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Income Tax A P

Location:

Austin, TX

Posted:

January 20, 2024

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Federal Electronic Filing Instructions

Tax Year *019

You are responsible for confirming the status of your electronically filed return. You can confirm the status of your return by going to /ef/efile-center. You will need to enter the primary social security number and last name on the return along with your ZIP code.

Self Select PIN: You do not need to mail any paper signature forms to the IRS. Your return has been successfully filed once you receive your acceptance from the IRS. Refund:

You have elected to receive your refund of $8,653 via direct deposit. You can start checking the status of your refund within 24 hours of e-filing at the IRS website https://www.irs.gov/Refunds under Where's My Refund. The IRS issues most refunds in less than 21 days. Updates to refund status are made once daily - usually at night.

Federal Electronic Filing Instructions Page 1

EFILE COPY

1040

Form

Department of the Treasury–Internal Revenue Service 2019 U.S. Individual Income Tax Return OMB No. 1545-0074 IRS Use Only – Do not write or staple in this space. Married filing separately (MFS) Head of household (HOH) Qualifying widow(er) (QW) Your first name and middle initial Last name Your social security number If joint return, spouse's first name and middle initial Last name Spouse's social security number You:

Home address (number and street). If you have a P.O. box, see instructions. Foreign country name

Apt. no.

If more than four dependents,

see inst. and check here

Presidential Election Campaign

You Spouse

Dependents (see instructions):

(1) First name Last name

(2) Social security number (3) Relationship to you (4) check if qualifies for (see inst.): Child tax credit Credit for other dependents

For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. UYA Form 1040 (2019) Filing status: Single Married filing jointly

(99)

Age/Blindness

Standard

Deduction

Were born before January 2, 1955 Are blind Spouse: Was born before January 2, 1955 Is blind Someone can claim: You as a dependent Your spouse as a dependent Spouse itemizes on a separate return or you were a dual-status alien City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions). Foreign province/state/county Foreign postal code

Check here if you, or your spouse if filing

jointly, want $3 to go to this fund.

Checking a box below will not change

If you checked the MFS box, enter the name of spouse. If you checked the HOH or QW box, enter the child’s name if the qualifying person is a child but not your dependent.

Check only

one box.

Wages, salaries, tips, etc. Attach Form(s) W-2

Tax-exempt interest

Qualified dividends

IRA distributions

Social security benefits

Capital gain or (loss). Attach Schedule D if required. If not required, check here 2a

Taxable amount

Standard

Deduction for -

Pensions and annuities d Taxable amount

7a Other income from Schedule 1, line 9 7a

b Add lines 1, 2b, 3b, 4b, 4d, 5b, 6, and 7a. This is your 7b 8a

8a Adjustments to income from Schedule 1, line 22

b Subtract line 8a from line 7b. This is your

total income

adjusted gross income

Standard deduction or itemized deductions

Qualified business income deduction. Attach Form 8995 or Form 8995-A 9

(from Schedule A)

11a Add lines 9 and 10

b Taxable income. Subtract line 11a from line 8b. If zero or less, enter -0- 9

11a

11b

Natalya A Washington ***-**-****

5716 Memorial Blue Star Hwy 6

Chattahoochee, FL 32324

Joseph Green ***-**-**** Son X

Joeshawn Green ***-**-**** Son X

28,851.

9,051. 9,051.

37,902.

18,350.

19,552.

EFILE COPY

Form 1040 (2019) Page2

12a

13a

Tax

Add Schedule 2, line 3, and line 12a and enter the total Other taxes, including self-employment tax, from Schedule 2, line 10 Add lines 14 and 15. This is your

Federal income tax withheld from Forms W-2 and 1099 Other payments and refundable credits:

Additional child tax credit. Attach Schedule 8812

Subtract line 13b from line 12b. If zero or less, enter -0- Earned income credit (EIC)

13b

20 If line 19 is more than line 16, subtract line 16 from line 19. This is the amount you 21a Amount of line 20 you want

b Routing number

d Account number

22 Amount of line 20 you want

23 Amount you owe.

24 Estimated tax penalty (see instructions)

overpaid 20

refunded to you. If Form 8888 is attached, check here c Type: Checking Savings

applied to your 2020 estimated tax

Subtract line 19 from line 16. For details on how to pay, see instructions 24

Form 1040 (2019)

UYA

Refund 21a

Direct deposit?

See instructions.

Go to www.irs.gov/Form1040 for instructions and the latest information. Child tax credit or credit for other dependents

(see inst.) Check if any from Form(s): 1-881*-*-**** 3 b

Amount

Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge. Sign

Here

Your signature Date Your occupation

Spouse's signature. If a joint return, both must sign. Date Spouse's occupation Preparer's name Preparer's signature Date

Firm's name

PTIN

Paid

Preparer

Joint return?

See instructions.

Keep a copy for

your records.

Check if:

Firm's address

Use Only Phone no.

12a

13a

b Add Schedule 3, line 7, and line 13a and enter the total 12b

c American opportunity credit from Form 8863, line 8 d Schedule 3, line 14

e Add lines 18a through 18d. These are your total other payments and refundable credits 19 Add lines 17 and 18e. These are your total payments 18a

18b

18c

18d

18e

Third Party

Designee

(Other than

paid preparer)

Do you want to allow another person (other than your paid preparer) to discuss this return with the IRS? See instructions. Designee’s

name

Phone

no.

Personal identification

number (PIN)

Yes.

Complete below.

Phone no. Email address

Firm's EIN

total tax

you owe

If you have a

qualifying child,

attach Sch. EIC.

If you have

nontaxable

combat pay,

see instructions.

Natalya A Washington ***-**-****

2,072.

1,267.

2,072.

905.

4,976.

1,849.

2,733.

4,582.

9,558.

8,653.

124303120 X

392*********

Customer Service Rep /CNA

352-***-**** ad2xl5@r.postjobfree.com

EFILE COPY

SCHEDULE 2 OMB No. 1545-0074

(Form 1040 or 1040-SR)

Department of the Treasury

Internal Revenue Service

Attach to Form 1040 or 1040-SR.

Attachment

Sequence No. 02

Name(s) shown on Form 1040 or 1040-SR Your social security number Go to

2019

Additional Taxes

www.irs.gov/Form1040 for instructions and the latest information. 1

For Paperwork Reduction Act Notice, see your tax return instructions. UYA Schedule 2 (Form 1040 or 1040-SR) 2019 Part I Tax

Alternative minimum tax. Attach Form 6251

Excess advance premium tax credit repayment. Attach Form 8962 Add lines 1 and 2. Enter here and include on Form 1040 or 1040-SR, line 12b Part II Other Taxes

Self-employment tax. Attach Schedule SE

Unreported social security and Medicare tax from Form: Additional tax on IRAs, other qualified retirement plans, and other tax-favored accounts. Attach Form 5329 if required

Household employment taxes. Attach Schedule H

Repayment of first-time homebuyer credit from Form 5405. Attach Form 5405 if required Taxes from: a Form 8959 b Form 8960

a 4137 b 8919

9 Section 965 net tax liability installment from Form 965-A 10 Add lines 4 through 8. These are your

1040-SR, line 15

c Instructions; enter code(s)

total other taxes. Enter here and on Form 1040 or

Natalya A Washington ***-**-****

905.

EFILE COPY

SCHEDULE 3 OMB No. 1545-0074

(Form 1040 or 1040-SR)

Department of the Treasury

Internal Revenue Service

Attach to Form 1040 or 1040-SR.

Attachment

Sequence No. 03

Name(s) shown on Form 1040 or 1040-SR Your social security number Go to

2019

Additional Credits and Payments

www.irs.gov/Form1040 for instructions and the latest information. Foreign tax credit. Attach Form 1116 if required

Credit for child and dependent care expenses. Attach Form 2441 Education credits from Form 8863, line 19

Retirement savings contributions credit. Attach Form 8880 Residential energy credits. Attach Form 5695

Other credits from Form: a

Add lines 1 through 6. Enter here and include on Form 1040 or 1040-SR, line 13b For Paperwork Reduction Act Notice, see your tax return instructions. UYA Schedule 3 (Form 1040 or 1040-SR) 2019 3800 b 8801 c

Part I Nonrefundable Credits

Part II Other Payments and Refundable Credits

2019 estimated tax payments and amount applied from 2018 return Net premium tax credit. Attach Form 8962

Amount paid with request for extension to file (see instructions) Excess social security and tier 1 RRTA tax withheld Credit for federal tax on fuels. Attach Form 4136

Credits from Form:

Add lines 8 through 13. Enter here and on Form 1040 or 1040-SR, line 18d 8

a 2439 b Reserved c 8885 d

Natalya A Washington ***-**-****

805.

EFILE COPY

Tax liability limit. Enter the amount from the Credit Form 2441 Child and Dependent Care Expenses OMB No. 1545-0074 Attach to Form 1040, 1040-SR, or 1040-NR.

Department of the Treasury

Internal Revenue Service

Attachment

Sequence No. 21

Name(s) shown on return Your social security number Persons or Organizations Who Provided the Care - You must complete this part.

(If you have more than two care providers, see the instructions.)

(b) Address

(number, street, apt. no., city, state, and ZIP code)

(d) Amount paid

(see instructions)

1 (SSN or EIN)

(a) Care provider's

name

Credit for Child and Dependent Care Expenses

Add the amounts in column (c) of line 2. Don't enter more than $3,000 for one qualifying person or $6,000 for two or more persons. If you completed Part III, enter the amount from line 31

Enter your earned income.

If married filing jointly, enter your spouse's earned income (if you or your spouse was a student or was disabled, see the instructions); all others, enter the amount from line 4 4 4

Enter the smallest of line 3, 4, or 5

7 Enter the amount from Form 1040 or 1040-SR, line 8b; or Form X

Decimal

amount is

If line 7 is:

Decimal

amount is

If line 7 is:

But not

Over over

But not

Over over

$0-15,000 .35 $29,000-31,000 .27

15,000-17,000 .34 31,000-33,000 .26

17,000-19,000 .33 33,000-35,000 .25

19,000-21,000 .32 35,000-37,000 .24

21,000-23,000 .31 37,000-39,000 .23

23,000-25,000 .30

Multiply line 6 by the decimal amount on line 8. If you paid 2018 expenses in 2019, see the instructions

For Paperwork Reduction Act Notice, see your tax return instructions. Form 2441 (2019) Part I

Part II

Enter on line 8 the decimal amount shown below that applies to the amount on line 7 Did you receive

dependent care benefits? Yes

Complete only Part II below.

Complete Part III on page 2 next.

Caution: If the care was provided in your home, you may owe employment taxes. For details, see the instructions for Schedule 2 Information about your qualifying person(s). If you have more than two qualifying persons, see the instructions.

(a) Qualifying person's name

First Last

(b) Qualifying person's social

security number

incurred and paid in 2019 for the

person listed in column (a)

Credit for child and dependent care expenses. Enter the smaller of line 9 or line 10 here and on Schedule 3 (Form 1040 or 1040-SR), line 2; or Form 1040-NR, line 47 11

25,000-27,000

27,000-29,000

.29

.28

39,000-41,000

41,000-43,000

.22

.21

.20

2019

UYA

See instructions

43,000-No limit

(Form 1040 or 1040-SR), line 7a; or Form 1040-NR, line 59a.

(99)

1040-NR, line 35

Limit Worksheet in the instructions

Go to www.irs.gov/Form2441

2441

. . . . . . . . . .

for instructions and the

latest information.

You cannot claim a credit for child and dependent care expenses if your filing status is married filing separately unless you meet the requirements listed in the instructions under “Married Persons Filing Separately.” If you meet these requirements, check this box. Natalya A Washington ***-**-****

Jennifer 1823 NE 31st Ave Gainesville See Stmt

Johnson Gainesville, FL 32609 3,500.

Joseph Green ***-**-**** 1,750.

Joeshawn Green ***-**-**** 1,750.

3,500.

28,851.

3,500.

37,902.

.23

805.

2,072.

805.

EFILE COPY

Form 2441 (2019) Page 2

Dependent Care Benefits

Enter the total amount of dependent care benefits you received in 2019. Amounts you received as an employee should be shown in box 10 of your Form(s) W-2. Don't include amounts reported as wages in box 1 of Form(s) W-2. If you were self-employed or a partner, include amounts you received under a dependent care assistance program from your sole proprietorship or partnership

Enter the amount, if any, you carried over from 2018 and used in 2019 during the grace Combine lines 12 through 14. See instructions

Enter the total amount of incurred

in 2019 for the care of the qualifying person(s)

Enter the smaller of line 15 or 16 17

Enter your earned income.

Enter the smallest of line 17, 18, or 19

Enter $5,000 ($2,500 if married filing separately

you were required to enter your spouse's earned income 17

Taxable benefits.

on Form 1040 or 1040-SR, line 1; or Form 1040-NR, line 8. On the dotted line next to Form 1040 or 1040-SR, line 1; or Form 1040-NR, line 8, enter “DCB” 18

Part III

To claim the child and dependent care

credit, complete lines 27 through 31 below.

Enter $3,000 ($6,000 if two or more qualifying persons) stop. You can't take the credit.

Exception. If you paid 2018 expenses in 2019, see the instructions for line 9 Enter the smaller of line 29 or 30. Also, enter this amount on line 3 on the front of this form form and complete lines 4 through 11 31

Complete line 2 on page 1 of this form. Don't include in column (c) any benefits shown on line 28 above. Then, add the amounts in column (c) and enter the total here 29

Form 2441(2019)

earned income (if you or your spouse

was a student or was disabled, see the

instructions for line 5).

instructions.

All others, enter the amount from line 18.

Subtract line 22 from line 15

Deductible benefits. Enter the smallest of line 20, 21, or 22. Also, include this amount on the appropriate line(s) of your return. See instructions 23

Otherwise, subtract line 24 from the smaller of line 20 or line 21. If zero or less, enter -0- 24

qualified expenses

Subtract line 28 from line 27. If zero or less,

UYA

See instructions

period. See instructions

Enter the amount, if any, you forfeited or carried forward to 2020. See instructions 31

Enter the amount shown below that applies to you.

If married filing jointly, enter your spouse's

If married filing separately, see

and

on line 19)

Is any amount on line 12 from your sole proprietorship or partnership? No. Enter -0-.

Yes. Enter the amount here

Excluded benefits. If you checked “No” on line 22, enter the smaller of line 20 or 21. Subtract line 25 from line 23. If zero or less, enter -0-. Also, include this Add lines 24 and 25.

Natalya A Washington ***-**-****

EFILE COPY

Early distributions included in income. For Roth IRA distributions, see instructions are reporting this tax directly on Form 1040, 1040-SR, or 1040-NR—see above). You also may have to complete this part to indicate that Additional Taxes on Qualified Plans OMB No. 1545-0074 Form 5329 (Including IRAs) and Other Tax-Favored Accounts Department of the Treasury

Internal Revenue Service

Attachment

Sequence No. 29

Attach to Form 1040, 1040-SR, or 1040-NR.

Name of individual subject to additional tax. If married filing jointly, see instructions. Your social security number Home address (number and street), or P.O. box if mail is not delivered to your home If this is an amended

return, check here

14 14

maximum allowable contribution, see instructions. Otherwise, enter -0- 15

2019 traditional IRA distributions included in income (see instructions) 15

2019 distributions of prior year excess contributions (see instructions) Add lines 10, 11, and 12

Prior year excess contributions. Subtract line 13 from line 9. If zero or less, enter -0- Excess contributions for 2019 (see instructions)

Additional Tax on Early Distributions.

distribution) before you reached age 59 from a qualified retirement plan (including an IRA) or modified endowment contract (unless you 1 1

Early distributions included on line 1 that are not subject to the additional tax (see instructions). Enter the appropriate exception number from the instructions: 2

3 Amount subject to additional tax. Subtract line 2 from line 1 3 4 Additional tax. Enter 10% (0.10) of line 3. Include this amount on Schedule 2 (Form 1040 or 4

For Privacy Act and Paperwork Reduction Act Notice, see your tax return instructions. Form 5329 (2019) Apt. no.

Part I

Part II

owe the additional 10% tax on early distributions, you may be able to report this tax directly on Schedule 2 (Form 1040 or 1040-SR), line 6, or Form 1040-NR, line 57, without filing Form 5329. See the instructions for Schedule 2 (Form 1040 or 1040-SR), line 6, or for Form 1040-NR, line 57. Fill in Your Address Only

If You Are Filing This

Form by Itself and Not

With Your Tax Return

Caution: If any part of the amount on line 3 was a distribution from a SIMPLE IRA, you may have to include 25% of that amount on line 4 instead of 10%. See instructions. 5 5

Additional Tax on Certain Distributions From Education Accounts and ABLE Accounts. Distributions included in income from a Coverdell ESA, a QTP, or an ABLE account 9

Distributions included on line 5 that are not subject to the additional tax (see instructions) 11

Amount subject to additional tax. Subtract line 6 from line 5 12

Part III Additional Tax on Excess Contributions to Traditional IRAs. Complete this part if you contributed more to your traditional IRAs for 2019 than is allowable or you had an amount on line 17 of your 2018 Form 5329.

Total excess contributions. Add lines 14 and 15 16 Additional tax. Enter 6% (0.06) of the smaller of line 16 or 17

if you included an amount in income, on Schedule 1 (Form 1040 or 1040-SR), line 8, or Form 1040-NR, line 21, from a Coverdell education savings account (ESA), a qualified tuition program (QTP), or an ABLE account. Go to

2019

Part IV Additional Tax on Excess Contributions to Roth IRAs. Enter your excess contributions from line 24 of your 2018 Form 5329. See instructions. If zero, go to line 23 If your Roth IRA contributions for 2019 are less than your maximum allowable contribution, see instructions. Otherwise, enter -0- 18 18

20 2019 distributions from your Roth IRAs (see instructions) 21 Add lines 19 and 20

22 Prior year excess contributions. Subtract line 21 from line 18. If zero or less, enter -0- 23 Excess contributions for 2019 (see instructions) 24 Total excess contributions. Add lines 22 and 23 25 Additional tax. Enter 6% (0.06) of the smaller of line 24 or 21

UYA

If your traditional IRA contributions for 2019 are less than your If you only

1040-SR), line 6, or Form 1040-NR, line 57

(99)

you qualify for an exception to the additional tax on early distributions or for certain Roth IRA distributions. See instructions. www.irs.gov/Form5329

Foreign country name Foreign province/state/county Foreign postal code IRAs for 2019 than is allowable or you had an amount on line 25 of your 2018 Form 5329. Complete this part

Complete this part if you contributed more to your Roth for instructions and the latest information.

Complete this part if you took a taxable distribution (other than a qualified disaster

(Rev. January 2020)

Natalya A Washington ***-**-****

9,051.

905.

EFILE COPY

SCHEDULE EIC Earned Income Credit OMB No. 1545-0074

(Form 1040 or 1040-SR)

Department of the Treasury

Internal Revenue Service

Attachment

Sequence No. 43

Qualifying Child Information

For Paperwork Reduction Act Notice, see your tax Schedule EIC (Form 1040 or 1040-SR) 2019 Before you begin: See the instructions for Form 1040 or 1040-SR, line 18a, to make sure that (a) you can take the EIC, and

(b) you have a qualifying child.

Qualifying Child Information

1 Child's name

Child's SSN

Child's relationship to you

months

Yes.

months

Yes.

First name Last name First name Last name

Name(s) shown on return Your social security number EIC

1040

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-***-****.

Child 1 Child 2

No. No.

Go to line 5. Go to line 4b. Go to line 5. Go to line 4b. Yes. No. Yes. No.

The child is not a

(for example, son, daughter, grandchild,

niece, nephew, eligible foster child, etc.)

Child's year of birth

If born after 2000 the child is younger

skip lines 4a and 4b; go to line 5.

Year Year

2019

CAUTION

UYA

First name Last name

Child 3

Year

Yes. No.

Go to line 5. Go to line 4b.

Yes. No.

months

(99)

than you (or your spouse, if filing jointly),

If born after 2000 the child is younger

than you (or your spouse, if filing jointly),

skip lines 4a and 4b; go to line 5.

If born after 2000 the child is younger

than you (or your spouse, if filing jointly),

skip lines 4a and 4b; go to line 5.

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 the instructions 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. qualifying child.

The child is not a

qualifying child.

The child is not a

qualifying child.

Do not enter more than 12 months. Do not enter more than 12 months. Do not enter more than 12 months. and and and

Go to line 5. Go to line 5. Go to line 5.

return instructions.

Complete and attach to Form 1040 or 1040-SR only if you have a Go to www.irs.gov/schueduleEIC

You can't claim the EIC for a child who didn't live with you for more than half of the year. for the latest information.

1040-SR

qualifying child.

Natalya A Washington ***-**-****

Joseph Joeshawn

Green Green

***-**-**** ***-**-****

2 0 1 1 2 0 1 2

Son Son

12 12

EFILE COPY

SCHEDULE 8812

Department of the Treasury

Internal Revenue Service (99)

Additional Child Tax Credit

Attach to Form 1040, 1040-SR, or 1040-NR.

Go to

OMB No. 1545-0074

Attachment

Sequence No. 47

Name(s) shown on return Your social security number Part I All Filers

Part II Certain Filers Who Have Three or More Qualifying Children 1

Enter the amount from line 8 of your Child Tax Credit and Credit for Other Dependents Worksheet (see the instructions for Forms 1040 and 1040-SR, line 13a.) If you file Form 2555,

2 Enter the amount from Form 1040, line 13a; Form 1040-SR, line 13a; or Form 1040-NR, line 49 2 3 Subtract line 2 from line 1. If zero, stop here; you cannot claim this credit 3 6a Earned income (see instructions) 6a

b Nontaxable combat pay (see

instructions) 6b

7 Is the amount on line 6a more than $2,500?

No. Leave line 7 blank and enter -0- on line 8.

Yes. Subtract $2,500 from the amount on line 6a. Enter the result 7 8 Multiply the amount on line 7 by 15% (0.15) and enter the result 8 Next. On line 4, is the amount $4,200 or more?

No. If line 8 is zero,

smaller

Yes. If line 8 is equal to or more than line 5, skip Part II and enter the amount from line 5 on line 15. Otherwise, go to line 9.

For Paperwork Reduction Act Notice, see your tax return instructions. Schedule 8812 (Form 1040 or 1040-SR) 2019 2019

UYA

www.irs.gov/Schedule8812 8812

. . . 1040 . . . . . . .

If you are required to use the worksheet in Pub. 972, enter the amount from line 10 of the Child Tax Credit for Other Dependents Worksheet in the publication. Otherwise: stop here; you cannot claim this credit. Otherwise, skip Part II and enter of line 5 or line 8 on line 15.

stop here; you cannot claim the additional child tax credit. for instructions and the latest

information.

Caution:

Enter the amount from line 8 of your Child Tax Credit and Credit for Other Dependents Worksheet (see the instructions for Form 1040-NR. line 49). 4 Number of qualifying children under 17 with the required social security number: Enter the result. If zero, 4

X $1,400.

5 Enter the smaller of line 3 or line 4 5

TIP: The number of children you use for this line is the same as the number of children you used for line 1 of the Child Tax Credit and Credit for Other Dependents Worksheet. the

9 Withheld social security, Medicare, and Additional Medicare taxes from 9

Form(s) W-2, boxes 4 and 6. If married filing jointly, include your spouse’s amounts with yours. If your employer withheld or you paid Additional Medicare Tax or tier 1 RRTA taxes, see instructions 10

Enter the total of the amounts from Form 1040-NR,

lines 27 and 56, plus any taxes that you identified using code “UT” and entered on line 60.

11 Add lines 9 and 10

13 Subtract line 12 from line 11. If zero or less, enter -0- 14 Enter the

Enter the amount from Form 1040-NR, line 67.

larger of line 8 or line 13

Next, enter the smaller of line 5 or line 14 on line 15. Part III Additional Child Tax Credit

15 This is your additional child tax credit 15

. . . 1040 . . . . . . .

Enter this amount on

Form 1040 line 18b;

Form 1040-NR, line 64.

stop here; you cannot claim this credit

Form 1040-SR, line 18b; or

Natalya A Washington ***-**-****

4,000.

1,267.

2,733.

2,800.

2,733.

28,851.

X 26,351.

3,953.

2,733.

EFILE COPY

Part II

2019

OMB No. 1545-0074

Form 8889 Health Savings Accounts (HSAs)

Department of the Treasury

Internal Revenue Service

Attach to Form 1040, 1040-SR, or 1040-NR.

Name(s) shown on Form 1040, 1040-SR, or 1040-NR

Form 8889 (2019)

HSA contributions you made for 2019 (or those made on your behalf), including those made from January 1, 2020, through April 15, 2020, that were for 2019. include employer HSA Distributions.

14a Total distributions you received in 2019 from all HSAs (see instructions) Qualified medical expenses paid using HSA distributions (see instructions) c

17a

Taxable HSA distributions. Subtract line 15 from line 14c. If zero or less, enter -0-. Also, include this amount in the total on Schedule 1 (Form 1040 or 1040-SR), line 8, or Form 1040-NR, line 21. Enter “HSA” and the amount on the line next to the box 16 Add lines 6 and 7

Subtract line 11 from line 8. If zero or less, enter -0- HSA deduction. Enter the smaller of line 2 or line 12 here and on Schedule 1 (Form 1040 or 6

14a

14b

Attachment

Sequence No. 52

For Paperwork Reduction Act Notice, see your tax return instructions. 4

Go to

If any of the distributions included on line 16 meet any of the Exceptions to the Additional 20% Tax (see instructions), check here

Additional 20% tax see instructions). Enter 20% (0.20) of the distributions included on line 16 that HSA Contributions and Deduction. See the instructions before completing this part. If you are filing Distributions included on line 14a that you rolled over to another HSA. Also include any excess contributions (and the earnings on those excess contributions) included on line 14a that were withdrawn by the due date of your return (see instructions) Subtract line 14b from line 14a 14c

15 15

17b

Social security number of HSA

beneficiary. If both spouses have

HSAs, see instructions

Part I

If you were age 55 or older at the end of 2019, married, and you or your spouse had family coverage under an HDHP at any time during 2019, enter your additional contribution amount

(see instructions) 7

Caution: If line 2 is more than line 13, you may have to pay an additional tax (see instructions). Before you begin: Complete Form 8853, Archer MSAs and Long-Term Care Insurance Contracts, if required. Check the box to indicate your coverage under a high-deductible health plan (HDHP) during 2019 (see instructions) Self-only Family

If you were under age 55 at the end of 2019 and, on the first day of every month during 2019, you were, or were considered, an eligible individual with the same coverage, enter $3,500

($7,000 for family coverage)., see the instructions for the amount to enter Enter the amount you and your employer contributed to your Archer MSAs for 2019 from Form 8853, lines 1 and 2. If you or your spouse had family coverage under an HDHP at any time during 2019, also include any amount contributed to your spouse’s Archer MSAs Subtract line 4 from line 3. If zero or less, enter -0- family coverage under an HDHP at any time during 2019, see the instructions for the amount to enter

Employer contributions made to your HSAs for 2019

UYA

Enter the amount from line 5. But if you and your spouse each have separate HSAs and had If you are filing jointly and both you and your spouse each have separate HSAs,

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