1:2-61 John R. Lane (SSN 111-44-6666) lives at 1010 Ipsen Street, Yorba Linda, California 90102. John, a single taxpayer, age 66, provided 60% of his cousin's support. The cousin lives in Arizona. He wants to take advantage of the presidential election campaign check- off. John was employed as an accountant before he retired during the year. Other relevant information includes Salary Pension (all taxable) Taxable interest income Deductible contribution to IRA Withholdings (Form W-2) $50,000 41,000 240 6,000 12,100 John's itemized deductions total $11,000 (none of which are charitable contributions). John does not have any transactions involving virtual currency. Complete Form 1040-SR and Schedule 1 for 2021. Assume any estimated tax penalty is zero. 1040-SR Return for Seniors Department of the Treasury-Internal Revenue Service (99) Filing Status Check only one box. Single Head of household (HOH) Your first name and middle initial John R. If joint return, spouse's first name and middle initial Home address (number and street). If you have a P.O. box, see instructions. 1010 Ipsen St 2021 OMB No. 1545-0074 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 Last name Lane Last name City, town, or post office. If you have a foreign address, also complete spaces below. State Yorba Linda Foreign country name Foreign province/state/county If more than four dependents, see instructions and check here I Married filing jointly Qualifying widow(er) (QW) Standard Someone can claim: You as a dependent Deduction Dependents (see instructions): (1) First name Attach Schedule B if required. At any time during 2021, did you receive, sell, exchange, or otherwise dispose of any financial interest in any virtual currency? . . Last name CA IRS Use Only-Do not write or staple in this space. Married filing separately (MFS) ZIP code 90102 Foreign postal code Apt. no. Spouse itemizes on a separate return or you were a dual-status alien Age/Blindness Spouse: Were born before January 2, 1957 Was born before January 2, 1957 (2) Social security number (3) Relationship to you Your spouse as a dependent Your social security number 1 1 1 4 4 6 6 6 6 Spouse's social security number 1 Wages, salaries, tips, etc. Attach Form(s) W-2 2a Tax-exempt interest 2a 3a Qualified dividends. . 3a 4a IRA distributions . . . 4a 5a Pensions and annuities 5a 6a Social security benefits. 6a 7 Capital gain or (loss). Attach Schedule D if required. If not required, check here 8 Other income from Schedule 1, line 10 .. 9 Add lines 1, 2b, 3b, 4b, 5b, 6b, 7, and 8. This is your total income. Adjustments to income from Schedule 1, line 26. 10 11 Subtract line 10 from line 9. This is your adjusted gross income For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 71930F Presidential Election Campaign Check here if you, or your spouse if filing jointly, want $3 to go to this fund. Checking a box below will not change your tax or refund. You Spouse Are blind Is blind (4) if qualifies for (see instructions): Child tax credit Credit for other dependents 1 2b b Taxable interest . b Ordinary dividends. 3b b Taxable amount 4b b Taxable amount 5b b Taxable amount. . 6b . . Yes No 7 8 9 10 11 Form 1040-SR (2021) SCHEDULE 1 (Form 1040) Department of the Treasury Internal Revenue Service Additional Income and Adjustments to Income Attach to Form 1040, 1040-SR, or 1040-NR. Go to www.irs.gov/Form 1040 for instructions and the latest information. Name(s) shown on Form 1040, 1040-SR, or 1040-NR Part I Additional Income 1 Taxable refunds, credits, or offsets of state and local income taxes. 2a Alimony received . . . . b Date of original divorce or separation agreement (see instructions) Business income or (loss). Attach Schedule C Other gains or (losses). Attach Form 4797. Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E Farm income or (loss). Attach Schedule F 3 4 5 6 7 Unemployment compensation. 8 Other income: a Net operating loss b Gambling income. c Cancellation of debt. d Foreign earned income exclusion from Form 2555 e Taxable Health Savings Account distribution f Alaska Permanent Fund dividends g Jury duty pay h Prizes and awards i Activity not engaged in for profit income j Stock options.. k Income from the rental of personal property if you engaged in the rental for profit but were not in the business of renting such property. I Olympic and Paralympic medals and USOC prize money (see instructions) .. m Section 951(a) inclusion (see instructions) n Section 951A(a) inclusion (see instructions) o Section 461(1) excess business loss adjustment. p Taxable distributions from an ABLE account (see instructions). z Other income. List type and amount 8a 8b 8c 8d 8e 8f 8g 8h 8i 8j 8k 81 8m 8n 80 8p OMB No. 1545-0074 2021 Attachment Sequence No. 01 Your social security number 8z 9 Total other income. Add lines 8a through 8z. 10 Combine lines 1 through 7 and 9. Enter here and on Form 1040, 1040-SR, or 1040-NR, line 8 For Paperwork Reduction Act Notice, see your tax return instructions. Cat. No. 71479F 1 2a 3 4 5 6 7 9 10 Schedule 1 (Form 1040) 2021 Schedule 1 (Form 1040) 2021 Part II Adjustments to Income 11 Educator expenses . . . . 12 Certain business expenses of reservists, performing artists, and fee-basis government officials. Attach Form 2106 13 Health savings account deduction. Attach Form 8889 14 Moving expenses for members of the Armed Forces. Attach Form 3903 15 Deductible part of self-employment tax. Attach Schedule SE 16 Self-employed SEP, SIMPLE, and qualified plans 17 Self-employed health insurance deduction. 18 Penalty on early withdrawal of savings 19a Alimony paid. b Recipient's SSN c Date of original divorce or separation agreement (see instructions) 20 IRA deduction 21 Student loan interest deduction 22 Reserved for future use 23 Archer MSA deduction. 24 Other adjustments: a Jury duty pay (see instructions) b Deductible expenses related to income reported on line 8k from the rental of personal property engaged in for profit c Nontaxable amount of the value of Olympic and Paralympic medals and USOC prize money reported on line 81 d Reforestation amortization and expenses e Repayment of supplemental unemployment benefits under the Trade Act of 1974. f Contributions to section 501(c)(18)(D) pension plans. g Contributions by certain chaplains to section 403(b) plans h Attorney fees and court costs for actions involving certain unlawful discrimination claims (see instructions) i Attorney fees and court costs you paid in connection with an award from the IRS for information you provided that helped the IRS detect tax law violations j Housing deduction from Form 2555 k Excess deductions of section 67(e) expenses from Schedule K-1 (Form 1041)..... z Other adjustments. List type and amount 24a 24b 24c 24d 24e 24f 24g 24h 24i 24j 24k 24z 25 Total other adjustments. Add lines 24a through 24z.. 26 Add lines 11 through 23 and 25. These are your adjustments to income. Enter here and on Form 1040 or 1040-SR, line 10, or Form 1040-NR, line 10a 11 12 13 14 15 16 17 18 19a 20 21 22 23 25 Page 2 26 Schedule 1 (Form 1040) 2021