Professional Documents
Culture Documents
[Sef ins iructlons on paqu 16.) Use the IRS label. Oth~rwi~~.
:i i~iJ~U
Re;tum
L A B E L H E
B~~ACK H
Ii a ioint return. spouse's Hrst name and iniUai
I
'1DU
.26
Last nama
I. Last name
~O~.
IOBAli~
Apt no.
MI0HELLE
hava a P.O.
OBAM~
A Important!
You must enter YDur SSN(s) above.
.'i
~IrTYpe.. E CHICAGO IL 60615 Presiuential L-...L.~""","",,""""-'='..J-.---=~_-==":""""=-- __ . EI'~Gtion Campaign r>.. Nole. Checldng "Yes" vAil not change your IHX or reduce your refund. :3"", pa~I!" 1,".~ 17 Do yo". or I'our 5pOU~5 ifliling a joint ~tLJrn. I"/<inl ':>3 go to this lund? to
oruu
1
-;:-;-_-J
Filing Status
Chr.ck only L'IlS 11O~. Exemptions
2 3
r::;o
~ ..'j
Single Married filing s~~aral~II'. Enter .pOU5~'S SSN above and lull name here,
D Head of household
!>
CXJ
You
Yes
D No
Spouse
[XJ
Yes
D ~lo
_
!ll>-
0 QualifvinQ I
'IIidow{er) with dependent child (S09 pagE 17) "...................... ~~~';; • ~r:;'~~.d •
No. 01 chlld,c""
W
, 11 Fi
I
If sorneune can elalrn ynu as a dependent, do ~O! check box 6a " "....... ('!lD.p,"doo". 0<:0'.'
L...1::;1'"ILll";'le
_2_ _2
I
.
I!!lo: .:iam!'J
:t>IALIA .A OBAlxTll,.
:ir;: 11:H):' .~~ ____
NhTJ.~SHA
__ "-__ Q~. .________
M OB.l\J::.lA_____ __
.
r
I
~=-=__
:::,f'.t::unly
numl:.:.r
I' ....
•
p) O"l'end.nl'o rel att.ans!iip In.
ytll-i
DAUGHTER"" F-AUGHTER
(;~'!~t1m
"'\I,JU
vou
0 di d f1QI
duo
'0
:~'~~n"UI·mr~:_,.t:Q~~~
~~~~:.i> 3
207
u _
C'~'''''d'n,"on50
.::Ia!mad . ,.....
Income
,lUBell ~iirn'(3)
7 83 f,-'=9c_::il-+
342 •
Tax-exempt
At1ech Sell.dule B f! r~quircd interest. Do not rnctude on lino 8a iI.t:Wch SdlaLlul~ B il requked
OrrJin;;,y divi!let\d~.
[J~atiil2tl divldend5 (see P~DC 20) .. ..... ...... .. L-'9"'b'--'-I_~.---- _=_---1 _ T~'iilit~ ,eltmcs, muils, or orlseis 01 ;!Hle and iUGelin~ome taxes ....... S1'.M:T... J.....'J;'}i;T .4 $ 10
305.
Business inClJma Qr (loss), Atticl, Sr.tleuula G ,)f G-EZ .... ....... . ..... CaoilJI ~ai~ or (luss). AWlch f,ctl~()uie 0 Ii reQUired. II not [r,r,llin;Li. ~h~cli here . .........:: Oilier gains m (loss?,) ..~linr.h Fnrm4797 IRA dislribulions ~_ Pensians and anl1l!llies . ,.... ~~-. farm income or (less), Mach Sche~ute F "
~.
~a9fl~.
15.
t:~r
. .. .
11 12
loa 11 16 19 20a 21 22 23
'-'---1
~..... ,..
---'
" . b Ta.~abl~ amount tsee page 22) b Taxable amount (see page 22) . . "
16h 17 16 19
Ren,al real estate, ruyalll.es. p~rtnerslllps, S ccrnorancns, IfUSt5. r.1C.Attllch Sehedule E .. , UnemplQ'lmcnl compensauon .. SDci" I securir! b~neiilE 1 _,,20"'ae.J.i L (lther income. List type ~nd amount (sac page 24)
b laxable amount (see page 24) 20b ---1 21 .~tld lhe "mounts in the lar riohl cotumn lor Irne5 7 thrfJIJ(ln 21. This is vnur tOI.1 Income "....... l> 22
207
647 .
2~ Adjusted Gross
income 25 ;>0 27 28 29 30 31 32
1'1,1.. d~~u"i1on (see pag~ "6)
,StlJc:wi I~all lnte;~st licdu~tir;n is'''' lillY. 7.81 :uillun and lee:; ;IH(llIct!on (see po~(' 21) .. 27
r=26~ 29 .
30 . 31
~1'
S"lh,mployed health insurance deducuon (see palle 30) Sell·em9loyed SEP, SIMPLE, and Qualilled plans
.
.. 33 _
<....><:34 ....a_,_I
P~naliY on early wfihdra\'lal oi Sllvings 33 34<1 ,\liI]lIJlJY pair! b Rp.ctplent·s SSN fi:". 35 36 ~'i.d. F'1' Di5closura, Ado tines 2J through 34a
-1,:· . 35
36
Sub ifile! line 35 from lin~ ~.2. Tills ISvcur ad justed gross income
PrjV'lCl'
207
647.
Reduction
Act Notice.
'.",m 10~~PD04i
BARACK
H & MICHELLE
L OB_2I._M.1l,
207,647-'..
1
~~~'~~~.:'~B.r
CledU'c\i~n rerP.ecpl!l:w.f1o o
DBlind.
checl[sd
nere
L~ 383_
~
!J
II reur
·88b ..
. ,'-'3:.::9-'-'~ 5 ,OJ 8 ,
~~~ ~J"~~;d0 4
"''' d.p"nd,nl
39 . Itemized deductions
Subtract line 39 from line 37 .. . '11 If line 37ls £107,025 or less, mulhply .~3-, 00 Dy 1.11(: numller 1 10lal Is over ~i 07 ,025, see Ihe worksl\~et on nane 33 ,
42
o ~I! olhodfS: Single Married $',,1,1850
MBlTIi;:d JOlnUyor ffllng ~t
43
T~xable lnooma. Sublract line 41 irom line ~(I.II lin~ 41 is more than line 40. enter -0· Tax. CheCk !fany tax is from: aD Form(s) 681<1 ilO form 4972 _
Allelllative minimum In. Milch Form 6251 _
I .j 1 I ~
r
!
~."O,-;
I
.J S:;; , Ei :.~ .
LR.L__
12 , 4: 0 ;J • 170 ,) 1 9 . __:3,,-,-7_,__o19 ,
c.::-----c:-------:_
mlng
.5_~I:;Ia-at!!I~',
Ou.lIlYlnQ Si_9,7r:10
44 45 46 47
4B
"
Foreign lID: nradlt Attach Form 1116 II required ::::........................... Credit for child and dependent care e)(penses. Attach Form 21)41 _.. _ Credit ior1he elderly or the disnbled. A~aclt Schedule A _
~·lrdD1,.·Jrc:r1.
H.w<:LQ of heLlsenold, 5;! 150
1-.24-".6_'t1 47 48 I .
. ..
'1'...........
I> 1----"4-"-5-+_ _
-:=_-1
1-1..:.4"',iC4
.---=3"--'-7 ,__,6'---'1"---o::...;~1 ~
700 •.
49' Educalion credils. Attach Form B863 .. _ sa Retirement savings contributions crediL Allach Form
aoaa
" ..
51 Child lax creclii (see page 37) . 52 Adoptiofl eredlt Attach Form 8839 5a Credits from: a D Form 3396 54 Other credits. Check applicable bO)«e5): b D Form 8aOl G 0 Specify
55 Add 56 57 58 59 60 61 62
I :~ 1-----------11,_-.<
4S
'521 1 53 ~.
r
b a
D Form
O·F~;~ ..85:9 3
3800
lines
----------------
I 5~
55 Irom line ~5.1f line 65 i~ more 11lan linfr 45. snifr ·I} Attach Schedule SE _ and Medicare tax on tip innorne not mporled 1'0emplover, Ar.ach Form 4137 .. __ .. :
r,...
. .. .. _ .. _..
55 56
other Taxes
Selt-employmentlax.
57
58
tax on IRAs, other qUilll.lied retimmB~1 plans, ete, Ma[;h Form 5$29 If required
59
60 61
Advance earned income credit paymMts from Form(s) W-2 Household employmenllaxes. Attach Schedule H .. _ _ Add lines 5611lrough 61. This Is your total tax .. . .. Federal income tax withhold from rorms 'N-2 "nd 1099 2004 estlrnsred lax paymenls and amount applied Irol1l2003 return .. ::::::::: ..
I I
i I I I
--
__
700.
I"
-.
_'_*4_~
~_.
3,5[,)7.
Payments
Uyou nave a qU3_,jrjt.ng 'Chll~, ~tla~ SL":nfldulD EtC.
63 54
II>
46
62
40,426.
628 • _
65: ~~~n~:~i;I:OC:~~:~~~;~I~!ti~~ 56 67 6B B9
;·T5·~br· ..
4136 ~DForm
Excess social securily and tler 1 RRTA Lax wilhheld (s~~ page 5(1) Addltion.1 child lax credit, Attach Form 8B12 Amountpaid with recuesttor extenslcn to lile (see page 54) other payments from:
I
66
DForm
2439 b Dform
70
Refund
Dir~1 depco;l?
Seo pogo 5,1 a.nd fjU ~n72b; nco 7'd. ~
to,.
If line 70 is more than line 62. subtract line 62 rum Ifn~ 70. Ttus is the amount ynu nverpaid ...
~o"ll~g
1I,"1~"
1
I 70,-+- _ _ 71
71
II
73
r-L
_._ _
.'''''1,---------·
,.,
,,, .. ,_,.
__
---,
'n~
Amount of line 71 vou want applied te vo u I 2005 eslil1l21ed I." Amount you owe. Subtractline
,1---=---73=--_:
Amount
'74
62. For
You Owe 75 Estimated lax Dsnaltv (see nace 55) '. . . '.' .. 75 Third Party Do you want to allow anoll1€l person 10 discuss 11115eturn 'IJilh the IRS I.m page 56)? r Designee ~~~<I'; J> PREPA.'R.ER
I$O-._i--'-7---'-4----"__
;~~"'I!>
CXJ YES.
~.~~~~,':P;'~f"r.:"r." t>
:J No
.'
C 11 cl TEl)( C red it IN 0 rks f1e e t if
~iErne(S): First Last X$l,OOO.Enlertheresull. __ .__
.. ""C.I.S ~ 'Part 1
.1:L"§:
1. 3.
:MICHEJ;.LE
, Your SSN 1
,",umberofQualiiyingelliidren:
OBAM..~~:==.=-:,_~~~~~=_~=-"=~'"'==_~~=-:="
2. Enler lile amount nom Form i040, line 37, or Form 1a 'lOA. line 22.
o
1040 iiiels: Enler Ihe total Of anyExclusfonoi income from Puerto Rico. and Arnnunts from form 2555, lines 43 and 43; form 2555·EZ, liile 15; ~nd;:m rn '1563, line 15.
J
...
2,000.
-"'2_=0~7!.....<..,_o6c.:4=-..!.7..!..
o.
207 647.
10'IOA m~rs: Ealer ·0-. ~. Aotllmcs 2 al1'J3. EnI~r thll 10lal, 5. Ent;;f lhe amount ~l1owl1below lor your illlnQ stli'U5.
o i',iarfl~d liIino
joinll'l - $I'IO,I}I}O
.. ;'i;7~.O(l0
'" M.rrled filing separately' $55,000 6. Is Ihe amount on line ~ more thaJl tne amount on line 5?
l J
---"'l"'l"-.:O~I_=O!..:O~O~.
No. Leave line 6 blank. Enter ·0- on line 7. Yes. Sublraclline 5 1rom line 4, ', .. __ __ __ .. 6 Ii the result Is not a mUltiple 01 $1,000, increase it to the next multiple or $1,000 (for r.xample, lncreasa $425 to $1,1)00, increase $1,025 to $2,000, etc). .,
-=9'-'8"-'-~O-"D:...;:O"-'-.
7. Mulliply Ule amount on fine 6 by'5% (.(5). Enter tho result O. Is tho amount on lina 1 more than the amount on linn 7? [][] No. I STClI'1
.7
----"'4"-'-"'9.:::0~O~.
yc~ cannot lake lile c~ild I;].~.;rerllt on Furm 11140,lille .',1, or f.}.m 104U.A line ,'33. ..
~~.
Pa
it. 2
I i YeJ.~!ilJt!3ct U!lll.7 tram [iQ.L:J.!2.!!!1 \!l~.I"~ull. _,.-:"'-_=~_...... ..,.._...;.",=='~"".....~ ......... ~=.b=~-==~~_~~ ,.~__ 9 __ 9. Enler ihe amount 110m Form 1')40, iine 45, or Form '1040A. line i~3. 10. 1040 Hiers: Enter tne :01.1 ollne amounts nom lines 46 tlif[luqh 50. }~ HI
1040A tllers: Enler Ih~ lolal 01 1I1€ amounts trom lines 29 IIlfough 32. 11. II.m yOu ctaiming any 01 the lollavling credits? '" Adoption credit, form 8539
o
0
o
I
District of Columbia first-time uomeouyer Gradit, Form B859 I~Q. En~r lh~ amount from line lQ. '(e~. Complp.ift The LillO '11 Worl:shecl 10 ligure Ihe amount to enter here. 1'Ilrom line 9. Enler [lie resull.
II ilIll
} ...... ;,__. 11 .
12
~
_
13. Is fhe alOuunt un lille B nl lhis wurksheet mor p. inan tim amount on noe 12'(
lin~ 3.
'I,
This is your
•
Ghi~ t~!dil;",..,_
.......,<===~~
__
"
2.1
A&B
Schedule 14 ~temgzedlDeductions
N
(Schedule
B is on page 2)
tor Schedules A and Ei (Form 1040).
RC!v~UE!! S2rviCij
1040.
See Instructions
BARACK H & MICHELLE L OB1>JvlA Caution. 00 not include espanses reimbursed or paid Ily others, 11J)edica! and Medical and denial expenses (see paJ;Je A·2) 2 Enter amount from Form 1040, line 37 Dental
Expenses
Taxes You Paid
(See pageA·2.)
lRL
··· ....
1;1':
3
4 5
Multiply
line 2 by 7.5% (.075) 3 tram line 1. If lina 3 is more than line 1. enter ·0·. ..
13"---".
..
---,--1 4
Sublraclliroe
a
b 6
0 General
[X]
Income taxes, or sales taxes (5,.9 page ,A"2) (see page A·3)
1
J
:..
,
.. "
I I.!
;-1.=.5_j-
6"-'•~·1=-=3-=5'-"i. .
Real estate
taxes
_I6
3 9 4 6.J
lnterest
You Paid
(See page A·3.) Note: Parsonal interest is net deductible.
10 11
~__12
13 1·t 15
Home mortgage interest and polnts reponed In you on Form ·1098 Home mortgage interest not reponsd to :fOU on Form 109a. If paid to the person from whom you bought the home. se8 pa£l~ i)..~ and snow that person's name. identifying no .• and address
..
-_=~Attach
-__--__.. ..
--
Points not reported to you on Form 1098. See pag", A·,I for speCial rules. lnvastrnant interesl. Form .1952 ~ rsqueed. .. Add lines '10 through Gifts by cash or check sae page 13..... (Sse page 1'..4.) ....
U
Id
I
I ,
-wi
14,395.
I9
10,081.
U .. 395.
Gifts to Charity
gift and got J beneiillor il.
Cll:!iUl:!II~'
A·"
2.500.1
Ii you mcde
il
16
page ,:1,.. 4.
-I
,
2.500.
_
17
1B 19 20
an d
1.1.:
! 181
.1 ...... • ..
---;-""'"'"'-'--"~~-'.:....:.1:9:..1
,I
Olhar
I>lftllQJ)[. .N1Jp_
21
22
expensea- loll travel, IJlliondues. lob education. Attach Form 2106 or2·I06·EZ If required. (See paqa A·6.)
61C:['
~:gQl!:I~..s_S):.9~1b!! ]2"ll.~S _
2_2jl_:
::..1
201
229.
_,8"-8""_,,1:...!-[.
Tax preparation
fuss
Investment. safe deposit box, etc. List lype and amount -
Other expenses·
---~----~----------------~----------~
23 24 Add lines 20 through 22 ... .. .... Enter amount Irorn Form ;0'10. line 37 Multiply Subtract line 24 by 2% (.02) , ~_
__ --_--_--
---
-_
1I
! 25,
1(
11 0 .;
I
0,
25
26
,.
..
4 , 153
line 25 irom lin~ 23. If line 25 is more than line 23. enter ·0·
1261
.1
Other
Deductions
28
(over $71,350
ST1:'.IT 5
No. Yes.
Your deduction is not limited. Add the amounts in the tar light column lor lines 4 through 27. Also, enter this amcurn on Form 1040, line 39. Your deduction Reduction rnav be limited. 5se page AS (or 11,e amount se e Form 1040 instructions. h) enter
I
---''''-=-
J>
28 1"-
25
L028~.
1:2·::W·DJ
LHA
For Paperwork
Act Notice.
Schedule
A (Form
'1040) 200 ..
~r ttir.!
TrcrlDU!'1 (91))
i>- Attach
to Form
1040.
instructions.
j·Jarne(;;;
HhOWll
on Form 1040
~:;~~~"ilc. 21
2lrn((]4
~B~AR~~~.(~~~K~H~&~M~I~C~H~E~L~L~E~'-=L~O~B~A~UiA~~·, ~~
B.. tore \'OU b6gin: You need to understand the f(!lIowing terms. S~e Definitions c Qualifying on page 1 ot tne instructions. Person(s) this
'" DBpendent
Care Benefits
o Qualified
E;:penses
Who Provided
of page 2.)
part.
"
(number,
streei,
.s.__
----------------------+-------------------+-------------:Err. \~.~
J,: __
,_,
___
I, •. -: _::,,:._,
~'';~_
.r.',
17 550.
•...:.),.
.L __
5,388.
----------;i>
•---Yes --------I>
dependent
Caution. If ,he
care benetlts?
care was
provided
ra,~e5, See
the Ins/ructions
I Part
2
ill
ln_ju_'r_n_12_t~io_r_'a_b_o_u_t~y_o_u_r~q .. u_a_lh~y_In~g~p_e_r5_0_n~(~5)~._lf~\~'o_u_l_la_\_~_._m_o_re __1I_1a_n_t_~_lo~q_uD_I_il~yi_n~g~p_e_rs_·o_n~s~,_s_e_8_t,h-e_in~s~t~ru~c_ii_o_n .. s_, ~'"~,~~~~~ ___ Ie) OUClliiyiflOperson', name (h)Oualifying person's Ie) QU3liifed expensesyou Finil L £1St social S8curity number 1~~C:~~dtJ~~j~~~;t:~I~m"'nr(!)
'OBAM,lI,
+-_--'1""'1=.l....,
..,._c--'1--
.::,.4"",6"",9.:c.'
N:<.:/.I' ?'-~J..i_A"--'·'-"'Mo..-__________
:j
iQBAMA ..
In ~r,l!Jrnn (c) o~ :In" 2. Do no! enter rnore than 't:3,OuO lor cne qll"lifying you completed SeE' instructlons earned income Part ll], enter the arncunr lrom lin= 32 ..... ..
Ii married 'filing loin!I)" antsr your spouse's di3a!;lied, see the instruclions):
of IIn8 3, <1, or 5
"
". ".
..
.
207
Decimal
amount
647.
Ent~f' ~", Il(1e S !!1"~~I?clr i::iJ amount shown be!ow that aoplies to ,he amount on line i , Illin~ ~~ Tis: But not aver DeCimal . amount
IF Iill~ 7 is:
But not ~O~v~e~r..,o~v~e~r __ ~i~
is
__
$0· '15,000 '15,000 ·17,000 H,OaO·19.0()O 19,000 . 2'1,000 2; ,000 . 23,000 23.!JOO·:<5,000 2S,COO·2',OOO
27,:lOG· 29,ODO
.27
.26
.25
x .20
28
,24 .23
I'
!J ~.-Iu,tloJyline
(j
by lile osclmal
(he mstructlons
10 t:nt~r Ii;.; amouor from Form 1040, line 45, minus all)' amounl on FiJrm 1040, line '"6
1 i Credit for child and dependent care expenses. Enter the smaller
10
11
LHA
For Paperwork
Reduction
Act Notice,
see separate
lnstructlcns.
.t.
rr
~F~o~rm~244~'~'1~(_20_04_"~)=B~AiU~~~C~K~H~~&~M~_~I~C~H~E==L~L~E~;L~O~B=lU~l~~~~~ t' ~aFfJtq Dependent Care Benefits ' -;-_-..,12 Ente.r ihe total amount of dependent care benefits you received in 2D04. Amounts you received reponed as an
D6g~
' .. . _
employee should be shown In box 10 of your Form(s) W-2. Do nat include amounts
box 1 of Form(s) W·2_ If you were self-smplnyatl dependent care assistance or a partner, include amounts
as wages in under a
you received
or partnership
" _"
.
13
2.500.
_ __ ••__
14
2.500.
the qualiiylng
person(s)
15 16
+1
_;;!::..::
2~,
9'--"'3~8~'1
.1 -
_._ _
_ ,
__
.
2 , 5 00
171
"
85 432.
was a student
or was disabled,
SS9
'1
18
..;
121910.
_.
,.,
, "'.
. ,.
,__ 19
,~r partnership,
2 500.
If y,~u did not
20 Enter the amount from line 12 that you received jrcrn your sale prcpnetorshlp
I
• ,_ ._ _ _~
21
::::::C:~i::::hi~O:o::s~:nt~r
~,'"." rnarrieo
:'."":
22
En,,, $5.000
line(s)
,".500'
""0,
22
separately and
Income on line 1 B)
23 Deductible
or your
in"
.1- ---'2=0=---+-
.. .
!-'
Q.9_Q...~
lnstrucnons)
__
on the apprcpnate
:,_f
..:9"'3:!...,!.1
24
of line 19 or
1241
r
2 500.1
----..__
.. .1
26
on Form 10~D. , ..
:2 1500.
27. Taxable
linG 26 from line 21. If zero or less, enter ·0·, Also. include this amount
care credi t,
..---~---
persons)
. tal,\) ill? .;;r,;dil. Exception. ', In column \c)any ,.. ,,, beneflts .. .. , shown . If you paid 2003
line 29 from lin8 28. If zero or less, stop. You cannot in 2004, see the Instructions for line 9. __
ey.penses
3'1 Complete
on lin€: 29
.. 31
above. Then, add 1I,e amounts in column (e) afld enter the total here
32 En!er the smaller of line 30 or 31. Also, enter this amount on Une 3 on page '1 of this form and _...:c"'0~m!.!!p=.::'e::.:l::..e~"n~e"'s-=4:..·1!...!1...:."'__.. ......-'........ =~-~"'-"-' ~- '''' --~ ... __ ""_"'''''' -"' .. ''' ..'''"'''.'''"'''''."''-'''''' .. ---'.'-''---. ~-------'--"'---"'"'_'_........,_=~'=--"~;="'_'""""''''''-'=-'_'_---'-' ..
__ .............'______ .... "''''
I
!
--=----3 , •• 5 G (I. Form 2441 L:~GC:.:.IJ
...:3::!.!2:....L1
,~l.li::;2
~1~1=.\J~
~-=rv:;.I!
ll'>
security
number number
Employer
Identification
=B~A~J?~t~F.~_C~I~\~F~l~O~B=P.J4~·~-iA=~
A Did you pay anyone household employee cash wages of $1.400 or more in 2004? (If any household
~
employee was yaur spouse,
.
your child
under age 21, your parent. or anyone under age 1S, see the line A instructions
[Xl
o
8
Yes. No,
C and go to line 1 ,
Did ',ou ·"it.hhold Federal income tax during 200'~ for any household
employee?
CJ
C
L _J
Yes. No.
any
calendar
quarter
employees?
100 not count cash wages paid in 2003 or 2004 to your spouse,
t~~
No. Yes.
Stop. Do 1101 ill" this schedule. Si~fr-lings 1·9 and go to line 10 on page 2_ (Calendar yea I taxpayers do not haVE to cornptste this form Tor 200.ol.) having no household employees in 2004
..._----------__.:.__------'-------------------------
..._---,------
10 scclal s~curity
L_1 _ __,__1
.._ _ _,
__
----"2'-"2'--',-=e5~5'_='5'_'__\J
".........
Social securit'J taxes. Multiply line 1 by -12.4% (:124; :-0(;:;1cash \'lag,;; ~l>biecllo
Medic~rR taxes. Multiply Medicare taxes (ses page 11·3)
Il~2-t4 5
-=2---"---'-7-=-9-'-7..::....
:?
I
_
3
"
22 555,
_..
654.
Medkare,
(a,1d
III,"';
2,
Il.
and 5)
............................................ -1 11--'-+7
, __ __ , _ employees?
.•
.. c._
_.
!-"'S......,.,
..:3:...L_,4,_,S",___,,1:...:...
Net taxes
[)
(sut.lract
. quarter
L_;:8.....J.
~3:...Lr ",4",5,,---=,1'--'..,
Did you pay total cash wages of $1,000 or more In any calendar
~DI) not count cash wages paid in '2003 or 20C4 to your spouse. your child under ag'3 21. or your parent)
o
_"i"~
~.h.:::'
No.
a ab'l'/Ei
Ime 9 lnstructions
on page lI·4.
Yes.
Schetluie
,i1·:;:·::'iJi 14.-~..!,·o,:
1':Ri:li-t Ii~,: I
.11 Did you
Sol,.duloH(Fcrm
contributions
j
.
allstate
unsmployment
contribunons fer
15, 2005?
Fiscal
year
filers. tax?
see
page .'1-4
are
unemployment
L1.L!
10
1,(,,5'
X X
i
i'lio.
l'-
12 : j['j
r~ext; If you checked the "Yes" box on all the lines above, complete Ssctlon Ali you checked the "No" box on any of the lines above, skip Section A and complete
SEction B.
Section A
13 Name 01 the state where you paid unarnployrnent contributions
IL ,.,
~1.
::
16 Total cash
to FUTA
:~a:::::::::~::mr:~~:::i;::a~~~~ ,,..
,.[;>."'" •••.
_ ,.,1.)," •. .. ..3.,
1-1:.:6,--;__ ,
tax
. .....
7 000. 56.
(il
'!':-:"Itr;b'~IIc.t"i!
:Jiild
all colcrms
M you
(c)
need more
(b)
Slater~p:;r11"9 r,umb'!!,. ea snDwn on state I)",emp!lt~~nl Ia,\:
space,
(ell
?J'!'11r,l~
Section 6
Si!e page H-4): (e)
SI::lla excertence I ,at.:.
(f)
!i"luIHply eot
te,
by ..1::5.1 (
tc
r..rf)oCl
:u.1I\ol
1Jn*·"n.:.Ji"'j.'j11~rl~
19 Totals
20 Add columns (h) and~) or line 19 ... __ ........ ,.....
'",
~ 20
FUlA. [a.~ (see the ],r,E '16 msrrucucna
--
.. 1LT-'19=-1'-T-
em
pagE' 1-\·4)
22 23
Multiply line
Multiply
21 by 6.2% (.062!.. ..
..
J-22
__
~_
24 Enterthesmallerofline20oriine23
(New Ynrk
Slate
employers
in the
separere
Instructions
.. , .
I p.arllll'l
26
25 FUlA
tax, Subtract
line 26
_____
,3_1.j_SJ"-".
(inp.26
Fan IV below.
3"'," 50'
[X] Yes,
I 'Parti\! I
';'=~~~!Ii(n.umhOr
No,
or
'0
perj!.nv, I ::te:c.l,jlra 'hH~ ,I ocve =-~;amlrH!" ,hr:::. ::or.JlDdul-:.. Il1cl't.ldli'"J il:::'~I;_mf ••1n.:..'."'-; :;! .... t~I";'~~·,H•• u"'l~ 7'1."I;;!:! t1c!:=.[ .-::Ii u etete lJn-ern[}IO"imcn~ fun.d cl.ilImud,£ a cr~dil ',','o!!,~', I;Ir I~ tc tI';" L.hIOl.fl'.:I~~ r~_"!M1II,,,, mi(j,:-':'!i: .e ~...... -vjIjI'J-..:'~.
=~. .
m~'
knQwl'i."~:;:
c;1..J ::ir:lUl';!r. t i
f.Q uuc
...
=c.u!!u:~, Jna
------
-noasa
-- r~~
Schedule H (Farm 104012004
'~·O-1-1J4
-.--
---_
1
STATEl'1ENT
2003
ILLINOIS GROSS INC TAX REFlJl'lJ"DS LESS: TAX PAID IN FOLLOWING YEF~ NET T.'L,{ REFUNDS ILLINOIS STATE/LOCAL
2002
2001
305.
305.
1'O'1'A_L NET
TF_]-~ F.EFL"lIDS
3 05 •
STATEMENT(S)
L OEAl-iA
FORM
1040
TAXA.BLE
STATE·
J.>._NDLOCAL
2003
NET TAX
LOCAL
REF~lDS FROM STATE M{D INCOME TAX REFUNDS ST:EiIT. BE~mFIT DUE
LESS:REFUNDS-NO
TO
J.>.~~
1
2
NET
TOTAL
REFUNDS
FOR RE~~LCULATION
4
5 6
ITEMIZED DEDUCTIONS BEFORE PHASEOUT DEDUCTION NOT SUBJ TO PHASEOUT NET REFUNDS FROM LINE 1 LINE 2 xrmrs LINES MUL~IPLY LINE 5 BY 3 AND 4 80~ (.80) THRESHOLD
21,352.
238;327. 139,500.
26,690.
8
9
10 11
12
13A 13B 14
SUBTR.ll,.CT LINE 8 FROM LINE 7 (IF ZERO OR LESS, SKIP LINES 10 THROUGH 15, A}TD ENTER ~~OUNT FROM LINE 1 ON LI}ffi16) MULTIPLY LINE 9 BY 3% (.03) ALLOWABLE ITEMIZED DEDUCTIONS (LINE 5 LESS THE LESSER OF LINE 6 OR LINE 10) ITE]lIDED. NOT SUBJ TO PHl',SEOUT TOTAL PRIOR
ADJ.
98,827.
2,965.
23,725.
15
16
17
18 19 20 21 22
THE GREATER OF LINE SUBTRACT 13A OR LINE 138 FROM LUTE 14 TA..K..AELE REFUNDS (LESSER OF LINE 15 OR LINE 1) . ALLOWABLE PRIOR YR. ITEllf DED. ILAIl LE PRIOR YEAR STD. DED. F._VA SUBTP..ACT LINE 18 FROM LINE 17 LESSER OF LINE 16 OR LUTE 19 INCOME PRIOR YEAR TAX..l'l...BLE
305.
AMOUNT TO INCLUDE ON FORN 1040, LUTE 10 '" IF LINE 21 IS -0- OR lvIORE,USE ';:\lIiOUNT FROM LINE 20 ;, IF LINE 21 IS A NEGATIVE AHOlTIlTT, NET L:::lifES AL'1D21 20 STATE TOTAL
F~D
305.
LOCAL
INCOME
TO
2001
TO FORM
1040,
LINE
]05.
STATE:MEN'l'i E
L OBAlifA
FOR11 1040
li>TAGES RECEIVED
]\.j_\TDTAXES
WITHHELD
STATEMENT
CITY
lIJj.\_l'iE
STATE Tll.1{
WITHHELD
Tj.\..,X W/H
SDI
FICA TAX
MEDICARE
Tll_X
934.
1,544. 3,657. .. 6,1"3"5.
1,993.
466.
874.
S f_THTiTERSIT1-
OF CHICAGO
HOSFI'l'ALS 'l'OTALS
5,450. 7,443.
1,783. 3,123.
-----------. ------------------------------------------------------------------------DE3CRIFTION
NI SCEI,LAN'EOUS SUBTOTALS TOTAL ORGANI ZED CHl>..RITIES MlOUNT 50% LINIT
.lll,{[OUNT
SCHEDULE
7>..
CASH
.CONTRIBUTIONS
'
-4
30% LII1IT
2,500.
2,500.
TO SCHEDULE
A, LINE
15
2,500.
1(:,
STATEMm~T(S)
3, 4
B_!l,__'R.AC1<H
&:
MI CHELLE
.L OBAN]l~
SCHEDULE
]l.~
ITEMIZED
DEDUCTIONS
t-TORKSHEET
STATEMENT
1.
2•
3.
4"
5.
6.
7.
LHl:ES 4, 9, 14, 18, , ..•....• ADD THE Jll.fOUNT S ON SCHED ULE P_, LINE S 4, 13, A.J,fD 19, PLUS JiliTY GAMBLING fI.NDCASU.~LTY OR THEFT LOSSES INCLUDED ON LIN'E 27 . ., , . . . . .. . .• ..".... IS THE )I._l10UNT ON LINE 2 LESS THAN THE )I._IyIOUl\IT ON LINE 1? IF NO, YOUR DEDUCTION IS NOT LIMITED. ENTER THE JL'10UNT FROM LINE 1 ABOVE ON SCHEDULE A, LINE 28. IF YES, SUBTRACT LINE 2 FROM LI,NE 1 • MULTIPLY LINE 3 ~~OVE BY 80% (,80) 21,581. ENTER THE AMOUNT FROM FORM 1040, LINE 36. 207,647. ENT.ER: $142,700 ($ 71,350 IF MJ"I.1mIED FILING _A..ND 27 ••••.....
I
26,975.
0,
26,976
..
8.
9.
10.
IF NO, YOUR DEDUCTIOl>J IS NOT LHHTED. .ENTER THE AMOUNT FROM LINE 1 JI..BOVE ON SCHEDULE ~b", LIl:>iE 2.8. I.F YES I SUBTR.~CT LINE 6 FROM LINE 5 MlJLTIPLY LINE 7 ABOVE BY 3% (.03) .... ENTER THE SMALLER OF LINE 4 OR LINE B . " TOTAL
ON LINE 5?
...•.
14 2
700 .
6 LESS
64,.947.
L948. 1. 25,028.
ENTER
11
S'I'AT'EHEN',r! S
..
Tl/llo .. Year ·
Comparison 'Norkshee"i.:
_._L.l. ~S()C_i.al.~e~UrilYnum_b~_.r ._
;;ame(s i R, sllO~m nnreiurn BF_RACK H &, MICHELLE L OBAKW__ ?Oo:!. FII,ng StilTliS MARR I ED F I""L""I""N_,_.,G,,-' -,J",-,O""I=:l\~1.=.T ~D03 Ta~ (jrJ(:k~1 O. 0 %
__
I
1_ _ .. .... ~~
Dmiiptio'Ti
_=___; __ _;
"\oIAGES, SALARIES,
OF STATE/
AND TIPS
28. 0 %
I·
..• .~-
"'liq'i]:H~{ _;.
,+_
.: "
~-.
-_,
:.
__ ..:.;;' . . ~ .-~ '2Q~O-,-lt' ~ 1 ••'_"_"+-"·_',_~ _' '~._.:-(_:._o~_"o_re_as:_:e;),--"--""'--:---1'-, -~._!J. ...~"= ~ ,.... ~:I ..~'~~" ..
I,QeAL
TJ<x .....
238,327.1 0
238,327,
INC01<lE
.j
207,342.
305.
207,647. 207,647.
~TEREST
(DEDUCTIBLE)
DEDUCTIONS
10,08l.
14,395.
2,500
>
-1,273.
2,154.
-900.
99B.
214,297. 9,2'72.
205,025.
!:,!.~~...
I~--"
49,104CREDITS
T;'_X BEFORE
37,619. 36,919.
FORM
18CH.
!
TJl...x AFTER
2441
(CHILD
CJI.RECREDIT)
EMPLOYMENT
NON~REFUNDABLE
700.
700. 55.
H (HOUSBHOL,D
TP'_x
TOTAL'
3,507.
!FEDERAL,
-11,430.
xx
-6,753. -6,753.
'ILLINOIS
STATE
RETURN
,, "
fI' ,">-."'{
1
iTjl._JUI..BLE INCONE
I
6,910, 305.
199,34.2.
5,980.
CREDITS
184. 7,031.
47.