Security Line
Resume:
Form Department of the Treasury Internal Revenue Service
1040A 2012
U.S. Individual Income Tax Return (99) IRS Use Only Do not write or staple in this space.
Your first name and initial Last name OMB No. 1545-0074
Your social security number
Jessica M Gabehart ***-**-****
If a joint return, spouse’s first name and initial Last name Spouse’s social security number
Home address (number and street). If you have a P.O. box, see instructions. Apt. no. Make sure the SSN(s) above
and on line 6c are correct.
25227 Foxbriar lane
City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions). Presidential Election Campaign
Check here if you, or your spouse if filing
spring TX 77373 jointly, want $3 to go to this fund. Checking
Foreign country name Foreign province/state/county Foreign postal code a box below will not change your tax or
refund. You Spouse
1 Single 4
Filing Head of household (with qualifying person). (See instructions.)
2 Married filing jointly (even if only one had income) If the qualifying person is a child but not your dependent,
status
enter this child’s name here.
3 Married filing separately. Enter spouse’s SSN above and
Check only
one box. full name here. 5 Qualifying widow(er) with dependent child (see instructions)
}
6a Yourself. If someone can claim you as a dependent, do not check
Exemptions Boxes
checked on
box 6a. 1
6a and 6b
b Spouse No. of children
on 6c who:
c Dependents: (4) if child under
• lived with
(3) Dependent’s
(2) Dependent’s social age 17 qualifying for
2
you
If more than six security number relationship to you child tax credit (see
(1) First name Last name instructions) • did not live
dependents, see
with you due to
instructions. Joe A Dominguez ***-**-**** Son divorce or
Jasmine S Dominguez ***-**-**** Daughter separation (see
instructions)
Dependents
on 6c not
entered above
Add numbers
on lines
3
d Total number of exemptions claimed. above
Income
7 Wages, salaries, tips, etc. Attach Form(s) W-2. 7 16,041.
Attach
Form(s) W-2 8a Taxable interest. Attach Schedule B if required. 8a
here. Also b Tax-exempt interest. Do not include on line 8a. 8b
attach
9a Ordinary dividends. Attach Schedule B if required. 9a
Form(s)
b Qualified dividends (see instructions). 9b
1099-R if tax
was 10 Capital gain distributions (see instructions). 10
withheld. 11a IRA 11b Taxable amount
distributions. 11a (see instructions). 11b
If you did not
get a W-2, see 12a Pensions and 12b Taxable amount
instructions.
annuities. 12a (see instructions). 12b
Enclose, but do
not attach, any
13 Unemployment compensation and Alaska Permanent Fund dividends. 13
payment. Also,
14a Social security 14b Taxable amount
please use Form
1040-V.
benefits. 14a (see instructions). 14b
Add lines 7 through 14b (far right column). This is your total income.
15 15 16,041.
Adjusted
16 Educator expenses (see instructions). 16
gross
17 IRA deduction (see instructions). 17
income
18 Student loan interest deduction (see instructions). 18
19 Tuition and fees. Attach Form 8917. 19
20 Add lines 16 through 19. These are your total adjustments. 20
21 Subtract line 20 from line 15. This is your adjusted gross income. 21 16,041.
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. BAA Form 1040A (2012)
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Page 2
Form 1040A (2012)
Tax, credits, 22 Enter the amount from line 21 (adjusted gross income). 22 16,041.
{ }
Blind Total boxes
23a Check You were born before January 2, 1948,
and
if: Spouse was born before January 2, 1948, Blind checked 23a
payments
b If you are married filing separately and your spouse itemizes
deductions, check here 23b
Standard
Deduction
8,700.
24 Enter your standard deduction. 24
for
25 Subtract line 24 from line 22. If line 24 is more than line 22, enter -0-. 25 7,341.
• People who
check any
26 Exemptions. Multiply $3,800 by the number on line 6d. 26 11,400.
box on line
23a or 23b or
27 Subtract line 26 from line 25. If line 26 is more than line 25, enter -0-.
who can be
0.
claimed as a This is your taxable income. 27
dependent,
28 Tax, including any alternative minimum tax (see instructions). 28 0.
see
instructions.
29 Credit for child and dependent care expenses. Attach
• All others:
Form 2441. 29
Single or
Married filing 30 Credit for the elderly or the disabled. Attach
separately,
Schedule R. 30
$5,950
Married filing 31 Education credits from Form 8863, line 19. 31
jointly or
32 Retirement savings contributions credit. Attach
Qualifying
widow(er),
Form 8880. 32
$11,900
0.
33 Child tax credit. Attach Schedule 8812, if required. 33
Head of
household,
34 Add lines 29 through 33. These are your total credits. 34 0.
$8,700
35 Subtract line 34 from line 28. If line 34 is more than line 28, enter -0-. This is
your total tax. 35 0.
36 Federal income tax withheld from Forms W-2 and
1099. 36 1,087.
37 2012 estimated tax payments and amount applied
If you have
from 2011 return. 37
a qualifying
child, attach 38a Earned income credit (EIC). 38a 5,236.
Schedule
b Nontaxable combat pay
EIC.
election. 38b
39 Additional child tax credit. Attach Schedule 8812. 39 1,956.
40 American opportunity credit from Form 8863, line 8. 40
41 Add lines 36, 37, 38a, 39, and 40. These are your total payments. 41 8,279.
42 If line 41 is more than line 35, subtract line 35 from line 41.
Refund This is the amount you overpaid. 42 8,279.
43a Amount of line 42 you want refunded to you. If Form 8888 is attached, check here 43a 8,279.
Direct
deposit?
Routing
b c Type: Checking Savings
See
number 1 1 1 0 0 0 6 1 4
instructions
and fill in
d Account 8 4 3 5 8 6 2 1 5
43b, 43c,
number
and 43d or
Form 8888. 44 Amount of line 42 you want applied to your
2013 estimated tax. 44
45 Amount you owe. Subtract line 41 from line 35. For details on how to pay,
Amount
see instructions. 45
you owe
46 Estimated tax penalty (see instructions). 46
Yes. Complete the following. No
Do you want to allow another person to discuss this return with the IRS (see instructions)?
Third party
Designee’s Phone Personal identification
designee name no. number (PIN)
Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge
Sign and belief, they are true, correct, and accurately list all amounts and sources of income I received during the tax year. Declaration of preparer (other
than the taxpayer) is based on all information of which the preparer has any knowledge.
here Your occupation Daytime phone number
Your signature Date
Joint return?
parishable
See instructions.
Spouse’s occupation
Spouse’s signature. If a joint return, both must sign. Date If the IRS sent you an Identity Protection
Keep a copy
PIN, enter it
for your records.
here (see inst.)
Print/type preparer's name Preparer’s signature Date PTIN
Paid Check if
self-employed
preparer Firm's name Firm's EIN
SELF PREPARED
use only Firm's address Phone no.
Form 1040A (2012)
REV 01/28/13 Intuit.cg.cfp.sp
Earned Income Credit
SCHEDULE EIC OMB No. 1545-0074
1040A
(Form 1040A or 1040)
2012
Qualifying Child Information
1040
Complete and attach to Form 1040A or 1040 only if you have a qualifying child.
EIC
Department of the Treasury Attachment
Information about Schedule EIC (Form 1040A or 1040) and its instructions is at www.irs.gov/form1040.
Sequence No. 43
Internal Revenue Service (99)
Your social security number
Name(s) shown on return
Jessica M Gabehart ***-**-****
• See the instructions for Form 1040A, lines 38a and 38b, or Form 1040, lines 64a and 64b, to make
Before you begin: sure that (a) you can take the EIC, and (b) you have a qualifying child.
• Be sure the child’s name on line 1 and social security number (SSN) on line 2 agree with the child’s social security card.
Otherwise, at the time we process your return, we may reduce or disallow your EIC. If the name or SSN on the child’s
social security card is not correct, call the Social Security Administration at 1-800-***-****.
• If you take the EIC even though you are not eligible, you may not be allowed to take the credit for up to 10 years. See page 2 for details.
! • It will take us longer to process your return and issue your refund if you do not fill in all lines that apply for each qualifying child.
CAUTION
Qualifying Child Information Child 1 Child 2 Child 3
1 Child’s name First name Last name First name Last name First name Last name
If you have more than three qualifying
children, you only have to list three to get
the maximum credit. Joe A Dominguez Jasmine S Dominguez
2 Child’s SSN
The child must have an SSN as defined in
the instructions for Form 1040A, lines 38a
and 38b, or Form 1040, lines 64a and 64b,
unless the child was born and died in
2012. If your child was born and died in
2012 and did not have an SSN, enter
“Died” on this line and attach a copy of
the child’s birth certificate, death
certificate, or hospital medical records. ***-**-**** ***-**-****
3 Child’s year of birth
Year 2 0 0 1 Year 2 0 0 6 Year
If born after 1993 and the child was If born after 1993 and the child was If born after 1993 and the child was
younger than you (or your spouse, if younger than you (or your spouse, if younger than you (or your spouse, if
filing jointly), skip lines 4a and 4b; filing jointly), skip lines 4a and 4b; filing jointly), skip lines 4a and 4b;
go to line 5. go to line 5. go to line 5.
4 a Was the child under age 24 at the end of
Yes. No. Yes. No. Yes. No.
2012, a student, and younger than you (or
your spouse, if filing jointly)?
Go to Go to Go to
Go to line 4b. Go to line 4b. Go to line 4b.
line 5. line 5. line 5.
b Was the child permanently and totally
disabled during any part of 2012?
Yes. No. Yes. No. Yes. No.
Go to Go to Go to
The child is not a The child is not a The child is not a
line 5. qualifying child. line 5. qualifying child. line 5. qualifying child.
5 Child’s relationship to you
(for example, son, daughter, grandchild,
niece, nephew, foster child, etc.) Son Daughter
6 Number of months child lived
with you in the United States
during 2012
• If the child lived with you for more than
half of 2012 but less than 7 months,
enter “7.”
• If the child was born or died in 2012 and 12 months 12 months months
your home was the child’s home for more
Do not enter more than 12 Do not enter more than 12 Do not enter more than 12
than half the time he or she was alive
months. months. months.
during 2012, enter “12.”
For Paperwork Reduction Act Notice, see your tax Schedule EIC (Form 1040A or 1040) 2012
REV 11/13/12 Intuit.cg.cfp.sp
BAA
return instructions.
SCHEDULE 8812 OMB No. 1545-0074
Child Tax Credit 2012
(Form 1040A
or 1040)
Attach to Form 1040, Form 1040A, or Form 1040NR. Attachment
Department of the Treasury
Sequence No. 47
Information about Schedule 8812 and its separate instructions is at www.irs.gov/form1040.
Internal Revenue Service (99)
Your social security number
Name(s) shown on return
Jessica M Gabehart ***-**-****
Part I Filers Who Have Certain Child Dependent(s) with an ITIN (Individual Taxpayer Identification Number)
! Complete this part only for each dependent who has an ITIN and for whom you are claiming the child tax credit.
If your dependent does not qualify for the credit, you cannot include that dependent in the calculation of this credit.
CAUTION
Answer the following questions for each dependent listed on Form 1040, line 6c; Form 1040A, line 6c; or Form 1040NR, line 7c, who has an ITIN
(Individual Taxpayer Identification Number) and that you indicated qualified for the child tax credit by checking column (4) for that dependent.
A For the first dependent identified with an ITIN and listed as a qualifying child for the child tax credit, did this child meet the substantial
presence test? See separate instructions.
No
Yes
B For the second dependent identified with an ITIN and listed as a qualifying child for the child tax credit, did this child meet the substantial
presence test? See separate instructions.
No
Yes
C For the third dependent identified with an ITIN and listed as a qualifying child for the child tax credit, did this child meet the substantial
presence test? See separate instructions.
No
Yes
D For the fourth dependent identified with an ITIN and listed as a qualifying child for the child tax credit, did this child meet the substantial
presence test? See separate instructions.
No
Yes
Note. If you have more than four dependents identified with an ITIN and listed as a qualifying child for the child tax credit, see the instructions
and check here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
}
Part II Additional Child Tax Credit Filers
1 Enter the amount from line 6 of your Child Tax Credit Worksheet (see the
1040 filers:
Instructions for Form 1040, line 51).
1040A filers: Enter the amount from line 6 of your Child Tax Credit Worksheet (see the
1
Instructions for Form 1040A, line 33). 2,000.
Enter the amount from line 6 of your Child Tax Credit Worksheet (see the
1040NR filers:
Instructions for Form 1040NR, line 48).
If you used Pub. 972, enter the amount from line 8 of the Child Tax Credit Worksheet in the publication.
2 2
Enter the amount from Form 1040, line 51; Form 1040A, line 33; or Form 1040NR, line 48 0.
3 Subtract line 2 from line 1. If zero, stop; you cannot take this credit . . . . . . . . . . . . . 3 2,000.
4a 4a
Earned income (see separate instructions) . . . . . . . . . . . 16,041.
b Nontaxable combat pay (see separate
4b
instructions) . . . . . . . . . . .
5 Is the amount on line 4a more than $3,000?
No. Leave line 5 blank and enter -0- on line 6.
Yes. Subtract $3,000 from the amount on line 4a. Enter the result . . . 5 13,041.
6 6
Multiply the amount on line 5 by 15% (.15) and enter the result . . . . . . . . . . . . . . 1,956.
Next. Do you have three or more qualifying children?
No. If line 6 is zero, stop; you cannot take this credit. Otherwise, skip Part III and enter the smaller of
line 3 or line 6 on line 13.
Yes. If line 6 is equal to or more than line 3, skip Part III and enter the amount from line 3 on line 13.
Otherwise, go to line 7.
For Paperwork Reduction Act Notice, see your tax return instructions. BAA Schedule 8812 (Form 1040A or 1040) 2012
REV 01/25/13 Intuit.cg.cfp.sp
Page 2
Schedule 8812 (Form 1040A or 1040) 2012
Part III Certain Filers Who Have Three or More Qualifying Children
7 Withheld social security and Medicare taxes from Form(s) W-2, boxes 4 and 6.
If married filing jointly, include your spouse’s amounts with yours. If you
}
7
worked for a railroad, see separate instructions . . . . . . . . . .
8 1040 filers: Enter the total of the amounts from Form 1040, lines
27 and 57, plus any taxes that you identified using code
“UT” and entered on line 60.
1040A filers: 8
Enter -0-.
1040NR filers: Enter the total of the amounts from Form 1040NR,
lines 27 and 55, plus any taxes that you identified using
code “UT” and entered on line 59.
}
9 9
Add lines 7 and 8 . . . . . . . . . . . . . . . . . . .
Enter the total of the amounts from Form 1040, lines
10 1040 filers:
64a and 69.
1040A filers: Enter the total of the amount from Form 1040A, line
10
38a, plus any excess social security and tier 1 RRTA
taxes withheld that you entered to the left of line 41
(see separate instructions).
1040NR filers: Enter the amount from Form 1040NR, line 65.
11 11
Subtract line 10 from line 9. If zero or less, enter -0- . . . . . . . . . . . . . . . . .
12 Enter the larger of line 6 or line 11 . . . . . . . . . . . . 12
. . . . . . . . . .
Next, enter the smaller of line 3 or line 12 on line 13.
Part IV Additional Child Tax Credit
This is your additional child tax credit
13 13
1,956.
Enter this amount on
Form 1040, line 65,
Form 1040A, line 39, or
Form 1040NR, line 63.
Schedule 8812 (Form 1040A or 1040) 2012
REV 01/25/13 Intuit.cg.cfp.sp
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