The following items reflect the amount as shown on the return (PR), and the amount as adjusted (PC),
if applicable. They do not show subsequent activity on the account.
|
| Income |
| WAGES, SALARIES, TIPS, ETC: | $132,205.00 |
| TAXABLE INTEREST INCOME: SCH B: | $0.00 |
| TAX-EXEMPT INTEREST: | $0.00 |
| ORDINARY DIVIDEND INCOME: SCH B: | $0.00 |
| QUALIFIED DIVIDENDS: | $0.00 |
| REFUNDS OF STATE/LOCAL TAXES: | $0.00 |
| ALIMONY RECEIVED: | $0.00 |
| BUSINESS INCOME OR LOSS (Schedule C): | $0.00 |
| BUSINESS INCOME OR LOSS: SCH C PER COMPUTER: | $0.00 |
| CAPITAL GAIN OR LOSS: (Schedule D): | $0.00 |
| CAPITAL GAINS OR LOSS: SCH D PER COMPUTER: | $0.00 |
| OTHER GAINS OR LOSSES (Form 4797): | $0.00 |
| TOTAL IRA DISTRIBUTIONS: | $0.00 |
| TAXABLE IRA DISTRIBUTIONS: | $0.00 |
| TOTAL PENSIONS AND ANNUITIES: | $0.00 |
| TAXABLE PENSION/ANNUITY AMOUNT: | $0.00 |
| ADDITIONAL INCOME: | $0.00 |
| ADDITIONAL INCOME PER COMPUTER: | $0.00 |
| REFUNDABLE CREDITS PER COMPUTER: | $0.00 |
| REFUNDABLE EDUCATION CREDIT PER COMPUTER: | $0.00 |
| QUALIFIED BUSINESS INCOME DEDUCTION: | $0.00 |
| RENT/ROYALTY/PARTNERSHIP/ESTATE (Schedule E): | $0.00 |
| RENT/ROYALTY/PARTNERSHIP/ESTATE (Schedule E) PER COMPUTER: | $0.00 |
| RENT/ROYALTY INCOME/LOSS PER COMPUTER: | $0.00 |
| ESTATE/TRUST INCOME/LOSS PER COMPUTER: | $0.00 |
| PARTNERSHIP/S-CORP INCOME/LOSS PER COMPUTER: | $0.00 |
| FARM INCOME OR LOSS (Schedule F): | $0.00 |
| FARM INCOME OR LOSS (Schedule F) PER COMPUTER: | $0.00 |
| UNEMPLOYMENT COMPENSATION: | $0.00 |
| TOTAL SOCIAL SECURITY BENEFITS: | $0.00 |
| TAXABLE SOCIAL SECURITY BENEFITS: | $0.00 |
| TAXABLE SOCIAL SECURITY BENEFITS PER COMPUTER: | $0.00 |
| OTHER INCOME: | $0.00 |
| SCHEDULE EIC SE INCOME PER COMPUTER: | $0.00 |
| SCHEDULE EIC EARNED INCOME PER COMPUTER: | $0.00 |
| SCH EIC DISQUALIFIED INC COMPUTER: | $0.00 |
| EXCESS ADV CHILD TAX CREDIT PER COMPUTER: | $0.00 |
| PRIMARY ECONOMIC IMPACT PAYMENT 2: | 0 |
| SECONDARY ECONOMIC IMPACT PAYMENT 2: | 0 |
| PRIMARY ADVANCED CTC PAYMENTS: | $0.00 |
| SECONDARY ADVANCED CTC PAYMENTS: | $0.00 |
| ADDITIONAL CTC EARNED INCOME: | $0.00 |
| EIC PRIOR YEAR EARNED INCOME: | $0.00 |
| CTC PRIOR YEAR EARNED INCOME: | $0.00 |
| QUALIFIED BUSINESS INCOME DEDUCTION: | $0.00 |
| F8995 QUALIFIED BUSINESS INCOME DEDUCTION COMPUTER: | $0.00 |
| PRIMARY ECONOMIC IMPACT PAYMENT: | $2,800.00 |
| SECONDARY ECONOMIC IMPACT PAYMENT: | $2,800.00 |
| SCHOLARSHIP FELLOWSHIP GRANT: | $0.00 |
| TOTAL INCOME: | $132,205.00 |
| TOTAL INCOME PER COMPUTER: | $132,205.00 |
|
| Adjustments to Income |
| EDUCATOR EXPENSES: | $0.00 |
| EDUCATOR EXPENSES PER COMPUTER: | $0.00 |
| RESERVIST AND OTHER BUSINESS EXPENSE: | $0.00 |
| HEALTH SAVINGS ACCT DEDUCTION: | $0.00 |
| HEALTH SAVINGS ACCT DEDUCTION PER COMPTR: | $0.00 |
| MOVING EXPENSES: F3903: | $0.00 |
| SELF EMPLOYMENT TAX DEDUCTION: | $0.00 |
| SELF EMPLOYMENT TAX DEDUCTION PER COMPUTER: | $0.00 |
| SELF EMPLOYMENT TAX DEDUCTION VERIFIED: | $0.00 |
| KEOGH/SEP CONTRIBUTION DEDUCTION: | $0.00 |
| SELF-EMP HEALTH INS DEDUCTION: | $0.00 |
| EARLY WITHDRAWAL OF SAVINGS PENALTY: | $0.00 |
| ALIMONY PAID SSN: | |
| ALIMONY PAID: | $0.00 |
| SCHOLARSHIP FELLOWSHIP EXCLUDED: | $0.00 |
| IRA DEDUCTION: | $0.00 |
| IRA DEDUCTION PER COMPUTER: | $0.00 |
| STUDENT LOAN INTEREST DEDUCTION: | $0.00 |
| STUDENT LOAN INTEREST DEDUCTION PER COMPUTER: | $0.00 |
| STUDENT LOAN INTEREST DEDUCTION VERIFIED: | $0.00 |
| TUITION AND FEES DEDUCTION: | $0.00 |
| TUITION AND FEES DEDUCTION PER COMPUTER: | $0.00 |
| OTHER ADJUSTMENTS: | $0.00 |
| ARCHER MSA DEDUCTION: | $0.00 |
| ARCHER MSA DEDUCTION PER COMPUTER: | $0.00 |
| TOTAL ADJUSTMENTS: | $0.00 |
| TOTAL ADJUSTMENTS PER COMPUTER: | $0.00 |
| ADJUSTED GROSS INCOME: | $132,205.00 |
| ADJUSTED GROSS INCOME PER COMPUTER: | $132,205.00 |
|
| Tax and Credits |
| 65-OR-OVER: | NO |
| BLIND: | NO |
| SPOUSE 65-OR-OVER: | NO |
| SPOUSE BLIND: | NO |
| STANDARD DEDUCTION PER COMPUTER: | $25,100.00 |
| ADDITIONAL STANDARD DEDUCTION PER COMPUTER: | $0.00 |
| TAX TABLE INCOME PER COMPUTER: | $106,505.00 |
| EXEMPTION AMOUNT PER COMPUTER: | $0.00 |
| TAXABLE INCOME: | $106,505.00 |
| TAXABLE INCOME PER COMPUTER: | $106,505.00 |
| TOTAL POSITIVE INCOME PER COMPUTER: | $132,205.00 |
| TENTATIVE TAX: | $14,928.00 |
| TENTATIVE TAX PER COMPUTER: | $14,928.00 |
| FORM 8814 ADDITIONAL TAX AMOUNT: | $0.00 |
| TAX ON INCOME LESS SOC SEC INCOME PER COMPUTER: | $0.00 |
| FORM 6251 ALTERNATIVE MINIMUM TAX: | $0.00 |
| FORM 6251 ALTERNATIVE MINIMUM TAX PER COMPUTER: | $0.00 |
| FOREIGN TAX CREDIT: | $0.00 |
| FOREIGN TAX CREDIT PER COMPUTER: | $0.00 |
| FOREIGN INCOME EXCLUSION PER COMPUTER: | $0.00 |
| FOREIGN INCOME EXCLUSION TAX PER COMPUTER: | $0.00 |
| EXCESS ADVANCE PREMIUM TAX CREDIT REPAYMENT AMOUNT: | $0.00 |
| EXCESS ADVANCE PREMIUM TAX CREDIT REPAYMENT VERIFIED AMOUNT: | $0.00 |
| CHILD & DEPENDENT CARE CREDIT: | $0.00 |
| CHILD & DEPENDENT CARE CREDIT PER COMPUTER: | $0.00 |
| CREDIT FOR ELDERLY AND DISABLED: | $0.00 |
| CREDIT FOR ELDERLY AND DISABLED PER COMPUTER: | $0.00 |
| EDUCATION CREDIT: | $2,000.00 |
| EDUCATION CREDIT PER COMPUTER: | $2,000.00 |
| GROSS EDUCATION CREDIT PER COMPUTER: | $2,000.00 |
| RETIREMENT SAVINGS CNTRB CREDIT: | $0.00 |
| RETIREMENT SAVINGS CNTRB CREDIT PER COMPUTER: | $0.00 |
| PRIM RET SAV CNTRB: F8880 LN6A: | $0.00 |
| SEC RET SAV CNTRB: F8880 LN6B: | $0.00 |
| TOTAL RETIREMENT SAVINGS CONTRIBUTION: F8880 CMPTR: | $0.00 |
| RESIDENTIAL ENERGY CREDIT: | $0.00 |
| RESIDENTIAL CLEAN ENERGY CREDIT PER COMPUTER: | $0.00 |
| CHILD AND OTHER DEPENDENT CREDIT: | $500.00 |
| CHILD AND OTHER DEPENDENT CREDIT PER COMPUTER: | $500.00 |
| ADOPTION CREDIT: F8839: | $0.00 |
| ADOPTION CREDIT PER COMPUTER: | $0.00 |
| FORM 8396 MORTGAGE CERTIFICATE CREDIT: | $0.00 |
| FORM 8396 MORTGAGE CERTIFICATE CREDIT PER COMPUTER: | $0.00 |
| TOTAL OTHER NON REFUNDABLE CREDIT: | $0.00 |
| FORM 3800 GENERAL BUSINESS CREDITS: | $0.00 |
| FORM 3800 GENERAL BUSINESS CREDITS PER COMPUTER: | $0.00 |
| PRIOR YR MIN TAX CREDIT: F8801: | $0.00 |
| PRIOR YR MIN TAX CREDIT: F8801 PER COMPUTER: | $0.00 |
| F8936 ELECTRIC MOTOR VEHICLE CREDIT AMOUNT: | $0.00 |
| F8936 ELECTRIC MOTOR VEHICLE CREDIT PER COMPUTER: | $0.00 |
| F8910 ALTERNATIVE MOTOR VEHICLE CREDIT AMOUNT: | $0.00 |
| F8910 ALTERNATIVE MOTOR VEHICLE CREDIT PER COMPUTER: | $0.00 |
| SICK FAMILY LEAVE CREDIT: | $0.00 |
| NON ITEMIZED CHARITABLE CONTRIBUTION DEDUCTION: | $600.00 |
| NON ITEMIZED CHARITABLE CONTRIBUTION PER COMPUTER: | $600.00 |
| REFUNDABLE CHILD CARE CREDIT: | $0.00 |
| SICK FAMILY LEAVE CREDIT AFTER 3-31-21: | $0.00 |
| REFUNDABLE CHILD CARE CREDIT VERIFIED: | $0.00 |
| RECOVERY REBATE CREDIT: | $0.00 |
| RECOVERY REBATE CREDIT PER COMPUTER: | $0.00 |
| RECOVERY REBATE CREDIT VERIFIED: | $0.00 |
| OTHER CREDITS: | $0.00 |
| TOTAL CREDITS: | $2,500.00 |
| TOTAL CREDITS PER COMPUTER: | $2,500.00 |
| INCOME TAX AFTER CREDITS PER COMPUTER: | $12,428.00 |
|
| Other Taxes |
| SE TAX: | $0.00 |
| SE TAX PER COMPUTER: | $0.00 |
| SOCIAL SECURITY AND MEDICARE TAX ON UNREPORTED TIPS: | $0.00 |
| SOCIAL SECURITY AND MEDICARE TAX ON UNREPORTED TIPS PER COMPUTER: | $0.00 |
| TAX ON QUALIFIED PLANS F5329 (PR): | $0.00 |
| TAX ON QUALIFIED PLANS F5329 PER COMPUTER: | $0.00 |
| IRAF TAX PER COMPUTER: | $0.00 |
| TP TAX FIGURES (REDUCED BY IRAF) PER COMPUTER: | $12,428.00 |
| IMF TOTAL TAX (REDUCED BY IRAF) PER COMPUTER: | $12,428.00 |
| TOTAL OTHER TAXES PER COMPUTER: | $0.00 |
| UNPAID FICA ON REPORTED TIPS: | $0.00 |
| INTEREST ON DEFERRED TAX: | $0.00 |
| TOTAL OTHER TAXES: | $0.00 |
| RECAPTURE TAX: F8611: | $0.00 |
| HOUSEHOLD EMPLOYMENT TAXES: | $0.00 |
| HOUSEHOLD EMPLOYMENT TAXES PER COMPUTER: | $0.00 |
| INTEREST DUE ON INSTALLMENT: | $0.00 |
| SCH 8812 ADDITIONAL TAX COMPUTER: | $0.00 |
| REFUNDABLE CHILD CARE COMPUTER: | $0.00 |
| HEALTH COVERAGE RECAPTURE: F8885: | $0.00 |
| DEFERRED TAX SCH H SE: | $0.00 |
| MAX DEFERRED TAX PER COMPUTER: | $0.00 |
| TOTAL ADDITIONAL TAXES: | $0.00 |
| TOTAL ASSESSMENT PER COMPUTER: | $12,428.00 |
| TOTAL TAX LIABILITY TP FIGURES: | $12,428.00 |
| TOTAL TAX LIABILITY TP FIGURES PER COMPUTER: | $12,428.00 |
|
| Payments |
| FEDERAL INCOME TAX WITHHELD: | $14,094.00 |
| SCH 8812 ADDITIONAL TAX: | $0.00 |
| ESTIMATED TAX PAYMENTS: | $0.00 |
| OTHER PAYMENT CREDIT: | $0.00 |
| REFUNDABLE EDUCATION CREDIT: | $0.00 |
| REFUNDABLE EDUCATION CREDIT PER COMPUTER: | $0.00 |
| REFUNDABLE EDUCATION CREDIT VERIFIED: | $0.00 |
| REFUNDABLE CREDITS: | $0.00 |
| EARNED INCOME CREDIT: | $0.00 |
| EARNED INCOME CREDIT PER COMPUTER: | $0.00 |
| EARNED INCOME CREDIT NONTAXABLE COMBAT PAY: | $0.00 |
| SCHEDULE 8812 NONTAXABLE COMBAT PAY: | $0.00 |
| EXCESS SOCIAL SECURITY & RRTA TAX WITHHELD: | $0.00 |
| SCHEDULE 8812 TOT SS/MEDICARE WITHHELD: | $0.00 |
| SCHEDULE 8812 ADDITIONAL CHILD TAX CREDIT: | $0.00 |
| SCHEDULE 8812 ADDITIONAL CHILD TAX CREDIT PER COMPUTER: | $0.00 |
| SCHEDULE 8812 ADDITIONAL CHILD TAX CREDIT VERIFIED: | $0.00 |
| AMOUNT PAID WITH FORM 4868: | $0.00 |
| FORM 2439 REGULATED INVESTMENT COMPANY CREDIT: | $0.00 |
| FORM 4136 CREDIT FOR FEDERAL TAX ON FUELS: | $0.00 |
| FORM 4136 CREDIT FOR FEDERAL TAX ON FUELS PER COMPUTER: | $0.00 |
| HEALTH COVERAGE TX CR: F8885: | $0.00 |
| SEC 965 TAX INSTALLMENT: | $0.00 |
| SEC 965 TAX LIABILITY: | $0.00 |
| PREMIUM TAX CREDIT AMOUNT: | $0.00 |
| PREMIUM TAX CREDIT VERIFIED AMOUNT: | $0.00 |
| PRIMARY NAP FIRST TIME HOME BUYER INSTALLMENT AMT: | $0.00 |
| SECONDARY NAP FIRST TIME HOME BUYER INSTALLMENT AMT: | $0.00 |
| FIRST TIME HOMEBUYER CREDIT REPAYMENT AMOUNT: | $0.00 |
| FORM 5405 TOTAL HOMEBUYERS CREDIT REPAYMENT PER COMPUTER: | $0.00 |
| SMALL EMPLOYER HEALTH INSURANCE PER COMPUTER: | $0.00 |
| SMALL EMPLOYER HEALTH INSURANCE PER COMPUTER (2): | $0.00 |
| TOTAL OTHER PAYMENTS REFUNDABLE: | $0.00 |
| TOTAL PAYMENTS: | $14,094.00 |
| TOTAL PAYMENTS PER COMPUTER: | $14,094.00 |
|
| Refund or Amount Owed |
| REFUND AMOUNT: | $-1,666.00 |
| APPLIED TO NEXT YEAR'S ESTIMATED TAX: | $0.00 |
| ESTIMATED TAX PENALTY: | $0.00 |
| TAX ON INCOME LESS STATE REFUND PER COMPUTER: | $0.00 |
| BAL DUE/OVER PYMT USING TP FIG PER COMPUTER: | $-1,666.00 |
| BAL DUE/OVER PYMT USING COMPUTER FIGURES: | $-1,666.00 |
| FORM 8888 TOTAL REFUND PER COMPUTER: | $0.00 |
|
| Third Party Designee |
| THIRD PARTY DESIGNEE ID NUMBER: | X0427 |
| AUTHORIZATION INDICATOR: | 1 |
| THIRD PARTY DESIGNEE NAME: | HR TA GROU IN |
|
| Form 8863 - Education Credits (Hope and Lifetime Learning Credits) |
|
| Part I - EDUCATION CREDITS |
| STUDENT 1 NAME CNTRL: | PUSA |
| STUDENT 1 SSN: | XXX-XX-4806 |
| STUDENT 2 NAME CNTRL: | |
| STUDENT 2 SSN: | |
| STUDENT 3 NAME CNTRL: | |
| STUDENT 3 SSN: | |
| TENTATIVE CREDIT AMOUNT: | $0.00 |
|
| PART II - LIFETIME LEARNING CREDITS |
| TOTL LIFETIM LRNING CR QLFD EXP: | $12,658.00 |
| EDUCATIONAL INSTITUTION FEDERAL ID NUMBER STUDENT 1: | XXXXX5396 |
| SECOND EDUCATIONAL INSTITUTION FEDERAL ID NUMBER, STUDENT 1: | 000000000 |
| EDUCATIONAL INSTITUTION FEDERAL ID NUMBER STUDENT 2: | 000000000 |
| SECOND EDUCATIONAL INSTITUTION FEDERAL ID NUMBER STUDENT 2: | 000000000 |
| EDUCATIONAL INSTITUTION FEDERAL ID NUMBER STUDENT 3: | 000000000 |
| SECOND EDUCATIONAL INSTITUTION FEDERAL ID NUMBER STUDENT 3: | 000000000 |
| PRIOR YEAR HOPE SCHOLARSHIP OR AOT CREDIT CLAIMED STUDENT 1: | NO |
| ACADEMIC ELIGIBILITY, STUDENT 1: | YES |
| POST-SECONDARY COMPLETE STUDENT 1: | YES |
| FELONY CONVICTION STUDENT 1: | NONE |
| PRIOR YEAR HOPE SCHOLARSHIP OR AOT CREDIT CLAIMED STUDENT 2: | NONE |
| ACADEMIC ELIGIBILITY STUDENT 2: | NONE |
| POST-SECONDARY COMPLETE STUDENT 2: | NONE |
| FELONY CONVICTION STUDENT 2: | NONE |
| PRIOR YEAR HOPE SCHOLARSHIP OR AOT CREDIT CLAIMED STUDENT 3: | NONE |
| ACADEMIC ELIGIBILITY STUDENT 3: | NONE |
| POST-SECONDARY COMPLETE STUDENT 3: | NONE |
| FELONY CONVICTION STUDENT 3: | NONE |
| VERIFIED NUMBER OF EDUCATION CREDIT ELIGIBLE STUDENTS: | |
| TOTL LIFETIM LRNING CR QLFD EXP PER COMPUTER: | $2,000.00 |
|
| PART III - ALLOWABLE EDUCATION CREDITS |
| GROSS EDUCATION CR PER COMPUTER: | $2,000.00 |
| TOTAL EDUCATION CREDIT AMOUNT: | $2,000.00 |
| TOTAL EDUCATION CREDIT AMOUNT PER COMPUTER: | $2,000.00 |
|
| Form 8867 Paid Preparer's Earned Income Credit Checklist |
| INCORRECT INFORMATION AOTC: | |
| F8867 CERTIFICATION: | Yes box checked |
| EIC CLAIMED: | Neither box checked |
| CTC ACTC CLAIMED: | Yes box checked |
| AOTC CLAIMED: | Neither box checked |
| HEAD OF HOUSEHOLD FILING STATUS CLAIMED: | Neither box checked |
