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P R I N T C L E A R L Y
OMB No. 1545-0074 Your rst name and initial If a joint return, spouses rst name and initial Last name Last name Apt. no. Your social security number Spouses social security number
Home address (number and street). If you have a P.O. box, see instructions. City, town or post o ce, state, and ZIP code. If you have a foreign address, see instructions.
Check here if you, or your spouse if ling jointly, want $3 to go to this fund .
You
Spouse
Filing Status
Check only one box.
1 2 3
Single Married ling jointly (even if only one had income) Married ling separately. Enter spouses SSN above and full name here. Yourself. If someone can claim you as a dependent, Spouse Dependents: . . . . . . . . . . . . .
(2) Dependents social security number
Head of household (with qualifying person). (See instructions.) If the qualifying person is a child but not your dependent, enter this childs name here.
Exemptions
6a b c
. .
. .
. .
Last name
(4) if child under age 17 qualifying for child tax credit (see page 15)
If more than four dependents, see instructions and check here d Total number of exemptions claimed . . . . . . . . . . . . . . . . .
(FOLD)
$
$ $ $ $ $ =$ x 20%
TAXES OWED
=$
Signature Signature
Date Date