8221

General

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1. Filing Status
?

Check here if you are 65 or older.
Check here if you are permanently blind.
Check here if spouse is 65 or older.
Check here if your spouse is permanently blind.

2.Number of Exemptions
?

Include 1 for yourself unless you are claimed by another person, 1 for your spouse (if applicable), and 1 for each dependent child.

3.Children Info
?

Enter the number of children included in line 2 that are under age 17.

4.Health Coverage
A. Number of adults without health care coverage.
B. Number of children without health care coverage.

5.Earned Income Credit
A. Number of children under age 19.
B. Number of children over age 18 and under the age of 24 that are full time students.
C. Number of children over age 18 and disabled.
 

Income

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1.Wages, Salaries and Tips 
?
$
A. Taxpayer 401(k) or other retirement plan contributions from work
?
$
B. Spouse 401(k) or other retirement plan contributions from work
$

2.Interest & Non-Stock Dividends 
?
$

3.Stock/Qualified Dividends 
?
$

4.Short-Term Capital Gains 
?
$

5.Long-Term Capital Gains 
?
$

6.Business Income/(Loss) - Schedule C or F
?
$

7.IRA/Pension Distributions
?
A. Subject to early distribution penalty:
$
B. Not subject to early distribution penalty:
$

8.Unemployment Compensation 
?
$

9.Social Security Benefits 
?
$

10.Other Income 
?

(Gambling income, baby sitting income, etc.)
$
 

Adjustments

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1.Health Savings Account (HSA) Deduction 
?
$

2.Moving Expenses 
?

Expenses incurred plus mileage of 24 cents
per mile.
$

3.Self Employment Health Insurance Deduction 
?
$

4.Alimony Paid 
?
$

5.IRA Contributions 
?

Maximum of $5,500 each for yourself and your spouse ($6,500 if 50 or over).
A. Taxpayer Contributions
$
B. Spouse Contributions
$

6.Student Loan Interest Paid 
?
$
 

Itemized Deductions

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1.Medical Expenses 
?
$

2.Real Estate Taxes 
?
$

3.Personal Property Taxes Paid 
?
$

4.Mortgage Interest & Points Paid 
?
$

5.Gifts to Charity 
?
$

6.Miscellaneous Expenses 
?

Include job hunting expenses, employee business expenses, tax prep fees, safe deposit boxes, etc.
$

7.State Taxes Paid 
?

(Do not include amount from line 6.)
$
 

Credits

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1.Child and Dependent Care Credit
A. Amount paid for child care expenses  
?
$
B. Number of children cared for  
?
   

2.Education Credits 
?

(Enter Tuition and Course Materials Only)
A. Qualified Student 1
$
B. Qualified Student 2
$
C. Qualified Student 3
$
D. Qualified Student 4
$

3.Repayment of ’2008’ First Time Homebuyer Credit 
?
$
 

Payments

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1.Federal Income Taxes Withheld From Wages (Form W-2)
$

2.Federal Income Taxes Withheld From IRA/Pension Distributions
$

3.Federal Income Taxes Withheld From Unemployment Compensation
$

4.Other Federal Income Tax Paid Estimated Tax Payments. 
?
$
 

Results

Refund
$
Balance Due
$

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Calculation Summary

1.Gross Income
$
2.Adjustments to Income
$
3.Adjusted Gross Income
$
4.Exemptions
$
5.Standard/Itemized Deductions
$
6.Taxable Income
$
7.Tax
$
8.Child and Dependent Care Credit
$
9.Education Credit
$
10.Retirement Contribution Credit
$
11.Child Tax Credit
$
12.Self-Employment Tax
$
13.Health Care Penalty
$
14.Total Tax
$
15.Federal Tax Payments
$
16.Earned Income Credit
$
17.Additional Education Credit
$
18.Additional Child Tax Credit
$
19.Repayment of First-Time Homebuyer Credit
$