filing
jointly or
Qualifying
widow(er),
$11,400
Head of
household,
$8,350

If you have
a qualifying
child, attach
Schedule
EIC.

Refund
Direct
deposit?
See page 64
and fill in
46b, 46c,
and 46d or
Form 8888.

Amount
you owe

24a

new motor vehicle taxes, attach Schedule L and check here (see page 34) © 24b

b Routing

©

©

number
© d Account
number

47
48
49

c Type:

Checking

©

25
26
27
28

34
35
36
37

44
45
46a

Savings

Amount of line 45 you want applied to your
2010 estimated tax.
47
Amount you owe. Subtract line 44 from line 37. For details on how to pay,
see page 66.
Estimated tax penalty (see page 66).
49

©

48

Yes. Complete the following.

Do you want to allow another person to discuss this return with the IRS (see page 67)?

Sign
here

Paid
preparer’s
use only

23b

Subtract line 24a from line 22. If line 24a is more than line 22, enter -0-.
Exemptions. If line 22 is $125,100 or less and you did not provide housing to a Midwestern
displaced individual, multiply $3,650 by the number on line 6d. Otherwise, see page 34.
27 Subtract line 26 from line 25. If line 26 is more than line 25, enter -0-.
©
This is your taxable income.
28 Tax, including any alternative minimum tax (see page 35).
29 Credit for child and dependent care expenses. Attach Form 2441.
29
30 Credit for the elderly or the disabled. Attach
Schedule R.
30
31 Education credits from Form 8863, line 29.
31
32 Retirement savings contributions credit. Attach Form 8880. 32
33 Child tax credit (see page 38).
33
34 Add lines 29 through 33. These are your total credits.
35 Subtract line 34 from line 28. If line 34 is more than line 28, enter -0-.
36 Advance earned income credit payments from Form(s) W-2, box 9.
©
37 Add lines 35 and 36. This is your total tax.
38 Federal income tax withheld from Forms W-2 and 1099. 38
39 2009 estimated tax payments and amount applied
from 2008 return.
39
40 Making work pay and government retiree credits.
Attach Schedule M.
40
41a Earned income credit (EIC).
41a
b Nontaxable combat pay election. 41b
42 Additional child tax credit. Attach Form 8812.
42
43 Refundable education credit from Form 8863, line 16. 43
©
44 Add lines 38, 39, 40, 41a, 42, and 43. These are your total payments.
45 If line 44 is more than line 37, subtract line 37 from line 44.
This is the amount you overpaid.
46a Amount of line 45 you want refunded to you. If Form 8888 is attached, check here ©

Third party
designee

Joint return?
See page 17.
Keep a copy
for your
records.

%

b If you are married filing separately and your spouse itemizes
©
deductions, see page 34 and check here
24a Enter your standard deduction (see left margin).
b If you are increasing your standard deduction by certain real estate taxes or
25
26

22

No

Designee’s
Phone
Personal identification
©
©
©
name
no.
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 accurately list all amounts and sources of income I received during the tax year. Declaration of preparer (other
than the taxpayer) is based on all information of which the preparer has any knowledge.
Your occupation
Daytime phone number
Your signature
Date
Spouse’s signature. If a joint return, both must sign.

Preparer’s
signature

Spouse’s occupation
Date

©

Firm’s name (or
yours if self-employed),
address, and ZIP code

Date

©

Check if
self-employed

Preparer’s SSN or PTIN

EIN
Phone no.
Form 1040A (2009)