Form
1040
Department of the Treasury—Internal Revenue Service
(99)
U.S. Individual Income Tax Return
2016
OMB No. 1545-0074
IRS Use Only—Do not write or staple in this space.
For the year Jan. 1–Dec. 31, 2016, or other tax year beginning , 2016, 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.
▶
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) 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 . . . . . . . . . . . . . . . . .
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.
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 Educator expenses . . . . . . . . . . . 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 Recipient’s SSN
▶
31a
32 IRA deduction . . . . . . . . . . . . . 32
33 Student loan interest deduction . . . . . . . . 33
34 Tuition and fees. Attach Form 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
Form 1040 (2016)
