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Form
1040
Department of the Treasury—Internal Revenue Service
OMB No. 1545-0074
(99)
IRS Use Only—Do not write or staple in this space.
U.S. Individual Income Tax Return
2012
For the year Jan. 1–Dec. 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, spouse’s first name and initial
Last name
Spouse’s 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 spouse’s 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 child’s
name here.
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5
Qualifying widow(er) with dependent child
Exemptions
6
a
Yourself.
If someone can claim you as a dependent,
do not
check box 6a
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b
Spouse
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}
c
Dependents:
(1)
First name
Last name
(2)
Dependent’s
social security number
(3)
Dependent’s
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
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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
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7
8
a
Taxable
interest. Attach Schedule B if required
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8a
b
Tax-exempt
interest.
Do not
include on line 8a
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8b
9
a
Ordinary dividends. Attach Schedule B if required
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9a
b
Qualified dividends
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9b
10
Taxable refunds, credits, or offsets of state and local income taxes
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10
11
Alimony received
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11
12
Business income or (loss). Attach Schedule C or C-EZ
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12
13
Capital gain or (loss). Attach Schedule D if required. If not required, check here
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13
14
Other gains or (losses). Attach Form 4797
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14
15
a
IRA distributions
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15a
b
Taxable amount
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15b
16
a
Pensions and annuities
16a
b
Taxable amount
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16b
17
Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E
17
18
Farm income or (loss). Attach Schedule F
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18
19
Unemployment compensation
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19
20
a
Social security benefits
20a
b
Taxable amount
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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
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22
Adjusted
Gross
Income
23
Educator expenses
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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
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25
26
Moving expenses. Attach Form 3903
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26
27
Deductible part of self-employment tax. Attach Schedule SE
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27
28
Self-employed SEP, SIMPLE, and qualified plans
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28
29
Self-employed health insurance deduction
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29
30
Penalty on early withdrawal of savings
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30
31
a
Alimony paid
b
Recipient’s SSN
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31a
32
IRA deduction
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32
33
Student loan interest deduction
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33
34
Tuition and fees. Attach Form 8917
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34
35
Domestic production activities deduction. Attach Form 8903
35
36
Add lines 23 through 35
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36
37
Subtract line 36 from line 22. This is your
adjusted gross income
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37
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 11320B
Form
1040
(2012)