Gregory and Lulu Clifden's Tax Return

Gregory R. and Lulu B. Clifden live with their family at the Rock Glen House Bed & Breakfast, which Gregory operates. The Bed & Breakfast (B&B) is located at 33333 Fume Blanc Way, Temecula, CA 92591. Gregory (born May 4, 1976) and Lulu (born June 12, 1977) enjoy good health and eyesight.

1. The Clifdens have three sons, Gerald was born April 16, 2002, Gary was born December 2, 2007, and Glenn was born January 13, 2009. All three boys live at home and the Clifdens provide more than 50% of their support.

2. The Rock Glen House B&B is operated as a sole proprietorship and had the following income and expenses for the year:

All of the above amounts relate to the business portion of the Bed & Breakfast; the personal portion is accounted for separately. The Rock Glen House B&B uses the cash method of accounting and has no inventory. The employer tax ID number is 95-1234567.

3. The Clifdens made estimated federal income tax payments of $2,000 and estimated state income tax payments of $6,000 (all made during 2019).

4. Lulu work about 1,000 hours as a substitute schoolteacher with the local school district. For the current year, Lulu's Form W-2 from the school district showed the following:

5. Gregory is retired from the U.S. Navy. His annual statement from the Navy, Form 1099-R.

6. Gregory and Lulu paid (and can substantiate) the following amounts during the year:

7. During the year, Gregory and Lulu received the following qualifying dividends and interest:

Also, Lulu owns Series EE U.S. savings bonds. During the year, the bond redemption value increased by $1,300. Lulu has not elected the accrual method for these bonds. There were no Irish taxes paid on the interest from the Bank of Ireland. All the above stocks, bonds, and bank accounts are community property.

8. Lulu has a stock portfolio. During the year she sold the following stock, shown on her Forms 1099-B as follows (Basis was provided to the IRS in all cases):

9. Lulu paid her ex-husband $4,800 alimony in the current year, as required under the divorce decree. Her ex-husband's name is Hector Leach and his Social Security number is 566-23-5431.

10. Gregory does all the significant work in the Bed & Breakfast and therefore he pays self-employment tax on 100 percent of the earnings from the B&B.

11. During the year, Gregory's uncle Martin died. Martin had a $50,000 life insurance policy that named Gregory as the beneficiary. Gregory received the check for the benefits payable under the policy on November 30 of the current year. Martin also left Gregory a parcel of land with an appraised value of $120,000.

12. Gary is a general partner in a partnership that owns a boutique hotel in northern California and leases the property to a hotel management company. Gary does not materially participate in the partnership activity but the partnership activity does rise to the level of a trade or business.

13. Lulu was not eligible for health care benefits due to the part-time nature of her job thus health insurance for the Clifden household was purchased by Gregory. The Clifdens purchased health insurance through the Covered California program and received the Form 1095-A. They had no other health insurance during 2019. Assume that the self-employed health insurance deduction is $1,424. The Clifdens did not claim an advance premium credit.

Required: Gregory and Lulu have come to you to prepare their 2019 federal income tax return. Do not complete a California state income tax return. Gregory and Lulu have given you several IRS forms. Make realistic assumptions about any missing data (addresses, etc.) that you need. Do not file a federal Form 4952. The following is a list of the forms and schedules that you will need to complete the tax return:

Form 1040 Schedule E

Schedule 1 Schedule SE

Schedule 2 Form 8812

Schedule 3 Form8949

Schedule A Form8962

Schedule B Form8995

Schedule C Child Tax Credit Worksheet

Schedule D Qualified Dividends and Capital Gain Tax Worksheet

$137,896 2,100 4,810 18,100 22,987 17,540 Room rental income Vending machine income Advertising expense Depreciation for book and tax purposes Mortgage interest on the B&B Wages of cleaning people Taxes and licenses Supplies consumed Business insurance Laundry expenses Accounting fees Office expenses Utilities 6,420 18,870 6,300 4,289 1,850 2,400 6,350 a Employee's social security number Safe, accurate, Visit the IRS website at OMB No. 1545-0008 FAST! Use irse , file 256-43-8819 www.irs.gov/efile b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld 43-7654321 $13,700.00 $1,694.00 c Employer's name, address, and ZIP code 3 Social security wages 4 Social security tax withheld Temecula Valley Unified School Dist. $13,700.00 $849.401 31350 Phone Num # 5 Medicare wages and tips 6 Medicare tax withheld Rancho Vista Rd. $13,700.00 $198.65 7 Social security tips 8 Allocated tips Temecula CA 92592 Country # d Control number 9 10 Dependent care benefits Suff. 11 Nonqualified plans 12a See instructions for box 12 Last name Clifden e Employee's first name and initial Lulu B. 33333 Fume Blanc Way Temecula 13 Statutory employee Phone Num # Retirement plan 12b Third-party sick pay 14 Other 12c CA 92591 Country 12d f Employee's address and ZIP code 15 State Employer's state ID number CA 18 Local wages, tips, etc. 19 Local income tax 20 Locality name 16 State wages, tips, etc. 17 State income tax $13,700.00 $400.00 # # # # # # Department of the Treasury-Internal Revenue Service W-2 Wage and Tax 2019 Form Statement Copy B-To Be Filed With Employee's FEDERAL Tax Return. This information is being furnished to the Internal Revenue Service. 2019 CORRECTED (if checked) PAYER'S name, street address, city or town, state or province, 1 Gross distribution OMB No. 1545-0119 Distributions From country, ZIP or foreign postal code, and phone no. Pensions, Annuities, Retirement or $ 14,545.00 Profit-Sharing Plans, 2a Taxable amount IRAs, Insurance Contracts, etc. $ 14,545.00 Form 1099-R United States Navy Retired Benefits Center 2b Taxable amount Total Copy B Cleveland, OH 43267 not determined distribution Report this PAYER'S TIN RECIPIENT'S TIN 3 Capital gain (included 4 Federal income tax income on your in box 2a) withheld federal tax return. If this form shows 11-4662891 543-88-9765 $ $ 1.487.12 federal income RECIPIENT'S name 5 Employee contributions/ 6 Net unrealized tax withheld in Designated Roth appreciation in contributions or employer's securities box 4, attach insurance premiums this copy to Gregory R. Clifden $ $ your return. Street address (including apt. no.) 7 Distribution IRA/ 8 Other SEP/ code(s) SIMPLE This information is 33333 Fume Blanc Way % being furnished to City or town, state or province, country, and ZIP or foreign postal code 9a Your percentage of total 9b Total employee contributions the IRS. Temecula, CA 92591 distribution %$ 10 Amount allocable to IRR 11 1st year of FATCA filing 12 State tax withheld 13 State/Payer's state no. 14 State distribution within 5 years desig. Roth contrib. requirement $ 350.00 CA $ 14.545 $ $ $ Account number (see instructions) Date of 15 Local tax withheld 16 Name of locality 17 Local distribution payment $ $ --===== Form 1099-R www.irs.gov/Form1099R Department of the Treasury - Internal Revenue Service $1,480 5,457 2,130 4,875 9,631 Mastercard interest Dental expenses (orthodontics for Gary) California state income tax (for 2018) Charitable contributions Deductible interest on home (personal portion) Real estate taxes (personal portion) Life insurance premiums Automobile registration fees (deductible portion) Tax return preparation fee Contributions to Donald Trump's re-election campaign 3,830 845 45 475 1,000 $ 381 Interest: Bob's Big Bank Bank of Ireland City of Temecula Tax Exempt Bonds Vintage Bank 271 1,490 See 1099-INT Qualified dividends: Southwest Airlines $ 220 Heinz Foods 560 CORRECTED (if checked) PAYER'S name, street address, city or town, state or province, country, ZIP Payer's RTN (optional) or foreign postal code, and telephone no. OMB No. 1545-0112 2019 Interest Income 1 Interest income Form 1099-INT $ 1,403.80 2 Early withdrawal penalty Vintage Bank 6792 Main Street Temecula, CA 92591 PAYER'S TIN Copy B RECIPIENT'S TIN $ 3 Interest on U.S. Savings Bonds and Treas. obligations For Recipient 96-8724390 543-88-9756 $ RECIPIENT'S name 4 Federal income tax withheld 5 Investment expenses This is important tax $ $ information and is being furnished to the Gregory R. Clifden 6 Foreign tax paid 7 Foreign country or U.S. possession IRS. If you are Street address (including apt. no.) $ required to file a 8 Tax-exempt interest 9 Specified private activity bond return, a negligence interest penalty or other 33333 Fume Blanc Way sanction may be City or town, state or province, country, and ZIP or foreign postal code $ $ imposed on you if 10 Market discount 11 Bond premium this income is taxable and the IRS Temecula, CA 92591 determines that it has FATCA filing $ $ not been reported. requirement 12 Bond premium on Treasury obligations 13 Bond premium on tax-exempt bond| $ $ Account number (see instructions) 14 Tax-exempt and tax credit 15 State 16 State identification no. 17 State tax withheld bond CUSIP no. $ Form 1099-INT (keep for your records) www.irs.gov/Form 1099INT Department of the Treasury - Internal Revenue Service Orange Co. Gold Co. Green Co. $8,114 $2,575 3,800 Sales price Basis Date acquired Date sold See Form 1099-B 1,450 02/11/19 10/31/14 06/19/19 10/23/19 2019 CORRECTED (if checked) PAYER'S name, street address, city or town, state or province, country, ZIP Applicable checkbox on Form 8949 OMB No. 1545-0715 Proceeds From or foreign postal code, and telephone no. Broker and Barter Exchange Transactions A Form 1099-B 1a Description of property (Example: 100 sh.XYZ Co.) Gold Company Common Bear Stearns 269 Wall Street 1b Date acquired 1c Date sold or disposed New York. Ny 10001 03/27/2019 09/18/2019 PAYER'S TIN RECIPIENT'S TIN 1d Proceeds 1e Cost or other basis Copy B $ 12,100.00 $ 14,188.00 For Recipient 1f Accrued market discount 1g Wash sale loss disallowed 11-4396782 256-43-8819 $ $ RECIPIENT'S name 2 Short-term gain or loss 7 3 If checked, proceeds from: Long-term gain or loss Collectibles Lulu B. Clifden Ordinary QOF This is important tax Street address (including apt. no.) 4 Federal income tax withheld 5 If checked, noncovered information and is $ security being furnished to 33333 Fume Blanc Way the IRS. If you are 6 Reported to IRS: 7 If checked, loss is not allowed based on amount in 1d required to file a City or town, state or province, country, and ZIP or foreign postal code Gross proceeds return, a negligence Net proceeds penalty or other Temecula, CA 92591 8 Profit or (loss) realized in 9 Unrealized profit or loss) on sanction may be 2019 on closed contracts open contracts - 12/31/2018 imposed on you if Account number (see instructions) this income is $ $ taxable and the IRS CUSIP number FATCA filing 10 Unrealized profit or loss) on 11 Aggregate profit or loss) determines that it requirement open contracts-12/31/2019 on contracts has not been 14 State name reported. $ 15 State identification no. 16 State tax withheld $ 12 If checked, basis reported 13 Bartering to IRS $ $ Form 1099-B (Keep for your records) www.irs.gov/Form 1099B Department of the Treasury - Internal Revenue Service $ 651119 r.1 Arr.1 CMNS 10122 Part III Partner's Share of Current Year Income, Deductions, Credits, and Other Items 1 Ordinary bus income oral 15 Crudita Schedule K-1 2019 (Form 1065) Department of the Treasury Forcalidir yar 2018, your begin 2010 Partner's Share of income, Deductions, Credits, etc. Se back of form and separate instructions Partl Information About the Partnership A trap's played on number 11-2343212 tep's address, city, and it code 2 Matruntal rule income forwa) 1,578 3 Othered coral 18 Function 4 paesaris lur uri 4. Buatatud pegunta for capital & Total guld 5 Berlin Be Ordinary chridade 6 Qualified dividende Bc Divided Arti AMT] 7 Royal 8 Not short-term capital gaire Wine Acres Partners 581 Coombs Street, Napa, CA 94559 C Center where partnership led tum Ogden, UT Dreck that is a pubby traded partners. Part II Information About the Partner E Partner Nor IN (Dorot ne TIN odesanded artty. Een niet 543-88 9756 Name, address, city, state and code for pertrand in Sardruction Gregory R. Clifden 33333 Fume Blanc Way, Temecula, CA 92591 General partner or LC United partner or other LLC Tember H1 domestic put For parte He it the partner in gedry Panter the partners TIN What type of entity is the partner? Individual 12 it this partner in a retirement plan laoghi check here - Pesan prott, low and capital intruction Tinginning Ending 2x Los 2x 2x 2x Check dere in continue rechange of partnership inimest 18 Time and Da Nang-lum capital gain oral (900) b Collectiblr29) girl * Urrecaptured on 1200 10 Notection 1231 gun owl 11 Other info 19 Uhr 400 20 Other information 12 Section 17deduction Z 1.578 13 Other deduction Kur's share on Beginning NO 5 4,679 5 4.679 Quid financing 5 $ 5 Check this band why were rower para Partrar's Capital Account Analysis 14 Sul-ployment miegal A 1,578 8 Beginning Capital Account Captable grey Camert your net income 8 3 13.256 0 690 Withdrawal distribution Ending capital account More than one activity for at fick purposes 22 More than one or purposes "See attached statement for additional information 16548 Med the partner comparty with an gain ora? No Yosch starts instruction N Partners Sharof Net Unrecognized Section 704 Gino Los Beginning Ending For Paperwork Meduction Act Notices Instruction for Form 10. www.in. w 100 For IRS Use Only 18 2 Cat No. 11:01 Schedule K-1 Term 1062019 Form 1095-A Health Insurance Marketplace Statement vold OMB No. 1545-2232 Department of the Treasury Do not attach to your tax return. Keep for your records. CORRECTED 2019 Intemal Revenue Service Go to www.irs.gov/Form 1095A for instructions and the latest information. Part I Recipient Information 1 Marketplace 2 Marketplace-resigned policy number 3 Policy we'a nama 31-1234567 A1000HT Covered California 4 Recipient's name 5 Recipient's SSN B Recipients date of birth Gregory R. Clifden 543-88-9756 05/04/1978 7 Recipient's spouse's name 8 Recipient's spouse's SSN 9 Recipient's spouse's date of birth Lulu B. Clifden 258-43-8819 06/12/1977 10 Policy start date 11 Policy termination date 12 Street address including apartment no 05/01/2018 12/31/2019 33333 Fume Blanc Way 13 Cty or town 14 Saate or province 15 Country and ZIP or foreign postal code Temecula CA 92591 Part II Covered Individuals A. Covorod individual name B. Covered individual SSN C. Covered individual date of birth D. Coverage start date E. Coverage formation date 18 Gregory R. Clifden 543-88-9758 05/04/1976 05/01/2019 12/31/2010 17 Lulu B. Cidden 258-43-8819 06/12/1977 05/01/2019 12/31/2019 18 Gerald Cifden 466-74-1131 04/16/2002 06/01/2019 12/31/2019 19 Gary Clifden 465-76-8375 12/02/2007 05/01/2019 12/31/2019 475-23-1426 01/13/2009 05/01/2019 12/31/2019 20 Glenn Clifden Part III Coverage Information Month A. Monthly enrollment premiums B. Monthly second lowest cost silver plan (SLCSP) premium C. Monthly advance payment of premium tax credit 21 January 22 February 23 March 24 April 25 May 1,533 1,621 0 26 June 1,533 1,621 0 27 July 1,533 1.621 0 28 August 1,533 1,621 0 29 September 1,533 1,621 0 30 October 1,533 1,621 0 31 November 1,533 1,621 0 32 December 1,533 1,621 0 33 Annual Totals 12 264 For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 12,988 Cal No. 807030 0 Form 1095-A 2019 $137,896 2,100 4,810 18,100 22,987 17,540 Room rental income Vending machine income Advertising expense Depreciation for book and tax purposes Mortgage interest on the B&B Wages of cleaning people Taxes and licenses Supplies consumed Business insurance Laundry expenses Accounting fees Office expenses Utilities 6,420 18,870 6,300 4,289 1,850 2,400 6,350 a Employee's social security number Safe, accurate, Visit the IRS website at OMB No. 1545-0008 FAST! Use irse , file 256-43-8819 www.irs.gov/efile b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld 43-7654321 $13,700.00 $1,694.00 c Employer's name, address, and ZIP code 3 Social security wages 4 Social security tax withheld Temecula Valley Unified School Dist. $13,700.00 $849.401 31350 Phone Num # 5 Medicare wages and tips 6 Medicare tax withheld Rancho Vista Rd. $13,700.00 $198.65 7 Social security tips 8 Allocated tips Temecula CA 92592 Country # d Control number 9 10 Dependent care benefits Suff. 11 Nonqualified plans 12a See instructions for box 12 Last name Clifden e Employee's first name and initial Lulu B. 33333 Fume Blanc Way Temecula 13 Statutory employee Phone Num # Retirement plan 12b Third-party sick pay 14 Other 12c CA 92591 Country 12d f Employee's address and ZIP code 15 State Employer's state ID number CA 18 Local wages, tips, etc. 19 Local income tax 20 Locality name 16 State wages, tips, etc. 17 State income tax $13,700.00 $400.00 # # # # # # Department of the Treasury-Internal Revenue Service W-2 Wage and Tax 2019 Form Statement Copy B-To Be Filed With Employee's FEDERAL Tax Return. This information is being furnished to the Internal Revenue Service. 2019 CORRECTED (if checked) PAYER'S name, street address, city or town, state or province, 1 Gross distribution OMB No. 1545-0119 Distributions From country, ZIP or foreign postal code, and phone no. Pensions, Annuities, Retirement or $ 14,545.00 Profit-Sharing Plans, 2a Taxable amount IRAs, Insurance Contracts, etc. $ 14,545.00 Form 1099-R United States Navy Retired Benefits Center 2b Taxable amount Total Copy B Cleveland, OH 43267 not determined distribution Report this PAYER'S TIN RECIPIENT'S TIN 3 Capital gain (included 4 Federal income tax income on your in box 2a) withheld federal tax return. If this form shows 11-4662891 543-88-9765 $ $ 1.487.12 federal income RECIPIENT'S name 5 Employee contributions/ 6 Net unrealized tax withheld in Designated Roth appreciation in contributions or employer's securities box 4, attach insurance premiums this copy to Gregory R. Clifden $ $ your return. Street address (including apt. no.) 7 Distribution IRA/ 8 Other SEP/ code(s) SIMPLE This information is 33333 Fume Blanc Way % being furnished to City or town, state or province, country, and ZIP or foreign postal code 9a Your percentage of total 9b Total employee contributions the IRS. Temecula, CA 92591 distribution %$ 10 Amount allocable to IRR 11 1st year of FATCA filing 12 State tax withheld 13 State/Payer's state no. 14 State distribution within 5 years desig. Roth contrib. requirement $ 350.00 CA $ 14.545 $ $ $ Account number (see instructions) Date of 15 Local tax withheld 16 Name of locality 17 Local distribution payment $ $ --===== Form 1099-R www.irs.gov/Form1099R Department of the Treasury - Internal Revenue Service $1,480 5,457 2,130 4,875 9,631 Mastercard interest Dental expenses (orthodontics for Gary) California state income tax (for 2018) Charitable contributions Deductible interest on home (personal portion) Real estate taxes (personal portion) Life insurance premiums Automobile registration fees (deductible portion) Tax return preparation fee Contributions to Donald Trump's re-election campaign 3,830 845 45 475 1,000 $ 381 Interest: Bob's Big Bank Bank of Ireland City of Temecula Tax Exempt Bonds Vintage Bank 271 1,490 See 1099-INT Qualified dividends: Southwest Airlines $ 220 Heinz Foods 560 CORRECTED (if checked) PAYER'S name, street address, city or town, state or province, country, ZIP Payer's RTN (optional) or foreign postal code, and telephone no. OMB No. 1545-0112 2019 Interest Income 1 Interest income Form 1099-INT $ 1,403.80 2 Early withdrawal penalty Vintage Bank 6792 Main Street Temecula, CA 92591 PAYER'S TIN Copy B RECIPIENT'S TIN $ 3 Interest on U.S. Savings Bonds and Treas. obligations For Recipient 96-8724390 543-88-9756 $ RECIPIENT'S name 4 Federal income tax withheld 5 Investment expenses This is important tax $ $ information and is being furnished to the Gregory R. Clifden 6 Foreign tax paid 7 Foreign country or U.S. possession IRS. If you are Street address (including apt. no.) $ required to file a 8 Tax-exempt interest 9 Specified private activity bond return, a negligence interest penalty or other 33333 Fume Blanc Way sanction may be City or town, state or province, country, and ZIP or foreign postal code $ $ imposed on you if 10 Market discount 11 Bond premium this income is taxable and the IRS Temecula, CA 92591 determines that it has FATCA filing $ $ not been reported. requirement 12 Bond premium on Treasury obligations 13 Bond premium on tax-exempt bond| $ $ Account number (see instructions) 14 Tax-exempt and tax credit 15 State 16 State identification no. 17 State tax withheld bond CUSIP no. $ Form 1099-INT (keep for your records) www.irs.gov/Form 1099INT Department of the Treasury - Internal Revenue Service Orange Co. Gold Co. Green Co. $8,114 $2,575 3,800 Sales price Basis Date acquired Date sold See Form 1099-B 1,450 02/11/19 10/31/14 06/19/19 10/23/19 2019 CORRECTED (if checked) PAYER'S name, street address, city or town, state or province, country, ZIP Applicable checkbox on Form 8949 OMB No. 1545-0715 Proceeds From or foreign postal code, and telephone no. Broker and Barter Exchange Transactions A Form 1099-B 1a Description of property (Example: 100 sh.XYZ Co.) Gold Company Common Bear Stearns 269 Wall Street 1b Date acquired 1c Date sold or disposed New York. Ny 10001 03/27/2019 09/18/2019 PAYER'S TIN RECIPIENT'S TIN 1d Proceeds 1e Cost or other basis Copy B $ 12,100.00 $ 14,188.00 For Recipient 1f Accrued market discount 1g Wash sale loss disallowed 11-4396782 256-43-8819 $ $ RECIPIENT'S name 2 Short-term gain or loss 7 3 If checked, proceeds from: Long-term gain or loss Collectibles Lulu B. Clifden Ordinary QOF This is important tax Street address (including apt. no.) 4 Federal income tax withheld 5 If checked, noncovered information and is $ security being furnished to 33333 Fume Blanc Way the IRS. If you are 6 Reported to IRS: 7 If checked, loss is not allowed based on amount in 1d required to file a City or town, state or province, country, and ZIP or foreign postal code Gross proceeds return, a negligence Net proceeds penalty or other Temecula, CA 92591 8 Profit or (loss) realized in 9 Unrealized profit or loss) on sanction may be 2019 on closed contracts open contracts - 12/31/2018 imposed on you if Account number (see instructions) this income is $ $ taxable and the IRS CUSIP number FATCA filing 10 Unrealized profit or loss) on 11 Aggregate profit or loss) determines that it requirement open contracts-12/31/2019 on contracts has not been 14 State name reported. $ 15 State identification no. 16 State tax withheld $ 12 If checked, basis reported 13 Bartering to IRS $ $ Form 1099-B (Keep for your records) www.irs.gov/Form 1099B Department of the Treasury - Internal Revenue Service $ 651119 r.1 Arr.1 CMNS 10122 Part III Partner's Share of Current Year Income, Deductions, Credits, and Other Items 1 Ordinary bus income oral 15 Crudita Schedule K-1 2019 (Form 1065) Department of the Treasury Forcalidir yar 2018, your begin 2010 Partner's Share of income, Deductions, Credits, etc. Se back of form and separate instructions Partl Information About the Partnership A trap's played on number 11-2343212 tep's address, city, and it code 2 Matruntal rule income forwa) 1,578 3 Othered coral 18 Function 4 paesaris lur uri 4. Buatatud pegunta for capital & Total guld 5 Berlin Be Ordinary chridade 6 Qualified dividende Bc Divided Arti AMT] 7 Royal 8 Not short-term capital gaire Wine Acres Partners 581 Coombs Street, Napa, CA 94559 C Center where partnership led tum Ogden, UT Dreck that is a pubby traded partners. Part II Information About the Partner E Partner Nor IN (Dorot ne TIN odesanded artty. Een niet 543-88 9756 Name, address, city, state and code for pertrand in Sardruction Gregory R. Clifden 33333 Fume Blanc Way, Temecula, CA 92591 General partner or LC United partner or other LLC Tember H1 domestic put For parte He it the partner in gedry Panter the partners TIN What type of entity is the partner? Individual 12 it this partner in a retirement plan laoghi check here - Pesan prott, low and capital intruction Tinginning Ending 2x Los 2x 2x 2x Check dere in continue rechange of partnership inimest 18 Time and Da Nang-lum capital gain oral (900) b Collectiblr29) girl * Urrecaptured on 1200 10 Notection 1231 gun owl 11 Other info 19 Uhr 400 20 Other information 12 Section 17deduction Z 1.578 13 Other deduction Kur's share on Beginning NO 5 4,679 5 4.679 Quid financing 5 $ 5 Check this band why were rower para Partrar's Capital Account Analysis 14 Sul-ployment miegal A 1,578 8 Beginning Capital Account Captable grey Camert your net income 8 3 13.256 0 690 Withdrawal distribution Ending capital account More than one activity for at fick purposes 22 More than one or purposes "See attached statement for additional information 16548 Med the partner comparty with an gain ora? No Yosch starts instruction N Partners Sharof Net Unrecognized Section 704 Gino Los Beginning Ending For Paperwork Meduction Act Notices Instruction for Form 10. www.in. w 100 For IRS Use Only 18 2 Cat No. 11:01 Schedule K-1 Term 1062019 Form 1095-A Health Insurance Marketplace Statement vold OMB No. 1545-2232 Department of the Treasury Do not attach to your tax return. Keep for your records. CORRECTED 2019 Intemal Revenue Service Go to www.irs.gov/Form 1095A for instructions and the latest information. Part I Recipient Information 1 Marketplace 2 Marketplace-resigned policy number 3 Policy we'a nama 31-1234567 A1000HT Covered California 4 Recipient's name 5 Recipient's SSN B Recipients date of birth Gregory R. Clifden 543-88-9756 05/04/1978 7 Recipient's spouse's name 8 Recipient's spouse's SSN 9 Recipient's spouse's date of birth Lulu B. Clifden 258-43-8819 06/12/1977 10 Policy start date 11 Policy termination date 12 Street address including apartment no 05/01/2018 12/31/2019 33333 Fume Blanc Way 13 Cty or town 14 Saate or province 15 Country and ZIP or foreign postal code Temecula CA 92591 Part II Covered Individuals A. Covorod individual name B. Covered individual SSN C. Covered individual date of birth D. Coverage start date E. Coverage formation date 18 Gregory R. Clifden 543-88-9758 05/04/1976 05/01/2019 12/31/2010 17 Lulu B. Cidden 258-43-8819 06/12/1977 05/01/2019 12/31/2019 18 Gerald Cifden 466-74-1131 04/16/2002 06/01/2019 12/31/2019 19 Gary Clifden 465-76-8375 12/02/2007 05/01/2019 12/31/2019 475-23-1426 01/13/2009 05/01/2019 12/31/2019 20 Glenn Clifden Part III Coverage Information Month A. Monthly enrollment premiums B. Monthly second lowest cost silver plan (SLCSP) premium C. Monthly advance payment of premium tax credit 21 January 22 February 23 March 24 April 25 May 1,533 1,621 0 26 June 1,533 1,621 0 27 July 1,533 1.621 0 28 August 1,533 1,621 0 29 September 1,533 1,621 0 30 October 1,533 1,621 0 31 November 1,533 1,621 0 32 December 1,533 1,621 0 33 Annual Totals 12 264 For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 12,988 Cal No. 807030 0 Form 1095-A 2019