Merchandise

Review your print out for checklist items.

Form

**** *.*. ********** ****** Tax Return 2021

Department of the Treasury—Internal Revenue Service (99) OMB No. 1545-0074 IRS Use Only—Do not write or staple in this space. Filing Status

Check only

one box.

Single Married filing jointly Married filing separately (MFS) Head of household (HOH) Qualifying widow(er) (QW) If you checked the MFS box, enter the name of your 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 a

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 Home address (number and street). If you have a P.O. box, see instructions. Apt. no. City, town, or post office. If you have a foreign address, also complete spaces below. State ZIP code Foreign country name Foreign province/state/county Foreign postal code 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.

You Spouse

At any time during 2021, did you receive, sell, exchange, or otherwise dispose of any financial interest in any virtual currency? Yes No Standard

Deduction

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 Age/Blindness You: Were born before January 2, 1957 Are blind Spouse: Was born before January 2, 1957 Is blind Dependents (see instructions):

If more

than four

dependents,

see instructions

and check

here a

(2) Social security

number

(3) Relationship

to you

(4) if qualifies for (see instructions):

(1) First name Last name Child tax credit Credit for other dependents 1 Wages, salaries, tips, etc. Attach Form(s) W-2 1 Attach

Sch. B if

required.

2a Tax-exempt interest . . . 2a b Taxable interest 2b 3a Qualified dividends . . . 3a b Ordinary dividends 3b 4a IRA distributions 4a b Taxable amount 4b 5a Pensions and annuities . . 5a b Taxable amount 5b 6a Social security benefits . . 6a b Taxable amount 6b 7 Capital gain or (loss). Attach Schedule D if required. If not required, check here a 7 8 Other income from Schedule 1, line 10 8 9 Add lines 1, 2b, 3b, 4b, 5b, 6b, 7, and 8. This is your total income a 9 10 Adjustments to income from Schedule 1, line 26 10 11 Subtract line 10 from line 9. This is your adjusted gross income a 11 Standard

Deduction for—

• Single or

Married filing

separately,

$12,550

• Married filing

jointly or

Qualifying

widow(er),

$25,100

• Head of

household,

$18,800

• If you checked

any box under

Standard

Deduction,

see instructions.

12a Standard deduction or itemized deductions (from Schedule A) . . 12a b Charitable contributions if you take the standard deduction (see instructions) 12b c Add lines 12a and 12b 12c 13 Qualified business income deduction from Form 8995 or Form 8995-A 13 14 Add lines 12c and 13 14 15 Taxable income. Subtract line 14 from line 11. If zero or less, enter -0- 15 For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Form 1040 (2021) 12,550.

12,550.

12,550.

0.

104 Quit Graves Rd

Taylorsville MS 391684347

Avis a lewis ***-**-****

Form 1040 (2021) Page 2

16 Tax (see instructions). Check if any from Form(s): 1-881*-*-**** 3 .. 16 17 Amount from Schedule 2, line 3 17 18 Add lines 16 and 17 18 19 Nonrefundable child tax credit or credit for other dependents from Schedule 8812 19 20 Amount from Schedule 3, line 8 20 21 Add lines 19 and 20 21 22 Subtract line 21 from line 18. If zero or less, enter -0- 22 23 Other taxes, including self-employment tax, from Schedule 2, line 21 23 24 Add lines 22 and 23. This is your total tax a 24 25 Federal income tax withheld from:

a Form(s) W-2 25a

b Form(s) 1099 25b

c Other forms (see instructions) 25c d Add lines 25a through 25c 25d 26 2021 estimated tax payments and amount applied from 2020 return 26 If you have a

qualifying child,

attach Sch. EIC.

27a Earned income credit (EIC) 27a

Check here if you were born after January 1, 1998, and before January 2, 2004, and you satisfy all the other requirements for taxpayers who are at least age 18, to claim the EIC. See instructions a b Nontaxable combat pay election 27b

c Prior year (2019) earned income 27c

28 Refundable child tax credit or additional child tax credit from Schedule 8812 28 29 American opportunity credit from Form 8863, line 8 29 30 Recovery rebate credit. See instructions 30 31 Amount from Schedule 3, line 15 31 32 Add lines 27a and 28 through 31. These are your total other payments and refundable credits a 32 33 Add lines 25d, 26, and 32. These are your total payments a 33 Refund 34 If line 33 is more than line 24, subtract line 24 from line 33. This is the amount you overpaid .. 34 35a Amount of line 34 you want refunded to you. If Form 8888 is attached, check here . . . a 35a Direct deposit?

See instructions.

a b Routing number a c Type: Checking Savings

a d Account number

36 Amount of line 34 you want applied to your 2022 estimated tax ..a 36 Amount

You Owe

37 Amount you owe. Subtract line 33 from line 24. For details on how to pay, see instructions . a 37 38 Estimated tax penalty (see instructions) a 38 Third Party

Designee

Do you want to allow another person to discuss this return with the IRS? See instructions a Yes. Complete below. No Designee’s

name a

Phone

no. a

Personal identification

number (PIN) a

Sign

Here

Joint return?

See instructions.

Keep a copy for

your records.

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. Your signature Date Your occupation If the IRS sent you an Identity Protection PIN, enter it here

(see inst.) a

Spouse’s signature. If a joint return, both must sign. Date Spouse’s occupation If the IRS sent your spouse an Identity Protection PIN, enter it here

(see inst.) a

Phone no. Email address

F

Paid

Preparer

Use Only

Preparer’s name Preparer’s signature Date PTIN Check if: Self-employed

Firm’s name a Phone no.

Firm’s address a Firm’s EIN a

Go to www.irs.gov/Form1040 for instructions and the latest information. Form 1040 (2021) No

0.

0.

0.

0.

0.

X X X X X X X X X

X X X X X X X X X X X X X X X X X

0.

Self-Prepared

601-***-****

Merchandiser

BAA REV 09/09/22 Intuit.cg.cfp.sp

IMPORTANT DISCLOSURES

If you are owed federal tax refund(s), you have a right to choose how you will receive the refund(s). There are several options available to you. Some options cost money and some options are free. Please read about these options below.

You can file your federal tax return(s) electronically or by paper and obtain your federal tax refund(s) directly from the Internal Revenue Service ("IRS") for free. If you file your tax return(s) electronically, you can receive refund checks directly from the IRS through the U.S. Postal Service in 21 to 28 days from the time you file your tax return(s) or the IRS can deposit your refund(s) directly into your bank account in less than 21 days from the time you file your tax return(s) unless there are delays by the IRS. If you file a paper return through the U.S. Postal Service, you can receive refund checks directly from the IRS through the U.S. Postal Service in 6 to 8 weeks from the time the IRS receives your return(s) or the IRS can deposit your refund(s) directly into your bank account in 6 to 8 weeks from the time the IRS receives your return(s). However, if your return(s) contains Earned Income Tax Credit or Additional Child Tax Credit, the IRS will issue your refund(s) no earlier than February 15, 2022. The RPS is not necessary to obtain your refund(s). If you have an existing bank account, you do not need to use the RPS, which requires the payment of a fee, in order to receive a direct deposit from the IRS. You may consult the IRS website (IRS.gov) for information about tax refund processing. If you select the RPS, no prior debt you may owe to Bank will be deducted from your refund(s). You can change your income tax withholdings which might result in you receiving additional funds throughout the year rather than waiting to receive these funds potentially in tax refund(s) next year. Please consult your employer or tax advisor for additional details. This Agreement requires all disputes to be resolved by way of binding arbitration. The terms of the arbitration provision appear in Section 11. Information regarding low-cost deposit accounts may be available at www.mymoney.gov The chart below shows the options for filing your federal tax returns (e-file or paper returns), the RPS product, refund disbursement options, estimated timing for obtaining your federal tax refund proceeds, and costs associated with the various options. You can file your federal tax return(s) electronically, select the Refund Processing Service ("RPS") for an additional fee of $0.00 (the "RPS fee"), and have your federal tax refund(s) processed through a processor using banking services of a financial institution. The RPS allows your refund(s) to be deposited into a bank account at Green Dot Bank ("Bank") and deducts your TurboTax fees and other amounts that you authorize from your federal refund(s). The balance of your federal refund(s) is delivered to you via the disbursement method you select. If you file your tax return(s) electronically and select the RPS, the IRS will deposit your refund(s) with Bank. Upon Bank's receipt of your refund(s), Santa Barbara Tax Products Group, LLC, a division of Green Dot Corporation, a Delaware corporation, a processor, will deduct from your federal refund(s) the RPS fee, any fees charged by TurboTax for the preparation and filing of your tax return(s) and any other amounts authorized by you and disburse the balance of your refund proceeds to you. Unless there are unexpected delays, federal refunds are received in less than 21 days from the time you file your tax return(s) electronically. However, if your return(s) contains Earned Income Tax Credit or Additional Child Tax Credit, the IRS will issue your refund(s) no earlier than February 15, 2022. WHAT TYPE WHAT ARE YOUR WHAT IS THE WHAT COSTS DO YOU OF FILING DISBURSEMENT ESTIMATED TIME TO INCUR IN ADDITION METHOD? OPTIONS? RECEIVE REFUND(S)? TO TAX PREPARATION FEES?

PAPER RETURN IRS direct deposit to Approximately No additional cost. your personal bank 6 to 8 weeks 1

No Refund Processing account.

Service

Check mailed by IRS Approximately

to address on tax 6 to 8 weeks 1

return(s).

ELECTRONIC IRS direct deposit to Usually within No additional cost. FILING your personal bank 21 days 1

(E-FILE) account.

No Refund Processing Check mailed by IRS Approximately Service to address on tax 21 to 28 days 1

return(s).

ELECTRONIC Direct deposit to Usually within $ 2

FILING your personal bank 21 days 1

(E-FILE) account.

Refund Processing

Service

Questions? Call 877-***-****

sbia5201.ptform 12/02/21 12/02/2021

1

2

You may experience delays with your tax refund(s) if, for example, you enter incorrect bank account or contact information, you enter a bank account in someone else's name, or if possible suspicious activity is detected. If your return(s) contains Earned Income Tax Credit or Additional Child Tax Credit, the IRS will issue your refund(s) no earlier than February 15, 2022.

The charges here consist of an RPS Fee, a TurboTax fee and any fees for additional products and services purchased. See Section 3 of the Refund Processing Service Agreement for the cost of the service you have chosen. 0.00

FORM 1040 or FORM 1040-SR WORKSHEET 2021

NOTE: Form 1040, 1040-SR and Schedules 1 - 3 are fully calculated. Use this worksheet to enter all data which will flow to the Form 1040 or Form 1040SR and Schedules 1- 3. Use these QuickZooms to jump to the entry sections for Schedules 1- 3 on this Worksheet: Form 1040 or Form 1040SR Worksheet Navigation QuickZooms QuickZoom to Schedule 1 ' Additional Income and Adjustments to Income QuickZoom to Schedule 2 ' Additional Taxes

QuickZoom to Schedule 3 ' Additional Credits and Payments Form 1040 or Form 1040-SR ' Personal Info, Filing Status, Dependent Info For the year January 1 - December 31, 2021, or other tax year beginning, 2021, ending, 20 .

Your First Name MI Last Name Your Social Security No. If Joint Return, Spouse's First Name MI Last Name Spouse's Social Security No. Home Address (No. and Street). If You Have a P.O. Box, See Instructions. Apt. No. City, Town or Post Office. If you have a foreign address, also complete below. State ZIP Code Foreign country name Foreign province/state/county Foreign postal code QuickZoom to explanation statement for overseas extension Presidential Election Campaign

Check here if you, or your spouse if filing jointly, want $3 to go to this fund. Checking a box will not change your tax or refund You Spouse At any time during 2021, did you receive, sell, exchange, or otherwise dispose of any financial interest in any virtual currency? Yes No Filing Status Check only one box.

All entries for filing status and dependents should be made on the Federal Information Worksheet. Single

Married filing jointly (even if only one had income) Married filing separately. Enter spouse's SSN above and full name here. Head of household (with qualifying person). (See instructions) If the qualifying person is a child but not your dependent, enter the child's name here. Qualifying widow(er) (See instructions)

Dependents If more than four dependents, see instructions and check here

(1) First name Last name (2) Social (3) (4)

security Relationship b if qualifies for:

number to you under age 18 Credit for

qualifying other

for child dependents

tax credit

QuickZoom to the Federal Information Worksheet

QuickZoom to the Dependent and Nondependent Information Worksheet X

This form may require an upgrade of TurboTax.

104 Quit Graves Rd

Taylorsville MS 39168-4347

Avis a lewis ***-**-****

Page 2

Standard Deduction

Someone can claim you as a dependent

Someone can claim your spouse as a dependent

a Check if: You were born before January 2, 1957 Blind Spouse was born before January 2, 1957 Blind

Total boxes checked a

b If your spouse itemizes on a separate return or you were a dual-status alien, check here b

QuickZoom to required PPP loan forgiveness statement to report tax-exempt income Form 1040 or Form 1040-SR, Lines 1 - 7

1 Wages, salaries, tips, etc. Attach Form(s) W-2 1 2 a Tax-exempt interest 2a

b Taxable interest 2b

3 a Qualified dividends 3a

b Ordinary dividends 3b

4 a IRA distributions 4a

b Taxable amount 4b

5 a Pensions and annuities 5a

b Taxable amount 5b

6 a Social security benefits 6a

b Taxable amount 6b

7 Capital gain or (loss). Attach Schedule D if required. If not required, check here 7

QuickZoom to Schedule 1 ' Additional Income and Adjustments to Income Form 1040 or Form 1040-SR, Lines 8 - 11

8 Other income from Schedule 1, line 10 8

9 Add lines 1, 2b, 3b, 4b, 5b, 6b, 7, and 8. This is your total income 9 10 Adjustments to income from Schedule 1, line 26 10 11 Subtract line 10 from line 9. This is your adjusted gross income. 11 AGI including excludable Puerto Rico Income

Form 1040 or Form 1040-SR, Line 12 ' Standard or Itemized Deduction 12 Standard deduction or itemized deductions (from Schedule A) Standard Deduction for '

@ People who checked blind or over 65 or who can be claimed as a dependent, see instructions.

@ All others:

Single or Married filing separately: $12,550

Married filing jointly or Qualifying widow(er): $25,100

Head of household: $18,800

If you checked any box under Standard Deduction, see instructions. QuickZoom to the Standard Deduction Worksheet

a Itemized deductions (from Schedule A) or your

standard deduction, see above 12 a

Enter the smaller of these cash contributions

made or $300 ($600 if married filing jointly)

on line12b below if you take the standard

deduction

b Charitable contributions if you take the

standard deduction 12 b

c Add lines 12a and 12b 12 c

Subtract itemized or standard deduction from adjusted gross income amount 12,550.

12,550.

-12,550.

Avis a lewis ***-**-****

Page 3

Form 1040 or Form 1040-SR, Lines 13 - 18

13 Qualified business income deduction from Form 8995 or Form 8995-A 13 14 Add lines 12c and 13 14

15 Taxable income. Subtract line 14 from line 11. If zero or less, enter -0- 15

16 Tax. Check if any from Forms(s):

1 8814

2 4972

3

17 Amount from Schedule 2, line 3 17

18 Add lines 16 and 17 18

QuickZoom to Schedule 2 ' Additional Tax section

Form 1040 or Form 1040-SR, Line 19 - 24

19 Nonrefundable child tax credit or credit for other dependents from Schedule 8812 19

20 Amount from Schedule 3, line 8 20

21 Add lines 19 and 20 21

22 Subtract line 21 from line 18. If zero or less, enter -0- 22 23 Other taxes, including self-employment tax, from Schedule 2, line 21 23 24 Add lines 22 and 23. This is your total tax 24

QuickZoom to Schedule 3 ' Additional Credits and Payments Form 1040 or Form 1040-SR, Lines 25 - 33

25 Federal income tax withheld from:

a Form(s) W-2 25 a

b Form(s) 1099 25 b

c Other forms 25 c

d Add lines 25a through 25c 25 d

26 2021 estimated tax payments and

amount applied from 2020 return 26

27 If you have a qualifying child, attach Sch. EIC. a Earned income

credit (EIC) 27 a

Check here if you were born after January 1, 1998, and before January 2, 2004, and you satisfy all the other requirements for taxpayers who are at least

age 18, to claim the EIC

b Nontaxable

combat pay

election 27 b

c Prior year (2019)

earned income 27 c

28 Refundable child tax credit or additional child tax credit from Schedule 8812 28

29 American opportunity credit from Form 8863, line 8 29 30 Recovery rebate credit 30

31 Amount from Schedule 3, line 15 31

32 Add lines 27a and 28 through 31.

These are your other payments and refundable credits 32 33 Add Lines 25d, 26, and 32.

These are your total payments 33

QuickZoom to Schedule EIC Worksheet, pg. 2 if credit is not calculated QuickZoom to "due diligence checklist" substitute for Form 8867 QuickZoom to Schedule 3 ' Additional Credits and Payments 12,550.

No

0.

0.

0.

0.

0.

0.

Avis a lewis ***-**-****

Page 4

Form 1040 or Form 1040-SR, Lines 34 - 36

Refund:

34 If total Payments is more than total tax, subtract total tax from payments This is the amount you overpaid 34

35 a Amount of overpayment you want refunded to you. If Form 8888 is attached, check here 35

Direct deposit?

G b Routing number

G c Type:

Checking

Savings

G d Account number

36 Amount of overpayment on line 34 you want

applied to your 2022 estimated tax 36

Form 1040 or Form 1040-SR, Lines 37 and 38

Amount You Owe:

37 Subtract total payments from total tax 37

Note: Schedule H and Schedule E SE filers, line 37 may not represent all of the taxes you owe for 2021. See Schedule 3, line 12e, and its instructions for details.

38 Estimated tax penalty 38

QuickZoom to Late Penalties and Interest Worksheet QuickZoom Schedule 1 ' Additional Income and Adjustments to Income Part I Additional Income

1 Taxable refunds, credits, or offsets of state and local income taxes 1 Alimony Received Smart Worksheet

Taxpayer Spouse Date of divorce/sep *

A

B

* Check the box if the pre-2019 decree was modified after 2018 to treat the payments as nontaxable 2 a Alimony received Taxpayer Spouse 2 a

b Date of original divorce or separation agreement 3 Business income or (loss). Attach Schedule C 3

4 Other gains or (losses). Attach Form 4797 4

5 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E 5

6 Farm income or (loss). Attach Schedule F 6

7 Unemployment compensation 7

8 Other income:

a Net operating loss 8 a

b Gambling income 8 b

c Cancellation of debt 8 c

d Foreign earned income exclusion from Form 2555 8 d e Taxable Health Savings Account distribution 8 e

f Alaska Permanent Fund dividends 8 f

g Jury duty pay 8 g

h Prizes and awards 8 h

i Activity not engaged in for profit income 8 i

j Stock options 8 j

k Income from the rental of personal property if you engaged in the rental for profit but were not in the business of renting such property 8 k

l Olympic and Paralympic medals and USOC

prize money 8 l

m Section 951(a) inclusion 8 m

n Section 951A(a) inclusion 8 n

o Section 461(l) excess business loss adjustment 8 o p Taxable distributions from an ABLE account 8 p

8 z Other income. List type and amount:

8 z

9 Total other income. Add lines 8a through 8z 9

10 Combine lines 1 through 7 and 9.

Enter here and on Form 1040, 1040-SR, or 1040-NR, line 8 10 Total Income. Combine Form 1040 lines 1- 7 and

Schedule 1, line 10, enter on Form 1040, line 9

Quickzoom to 1040 Worksheet, line 9 ' Total Income QuickZoom XXXXXXXXX

XXXXXXXXXXXXXXXXX

0.

Avis a lewis ***-**-****

Page 5

Part II Adjustments to Income

11 Educator expenses 11

12 Certain business expenses of reservists, performing artists, and fee-basis government officials. Attach Form 2106 12

13 Health savings account deduction. Attach Form 8889 13 14 Moving expenses for members of the Armed Forces. Attach Form 3903 14

15 Deductible part of self-employment tax. Attach Schedule SE 15 16 Self-employed SEP, SIMPLE, and qualified plans 16 17 Self-employed health insurance deduction 17

18 Penalty on early withdrawal of savings 18

Alimony Paid Smart Worksheet

Recipient's name Recipient's SSN Date of divorce/sep * Alimony paid A

B

* Check the box if the pre-2019 decree was modified after 2018 to treat the payments as nondeductible 19 a Alimony paid 19 a

b Recipient's SSN

c Date of original divorce or separation agreement 20 IRA deduction 20

21 Student loan interest deduction 21

22 Reserved for future use 22

23 Archer MSA deduction 23

24 Other adjustments:

a Jury duty pay 24 a

b Deductible expenses related to income reported on line 8k from the rental of personal property engaged in for profit 24 b

c Nontaxable amount of the value of Olympic and

Paralympic medals and USOC prize money reported

on line 8l 24 c

d Reforestation amortization and expenses 24 d

e Repayment of supplemental unemployment

benefits under the Trade Act of 1974 24 e

f Contributions to section 501(c)(18)(D) pension plans 24 f g Contributions by certain chaplains to section

403(b) plans 24 g

h Attorney fees and court costs for actions involving certain unlawful discrimination claims 24 h

i Attorney fees and court costs you paid in connection with an award from the IRS for information you

provided that helped the IRS detect tax law violations 24 i j Housing deduction from Form 2555 24 j

k Excess deductions of section 67(e) expenses from Schedule K-1 (Form 1041) 24 k

z Other adjustments. List type and amount:

G

24 z

25 Total other adjustments. Add lines 24a through 24z 25 26 Add lines 11 through 23 and 25

These are your adjustments to income. Enter here and on Form 1040 or 1040-SR, line 10, or Form 1040-NR, line 10a 26

Schedule 2 ' Additional Taxes

Part I Tax

1 Alternative minimum tax (see instructions). Attach Form 6251 1 2 Excess advance premium tax credit repayment. Attach Form 8962 2 3 Add lines 1 and 2.

Enter here and include on Form 1040, 1040-SR, or 1040-NR, line 17 3 Avis a lewis ***-**-****

Page 6

Part II Other Taxes

4 Self-employment tax.

Attach Schedule SE 4

5 Social security and Medicare tax

on unreported tip income.

Attach Form 4137 5

6 Uncollected social security and Medicare tax on

wages. Attach Form 8919 6

7 Total additional social security and Medicare tax. Add lines 5 and 6 7 8 Additional tax on IRAs or other tax-favored accounts. Attach Form 5329 if required 8

9 Household employment taxes from Schedule H 9

10 Repayment of first-time homebuyer credit. Attach Form 5405 if required 10 11 Additional Medicare Tax. Attach Form 8959 11

12 Net investment income tax. Attach Form 8960 12

13 Uncollected social security and Medicare or RRTA tax on tips or group-term life insurance from W-2, box 12 13

14 Interest on tax due on installment income from the sale of certain residential lots and timeshares 14

15 Interest on the deferred tax on gain from certain installment sales with a sales price over $150,000 15

16 Recapture of low-income housing credit. Attach Form 8611 16 17 Other additional taxes:

a Recapture of other credits. List type, form number, and amount:

G

17 a

b Recapture of federal mortgage subsidy. If you sold your home in 2021, see instructions 17 b

c Additional tax on HSA distributions. Attach Form 8889 17 c d Additional tax on an HSA because you didn't remain an eligible individual. Attach Form 8889 17 d

e Additional tax on Archer MSA distributions.

Attach Form 8853 17 e

f Additional tax on Medicare Advantage MSA

distributions. Attach Form 8853 17 f

g Recapture of a charitable contribution deduction related to a fractional interest in tangible

personal property 17 g

h Income you received from a nonqualified deferred compensation plan that fails to meet the requirements of section 409A 17 h

i Compensation you received from a nonqualified

deferred compensation plan described in

section 457A 17 i

j Section 72(m)(5) excess benefits tax 17 j

k Golden parachute payments 17 k

l Tax on accumulation distribution of trusts 17 l

m Excise tax on insider stock compensation from an expatriated corporation 17 m

n Look-back interest under section 167(g) or 460(b) from Form 8697 or 8866 17 n

o Tax on non-effectively connected income for any

part of the year you were a nonresident alien from Form 1040-NR 17 o

p Any interest from Form 8621, line 16f, relating to distributions from, and dispositions of, stock of

a section 1291 fund 17 p

q Any interest from Form 8621, line 24 17 q

z Any other taxes. List type and amount:

G

17 z

18 Total additional taxes. Add lines 17a through 17z 18 19 Additional tax from Schedule 8812 19

20 Section 965 net tax liability installment from

Form 965-A 20

21 Add lines 4, 7 through 16, 18, and 19.

These are your total other taxes.

Enter here and on Form 1040 or 1040-SR, line 23, or Form 1040-NR, line 23b 21 Total tax (add line 21 and Schedule 3, line 7b)

0.

0.

Avis a lewis ***-**-****

Page 7

Schedule 3 ' Additional Credits and Payments

Part I Nonrefundable Credits

1 Foreign tax credit. Attach Form 1116 if required 1 2 Credit for child and dependent care expenses from Form 2441, line 11. 2 Attach Form 2441 2

3 Education credits from Form 8863, line 19 3

4 Retirement savings contributions credit. Attach Form 8880 4 5 Residential Energy Credit. Attach Form 5695 5

6 Other nonrefundable credits:

a General business credit. Attach Form 3800 6 a

b Credit for prior year minimum tax. Attach Form 8801 6 b c Adoption credit. Attach Form 8839 6 c

d Credit for the elderly or disabled. Attach Schedule R 6 d e Alternative motor vehicle credit. Attach Form 8910 6 e f Qualified plug-in motor vehicle credit.

Attach Form 8936 6 f

g Mortgage interest credit. Attach Form 8396 6 g

h District of Columbia first-time homebuyer credit. Attach Form 8859 6 h

i Qualified electric vehicle credit. Attach Form 8834 6 i j Alternative fuel vehicle refueling property credit. Attach Form 8911 6 j

k Credit to holders of tax credit bonds. Attach Form 8912 6 k l Amount on Form 8978, line 14 6 l

z Other nonrefundable credits. List type and amount: G

6 z

7 Total other nonrefundable credits. Add lines 6a through 6z 7 8 Add lines 1 through 5 and 7.

Enter here and on Form 1040, 1040-SR, or 1040-NR, line 20 8 a Add line 8 plus child tax/other dep. credit on line 19 above b Subtract total credits on line 8a from tax on line 18 above Quickzoom to 1040 Worksheet, line 24 ' Total Tax QuickZoom Part II Other Payments and Refundable Credits

9 Net premium tax credit. Attach Form 8962 9

10 Amount paid with request for extension to file 10 11 Excess social security and tier 1 RRTA tax withheld 11 12 Credit for federal tax on fuels. Attach Form 4136 12 13 Other payments or refundable credits:

a Form 2439 13 a

b Qualified sick and family leave credits from

Schedule(s) H and Form(s) 7202 for leave

taken before April 1, 2021 13 b

c Health coverage tax credit from Form 8885 13 c

d Credit for repayment of amounts included in

income from earlier years 13 d

e Reserved for future use 13 e

f 13 f

g Credit for child and dependent care expenses from Form 2441, line 10. Attach Form 2441 13 g

h Qualified sick and family leave credits from

Schedule(s) H and Form(s) 7202 for leave

taken after March 31, 2021 13 h

z Other payments or refundable credits. List type and amount

13 z

14 Total other payments or refundable credits. Add lines 13a through 13z 14 15 Total Payments: Part II, lines 9 through 12 and 14, Withholding (Form 1040, line 25d),

Estimated Tax Payments (Form 1040, line 26) and Form 1040, lines 27-30 15 Other Payments and Refundable Credits (Form 1040, line 32) 0.

Page 8

Third Party Designee

Do you want to allow another person to discuss this return with the IRS (see instructions)? Yes. Complete the following. No Designee's Name

Phone Number Personal Identification Number (PIN)

Signature and Paid Preparer

Sign Here

Joint return? See instructions.

Keep a copy of this return for your records.

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 accurately list all amounts and sources of income I received during the year. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge. If the IRS sent

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