John and Jane Doe are married retired taxpayers who care for their three-year-old grandson. The following information was provided to you as documentation necessary to prepare their 2017 tax return. You will gather the appropriate information and complete the forms provided in Blackboard (1040, Schedule A, Schedule B and Schedule D) in preparation of their tax file. Please note that the forms provided may not match the tax year of the course, as IRS forms are not available until just before the start of the filing season, and this course generally is approximately a year ahead of the actual form releases. Therefore, do not worry about the year on top of the forms, but utilize information for the current year of the textbook in use for this course when determining deduction amounts, exemption amounts, and tax rates.
Taxpayer:
Name: John Doe
DOB: 6/29/1950
SSN: 555-12-3456
Spouse:
Name: Jane Doe
DOB: 7/4/1948
SSN: 555-65-4321
Dependent:
Name: Jimmy Doe
DOB: 1/12/2014
SSN: 555-68-9101
Mailing Address:
12345 Any Street
Los Angeles, Ca 90124
Deductions
Prescription Medication: $638
Doctors Visits: $2,904
Insurance Premiums out of pocket (not including Medicare premiums deducted from social security): $5,125
Medical Miles Driven: 410
Deductible DMV registration fees: $170
Income:
Received a gift from Janes mother, $12,000
Sold Stock with a basis of $10,000 for $13,500. Held the stock for more than one year
Sold stock with a basis of $5,000 for $5,500. Held the stock for less than one year.
X
Finally, all three members of the family had qualifying health insurance for the entire year.
2016 CORRECTED if checked) DAYEHS street anteness, we province country Per Niohioma OMB No 1545-0112 ZIP Postal code, Stepfotleta GOVERNMENT PERSONNEL MUTUAL LIFE INS CO 2211 NE LOOP 410 P.O. BOX 659567 Interest Income SAN ANTONIO, TX 78265 9567 $56.98 800-929.4765 2 Early when Form 1099-INT a interest. Sings Bonds and results SAYERS fede encombe WEC:PIENTS dent can be 74-0651020 For Recipient PECIELT Sure to restoran Gale or province 4 Fedeancome tax with Sinestent ex This is important tax yang pala reformation and is being furnished to the John Doe 6 Faxud 7 Foreign county U.S. POUSSE lental Revenue 12345 Any Street Service. If you are required to lile a reluma Los Angeles, Ca 90124 sax-exemptores! Speciale actly conderes a negligence penalty other action may be 1 Maiket.count imposed on you 11 Goti piemai income is taxable and the IRS determines that 12 Bord monde 13 B6 pretro xexent it has not been reported et serruction 000275767 FATCA 14 Taxat ang red bond CUSIP Form 1099-INT 15 5 16 Stalentification 17 Sated NM 03-221595-009 Department of the Treasury - Internal Revenue Service (keep for your records www.irs.gov/form 1093int ORTOB Rev. 1215) CORRECTED (if checked) Dividends and Distributions Verizon Communications Inc. 2016 PAYER'S Federal identification number: 23-2259884 PAYER'S name, street address, city, state, and ZIP code VERIZON COMMUNICATIONS INC C/O COMPUTERSHARE PO BOX 43078 PROVIDENCE RI 02940-3078 $ 0.00 $ 0.00 ta Toordinary dividende the divine S5404.41 S 1404.41 2a Total against 2b Ucap Sec 1250 g OMB No 1545-0110 $ 0.00 $ 000 2c Section 1202 2d Collectibles (20% geet $ 0.00 Com $ 0.00 3 Nondividend die S 4 Federal income tax withheld Form 1099-DIV 6 Forint paid $ 0.00 $ 7 Formign country or U.S. Cashligion distribution Copy B For Recipient 10 Esenterest dividend 11 forced practing terdiri di The la important tax information $ 0.00 and is being furnished to the Internal Revenue Service. you The reportable arounts above include the following additional Income: are required to learstum, a Company Pad Fees negligence penalty or other Company Paid Service Charges sanction may be imposed on $ 0.00 $ 0.00 you. If this income is taxable and Discount on Reiwestiment the IRS determines that has $ 0.00 not been reported is 0.00 RECIPIENT'S ID No. ending in: ***"-6711 Account number (see instructions): C0001413651 RECIPIENT'S name, street address, city, state, ZIP code $ 0.00 John & Jane Doe 12345 Any Street Los Angeles, Ca 90124 Form 1099-DIV (keep for your records) Department of the Treasury - Internal Revenue Service CORRECTED (if checked) Dividends and Distributions BOX 43078 SHARE OORTDB Rev. 12/15) .bc PAYER'S Federal identification number: 95-3551121 PAYER'S name, street address, city, state, and ZIP code PUBLIC STORAGE PROVIDENCE RI 02940-3078 Public Storage fa Total de The videos 52100.70 $ 0.00 Total 2. Sec. 1250 g OMB No 1545-0110 $ 0.00 $ 0.00 1. Se 1202 3d Collec (289) 2016 $ 0.00 $ 0.00 3 Nondividu 4federal income tax wihald $ 0.00 $ 8.00 Form 1099-DIV Sagenes Forg la pod $ 0.00 $ Copy B 7 Foreign county or Somesos Cachondas For Recipient $ 0.00 10 Exempore divided 11 Set This is important information 5 000 $ 0.00 and being furnished to the Intemal Revenue Service, you The reportable amounts above include the following clonal Income are required to do a mom, a Company Paid Foes degligence paraty or other Coripany Paid Service Charges sanction may be imposed on $ you this one is able and Discount on to the IRS di hati has not been reported RECIPIENT'S namo, street address, city, stato, ZIP code John & Jane Doe 12345 Any Street Los Angeles, Ca 90124 S Form 1099-DIV (keep for your records) Department of the Treasury - omal Revenue Service 95 2834236 RECIPIENT'S cutification number Permint PTG CUST FOLLOVER IRA FBO Jane Doe 12345 Any Street Los Angeles, Ca 90124 PAYER's foderal identification number: Payer LPL Financial 1065 LPL Way Fort MSG 29715 98 FAICA gent 1 Gross distribution 2a Taxiunt 25 Taxable amount to determined Total distribution 3 Capital gain ancluded on line 2a 4 Focal income tax with 5 Eye contbution Designated Roth contations or insurance promiums 6 Netralized appreciation employer's securities 7 Distribution codes IRA SE SIMPLE $17,700.00 8 Other amount $17.700.00 Other amount porcentage 10 Sa Yout percentage of total distribution Usb Totalcmployee contributions 10 Amount allocable to TRA within 5 yesis $3.540 08 11 197 your otsigFell cutti 12 State tax withhell 13 State Payer's stato urber 7 14 Site distribution $884.88 CA 02-074930-000 2016 OM NA 1545.01 Form: 0 Distributions to Pensioes, Anti Retirement or Pro Sharing Plus, IR Insurance Contracts.c 1. Gross distribution 41016.00 OFFICE OF PERSONNEL MANAGEMENT STATEMENT OF ANNUITY PAID RETIREMENT OPERATIONS Copy 2A- To be filed with annuitant's state or local P.O. BOX 45 tax return BOYERS, PA 16017-0045 PAYER'S Federal Identification Recipient's ID No Annuitant Account number Retirement Cham No 52-6083699 Employee EGGS Dato ROTH Contributions PAID nance Premium TO John Doe 2641 80 12345 Any Street 7. Distribution Codes Los Angeles, Ca 90124 12. State tax withheld 7 NON DISABILITY 1440.00 Tor Employee Contribution 12. State tax withheld 3891.00 NONE 2a. Taxable amount 38553.00 4 Federal Income Tax Withheld 3942.00 13. State Payer's state no. CA 13. State Payer's state no. FORM SSA-1099 - SOCIAL SECURITY BENEFIT STATEMENT 2016 PART OF YOUR SOCIAL SECURITY BENEFITS SHOWN IN BOX 5 MAY BE TAXABLE INCOME. SEE THE REVERSE FOR MORE INFORMATION. Box 1. Name Jane Doe Box 2. Beneficiary's Social Security Number Box 3. Benefits Paid in 2016 Box 4. Benefits Repaid to SSA in 2016 BOKS. Net Benefits for 2016 Bormius Bor $19.894.80 NONE $19,894,80 DESCRIPTION OF AMOUNT IN BOX 3 DESCRIPTION OF AMOUNT IN BOX 4 Paid by check or direct deposit $18,636.00 NONE Medicare Part B premiums deducted from your benefits $1.258.BD Total Additions $19,894.80 Benefits for 2016 $19,894.80 Box 6. Voluntary Federal Income Tax Withheld NONE Box 7. Address San Clemente Parish Contributions Summary Family Statement John & Jane Doe 12345 Any Street Los Angeles, Ca 90124 Below is your monetary gifts to San Clemente Parish for the period January 1, 2016 - December 31, 2016 Without your support of time, talent and treasure, San Clemente Parish would not be a vibrant and faithful community. Your donations support many needed activities for the youti, elderly, religious education of our members, the poor and the works of the Archdiocese of Santa Fe and the Catholic Church as a whole. Please keep this letter as receipt of your contributions for tax purposes. If you need to update your parish registration information, please contact the parish office. If you have any questions, please feel free to contact the parish office at San Clemente did not provide any goods or services for any donations received. Deacon Jim Snell Business Manager San Clemente Parish Fund Amount Fund Amount Building Fund DrivePm Pledge Christmas Seminary Support World Mission Sunday Total Contributions: $80.00 $20.00 $15.00 $20.00 Cemetary Improvement Fund contributions SVDP Contributions $10.00 $390.00 $90.00 $625.00 2016 $ 12,215 CORRECTED (if checked) RECIPIENT SLENDER S name, strast dress, city or town, state or Caution: The amount shown may OMB No. 1545-0001 province, country. ZIP or foreign postal code, and telephone n. not be deduct by you Limoged on the car amount Mortgage John & Jane Doe and the cost and value of the Our property may apply. Also, Interest 12345 Any Street you may only deduct Interest to the at was in unted by you Rev. Juy 2016 Los Angeles, Ca 90124 Statement actually paid by you, and fronted by another person Form 1098 Morte cantante ved from Daversy borrow Copy B For Payer/ FECPIENT'S/LENDER'S federal PAYERS/BORROWER'S taxpayer 2 Outstanding mortgage 3 Mortgage origination date Borrower identification number identication principal as of 1/1/2016 LOAN ORIGINATION $74, 101.26 DATE: 05/28/2006 The information in boxes 1 73-0780382 4 bund af varpaid 5 Mortgage Insurance through is important tex interest premiurns normation and is being furnished to the Internal PAYER'S/BORROWER'S name $ 0.00 $0.00 Prevenus Service you 6 Points paid on purchase of principal sidence required to file a rotum, a $ 0.00 negligence ponety or other Sret address including act no 7 is address of property securing mortgage samas sanction may be imposed PAYER'S/BORACWER'Saddress? an you if the IRS determines Yes, box is checked. het an underpayment of No. 900 box 8 or 9. below takutts because you City or town, state or province, country, and ZIF or foregn postal code Oerstated a deduction a Address of property securing mortgage for this mortgage interest ar for the points, reported in boxes 1 and or 10 Other because you didn't sport Real Estate Tax Paid: $2,215 9 f property securing mangge has no ress, telow is the the round of interest coacription of the properly box 45, because you claimed non-deductible Account number see instructions) tem. Form 1098 Keep for your records www.irs.gowform 1098 Department of the Treasury - Internal Revenue Service SCHEDULED (Form 1040) OMB No. 1545-0074 Capital Gains and Losses Attach to Form 1040 or Form 1040NR. 2016 Information about Schedule D and its separate instructions is at www.irs.gov/scheduled. Attachment Use Form 8949 to list your transactions for lines 1b, 2, 3, 8, 9, and 10. Sequence No. 12 Your social security number Department of the Treasury Internal Revenue Service (99) Name(s) shown on retum Part I Short-Term Capital Gains and Losses-Assets Held One Year or Less (d) Proceeds (sales price) Cost (or other basis) (g) Adjustments to gain or loss from Formis) 8949, Part I. line 2 column (gl Gain or loss) Subtract calumn) from column (d) and combine the result with columna) See instructions for how to figure the amounts to enter on the lines below. This form may be easier to complete if you round off cents to whole dollars. 1a Totals for all short-term transactions reported on Form 1099-B for which basis was reported to the IRS and for which you have no adjustments (see instructions). However, if you choose to report all these transactions on Form 8949, leave this line blank and go to line 1b 1b Totals for all transactions reported on Form(s) 8949 with Box A checked 2 Totals for all transactions reported on Form(s) 8949 with Box B checked 3 Totals for all transactions reported on Form(s) 8949 with Box C checked 4 5 4 Short-term gain from Form 6252 and short-term gain or loss) from Forms 4684, 6781, and 8824 5 Net short-term gain or loss) from partnerships, S corporations, estates, and trusts from Schedule(s) K-1 .... 6 Short-term capital loss carryover. Enter the amount, if any, from line 8 of your Capital Loss Carryover Worksheet in the instructions 7 Net short-term capital gain or loss). Combine lines 1a through 6 in column (h). If you have any long- term capital gains or losses, go to Part II below. Otherwise, go to Part Ill on the back Part II Long-Term Capital Gains and Losses-Assets Held More Than One Year 6 7 column) See instructions for how to figure the amounts to enter on the (9) Gain or loss) lines below. (d) le) Adjustments Subtract column le) Proceeds Cost to gain or loss from from colind and This form may be easier to complete if you round off cents to (sales price) (or other basis) Form(s) 8949, Part II, combine the result with whole dollars. line 2, column (9) 8a Totals for all long-term transactions reported on Form 1099-B for which basis was reported to the IRS and for which you have no adjustments (see instructions). However, if you choose to report all these transactions on Form 8949, leave this line blank and go to line 8b 8b Totals for all transactions reported on Form(s) 8949 with Box D checked .....:: 9 Totals for all transactions reported on Form(s) 8949 with Box E checked 10 Totals for all transactions reported on Form(s) 8949 with Box F checked...!! 11 Gain from Form 4797, Part I: long-term gain from Forms 2439 and 6252; and long-term gain or (loss) from Forms 4684, 6781, and 8824 11 12 Net long-term gain or (loss) from partnerships, Scorporations, estates, and trusts from Schedule(s) K-1 12 13 Capital gain distributions. See the instructions. 13 14 Long-term capital loss carryover. Enter the amount, if any, from line 13 of your Capital Loss Carryover Worksheet in the instructions 14 15 Net long-term capital gain or loss). Combine lines &a through 14 in column (h). Then go to Part Ill on the back. ...... 15 For Paperwork Reduction Act Notice, see your tax retum instructions. Cat. No. 11338H Schedule D (Form 1040) 2016 Schedule D (Form 1040) 2016 Page 2 Part III Summary 16 Combine lines 7 and 15 and enter the result 16 If line 16 is a gain, enter the amount from line 16 on Form 1040, line 13, or Form 1040NR, line 14. Then go to line 17 below. If line 16 is a loss, skip lines 17 through 20 below. Then go to line 21. Also be sure to complete line 22. If line 16 is zero, skip lines 17 through 21 below and enter-O-on Form 1040, line 13, or Form 1040NR, line 14. Then go to line 22. 17 Are lines 15 and 16 both gains? Yes. Go to line 18. No. Skip lines 18 through 21, and go to line 22. 18 Enter the amount, if any, from line 7 of the 28% Rate Gain Worksheet in the instructions 18 19 Enter the amount, if any, from line 18 of the Unrecaptured Section 1250 Gain Worksheet in the instructions 19 20 Are lines 18 and 19 both zero or blank? Yes. Complete the Qualified Dividends and Capital Gain Tax Worksheet in the instructions for Form 1040, line 44 (or in the instructions for Form 1040NR, line 42). Don't complete lines 21 and 22 below. No. Complete the Schedule D Tax Worksheet in the instructions. Don't complete lines 21 and 22 below. 21 If line 16 is a loss, enter here and on Form 1040, line 13, or Form 1040NR, line 14, the smaller of: The loss on line 16 or ($3,000), or if married filing separately, ($1,500) 21 Note: When figuring which amount is smaller, treat both amounts as positive numbers. 22 Do you have qualified dividends on Form 1040, line 9b, or Form 1040NR, line 10b? Yes. Complete the Qualified Dividends and Capital Gain Tax Worksheet in the instructions for Form 1040, line 44 (or in the instructions for Form 1040NR, line 42). No. Complete the rest of Form 1040 or Form 1040NR. Schedule D (Form 1040) 2016 OMB No. 1545-0074 SCHEDULE B (Form 1040A or 1040) (Rev. January 2017) Department of the Treasury Internal Revenue Service (169) Names) shown on return Interest and Ordinary Dividends Attach to Form 1040A or 1040. Information about Schedule B and its instructions is at www.irs.gov/scheduleb. 2016 Attachment Sequence No. 08 Your social security number Part 1 1 Amount List name of payer. If any interest is from a seller-financed mortgage and the buyer used the property as a personal residence, see instructions on back and list this interest first. Also, show that buyer's social security number and address Interest (See instructions on back and the instructions for Form 1040A, or Form 1040, line 8a.) 1 Note: If you received a Form 1099-INT, Fom 1099-OID, or substitute statement from a brokerage firm, list the firm's name as the 2 Add the amounts on line 1 payer and enter the total interest 3 Excludable interest on series EE and I U.S. Savings bonds issued after 1989. shown on that Attach Form 8815 form. 4 Subtract line 3 from line 2. Enter the result here and on Form 1040A, ar Form 1040, line 8a Note: If line 4 is over $1,500, you must completo Part III. Part II 5 List name of payer 2 3 4 Amount Ordinary Dividends (See instructions on back and the instructions for Form 1040A, or For 1040, line 9a.) 5 Note: If you received a Form 1099-DIV or substitute statement from a brokerage firm, list the firm's name as the payer and enter the ordinary 6 dividends shown Add the amounts on line 5. Enter the total here and on Form 1040A, or Form on that form. 1040, line 90 6 Note: If line 6 is over $1,500, you must complete Part III. You must complete this part if you (a) had over $1,500 of taxable interest or ordinary dividends; (b) had a foreign account; or (c) received a distribution from, or were a grantor of, or a transferorto, a foreign trust. Yes No Part III 7a At any time during 2016, did you have a financial interest in or signature authority over a financial Foreign account (such as a bank account, securities account, or brokerage account) located in a foreign country? See instructions .................. Accounts and Trusts If "Yes," are you required to file FinCEN Form 114, Report of Foreign Bank and Financial Accounts (FBAR), to report that financial interest or signature authority? See FinCEn Form 114 (See and its instructions for filing requirements and exceptions to those requirements instructions an b If you are required to file FinCEN Form 114, enter the name of the foreign country where the back.) financial account is located 8 During 2016, did you receive a distribution from, or were you the grantor of, or transferor to, a foreign trust? If "Yes," you may have to file Form 3520. See instructions on back For Paperwork Reduction Act Notice, see your tax return instructions. Gat. No. 17146N Schedule B (Form 1040A or 1040) 2016 Schedule B (Form 1040A or 1040) 2016 Page 2 General Instructions Future Developments For the latest information about developments related to Schedule B (Form 1040A or 1040) and its instructions, such as legislation enacted after they were published, go to www.lrs.gov/schedule. What's New The due date for filing FinCEN Form 114 has changed. See below Purpose of Form Use Schedule B if any of the following applies. You had over $1,500 of laxable interest or ordinary dividends. You received interest from a seller-financed mortgage and the buyer used the property as a personal residence . You have accrued interest from a bond, - You are reporting original issue discount (OID) of less than the amount shown on Form 1099-OID. You are reducing your interest income on a bond by the amount of amortizable bond premium. You are claiming the exclusion of Interest from series EE or U.S. savings bonds issued after 1989. You received interest or ordinary dividends as a nominoe. You had a financial interest in, or signature authority over, a financial account in a foreign country or you received a distribution from, or were a grantor of, or transferorto, a foreign trust Specific Instructions You can list more than one payer on TIP be sure to clearly show the amount Pics cach entry space for lines 1 and 5, but next to the payor's name. Add the separate amounts pals by the payers listed on an entry space and enter the total in the "Amount" column. If you still need more space, attach separate statements using the same format as lines and 5, but show your love's on Schedule 8. Pul your name and social security number (SSN) on the statements and attach them at the end of your return Part I. Interest Line 1. Report on line 1 all of your taxable interest. Taxalole interest generally should be shown on your Forms 1099-INT, Forms 1049-OID, or substituto statements. Include interest from series EE, H, HH, and I U.S. savings bonds. Also include any accrued market discount that is includible in income. List each payer's name and show the arount. Don't report on this line any tax-exempt interest from box 8 or box 9 of Form 1099-INT. Instead, report the amount from box 8 on line 6b of Form 1040A or 1040. If an amount is shown in box 9 of Form 1099-INT, you generally must report it on line 12 of Form 6251. See the Instructions for Form 6251 for more details. For more information on market discount and other investment income, see Pub. 550. Seller-financed mortgages. If you sold your home or other property and the buyer used the property as a personal residence, list first any interest the buyer paid you on a mortgage or other form of seller financing. Be sure to show the buyer's name, address, and SSN. You must also let the buyer know your SSN. If you don't show the buyer's name, address, and SSN, or let the buyer know your SSN, you may have to pay a $60 penalty Nominees. If you received a Form 1099-INT that cludes interest you received as a nomina (that is, in your name, but the interest actually belongs to someone else), report the total on line 1. Do this even if you later distributed some or all of this income to others. Under your last entry on line 1, put a subtotal of all interest listed on line 1. Below this subtotal, enter "Nominee Distribution and show the total interest you recalved as a nominee Subtract this amount from the subtotal and enter the result on line 2 If you received interest as a nominee, you must give the actual owner a Form TIP 1099-INT (less the owner is your Spouse) and Millo Forms 1095 and 1099-INT with the IRS. For more details. see the General Instructions for Certain Information Returns and the Instructions for Futus 1099-INT and 1099 OID. Accrued interest. When you buy bonds between interest payment dates and pay accrued interest to the seller, this interest is taxable to the seller. If you received a Form 1099 for interest as a purchaser of a bond with accrued interest, follow the rules carlier under Nominees to see how to report the accrued interest. But identify the amount to be subtracted as "Accrued Interest." Original issue discount (OID). If you are reporting OID in an amount less than the amount shown on Form 1099-OID, follow the rules earlier under Nominees to see how to report the OID, Aut identify the amount to be subtracted as "OID Adjustment." Amortizable bond premium. If you are reducing your interest in me on a bond by the amount of amortizable hand promium, follow the rules carlier under Nominees to see how to report the interest. But ideally the amount to be subtracted as "ABP Adjustment." Line 3. If, during 2016, you cashed series EF or 1 U.S. savings bonds issued after 1989 and you paid qualified higher education expenses for yourself, your spouse, or your dependents, you may be able to exclude part or all of the interest on those bonds. See Form a15 for details. Part II. Ordinary Dividends You may have to file Form 5471 ilin 2016, you were an office or director of TIP a foreign corporation. You may also have to file Form 5471 if, in 2016, you owned 10% or more of the fola (a) value of a foreign corporation's stock, or (b) combined voting power of all classes of a foreign corporation's stock with voting rights. For details, see Form 5471 and its instructions Line 5. Report on line 5 all of your ordinary dividends. This amount should be shown in box la of your Forms 1099-DIV or substitute statements. Nominees. If you received a Form 1099-DIV that includos ordinary dividends you received as a nominee (thal is, in your name, but the ordinary dividends actually belong to someone else), report the total on line 5. Do this even if you later distributed some or all of this income to others. Under your last entry on line 5, put a subtotal of all ordinary dividends listed on line 5. Below this aubtotal, enter "Nominee Distribution and show the tolal ordinary dividends you received as a nomine Subtract this amount from the subtotal and enter the result on line 6 If you received dividends as a nomino, you must give the actual owner a Fom TIP1099-DIV inless the owner is your spouse) and file Forms 1096 and 1099- DV IRS. For more details, see the General Instructions for Certain Information Returns and the Instructions for Form 1039-DIV. Part III. Foreign Accounts and Trusts Regardless of whether you are required to file FinCEN Form 114 (FBA), you TIP may be required to file Porn 1938 Statement of Specified Foreign Financial Assets, with your income tax retur. Failure to file Form 8938 y result in penalties and exterision of the statute of bilations. See www.irs.gov/forma938 for more information Line 7a-Question 1. Chock the "Yes" box if at any time during 2016 you had a financial interest in or signature Ruthority over a financial account located in a foreign country. See the definitions that follow. Check the "Yes" box even if you aren't required to filo FinCEN Form 114. Financial account. A financial account includes but isn't limited to, a securities, brokerage, savings demand, checking, deposit, time deposit, or other account maintained with a financial institution for other person performing the services of a financial institution). A financial account also includes a commodity futures or options account, an insurance policy with a cash value (such as a whole life insurance policy), an annuity policy with a cash value, and shares in a mutual fund or similar pooled fund that is, a fund that is available to the general public with a regular net asset value determination and regular redemptions). Financial account located in a foreign country. A financial count is located in a foreign country if the account is physically located outside of the United States. For example, an account maintained with a branch of a United States bark that is physically located outside of the United States is a foreign financial account. An account maintained with a branch of a foreign bank that is physically located in the United States isn't a foreign financial account. Signature authority. Signature authority is the authority of an individual (alone or in conjunction with another individual) to control the disposition of assots hold in a foreign financial account by direct communication (whether in writing or otherwise) to the bank or other financial institution that maintains the financial account. See the FinCEN Form 114 Instructions for exceptions. Don't consider the exceptions relating to signature authority in answering Question 1 on line 7 Other definitions. For definitions of financial interest," United States," and other relevant terms, see the instructions for FinCEN Form 114. Line 78-Question 2. See FinCENTO 114 and its instructions at www.focen.gov/lbar to determine whether you must file the form. Check the "Yes" box if you are required to file the forme, check the "No box if you aren't required to file the form If you checked tho ''Yes' box to Question 2 online 73, you must electronically file FinCEN Form 114 with Treasury's Financial Crimes Enforcement Network, go to www.fincen.gov/lbar for details. Do not attach FinCEN Form 114 to your tax retum. FinCEN Form 114 for 2016 is now generally dus April 18, 2017, but FinCEN is providing an automatic extension for all filers until October 16, 2017. See www.finceri.gov for details. If you are required to file FinCEN Fom 114 but don't properly do so, you may have to pay a civil penally up to CAUTION $70,000. A person who willfully fails to report an account or provide account identifying Information may be subject to a civil penalty equal to the greater of $100.000 or 50% of the balance in the account at the time of the volation. WwWl violations may also be subject to criminal penalties Line 7b. If you are required to file FinCEN Form 114, enter the name of the foreign country or countries in the space provided on line 7b. Attach a separate statement if you nesd more space Line 8. If you received a distribution from a foreign trust, you must provide additional information. For this purpose, a loan of cash or marketable securities generally is considered to be a distribution. So Form 3520 for details. If you were the grantor of, or transferorto, a foreign trust that existed during 2016, you may have to file Form 3520 Don't attach Form 3520 to Form 1040. Instead, lile it at the address shown in its instructions. If you were treated as the owner of a foreign trust under the grantor trust rules, you are also responsible for ensuring that the foreign trust files Form 3520-A, Form 3520-A is due on March 15, 2017, for a calendar year trust. See the instructions for Form 3520-A for more details. w the SCHEDULE A (Form 1040) OMB No. 1545-0074 Itemized Deductions Information about Schedule A and its separate instructions is at www.irs.gov/schedulea. Attachment Attach to Form 1040. Sequence No. 07 Your social security number 2016 Department of the Treasury Internal Revenue Service (99) Names) shown on Form 1040 9 15 Caution: Do not include expenses reimbursed or paid by others. Medical 1 Modical and dental expenses (see instructions) 1 and 2 Enter amount from Form 1040, line 382 Dental 3 Multiply line 2 by 10% (0.10). But if either you or your spouse was Expenses bom before January 2, 1952, multiply line 2 by 7.5% (0.075) instead 3 4 Subtract line 3 from line 1. If line 3 is more than line 1, enter-O- Taxes You 5 State and local (check only one box): Paid a Income taxes, or 5 b General sales taxes 6 Real estate taxes (see instructions) 6 7 Personal property taxes 7 8 Other taxes. List type and amount 8 9 Add lines 5 through 8 Interest 10 Home mortgage interest and points reported to you on Form 1098 10 You Paid 11 Home mortgage interest not reported to you on Form 1098. If paid to the person from whom you bought the home, see instructions Note: and show that person's name, identifying no., and address Your mortgage interest deduction may 11 be limited (see 12 Points not reported to you on Form 1098. See instructions for instructions special rules..... 12 13 Mortgage insurance premiums (see instructions) 13 14 Investment interest. Attach Form 4952 if required. (See instructions.) 14 15 Add lines 10 through 14.. Gifts to 16 Gifts by cash or check. If you made any gift of $250 or more, Charity see instructions.. 16 If you made a 17 Other than by cash or check. If any gift of $250 or more, see gift and got a instructions. You must attach Form 8283 if over $500 17 benefit for it 18 Carryover from prior year 18 see instructions. 19 Add lines 16 through 18 Casualty and Theft Losses 20 Casualty or theft loss(es). Attach Form 4684. (See instructions.) Job Expenses 21 Unreimbursed employee expenses-job travel, union dues, and Certain job education, etc. Attach Form 2106 or 2106-EZ if required. Miscellaneous (See instructions.) 21 Deductions 22 Tax preparation fees 22 23 Other expenses-investment, safe deposit box, etc. List type and amount 23 24 Add lines 21 through 23 24 25 Enter amount from Form 1040, line 38 25 26 Multiply line 25 by 2% (0.02) 26 27 Subtract line 26 from line 24. If line 26 is more than line 24, enter-O- Other 28 Other-from list in instructions. List type and amount Miscellaneous Deductions Total 29 Is Form 1040, line 38, over $155,650? Itemized No. Your deduction is not limited. Add the amounts in the far right column Deductions for lines 4 through 28. Also, enter this amount on Form 1040, line 40. Yes. Your deduction may be limited. See the ltemized Deductions Worksheet in the instructions to figure the amount to enter. 30 If you elect to itemize deductions even though they are less than your standard deduction, check here For Paperwork Reduction Act Notice, see Form 1040 instructions. Cat. No. 17145C 19 20 27 28 29 Schedule A Form 1040) 2016 1040 Department of the Treasury-Internal Revenue Service (99) U.S. Individual Income Tax Return For the year Jan, 1-Dec 31, 2016, or other tax year beginning Your first name and initial Last namne , 2016, ending OMB No. 1545-0074 IS Use Only-Do not write or stapin in this apace. 20 See separate instructions. Your social security number Fa joint retum, spouse's first name and initial Last name Spouse's social security number 9b Home address (number and street). If you have a P.O. box, en instructions. Apt. no. Make sure the SSNis) above and on line 6c are correct. City, town or cst office, state, and ZIP code. If you have a foreign address, also complete spaces below (sas instructions). Presidential Election Campaign Check here it you or your spouse il ting Foreign country name Foreign province/stata/county Foreign postal code jantly, wart Ss to go to this fund. Checking a box below will not change your tax or refund. You Spouse Filing Status 1 Single 4 Head of household with qualifying person). (See instructions. It 2 Married filing jointly (even if only one had income) the qualifying person is a child but not your dependent, enter this Check only one 3 Married filing separately. Enter spouse's SSN above child's name here. box and full name here. 5 D Qualifying widow(er) with dependent child Exemptions Yourself. If someone can claim you as a dependent, do not check box 6a Boxes checked on ba and 6b b Spouse No. of children c Dependents: (2) Dependent's (3) Dependent's (4) if child under age 17 17 on Bc who: (1) First name social security number qualifying for child tax credit Laste relationship to you lived with you see instructions) . did not live with you due to divorce U If more than four or separation o [See instructions dependents, see Dependents on 6C instructions and not entered above check here I Add numbers on d Total number of exemptions claimed lines above Income 7 Wages, salaries, tips, etc. Attach Form(s) W-2 7 8a Taxable interest. Attach Schedule B if required 8a b Tax-exempt interest. Do not include on line 8a 8b Attach Form(s) 9a W-2 here. Also Ordinary dividends. Attach Schedule B if required 9a attach Forms b Qualified dividends W-2G and 10 Taxable refunds, credits, or offsets of state and local income taxes 10 1099-R if tax 11 Alimony received 11 was withheld. ..... 12 Business income or (loss). Attach Schedule Cor C-EZ 12 12 13 Capital gain or loss). Attach Schedule Dif required. If not required, check here 13 10 if you did not 14 Other gains or losses). Attach Form 4797. 14 14 get a W-2, see instructions. 15a IRA distributions 15a b Taxable amount 15b To 16a Pensions and annuities 16a b Taxable amount 16b 17 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E 17 18 Farm income or floss). Attach Schedule F. 18 19 Unemployment compensation 19 20a Social security benefits 20a b Taxable amount 20b 21 Other income. List type and amount 21 22 Combine the amounts in the far right column for lines 7 through 21. This is your total income 22 23 Educator expenses Adjusted 23 wa expenses ........... 24 Certain business expenses of reservists, performing artists, and Gross fee-basis government officials. Attach Form 2106 or 2106-EZ 24 Income 2 25 Health savings account deduction. Attach Form 8889 25 2 26 Moving expenses. Attach Form 3903 26 27 Deductible part of self-employment tax. Attach Schedule SE 27 28 Self-employed SEP, SIMPLE, and qualified plans. 28 29 Selt-employed health insurance deduction 29 30 Penalty on early withdrawal of savings 30 31a Alimony paid b Recipient's SSN 31a 32 IRA deduction 32 33 Student loan interest deduction 33 34 Tuition and foes. Attach For 8917. 34 35 Domestic production activities deduction. Attach Form 8903 35 36 Add lines 23 through 35 36 37 Subtract line 36 from line 22. This is your adjusted gross income 37 For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 11320B Fonti 1040 (2016) Page 2 anod Forn 1040 (2016) 38 Amount from line 37 (adjusted gross income) 38 Tax and 39a Check You were born before January 2, 1952, Blind. Total boxes if: Credits Spouse was born before January 2, 1952, Blind.) checked 39a b If your spouse itemizes on a separate retum or you were a dual-status alien, check here 396 Standard 40 Itemized deductions (from Schedule A) or your standard deduction (see left margin) 40 Deduction far- 41 Subtract line 40 from line 38 41 ............... People who 42 Exemptions. If line 38 is $156,650 or less, multiply $4,050 by the number on line 6d. Otherwise, see instructions 42 check any box on line 43 Taxable income. Subtract line 42 from line 41. If line 42 is more than line 41. enter-O- 22 43 39a or 39b or 44 who can be Tax (see instructions). Check if any from: a Form(s) 8814 b Form 4972 O 44 claimed as a 45 Alternative minimum tax (see instructions). Attach Form 6251 45 45 dependent, Ae see 46 Excess advance premium tax credit repayment. Attach Form 8962 46 instructions. 47 47 Adana Add lines 44, 45, and 46 47 All others: Ag Forint! 48 Foreign tax credit. Attach Form 1116 if required Single or 48 Married filing 49 Credit for child and dependent care expenses. Attach Form 2441 49 separately, $6,300 50 Education credits from Forrn 8863, line 19 50 Married filing 51 0 Retirement savings contributions credit. Attach Form 8880 jointly or 51 Qualifying 52 Child tax credit. Attach Schedule 8812, if required. 52 widower. $12,600 53 Residential energy credits. Attach Form 5695 53 Head of 54 Other credits from Form: a 3800 b 8801 co 54 55 $9,300 Add lines 48 through 54. These are your total credits 55 56 Subtract line 55 from line 47. If line 55 is more than line 47, enter -- 56 57 Self-employment tax. Attach Schedule SE SE... 57 Other 58 Unreported social security and Medicare tax from Form: a 4137 b8919 58 59 Taxes Additional tax on IRAs, other qualified retirement plans, etc. Attach Form 5329 if required 59 60a Household employment taxes from Schedule H 60a b First-time homebuyer credit repayment. Attach Form 5405 if required 60b 61 Health care: individual responsibility (see instructions) Full-year coverage 61 62 Taxes from: a Form 1959 b Form 1960 c Instructions; enter code(s) 62 63 Add lines 56 through 62. This is your total tax 63 Payments 64 Federal income tax withheld from Forms W-2 and 1099 84 65 2016 estimated tax payments and amount applied from 2015 return 65 If you have a 66a se. Earned income credit (EIC) 66a qualifying child, attach b Nontaxable combat pay election Schedule EIC. 67 Additional child tax credit. Altach Schedule 8812 67 68 American opportunity credit from Form 8863. line 8 68 69 Net premium tax credit. Attach Form 8962 69 70 Amount paid with request for extension to file 70 71 Excess social security and tier 1 RRTA tax withheld 71 72 Credit for federal tax on fuels. Attach Form 1136 72 73 Credits from Fome a 2439 b Reserved c8665 d 73 74 Add lines 64, 65, 66a, and 67 through 73. These are your total payments ..... 74 Refund 75 If line 74 is more than line 63, subtract line 63 from line 74. This is the amount you overpaid 75 76a Amount of line 75 you want refunded to you. If Form 8888 is attached, check here 76a Direct deposit b Routing number Type: Checking Q Savings Soo d Account number insiructions. 77 Amount of line 75 you want applied to your 2017 estimated tax 77 Amount 78 Amount you owe. Subtract line 74 from line 63. For details on how to pay, see instructions 78 You Owe 79 Estimated tax penalty (see instructions). 1791 Third Party Do you want to allow another person to discuss this return with the IRS (see instructions)? Yes. Complete below. No Designee Designee's Phone Personal identification narno no. number (PIN) Sign 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 balat, they are tro, correct, and accurately list all amounts and sources of income I received during the tax year. Daciaration of prepare (ulher than tepayer) is based on all information of which preparar has any knowledge. Here Your signature Date Your occupation Daytime phone number Joint return? Sas instructions. Keep a copy for Spouse's signature. If a joint return, both must sign. Date Spouse's occupation If the IRS sent you an identity Protection your records heto (se inst.TTT Print/Type preparer's name Paid Preparer's signature Date PTIN Check O. Preparer self-employed Use Only Firm's name Firm's EIN Firm's address Phone no www.its.gov/form1040 Form 1040 (2016) 66b H 2016 CORRECTED if checked) DAYEHS street anteness, we province country Per Niohioma OMB No 1545-0112 ZIP Postal code, Stepfotleta GOVERNMENT PERSONNEL MUTUAL LIFE INS CO 2211 NE LOOP 410 P.O. BOX 659567 Interest Income SAN ANTONIO, TX 78265 9567 $56.98 800-929.4765 2 Early when Form 1099-INT a interest. Sings Bonds and results SAYERS fede encombe WEC:PIENTS dent can be 74-0651020 For Recipient PECIELT Sure to restoran Gale or province 4 Fedeancome tax with Sinestent ex This is important tax yang pala reformation and is being furnished to the John Doe 6 Faxud 7 Foreign county U.S. POUSSE lental Revenue 12345 Any Street Service. If you are required to lile a reluma Los Angeles, Ca 90124 sax-exemptores! Speciale actly conderes a negligence penalty other action may be 1 Maiket.count imposed on you 11 Goti piemai income is taxable and the IRS determines that 12 Bord monde 13 B6 pretro xexent it has not been reported et serruction 000275767 FATCA 14 Taxat ang red bond CUSIP Form 1099-INT 15 5 16 Stalentification 17 Sated NM 03-221595-009 Department of the Treasury - Internal Revenue Service (keep for your records www.irs.gov/form 1093int ORTOB Rev. 1215) CORRECTED (if checked) Dividends and Distributions Verizon Communications Inc. 2016 PAYER'S Federal identification number: 23-2259884 PAYER'S name, street address, city, state, and ZIP code VERIZON COMMUNICATIONS INC C/O COMPUTERSHARE PO BOX 43078 PROVIDENCE RI 02940-3078 $ 0.00 $ 0.00 ta Toordinary dividende the divine S5404.41 S 1404.41 2a Total against 2b Ucap Sec 1250 g OMB No 1545-0110 $ 0.00 $ 000 2c Section 1202 2d Collectibles (20% geet $ 0.00 Com $ 0.00 3 Nondividend die S 4 Federal income tax withheld Form 1099-DIV 6 Forint paid $ 0.00 $ 7 Formign country or U.S. Cashligion distribution Copy B For Recipient 10 Esenterest dividend 11 forced practing terdiri di The la important tax information $ 0.00 and is being furnished to the Internal Revenue Service. you The reportable arounts above include the following additional Income: are required to learstum, a Company Pad Fees negligence penalty or other Company Paid Service Charges sanction may be imposed on $ 0.00 $ 0.00 you. If this income is taxable and Discount on Reiwestiment the IRS determines that has $ 0.00 not been reported is 0.00 RECIPIENT'S ID No. ending in: ***"-6711 Account number (see instructions): C0001413651 RECIPIENT'S name, street address, city, state, ZIP code $ 0.00 John & Jane Doe 12345 Any Street Los Angeles, Ca 90124 Form 1099-DIV (keep for your records) Department of the Treasury - Internal Revenue Service CORRECTED (if checked) Dividends and Distributions BOX 43078 SHARE OORTDB Rev. 12/15) .bc PAYER'S Federal identification number: 95-3551121 PAYER'S name, street address, city, state, and ZIP code PUBLIC STORAGE PROVIDENCE RI 02940-3078 Public Storage fa Total de The videos 52100.70 $ 0.00 Total 2. Sec. 1250 g OMB No 1545-0110 $ 0.00 $ 0.00 1. Se 1202 3d Collec (289) 2016 $ 0.00 $ 0.00 3 Nondividu 4federal income tax wihald $ 0.00 $ 8.00 Form 1099-DIV Sagenes Forg la pod $ 0.00 $ Copy B 7 Foreign county or Somesos Cachondas For Recipient $ 0.00 10 Exempore divided 11 Set This is important information 5 000 $ 0.00 and being furnished to the Intemal Revenue Service, you The reportable amounts above include the following clonal Income are required to do a mom, a Company Paid Foes degligence paraty or other Coripany Paid Service Charges sanction may be imposed on $ you this one is able and Discount on to the IRS di hati has not been reported RECIPIENT'S namo, street address, city, stato, ZIP code John & Jane Doe 12345 Any Street Los Angeles, Ca 90124 S Form 1099-DIV (keep for your records) Department of the Treasury - omal Revenue Service 95 2834236 RECIPIENT'S cutification number Permint PTG CUST FOLLOVER IRA FBO Jane Doe 12345 Any Street Los Angeles, Ca 90124 PAYER's foderal identification number: Payer LPL Financial 1065 LPL Way Fort MSG 29715 98 FAICA gent 1 Gross distribution 2a Taxiunt 25 Taxable amount to determined Total distribution 3 Capital gain ancluded on line 2a 4 Focal income tax with 5 Eye contbution Designated Roth contations or insurance promiums 6 Netralized appreciation employer's securities 7 Distribution codes IRA SE SIMPLE $17,700.00 8 Other amount $17.700.00 Other amount porcentage 10 Sa Yout percentage of total distribution Usb Totalcmployee contributions 10 Amount allocable to TRA within 5 yesis $3.540 08 11 197 your otsigFell cutti 12 State tax withhell 13 State Payer's stato urber 7 14 Site distribution $884.88 CA 02-074930-000 2016 OM NA 1545.01 Form: 0 Distributions to Pensioes, Anti Retirement or Pro Sharing Plus, IR Insurance Contracts.c 1. Gross distribution 41016.00 OFFICE OF PERSONNEL MANAGEMENT STATEMENT OF ANNUITY PAID RETIREMENT OPERATIONS Copy 2A- To be filed with annuitant's state or local P.O. BOX 45 tax return BOYERS, PA 16017-0045 PAYER'S Federal Identification Recipient's ID No Annuitant Account number Retirement Cham No 52-6083699 Employee EGGS Dato ROTH Contributions PAID nance Premium TO John Doe 2641 80 12345 Any Street 7. Distribution Codes Los Angeles, Ca 90124 12. State tax withheld 7 NON DISABILITY 1440.00 Tor Employee Contribution 12. State tax withheld 3891.00 NONE 2a. Taxable amount 38553.00 4 Federal Income Tax Withheld 3942.00 13. State Payer's state no. CA 13. State Payer's state no. FORM SSA-1099 - SOCIAL SECURITY BENEFIT STATEMENT 2016 PART OF YOUR SOCIAL SECURITY BENEFITS SHOWN IN BOX 5 MAY BE TAXABLE INCOME. SEE THE REVERSE FOR MORE INFORMATION. Box 1. Name Jane Doe Box 2. Beneficiary's Social Security Number Box 3. Benefits Paid in 2016 Box 4. Benefits Repaid to SSA in 2016 BOKS. Net Benefits for 2016 Bormius Bor $19.894.80 NONE $19,894,80 DESCRIPTION OF AMOUNT IN BOX 3 DESCRIPTION OF AMOUNT IN BOX 4 Paid by check or direct deposit $18,636.00 NONE Medicare Part B premiums deducted from your benefits $1.258.BD Total Additions $19,894.80 Benefits for 2016 $19,894.80 Box 6. Voluntary Federal Income Tax Withheld NONE Box 7. Address San Clemente Parish Contributions Summary Family Statement John & Jane Doe 12345 Any Street Los Angeles, Ca 90124 Below is your monetary gifts to San Clemente Parish for the period January 1, 2016 - December 31, 2016 Without your support of time, talent and treasure, San Clemente Parish would not be a vibrant and faithful community. Your donations support many needed activities for the youti, elderly, religious education of our members, the poor and the works of the Archdiocese of Santa Fe and the Catholic Church as a whole. Please keep this letter as receipt of your contributions for tax purposes. If you need to update your parish registration information, please contact the parish office. If you have any questions, please feel free to contact the parish office at San Clemente did not provide any goods or services for any donations received. Deacon Jim Snell Business Manager San Clemente Parish Fund Amount Fund Amount Building Fund DrivePm Pledge Christmas Seminary Support World Mission Sunday Total Contributions: $80.00 $20.00 $15.00 $20.00 Cemetary Improvement Fund contributions SVDP Contributions $10.00 $390.00 $90.00 $625.00 2016 $ 12,215 CORRECTED (if checked) RECIPIENT SLENDER S name, strast dress, city or town, state or Caution: The amount shown may OMB No. 1545-0001 province, country. ZIP or foreign postal code, and telephone n. not be deduct by you Limoged on the car amount Mortgage John & Jane Doe and the cost and value of the Our property may apply. Also, Interest 12345 Any Street you may only deduct Interest to the at was in unted by you Rev. Juy 2016 Los Angeles, Ca 90124 Statement actually paid by you, and fronted by another person Form 1098 Morte cantante ved from Daversy borrow Copy B For Payer/ FECPIENT'S/LENDER'S federal PAYERS/BORROWER'S taxpayer 2 Outstanding mortgage 3 Mortgage origination date Borrower identification number identication principal as of 1/1/2016 LOAN ORIGINATION $74, 101.26 DATE: 05/28/2006 The information in boxes 1 73-0780382 4 bund af varpaid 5 Mortgage Insurance through is important tex interest premiurns normation and is being furnished to the Internal PAYER'S/BORROWER'S name $ 0.00 $0.00 Prevenus Service you 6 Points paid on purchase of principal sidence required to file a rotum, a $ 0.00 negligence ponety or other Sret address including act no 7 is address of property securing mortgage samas sanction may be imposed PAYER'S/BORACWER'Saddress? an you if the IRS determines Yes, box is checked. het an underpayment of No. 900 box 8 or 9. below takutts because you City or town, state or province, country, and ZIF or foregn postal code Oerstated a deduction a Address of property securing mortgage for this mortgage interest ar for the points, reported in boxes 1 and or 10 Other because you didn't sport Real Estate Tax Paid: $2,215 9 f property securing mangge has no ress, telow is the the round of interest coacription of the properly box 45, because you claimed non-deductible Account number see instructions) tem. Form 1098 Keep for your records www.irs.gowform 1098 Department of the Treasury - Internal Revenue Service SCHEDULED (Form 1040) OMB No. 1545-0074 Capital Gains and Losses Attach to Form 1040 or Form 1040NR. 2016 Information about Schedule D and its separate instructions is at www.irs.gov/scheduled. Attachment Use Form 8949 to list your transactions for lines 1b, 2, 3, 8, 9, and 10. Sequence No. 12 Your social security number Department of the Treasury Internal Revenue Service (99) Name(s) shown on retum Part I Short-Term Capital Gains and Losses-Assets Held One Year or Less (d) Proceeds (sales price) Cost (or other basis) (g) Adjustments to gain or loss from Formis) 8949, Part I. line 2 column (gl Gain or loss) Subtract calumn) from column (d) and combine the result with columna) See instructions for how to figure the amounts to enter on the lines below. This form may be easier to complete if you round off cents to whole dollars. 1a Totals for all short-term transactions reported on Form 1099-B for which basis was reported to the IRS and for which you have no adjustments (see instructions). However, if you choose to report all these transactions on Form 8949, leave this line blank and go to line 1b 1b Totals for all transactions reported on Form(s) 8949 with Box A checked 2 Totals for all transactions reported on Form(s) 8949 with Box B checked 3 Totals for all transactions reported on Form(s) 8949 with Box C checked 4 5 4 Short-term gain from Form 6252 and short-term gain or loss) from Forms 4684, 6781, and 8824 5 Net short-term gain or loss) from partnerships, S corporations, estates, and trusts from Schedule(s) K-1 .... 6 Short-term capital loss carryover. Enter the amount, if any, from line 8 of your Capital Loss Carryover Worksheet in the instructions 7 Net short-term capital gain or loss). Combine lines 1a through 6 in column (h). If you have any long- term capital gains or losses, go to Part II below. Otherwise, go to Part Ill on the back Part II Long-Term Capital Gains and Losses-Assets Held More Than One Year 6 7 column) See instructions for how to figure the amounts to enter on the (9) Gain or loss) lines below. (d) le) Adjustments Subtract column le) Proceeds Cost to gain or loss from from colind and This form may be easier to complete if you round off cents to (sales price) (or other basis) Form(s) 8949, Part II, combine the result with whole dollars. line 2, column (9) 8a Totals for all long-term transactions reported on Form 1099-B for which basis was reported to the IRS and for which you have no adjustments (see instructions). However, if you choose to report all these transactions on Form 8949, leave this line blank and go to line 8b 8b Totals for all transactions reported on Form(s) 8949 with Box D checked .....:: 9 Totals for all transactions reported on Form(s) 8949 with Box E checked 10 Totals for all transactions reported on Form(s) 8949 with Box F checked...!! 11 Gain from Form 4797, Part I: long-term gain from Forms 2439 and 6252; and long-term gain or (loss) from Forms 4684, 6781, and 8824 11 12 Net long-term gain or (loss) from partnerships, Scorporations, estates, and trusts from Schedule(s) K-1 12 13 Capital gain distributions. See the instructions. 13 14 Long-term capital loss carryover. Enter the amount, if any, from line 13 of your Capital Loss Carryover Worksheet in the instructions 14 15 Net long-term capital gain or loss). Combine lines &a through 14 in column (h). Then go to Part Ill on the back. ...... 15 For Paperwork Reduction Act Notice, see your tax retum instructions. Cat. No. 11338H Schedule D (Form 1040) 2016 Schedule D (Form 1040) 2016 Page 2 Part III Summary 16 Combine lines 7 and 15 and enter the result 16 If line 16 is a gain, enter the amount from line 16 on Form 1040, line 13, or Form 1040NR, line 14. Then go to line 17 below. If line 16 is a loss, skip lines 17 through 20 below. Then go to line 21. Also be sure to complete line 22. If line 16 is zero, skip lines 17 through 21 below and enter-O-on Form 1040, line 13, or Form 1040NR, line 14. Then go to line 22. 17 Are lines 15 and 16 both gains? Yes. Go to line 18. No. Skip lines 18 through 21, and go to line 22. 18 Enter the amount, if any, from line 7 of the 28% Rate Gain Worksheet in the instructions 18 19 Enter the amount, if any, from line 18 of the Unrecaptured Section 1250 Gain Worksheet in the instructions 19 20 Are lines 18 and 19 both zero or blank? Yes. Complete the Qualified Dividends and Capital Gain Tax Worksheet in the instructions for Form 1040, line 44 (or in the instructions for Form 1040NR, line 42). Don't complete lines 21 and 22 below. No. Complete the Schedule D Tax Worksheet in the instructions. Don't complete lines 21 and 22 below. 21 If line 16 is a loss, enter here and on Form 1040, line 13, or Form 1040NR, line 14, the smaller of: The loss on line 16 or ($3,000), or if married filing separately, ($1,500) 21 Note: When figuring which amount is smaller, treat both amounts as positive numbers. 22 Do you have qualified dividends on Form 1040, line 9b, or Form 1040NR, line 10b? Yes. Complete the Qualified Dividends and Capital Gain Tax Worksheet in the instructions for Form 1040, line 44 (or in the instructions for Form 1040NR, line 42). No. Complete the rest of Form 1040 or Form 1040NR. Schedule D (Form 1040) 2016 OMB No. 1545-0074 SCHEDULE B (Form 1040A or 1040) (Rev. January 2017) Department of the Treasury Internal Revenue Service (169) Names) shown on return Interest and Ordinary Dividends Attach to Form 1040A or 1040. Information about Schedule B and its instructions is at www.irs.gov/scheduleb. 2016 Attachment Sequence No. 08 Your social security number Part 1 1 Amount List name of payer. If any interest is from a seller-financed mortgage and the buyer used the property as a personal residence, see instructions on back and list this interest first. Also, show that buyer's social security number and address Interest (See instructions on back and the instructions for Form 1040A, or Form 1040, line 8a.) 1 Note: If you received a Form 1099-INT, Fom 1099-OID, or substitute statement from a brokerage firm, list the firm's name as the 2 Add the amounts on line 1 payer and enter the total interest 3 Excludable interest on series EE and I U.S. Savings bonds issued after 1989. shown on that Attach Form 8815 form. 4 Subtract line 3 from line 2. Enter the result here and on Form 1040A, ar Form 1040, line 8a Note: If line 4 is over $1,500, you must completo Part III. Part II 5 List name of payer 2 3 4 Amount Ordinary Dividends (See instructions on back and the instructions for Form 1040A, or For 1040, line 9a.) 5 Note: If you received a Form 1099-DIV or substitute statement from a brokerage firm, list the firm's name as the payer and enter the ordinary 6 dividends shown Add the amounts on line 5. Enter the total here and on Form 1040A, or Form on that form. 1040, line 90 6 Note: If line 6 is over $1,500, you must complete Part III. You must complete this part if you (a) had over $1,500 of taxable interest or ordinary dividends; (b) had a foreign account; or (c) received a distribution from, or were a grantor of, or a transferorto, a foreign trust. Yes No Part III 7a At any time during 2016, did you have a financial interest in or signature authority over a financial Foreign account (such as a bank account, securities account, or brokerage account) located in a foreign country? See instructions .................. Accounts and Trusts If "Yes," are you required to file FinCEN Form 114, Report of Foreign Bank and Financial Accounts (FBAR), to report that financial interest or signature authority? See FinCEn Form 114 (See and its instructions for filing requirements and exceptions to those requirements instructions an b If you are required to file FinCEN Form 114, enter the name of the foreign country where the back.) financial account is located 8 During 2016, did you receive a distribution from, or were you the grantor of, or transferor to, a foreign trust? If "Yes," you may have to file Form 3520. See instructions on back For Paperwork Reduction Act Notice, see your tax return instructions. Gat. No. 17146N Schedule B (Form 1040A or 1040) 2016 Schedule B (Form 1040A or 1040) 2016 Page 2 General Instructions Future Developments For the latest information about developments related to Schedule B (Form 1040A or 1040) and its instructions, such as legislation enacted after they were published, go to www.lrs.gov/schedule. What's New The due date for filing FinCEN Form 114 has changed. See below Purpose of Form Use Schedule B if any of the following applies. You had over $1,500 of laxable interest or ordinary dividends. You received interest from a seller-financed mortgage and the buyer used the property as a personal residence . You have accrued interest from a bond, - You are reporting original issue discount (OID) of less than the amount shown on Form 1099-OID. You are reducing your interest income on a bond by the amount of amortizable bond premium. You are claiming the exclusion of Interest from series EE or U.S. savings bonds issued after 1989. You received interest or ordinary dividends as a nominoe. You had a financial interest in, or signature authority over, a financial account in a foreign country or you received a distribution from, or were a grantor of, or transferorto, a foreign trust Specific Instructions You can list more than one payer on TIP be sure to clearly show the amount Pics cach entry space for lines 1 and 5, but next to the payor's name. Add the separate amounts pals by the payers listed on an entry space and enter the total in the "Amount" column. If you still need more space, attach separate statements using the same format as lines and 5, but show your love's on Schedule 8. Pul your name and social security number (SSN) on the statements and attach them at the end of your return Part I. Interest Line 1. Report on line 1 all of your taxable interest. Taxalole interest generally should be shown on your Forms 1099-INT, Forms 1049-OID, or substituto statements. Include interest from series EE, H, HH, and I U.S. savings bonds. Also include any accrued market discount that is includible in income. List each payer's name and show the arount. Don't report on this line any tax-exempt interest from box 8 or box 9 of Form 1099-INT. Instead, report the amount from box 8 on line 6b of Form 1040A or 1040. If an amount is shown in box 9 of Form 1099-INT, you generally must report it on line 12 of Form 6251. See the Instructions for Form 6251 for more details. For more information on market discount and other investment income, see Pub. 550. Seller-financed mortgages. If you sold your home or other property and the buyer used the property as a personal residence, list first any interest the buyer paid you on a mortgage or other form of seller financing. Be sure to show the buyer's name, address, and SSN. You must also let the buyer know your SSN. If you don't show the buyer's name, address, and SSN, or let the buyer know your SSN, you may have to pay a $60 penalty Nominees. If you received a Form 1099-INT that cludes interest you received as a nomina (that is, in your name, but the interest actually belongs to someone else), report the total on line 1. Do this even if you later distributed some or all of this income to others. Under your last entry on line 1, put a subtotal of all interest listed on line 1. Below this subtotal, enter "Nominee Distribution and show the total interest you recalved as a nominee Subtract this amount from the subtotal and enter the result on line 2 If you received interest as a nominee, you must give the actual owner a Form TIP 1099-INT (less the owner is your Spouse) and Millo Forms 1095 and 1099-INT with the IRS. For more details. see the General Instructions for Certain Information Returns and the Instructions for Futus 1099-INT and 1099 OID. Accrued interest. When you buy bonds between interest payment dates and pay accrued interest to the seller, this interest is taxable to the seller. If you received a Form 1099 for interest as a purchaser of a bond with accrued interest, follow the rules carlier under Nominees to see how to report the accrued interest. But identify the amount to be subtracted as "Accrued Interest." Original issue discount (OID). If you are reporting OID in a
