Form 1040 A U.S. Individual Income Tax Return

Form

Department of the Treasury—Internal Revenue Service

1040A
Name,
Address,
and SSN
See separate
instructions.

U.S. Individual Income Tax Return (99)
Your first name and initial
P
R
I
N
T
C
L
E
A
R
L
Y

2010

OMB No. 1545-0074
Your social security number

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

Spouse’s social security number

Last name
Apt. no.

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

Check only
one box.

Exemptions

▲

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

Presidential
Election Campaign ▶ Check here if you, or your spouse if filing jointly, want $3 to go to this fund .

Filing
status

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

Last name

.

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

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 instructions.)
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 instructions)
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:
(4) ✓ if child under
c Dependents:
• lived with

}

If more than six
dependents, see
instructions.

(1) First name

Last name

(2) Dependent’s social
security number

(3) Dependent’s
relationship to you

age 17 qualifying for
child tax credit (see
page 16)

you

• did not live
with you due to
divorce or
separation (see
instructions)
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 20.
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 instructions).
9b
Capital gain distributions (see instructions).
IRA
11b Taxable amount
distributions.
11a
(see instructions).
12a Pensions and
12b Taxable amount
annuities.
12a
(see instructions).

8a
9a
10
11b
12b

13 Unemployment compensation and Alaska Permanent Fund dividends.
14a Social security
14b Taxable amount
benefits.
14a
(see instructions).
15

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

16
17
18

Educator expenses (see instructions).
16
IRA deduction (see instructions).
17
Student loan interest deduction (see instructions). 18

19
20

Tuition and fees. 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.

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

13
14b

▶

15

20
▶

21

Cat. No. 11327A

Form 1040A (2010)

Page 2

Form 1040A (2010)

Tax, credits, 22 Enter the amount from line 21 (adjusted gross income).
23a Check
You were born before January 2, 1946,
Blind Total boxes
and
if:
Spouse
was
born
before
January
2,
1946,
Blind checked ▶ 23a
payments

{

If you have
a qualifying
child, attach
Schedule
EIC.

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

Amount
you owe

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

Sign
here

▲

Paid
preparer
use only

}

b If you are married filing separately and your spouse itemizes
▶ 23b
deductions, see page 30 and check here
24 Enter your standard deduction (see instructions).
25 Subtract line 24 from line 22. If line 24 is more than line 22, enter -0-.
26 Exemptions. Multiply $3,650 by the number on line 6d.
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 instructions).
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 23.
31
32 Retirement savings contributions credit. Attach Form 8880. 32
33 Child tax credit (see instructions).
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 2010 estimated tax payments and amount applied
from 2009 return.
39
40 Making work pay credit. 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 American opportunity credit from Form 8863, line 14.
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 ▶
Routing
▶ c Type:
Checking
Savings
▶ b
number
Account
▶ d
number
47 Amount of line 45 you want applied to your
47
2011 estimated tax.
48 Amount you owe. Subtract line 44 from line 37. For details on how to pay,
▶
see instructions.
49 Estimated tax penalty (see instructions).
49

Third party
designee

Joint return?
See page 13.
Keep a copy
for your
records.

22

24
25
26
27
28

34
35
36
37

44
45
46a

48

Yes. Complete the following.

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.
Print/type preparer's name

Date

Preparer’s signature

Spouse’s occupation
Date

Check ▶
if
self-employed

Firm's name ▶

Firm's EIN ▶

Firm's address ▶

Phone no.

PTIN

Form 1040A (2010)