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 c 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. a 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. a 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 a 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 a 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 a 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 a 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 a 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 . . . . . a 37 For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 11320B Form 1040 (2016)