Form

1040

Department of the Treasury - Internal Revenue Service

(99)

U.S. Individual Income Tax Return
Last name

2012
OMB No. 1545-0074 , 2012, ending , 20 IRS Use Only-Do not write or staple in this space.

For the year Jan. 1-Dec. 31, 2012, or other tax year beginning Your first name and initial

See separate instructions.
Your social security number

Same A
If a joint return, spouse's first name and initial

Morris
Last name

741-85-2963
Spouse's social security number

Sarah B
Home address (number and street).

Morris
Apt. no.

321-65-4987
Make sure the SSN(s) above and on line 6c are correct.
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.

54321 Gala Avenue
City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions).

Tyler
Foreign country name

TX
1 2 3 Single X Married filing jointly (even if only one had income)
Married filing separately. Enter spouse's SSN above and full name here.

75701
Foreign postal code

Foreign province/state/county

You

Spouse

Filing Status
Check only one box.

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.

5

Qualifying widow(er) with dependent child
Boxes checked on 6a and 6b No. of children (4) Chk If child under on 6c who: age 17 qualifying lived with you for child tax credit (see instructions) did not live with you due to divorce or separation (see instructions) Dependents on 6c not entered above

Exemptions

6a b c Beth

X Yourself. If someone can claim you as a dependent, do not check box 6a . . . . . . . . . . } X Spouse . . . . . . . . . . . . . . . . . .