1040 U.S. Individual Tax Return

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Form

1040 U.S. Individual Income Tax Return 2021
(99)

Department of the Treasury—Internal Revenue Service

Filing Status
Check only
one box.

Single

Married filing jointly

OMB No. 1545-0074

Married filing separately (MFS)

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

Head of household (HOH)

Qualifying widow(er) (QW)

If you checked the MFS box, enter the name of your spouse. If you checked the HOH or QW box, enter the child’s name if the qualifying
person is a child but not your dependent ▶

Your first name and middle initial

Last name

Your social security number

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

Last name

Spouse’s social security number

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

Apt. no.

City, town, or post office. If you have a foreign address, also complete spaces below.

Presidential Election Campaign
Check here if you, or your
spouse if filing jointly, want $3
ZIP code
to go to this fund. Checking a
box below will not change
Foreign postal code your tax or refund.

State

DRAFT AS OF
November 4, 2021
DO NOT FILE

Foreign country name

Foreign province/state/county

At any time during 2021, did you receive, sell, exchange, or otherwise dispose of any financial interest in any virtual currency?

Standard
Deduction

Were born before January 2, 1957

(1) First name
If more
than four
dependents,
see instructions
and check
here ▶

• Single or
Married filing
separately,
$12,550
• Married filing
jointly or
Qualifying
widow(er),
$25,100
• Head of
household,
$18,800
• If you checked
any box under
Standard
Deduction,
see instructions.

Spouse:

Are blind

Dependents (see instructions):

Standard
Deduction for—

Spouse

Yes

No

Someone can claim:
You as a dependent
Your spouse as a dependent
Spouse itemizes on a separate return or you were a dual-status alien

Age/Blindness You:

Attach
Sch. B if
required.

You

(2) Social security
number

Last name

Was born before January 2, 1957

(4) ✔ if qualifies for (see instructions):
Child tax credit
Credit for other dependents

(3) Relationship
to you

1

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

2a
3a
4a

Tax-exempt interest .
Qualified dividends .
IRA distributions . .

5a
6a
7

Pensions and annuities . .
5a
b Taxable amount .
Social security benefits . .
6a
b Taxable amount .
Capital gain or (loss). Attach Schedule D if required. If not required, check here
.

8
9
10

Other income from Schedule 1, line 10 . . . . . . . .
Add lines 1, 2b, 3b, 4b, 5b, 6b, 7, and 8. This is your total income
Adjustments to income from Schedule 1, line 26
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5b
6b
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8
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10

11
12a
b

Subtract line 10 from line 9. This is your adjusted gross income
. . . . .
Standard deduction or itemized deductions (from Schedule A)
. .
12a
Charitable contributions if you take the standard deduction (see instructions)
12b

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▶

11

c
13
14
15

Add lines 12a and 12b . . . . . . . . . . . . . .
Qualified business income deduction from Form 8995 or Form 8995-A
Add lines 12c and 13
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Taxable income. Subtract line 14 from line 11. If zero or less, enter -0-

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2a
3a
4a

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2b
3b
4b

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b Taxable interest
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b Ordinary dividends .
b Taxable amount . .

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

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Is blind

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Cat. No. 11320B

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12c
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Form

1040 (2021)

Page 2

Form 1040 (2021)

16
17

Tax (see instructions). Check if any from Form(s): 1
8814
Amount from Schedule 2, line 3
. . . . . . . .

2

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18
19
20

Add lines 16 and 17 . . . . . . . . . . . . . . . . . . .
Nonrefundable child tax credit or credit for other dependents from Schedule 8812
Amount from Schedule 3, line 8
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21
22
23

Add lines 19 and 20 . . . . . . . . . . . . . . .
Subtract line 21 from line 18. If zero or less, enter -0- . . . . .
Other taxes, including self-employment tax, from Schedule 2, line 21

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24
25
a

Add lines 22 and 23. This is your total tax
Federal income tax withheld from:
Form(s) W-2 . . . . . . . . .

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Form(s) 1099 . . . . . .
Other forms (see instructions) .
Add lines 25a through 25c . .

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4972 3
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24

25b
25c
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25d

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26

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32
33
34

DRAFT AS OF
November 4, 2021
DO NOT FILE
b
c
d

If you have a
qualifying child,
attach Sch. EIC.

Refund

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25a

26
27a

2021 estimated tax payments and amount applied from 2020 return . .
Earned income credit (EIC) . . . . . . . . . . . . . .
Check here if you were born after January 1, 1998, and before
January 2, 2004, and you satisfy all the other requirements for
taxpayers who are at least age 18, to claim the EIC. See instructions ▶

b
c
28

Nontaxable combat pay election . . . .
27b
Prior year (2019) earned income . . . .
27c
Refundable child tax credit or additional child tax credit from Schedule 8812

29
30
31

32
33

American opportunity credit from Form 8863, line 8 . . . . . . .
29
Recovery rebate credit. See instructions . . . . . . . . . .
30
Amount from Schedule 3, line 15 . . . . . . . . . . . .
31
Add lines 27a and 28 through 31. These are your total other payments and refundable credits
Add lines 25d, 26, and 32. These are your total payments
. . . . . . . . . . .

34

If line 33 is more than line 24, subtract line 24 from line 33. This is the amount you overpaid

. .
27a

28

35a
▶b
Direct deposit?
See instructions. ▶
d
36

Amount of line 34 you want refunded to you. If Form 8888 is attached, check here .
▶ c Type:
Routing number
Checking
Account number
Amount of line 34 you want applied to your 2022 estimated tax . . ▶
36

Amount
You Owe
Third Party
Designee

Amount you owe. Subtract line 33 from line 24. For details on how to pay, see instructions
Estimated tax penalty (see instructions) . . . . . . . . . ▶
38

37
38

Do you want to allow another person to discuss this return with the IRS? See
instructions
. . . . . . . . . . . . . . . . . . . . ▶
Designee’s
name ▶

Sign
Here

Paid
Preparer
Use Only

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35a

▶

Savings

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▶

37

Yes. Complete below.

No

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.
Date

Your occupation

If the IRS sent you an Identity
Protection PIN, enter it here
(see inst.) ▶

Spouse’s signature. If a joint return, both must sign.

Date

Spouse’s occupation

If the IRS sent your spouse an
Identity Protection PIN, enter it here
(see inst.) ▶

Phone no.

Email address

Your signature

▲

Joint return?
See instructions.
Keep a copy for
your records.

Phone
no. ▶

.

▶

Preparer’s name

Preparer’s signature

Date

PTIN

Check if:
Self-employed

Firm’s name

Phone no.

▶

Firm’s address

▶

Go to www.irs.gov/Form1040 for instructions and the latest information.

Firm’s EIN

▶

Form

1040 (2021)