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Department of the TreasuryInternal Revenue ServiceForm

U.S. Individual IncomeTax Return

1040A1991 OMB No. 1545-0085

Step 1Your social sec urity no.Last nameYour first name and initial

LabelL

A

B

E

L

HE

R

E

(See page 16.)Spouses social security no.Last nameIf a joint ret urn, spouses first name an d initial

Use the IRSlabel.Otherwise,please printor type.

Home address (number and st reet ). (If you have a P.O. box, see page 16.) Apt . no.

For Privacy Actand PaperworkReduction ActNotice , see page 3.

City, town or post office, state, and ZIP code. (If you have a foreign address, see page 16.)

Presidential Election Campaign Fund (see page 17) Note: Checki ng Yeswill not change your tax

or redu ce your refund .

NoYesDo you want $1 to go to this fund?If joint retu rn, does your spouse want $1 to go to this fun d? NoYes

Single1Step 2Married filing joint return (even if only one had income)2Check your

filing status 3 Marr ied filing separa te r etur n. E nt er spouses social security n umberabove and spouses full name here (Check only one.)

4 Head of household (with qualifying person). (See page 18.) If the qualifying person is achild but not your dependent, en ter t his childs na me her e

Qualifying widow(er) with dependent child (year spouse died 19 ). (See page 19.)5

No. of boxeschecked on6a and 6b

Step 3 Yourself .6a If your parent (or someone else) can claim you as a dependent on his or her taxreturn, do not check box 6a. But be sure to check the box on line 18b on page 2.

Figure yourexemptions

SpousebNo. of yourchi ldren on6c who:

(5) No. of monthslived in yourhome in 1991

(4 ) Dependent srelationship to

you

(3 ) If age 1 or older,dependen ts s ocialsecurity n umber

(2 ) Checkif under

age 1

c(See page 20.)

(1) Name (first, initial, and last name)

l ivedwi th you

didnt l ivewi th you dueto divorce orseparation(see page 23)

If more tha nsevendependents,see page 23.

No. of otherdependentsl i sted on 6c

If your child didnt live with you but is claimed as yourdependent under a pre-1985 agreement, check here

dAdd numbersentered onl ines aboveTotal number of exemptions claimed.e

Wages, salaries, tips, etc. This should be shown in Box 10 of yourW-2 form(s). (Attach Form(s) W-2.)

7Step 47

Figure yourtotal income Taxable interest income (see page 26). (If over $400, also complete

and atta ch Schedule 1, Part I .)8a

8a8bTax-exempt interest. (DO NOT include on line 8a.)b

Attach Copy B

of your FormsW-2 and 1099-R

here .

Dividends. (If over $400, also complete and attach Schedule 1, Part II.)9 9

Total IRAdistributions.

10a Taxable amount(see page 27).

10b

Attach check ormoney order ontop of any FormsW-2 or 1099-R.

10a 10b

Taxable amount(see page 27).

11b11a Total pensionsand annuities. 11b11a

12 Unemployment compensation (insurance) from Form(s) 1099-G. 12

13a Taxable amount(see page 31).

Social securitybenefits.

13b13b13a

Add lines 7 through 13b (far right column). This is your to ta l income. 14 14Your IRA deduction from applicable worksheet.15a 15aStep 5Spouses IRA deduction from applicable work-sheet. Note:Rules for IRAs begin on page 33.

bFigure youradjustedgrossincome

15bc Add lines 15a an d 15b. These are your total adjustments. 15c

Subtract line 15c from line 14. This is your adjus ted gross incom e .(If less th an $21,250, see Ear ned in come credit on pa ge 41.)

16

16

D ependent s :

Cat. No. 11327A

8/14/2019 US Internal Revenue Service: f1040a--1991

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1991 Form 1040A Page 2

17Enter the amount from line 16.17Step 6

Enter number of

boxes checked BlindYou were 65 or olderCheck

if:18a

18aBlindSpouse was 65 or older

If your parent (or someone else) can claim you as a dependent,check h ere

b18b

If you are married filing separately and your spouse files Form

1040 and item izes deductions, see page 37 a nd check here

c

Figure yourstandarddeduction,

18c19

19Subtract line 19 from line 17. (If line 19 is more than line 17, enter -0-.)20 20

exemptionamount, and 21 Multiply $2,150 by the total number of exemptions claimed on line 6e. 21

Subtract line 21 from line 20. (If line 21 is more than line 20, enter -0-.)This is your taxable income.

22taxableincome 22

Find the tax on the amount on line 22. Check if from:Tax Table (pages 4449) or Form 8615 (see page 39)

23Step 723

Figure yourtax, credits,andpayments

Credit for child and depen dent car e expenses.Complete and attach Schedule 2.

24a

24a

b Credit for the elderly or the disabled.Complete and attach Schedule 3. 24b

24cAdd lines 24a an d 24b. These are your total credits .cIf you want theIRS to figureyour ta x, seethe instructionsfor line 22 onpage 38.

25 Subtract line 24c from line 23. (If line 24c is more than line 23, enter -0-.) 2526 Advance earned income credit payments from Form W-2. 26

27Add lines 25 and 26. This is your total tax. 27

Total F ederal income t ax withh eld. (If anytax is from Form(s) 1099, check here .)

28a28a

1991 estimated t ax payments and amount

applied from 1990 return.

b

28bEarned income credi t . Complete andattach Schedule EIC.

c28c

Add lines 28a, 28b, and 28c. These are your total payments . d 28d

Step 8 If line 28d is more than line 27, subtract line 27 from line 28d.This is the am ount you overpaid .

2929

Figure yourrefund oramount youowe

30 Amount of line 29 you want re funded to you . 30

Amount of line 29 you want appl ied to your1992 e s t imated tax .

3131

Attach check ormoney order ontop of Form(s)

W-2, etc., onpage 1.

If line 27 is more tha n line 28d, subtra ct line 28d from line 27. This is th eamount you owe. Attach check or m oney order for full amount payable tothe Inter nal Revenue Service. Write your nam e, address, social securitynum ber, daytime phone nu mber, an d 1991 Form 1040A on it.

32

3233 33Estima ted ta x penalty (see page 43).

Under penalties of perjury, I declare th at I have examined this ret urn and a ccompanying schedules and sta tements, an d to the best of my knowledgeand belief, they are true, correct, and complete. Declaration of preparer (other than the taxpayer) is based on all information of which the preparerhas any knowledge.

Step 9Sign yourreturn

DateYour signat ure

Keep a copy ofthis return foryour records.

Spou ses signat ur e (if joint r et ur n, BOTH mu st sign ) Da te

Date Prepa rers social securit y no.PreparerssignaturePaid

preparersuse only

Check ifself-employed

Firm s nam e (or yoursif self-employed) andaddress

E.I. No.

ZIP code

Enter the s tandard deduct ion shown below for your filing status.But i f you ch ecke d any box on l ine 18a or b, go to page 37 tofind your stan dar d deduction. If you ch ecke d box 18c, enter -0-.

Single$3,400 Head of household$5,000

Mar ried filing joint ly or Qu alifying widow(er)$5,700

Married filing separately$2,850

Your occupation

Spouses occupation