Publication 54 - Tax Guide For U.s. Citizens And U.s. Citizens Abroad - 2001 Page 23
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441040
Department of the Treasury—Internal Revenue Service
2001
U.S. Individual Income Tax Return
(99)
IRS Use Only—Do not write or staple in this space.
For the year Jan. 1–Dec. 31, 2001, or other tax year beginning
, 2001, ending
, 20
OMB No. 1545-0074
Label
Your first name and initial
Last name
Your social security number
James M.
Adams
1 1 1
00
1 1 1 1
L
(See
A
instructions
If a joint return, spouse’s first name and initial
Last name
Spouse’s social security number
B
on page 19.)
E
Judith E.
Adams
222
00
2222
L
Use the IRS
Home address (number and street). If you have a P.O. box, see page 19.
Apt. no.
label.
Important!
H
Otherwise,
21 Rue Reynaud
E
R
please print
You must enter
City, town or post office, state, and ZIP code. If you have a foreign address, see page 19.
E
or type.
your SSN(s) above.
Paris, France
Presidential
You
Spouse
Election Campaign
Note. Checking “Yes” will not change your tax or reduce your refund.
(See page 19.)
Do you, or your spouse if filing a joint return, want $3 to go to this fund?
Yes
No
Yes
No
1
Single
Filing Status
2
Married filing joint return (even if only one had income)
3
Married filing separate return. Enter spouse’s social security no. above and full name here.
4
Head of household (with qualifying person). (See page 19.) If the qualifying person is a child but not your dependent,
Check only
enter this child’s name here.
one box.
5
Qualifying widow(er) with dependent child (year spouse died
). (See page 19.)
6a
Yourself. If your parent (or someone else) can claim you as a dependent on his or her tax
No. of boxes
Exemptions
checked on
return, do not check box 6a
2
6a and 6b
b
Spouse
No. of your
(4)
if qualifying
(3) Dependent’s
c
Dependents:
children on 6c
(2) Dependent’s
relationship to
child for child tax
who:
social security number
(1) First name
Last name
you
credit (see page 20)
2
● lived with you
Chris T. Adams
333
00
3333
Daughter
● did not live with
If more than six
Stephen F. Adams
444
00
4444
Son
you due to divorce
dependents,
or separation
see page 20.
(see page 20)
Dependents on 6c
not entered above
Add numbers
entered on
4
d Total number of exemptions claimed
lines above
133,000
7
7
Wages, salaries, tips, etc. Attach Form(s) W-2
Income
7,500
8a
8a Taxable interest. Attach Schedule B if required
8b
b Tax-exempt interest. Do not include on line 8a
Attach
9
Forms W-2 and
9
Ordinary dividends. Attach Schedule B if required
W-2G here.
10
10
Taxable refunds, credits, or offsets of state and local income taxes (see page 22)
Also attach
11
11
Alimony received
Form(s) 1099-R
12
if tax was
12
Business income or (loss). Attach Schedule C or C-EZ
withheld.
13
13
Capital gain or (loss). Attach Schedule D if required. If not required, check here
14
14
Other gains or (losses). Attach Form 4797
15a
15b
If you did not
15a
Total IRA distributions
b Taxable amount (see page 23)
get a W-2,
16a
16b
16a
Total pensions and annuities
b Taxable amount (see page 23)
see page 21.
17
17
Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E
18
Enclose, but do
18
Farm income or (loss). Attach Schedule F
Unemployment compensation
not attach, any
19
19
payment. Also,
20a
20b
20a Social security benefits
b Taxable amount (see page 25)
please use
(133,000)
Forms 2555 & 2555-EZ
21
Form 1040-V.
21
Other income. List type and amount (see page 27)
7,500
22
Add the amounts in the far right column for lines 7 through 21. This is your total income
22
23
23
IRA deduction (see page 27)
Adjusted
24
24
Student loan interest deduction (see page 28)
Gross
25
25
Archer MSA deduction. Attach Form 8853
Income
26
26
Moving expenses. Attach Form 3903
27
27
One-half of self-employment tax. Attach Schedule SE
28
28
Self-employed health insurance deduction (see page 30)
29
29
Self-employed SEP, SIMPLE, and qualified plans
30
30
Penalty on early withdrawal of savings
31a
31a
Alimony paid
b Recipient’s SSN
-0-
32
32
Add lines 23 through 31a
7,500
33
Subtract line 32 from line 22. This is your adjusted gross income
33
1040
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see page 72.
Cat. No. 11320B
Form
(2001)
Chapter 4 Foreign Earned Income and Housing: Exclusion – Deduction
Page 23
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