Form 1040a - U.s. Individual Income Tax Return - 2012
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1
2Form
Department of the Treasury—Internal Revenue Service
1040A
2012
U.S. Individual Income Tax Return
IRS Use Only—Do not write or staple in this space.
(99)
Your first name and initial
Last name
OMB No. 1545-0074
Your social security number
Spouse’s social security number
If a joint return, spouse’s first name and initial
Last name
Home address (number and street). If you have a P.O. box, see instructions.
Apt. no.
Make sure the SSN(s) above
▲
and on line 6c are correct.
City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions).
Presidential Election Campaign
Check here if you, or your spouse if filing
jointly, want $3 to go to this fund. Checking
Foreign country name
Foreign province/state/county
Foreign postal code
a box below will not change your tax or
refund.
You
Spouse
Filing
1
Single
4
Head of household (with qualifying person).
(See instructions.)
2
Married filing jointly (even if only one had income)
If the qualifying person is a child but not your dependent,
status
enter this child’s name here.
3
Married filing separately. Enter spouse’s SSN above and
▶
Check only
full name here.
5
Qualifying widow(er) with dependent child
one box.
(see instructions)
▶
}
6a
Yourself. If someone can claim you as a dependent, do not check
Exemptions
Boxes
checked on
box 6a.
6a and 6b
b
Spouse
No. of children
on 6c who:
✓
c Dependents:
(4)
if child under
• lived with
(3) Dependent’s
(2) Dependent’s social
age 17 qualifying for
you
If more than six
security number
relationship to you
child tax credit (see
(1) First name
Last name
instructions)
• did not live
dependents, see
with you due to
instructions.
divorce or
separation (see
instructions)
Dependents
on 6c not
entered above
Add numbers
on lines
d Total number of exemptions claimed.
above
▶
Income
7
Wages, salaries, tips, etc. Attach Form(s) W-2.
7
Attach
Form(s) W-2
8a Taxable interest. Attach Schedule B if required.
8a
here. Also
b Tax-exempt interest. Do not include on line 8a.
8b
attach
9a Ordinary dividends. Attach Schedule B if required.
9a
Form(s)
b Qualified dividends (see instructions).
9b
1099-R if tax
was
10
Capital gain distributions (see instructions).
10
withheld.
11 a IRA
11b Taxable amount
distributions.
11a
(see instructions).
11b
If you did not
12 a Pensions and
12b Taxable amount
get a W-2, see
instructions.
annuities.
12a
(see instructions).
12b
Enclose, but do
not attach, any
13
Unemployment compensation and Alaska Permanent Fund dividends.
13
payment. Also,
14 a Social security
14b Taxable amount
please use Form
1040-V.
benefits.
14a
(see instructions).
14b
Add lines 7 through 14b (far right column). This is your total income.
15
15
▶
Adjusted
16
Educator expenses (see instructions).
16
gross
17
IRA deduction (see instructions).
17
income
18
Student loan interest deduction (see instructions).
18
19
Tuition and fees. Attach Form 8917.
19
20
Add lines 16 through 19. These are your total adjustments.
20
21
Subtract line 20 from line 15. This is your adjusted gross income.
21
▶
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions.
Form 1040A (2012)
Cat. No. 11327A
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