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1040
Department of the TreasuryInternal Revenue Service
OMB No. 1545-0074
(99)
IRS Use OnlyDo not write or staple in this space. U.S. Individual Income Tax Return
2012
For the year Jan. 1Dec. 31, 2012, or other tax year beginning , 2012, ending , 20 See separate instructions.
Your first name and initial Last name Your social security number
If a joint return, spouses first name and initial Last name Spouses social security number

Make sure the SSN(s) above

and on line 6c are correct.
Home address (number and street). If you have a P.O. box, see instructions. Apt. no.
City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions).
Foreign country name Foreign province/state/county Foreign postal code
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
Filing Status
Check only one
box.
1 Single
2 Married filing jointly (even if only one had income)
3 Married filing separately. Enter spouses SSN above
and full name here.
4 Head of household (with qualifying person). (See instructions.) If
the qualifying person is a child but not your dependent, enter this
childs name here.

5 Qualifying widow(er) with dependent child

Exemptions
6a Yourself. If someone can claim you as a dependent, do not check box 6a . . . . .
b Spouse . . . . . . . . . . . . . . . . . . . . . . . .
}
c Dependents:
(1) First name Last name
(2) Dependents
social security number
(3) Dependents
relationship to you
(4) if child under age 17
qualifying for child tax credit
(see instructions)
If more than four
dependents, see
instructions and
check here

d Total number of exemptions claimed . . . . . . . . . . . . . . . . .

Boxes checked
on 6a and 6b
No. of children
on 6c who:
lived with you
did not live with
you due to divorce
or separation
(see instructions)
Dependents on 6c
not entered above
Add numbers on
lines above

Income
Attach Form(s)
W-2 here. Also
attach Forms
W-2G and
1099-R if tax
was withheld.
If you did not
get a W-2,
see instructions.
Enclose, but do
not attach, any
payment. Also,
please use
Form 1040-V.
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
9 a Ordinary dividends. Attach Schedule B if required . . . . . . . . . . . 9a
b Qualified dividends . . . . . . . . . . . 9b
10 Taxable refunds, credits, or offsets of state and local income taxes . . . . . . 10
11 Alimony received . . . . . . . . . . . . . . . . . . . . . 11
12 Business income or (loss). Attach Schedule C or C-EZ . . . . . . . . . . 12
13 Capital gain or (loss). Attach Schedule D if required. If not required, check here

13
14 Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . . . 14
15 a IRA distributions . 15a b Taxable amount . . . 15b
16 a 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 (loss). Attach Schedule F . . . . . . . . . . . . . . 18
19 Unemployment compensation . . . . . . . . . . . . . . . . . 19
20 a 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
Adjusted
Gross
Income
23 Reserved . . . . . . . . . . . . . 23
24 Certain business expenses of reservists, performing artists, and
fee-basis government officials. Attach Form 2106 or 2106-EZ 24
25 Health savings account deduction. Attach Form 8889 . 25
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 Self-employed health insurance deduction . . . . 29
30 Penalty on early withdrawal of savings . . . . . . 30
31 a Alimony paid b Recipients SSN

31a
32 IRA deduction . . . . . . . . . . . . . 32
33 Student loan interest deduction . . . . . . . . 33
34 Reserved . . . . . . . . . . . . . . 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 Form 1040 (2012)

1
1
11255
17710
7220
36185
1251
6000
7251
28934
Form 1040 (2012) Page 2
Tax and
Credits
38 Amount from line 37 (adjusted gross income) . . . . . . . . . . . . . . 38
39a Check
if:
{
You were born before January 2, 1948, Blind.
Spouse was born before January 2, 1948, Blind.
}
Total boxes
checked

39a
b If your spouse itemizes on a separate return or you were a dual-status alien, check here

39b Standard
Deduction
for
People who
check any
box on line
39a or 39b or
who can be
claimed as a
dependent,
see
instructions.
All others:
Single or
Married filing
separately,
$5,950
Married filing
jointly or
Qualifying
widow(er),
$11,900
Head of
household,
$8,700
40 Itemized deductions (from Schedule A) or your standard deduction (see left margin) . . 40
41 Subtract line 40 from line 38 . . . . . . . . . . . . . . . . . . . 41
42 Exemptions. Multiply $3,800 by the number on line 6d. . . . . . . . . . . . 42
43 Taxable income. Subtract line 42 from line 41. If line 42 is more than line 41, enter -0- . . 43
44 Tax (see instructions). Check if any from: a Form(s) 8814 b Form 4972 c 962 election 44
45 Alternative minimum tax (see instructions). Attach Form 6251 . . . . . . . . . 45
46 Add lines 44 and 45 . . . . . . . . . . . . . . . . . . . . .

46
47 Foreign tax credit. Attach Form 1116 if required . . . . 47
48 Credit for child and dependent care expenses. Attach Form 2441 48
49 Education credits from Form 8863, line 19 . . . . . 49
50 Retirement savings contributions credit. Attach Form 8880 50
51 Child tax credit. Attach Schedule 8812, if required. . . 51
52 Residential energy credit. Attach Form 5695 . . . . . 52
53 Other credits from Form: a 3800 b 8801 c 53
54 Add lines 47 through 53. These are your total credits . . . . . . . . . . . . 54
55 Subtract line 54 from line 46. If line 54 is more than line 46, enter -0- . . . . . .

55
Other
Taxes
56 Self-employment tax. Attach Schedule SE . . . . . . . . . . . . . . . 56
57 Unreported social security and Medicare tax from Form: a 4137 b 8919 . . 57
58 Additional tax on IRAs, other qualified retirement plans, etc. Attach Form 5329 if required . . 58
59a 59a
b 59b
Household employment taxes from Schedule H . . . . . . . . . . . . . .
First-time homebuyer credit repayment. Attach Form 5405 if required . . . . . . . .
60 Other taxes. Enter code(s) from instructions 60
61 Add lines 55 through 60. This is your total tax . . . . . . . . . . . . .

61
Payments
62 Federal income tax withheld from Forms W-2 and 1099 . . 62
63 2012 estimated tax payments and amount applied from 2011 return 63
If you have a
qualifying
child, attach
Schedule EIC.
64a Earned income credit (EIC) . . . . . . . . . . 64a
b Nontaxable combat pay election 64b
65 Additional child tax credit. Attach Schedule 8812 . . . . . 65
66 American opportunity credit from Form 8863, line 8 . . . . 66
67 Reserved . . . . . . . . . . . . . . . . 67
68 Amount paid with request for extension to file . . . . . 68
69 Excess social security and tier 1 RRTA tax withheld . . . . 69
70 Credit for federal tax on fuels. Attach Form 4136 . . . . 70
71 Credits from Form: a 2439 b Reserved c 8801 d 8885 71
72 Add lines 62, 63, 64a, and 65 through 71. These are your total payments . . . . .

72
Refund
Direct deposit?
See
instructions.
73 If line 72 is more than line 61, subtract line 61 from line 72. This is the amount you overpaid 73
74a Amount of line 73 you want refunded to you. If Form 8888 is attached, check here .

74a

b Routing number

c Type: Checking Savings

d Account number
75 Amount of line 73 you want applied to your 2013 estimated tax

75
Amount
You Owe
76 Amount you owe. Subtract line 72 from line 61. For details on how to pay, see instructions

76
77 Estimated tax penalty (see instructions) . . . . . . . 77
Third Party
Designee
Do you want to allow another person to discuss this return with the IRS (see instructions)? Yes. Complete below. No
Designees
name

Phone
no.

Personal identification
number (PIN)

Sign
Here
Joint return? See
instructions.
Keep a copy for
your records.
Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief,
they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Your signature Date Your occupation Daytime phone number
Spouses signature. If a joint return, both must sign.

Date Spouses occupation If the IRS sent you an Identity Protection

PIN, enter it
here (see inst.)
Paid
Preparer
Use Only
Print/Type preparers name Preparers signature Date
Check if
self-employed
PTIN
Firms name
Firms address
Firm's EIN
Phone no.
Form 1040 (2012)