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1 Deprtment of the Tresury Internl Revenue Service (99) 1040 U.S. Iniviul Income Tx Return 2016 OM No For the yer Jn. 1-Dec. 31, 2016, or other tx yer beginning, ening Form Your first nme n initil ob Lst nme obster If joint return, spouse's first nme n initil Lst nme IRS Use Only Do not write or stple in this spce. See seprte instructions. Your socil security number Spouse's socil security number Home ress (number n street). If you hve P.O. box, see instructions. Apt. no. Mke sure the SSN(s) bove n on line 6c re correct. ity, town or post office, stte, n ZIP coe. If you hve foreign ress, lso complete spces below (see instructions)., Foreign country nme Foreign province/stte/county Foreign postl coe Filing Sttus heck only one box. Exemptions If more thn four epenents, see instructions n check here Income Attch Form(s) W-2 here. Also ttch Forms W-2G n 1099-R if tx ws withhel. If you i not get W-2, see instructions. Ajuste Gross Income 1 Single 2 Mrrie filing jointly (even if only one h income) 3 Qulifying wiow(er) with epenent chil 6 Yourself. If someone cn clim you s epenent, o not check box b Spouse c Depenents: (4) if chil (2) Depenent's (3) Depenent's uner ge 17 socil security number reltionship to you qulifying for chil tx creit (1) First nme Lst nme (see instr.) A numbers on Totl number of exemptions clime lines bove 1 7 Wges, slries, tips, etc. Attch Form(s) W ,00 8 Txble interest. Attch Scheule if require ,10 b Tx-exempt interest. Do not inclue on line b 9 Orinry iviens. Attch Scheule if require b Qulifie iviens b 1,00 1,50 10 Txble refuns, creits, or offsets of stte n locl income txes Alimony receive usiness income or (loss). Attch Scheule or -EZ pitl gin or (loss). Attch Scheule D if require. If not require, check here ,00 14 Other gins or (losses). Attch Form IRA istributions b Txble mount b 16 Pensions n nnuities.. 16 b Txble mount b 17 Rentl rel estte, roylties, prtnerships, S corportions, trusts, etc. Attch Scheule E Frm income or (loss). Attch Scheule F Unemployment compenstion Socil security benefits.. 20 b Txble mount b 21 Other income. List type n mount See Attche ombine the mounts in the fr right column for lines 7 through 21. This is your totl income 22-50,00 18,60 23 Euctor expenses ertin business expenses of reservists, performing rtists, n fee-bsis government officils. Attch Form 2106 or 2106-EZ Helth svings ccount euction. Attch Form Moving expenses. Attch Form Deuctible prt of self-employment tx. Attch Scheule SE Self-employe SEP, SIMPLE, n qulifie plns Self-employe helth insurnce euction Penlty on erly withrwl of svings Mrrie filing seprtely. Enter spouse's SSN bove n full nme here. Alimony pi b Recipient's SSN 31 IRA euction Stuent lon interest euction Tuition n fees. Attch Form Domestic prouction ctivities euction. Attch Form A lines 23 through Subtrct line 36 from line 22. This is your juste gross income For Disclosure, Privcy Act, n Pperwork Reuction Act Notice, see seprte instructions. 4 5 He of househol (with qulifying person). (See instructions.) If the qulifying person is chil but not your epenent, enter this chil's nme here. Presientil Election mpign heck here if you, or your spouse if filing jointly, wnt $3 to go to this fun. hecking box below will not chnge your tx or refun. You Spouse } oxes checke on 6 n 6b No. of chilren on 6c who: live with you i not live with you ue to ivorce or seprtion (see instructions) Depenents on 6c not entere bove ,60 Form 1040 (2016)

2 Form 1040 (2016) Tx n reits Stnr Deuction for- People who check ny box on line 39 or 39b or who cn be clime s epenent, see instructions. All others: Single or Mrrie filing seprtely, $6,300 Mrrie filing jointly or Qulifying wiow(er), $12,600 He of househol, $9, Amount from line 37 (juste gross income) heck You were born before Jnury 2, 1952, lin. Totl boxes if: { Spouse ws born before Jnury 2, 1952, lin. } checke 39 0 b If your spouse itemizes on seprte return or you were ul-sttus lien, check here 40 Itemize euctions (from Scheule A) or your stnr euction (see left mrgin) Subtrct line 40 from line Exemptions Txble income. Subtrct line 42 from line 41. If line 42 is more thn line 41, enter (see instructions). heck if ny from: Form(s) 8814 b Form 4972 c Alterntive minimum tx (see instructions). Attch Form Excess vnce premium tx creit repyment. Attch Form A lines 44, 45, n Foreign tx creit. Attch Form 1116 if require reit for chil n epenent cre expenses. Attch Form Euction creits from Form 8863, line Retirement svings contributions creit. Attch Form hil tx creit. Attch Scheule 8812, if require Resientil energy creits. Attch Form c A lines 48 through 54. These re your totl creits Subtrct line 55 from line 47. If line 55 is more thn line 47, enter Self-employment tx. Attch Scheule SE Unreporte socil security n Meicre tx from Form: 4137 b Other Aitionl tx on IRAs, other qulifie retirement plns, etc. Attch Form 5329 if require 59 Txes Househol employment txes from Scheule H b First-time homebuyer creit repyment. Attch Form 5405 if require b 61 Helth cre: iniviul responsibility (see instructions) Full-yer coverge Txes from: Form 8959 b Form 8960 c Instructions; enter coe(s) A lines 56 through 62. This is your totl tx Pyments 64 Feerl income tx withhel from Forms W-2 n estimte tx pyments n mount pplie from 2015 return 65 If you hve 66 Erne income creit (EI) NO qulifying chil, ttch b Nontxble combt py election.. 66b Scheule EI. 67 Aitionl chil tx creit. Attch Scheule Americn opportunity creit from Form 8863, line Net premium tx creit. Attch Form Amount pi with request for extension to file Excess socil security n tier 1 RRTA tx withhel reit for feerl tx on fuels. Attch Form Refun Direct eposit? See instructions. Amount You Owe Thir Prty Designee Sign Here Joint return? See instr. Keep copy for your recors. Pi Preprer Use Only b c A lines 64, 65, 66, n 67 through 73. These re your totl pyments If line 74 is more thn line 63, subtrct line 63 from line 74. This is the mount you overpi Amount of line 75 you wnt refune to you. If Form 8888 is ttche, check here b Routing number c Type: hecking Svings 77 Account number Amount of line 75 you wnt pplie to your 2017 estimte tx 78 Amount you owe. Subtrct line 74 from line 63. For etils on how to py, see instructions Estimte tx penlty (see instructions) Do you wnt to llow nother person to iscuss this return with the IRS (see instructions)? Yes. omplete below. Designee's Phone Personl ientifiction nme no. number (PIN) Your signture Spouse's signture. If joint return, both must sign. Print/Type preprer's nme Firm's nme Firm's ress Preprer's signture Dte Dte Dte 77 Your occuption Spouse's occuption Pge 2 If the IRS sent you n Ientity Protection PIN, enter it here (see inst.) heck if PTIN self-employe Firm's EIN Phone no. Dytime phone number 18,60 6,30 12,30 4,05 8,25 No Form 1040 (2016)

3 SHEDULE (Form 1040A or 1040) Deprtment of the Tresury Internl Revenue Service (99) Nme(s) shown on return Attch to Form 1040A or 104 Prt I Interest 1 List nme of pyer. If ny interest is from seller-finnce mortgge n the buyer use the property s personl resience, see instructions n list this interest first. Also, show tht buyer's socil security number n ress Amount US nk Foreign nk 10 1,00 (See instructions for Form 1040A, or Form 1040, line 8.) Interest n Orinry Diviens 1 OM No Attchment Sequence No. 08 Your socil security number Note: If you receive Form 1099-INT, Form 1099-OID, or substitute sttement from brokerge firm, list the firm's nme s the pyer n enter the totl interest shown on tht form. Prt II 2 A the mounts on line Excluble interest on series EE n I U.S. svings bons issue fter Attch Form Subtrct line 3 from line 2. Enter the result here n on Form 1040A, or Form 1040, line Note: If line 4 is over $1,500, you must complete Prt III. 5 List nme of pyer ,10 1,10 Amount US rokerge 1,50 Orinry Diviens (See instructions for Form 1040A, or Form 1040, line 9.) Note: If you receive Form 1099-DIV or substitute sttement from brokerge firm, list the firm's nme s the pyer n enter the orinry iviens shown on tht form. 6 A the mounts on line 5. Enter the totl here n on Form 1040A, or Form 1040, line Note: If line 6 is over $1,500, you must complete Prt III. You must complete this prt if you () h over $1,500 of txble interest or orinry iviens; (b) h foreign ccount; or (c) receive istribution from, or were grntor of, or trnsferor to, foreign trust. Prt III 7 At ny time uring 2016, i you hve finncil interest in or signture uthority over finncil Foreign ccount (such s bnk ccount, securities ccount, or brokerge ccount) locte in foreign Accounts country? See instructions n Trusts If "Yes," re you require to file FinEN Form 114, Report of Foreign nk n Finncil (See instructions.) 8 b Accounts (FAR), to report tht finncil interest or signture uthority? See FinEN Form 114 n its instructions for filing requirements n exceptions to those requirements If you re require to file FinEN Form 114, enter the nme of the foreign country where the finncil ccount is locte During 2016, i you receive istribution from, or were you the grntor of, or trnsferor to, foreign trust? If "Yes," you my hve to file Form 352 See instructions For Pperwork Reuction Act Notice, see your tx return instructions. Scheule (Form 1040A or 1040) ,50 Yes No

4 SHEDULE D (Form 1040) Deprtment of the Tresury Internl Revenue Service (99) Nme(s) shown on return Prt I pitl Gins n Losses OM No Attch to Form 1040 or Form 1040NR. Informtion bout Scheule D n its seprte instructions is t Attchment Use Form 8949 to list your trnsctions for lines 1b, 2, 3, 8b, 9, n 1 Sequence No. 12 Your socil security number () Procees (sles price) (e) ost (or other bsis) (g) Ajustments to gin or loss from Form(s) 8949, Prt I, line 2, column (g) 4 Short-term gin from Form 6252 n short-term gin or (loss) from Forms 4684, 6781, n Net short-term gin or (loss) from prtnerships, S corportions, esttes, n trusts from Scheule(s) K Short-term cpitl loss crryover. Enter the mount, if ny, from line 8 of your pitl Loss 7 rryover Worksheet in the instructions Net short-term cpitl gin or (loss). ombine lines 1 through 6 in column (h). If you hve ny 6 long-term cpitl gins or losses, go to Prt II below. Otherwise, go to Prt III on pge Prt II This form my be esier to complete if you roun off (sles price) (or other bsis) cents to whole ollrs. 8 Totls for ll long-term trnsctions reporte on Form for which bsis ws reporte to the IRS n for which you hve no justments (see instructions). However, if you choose to report ll these trnsctions on Form 8949, leve this line blnk n go to line 8b b Totls for ll trnsctions reporte on Form(s) 8949 with ox D checke Totls for ll trnsctions reporte on Form(s) 8949 with ox E checke Totls for ll trnsctions reporte on Form(s) 8949 with ox F checke Gin from Form 4797, Prt I; long-term gin from Forms 2439 n 6252; n long-term gin or (loss) from Forms 4684, 6781, n Net long-term gin or (loss) from prtnerships, S corportions, esttes, n trusts from Scheule(s) K Short-Term pitl Gins n Losses - Assets Hel One Yer or Less See instructions for how to figure the mounts to enter on the lines below. This form my be esier to complete if you roun off cents to whole ollrs. 1 Totls for ll short-term trnsctions reporte on Form for which bsis ws reporte to the IRS n for which you hve no justments (see instructions). However, if you choose to report ll these trnsctions on Form 8949, leve this line blnk n go to line 1b b Totls for ll trnsctions reporte on Form(s) 8949 with ox A checke Totls for ll trnsctions reporte on Form(s) 8949 with ox checke Totls for ll trnsctions reporte on Form(s) 8949 with ox checke Long-Term pitl Gins n Losses - Assets Hel More Thn One Yer See instructions for how to figure the mounts to enter on the lines below. () Procees (g) Ajustments to gin or loss from pitl gin istributions. See the instructions Long-term cpitl loss crryover. Enter the mount, if ny, from line 13 of your pitl Loss rryover Worksheet in the instructions Net long-term cpitl gin or (loss). ombine lines 8 through 14 in column (h). Then go to Prt III on pge (h) Gin or (loss) Subtrct column (e) from column () n combine the result with column (g) 2, ,00 ( ) (h) Gin or (loss) Subtrct column (e) from column () n combine the result with column (g) ( ) For Pperwork Reuction Act Notice, see your tx return 01/08/2017 instructions. 06:42:04PM Scheule D (Form 1040) 2016 (e) ost Form(s) 8949, Prt II, line 2, column (g) 2,00 14, ,00 14,00

5 Scheule D (Form 1040) 2016 Prt III Summry Pge 2 16 ombine lines 7 n 15 n enter the result ,00 If line 16 is gin, enter the mount from line 16 on Form 1040, line 13, or Form 1040NR, line 14. Then go to line 17 below. If line 16 is loss, skip lines 17 through 20 below. Then go to line 21. Also be sure to complete line 22. If line 16 is zero, skip lines 17 through 21 below n enter -0- on Form 1040, line 13, or Form 1040NR, line 14. Then go to line Are lines 15 n 16 both gins? Yes. Go to line 18. No. Skip lines 18 through 21, n go to line Enter the mount, if ny, from line 7 of the 28% Rte Gin Worksheet in the instructions Enter the mount, if ny, from line 18 of the Unrecpture Section 1250 Gin Worksheet in the instructions Are lines 18 n 19 both zero or blnk? Yes. omplete the Qulifie Diviens n pitl Gin Tx Worksheet in the instructions for Form 1040, line 44 (or in the instructions for Form 1040NR, line 42). Don't complete lines 21 n 22 below. No. omplete the Scheule D Tx Worksheet in the instructions. Don't complete lines 21 n 22 below. 21 If line 16 is loss, enter here n on Form 1040, line 13, or Form 1040NR, line 14, the smller of: The loss on line 16 or ($3,000), or if mrrie filing seprtely, ($1,500)} 21 ( ) Note: When figuring which mount is smller, tret both mounts s positive numbers. 22 Do you hve qulifie iviens on Form 1040, line 9b, or Form 1040NR, line 10b? Yes. omplete the Qulifie Diviens n pitl Gin Tx Worksheet in the instructions for Form 1040, line 44 (or in the instructions for Form 1040NR, line 42). No. omplete the rest of Form 1040 or Form 1040NR. Scheule D (Form 1040) 2016

6 Form 1116 Deprtment of the Tresury Internl Revenue Service (99) Nme b f Pssive ctegory income Generl ctegory income Resient of (nme of country) Foreign Tx reit (Iniviul, Estte, or Trust) Attch to Form 1040, 1040NR, 1041, or 990-T. Informtion bout Form 1116 n its seprte instructions is t ertin income re-source by trety OM No Attchment Sequence No. 19 Ientifying number s shown on pge 1 of your tx return Lump-sum istributions Note: If you pi txes to only one foreign country or U.S. possession, use column A in Prt I n line A in Prt II. If you pi txes to more thn one foreign country or U.S. possession, use seprte column n line for ech country or possession. Prt I Txble Income or Loss From Sources Outsie the Unite Sttes (for tegory hecke Above) Foreign ountry or U.S. Possession Totl g Use seprte Form 1116 for ech ctegory of income liste below. See tegories of Income in the instructions. heck only one box on ech Form Report ll mounts in U.S. ollrs except where specifie in Prt II below. 1 Enter the nme of the foreign country or U.S. possession shown bove n of the type checke bove (see instructions): A (A cols. A,, n.) A Interest 1,00 1 1,00 b heck if line 1 is compenstion for personl services s n employee, your totl compenstion from ll sources is $250,000 or more, n you use n lterntive bsis to etermine its source (see instructions).. Deuctions n losses (ution: See instructions.): 2 Expenses efinitely relte to the income on line 1 (ttch sttement) 3 Pro rt shre of other euctions not efinitely relte: euction (see instructions) b Other euctions (ttch sttement) c e f g A lines 3 n 3b Gross foreign source income (see instructions) Gross income from ll sources (see instructions) Divie line 3 by line 3e (see instructions) Multiply line 3c by line 3f 4 Pro rt shre of interest expense (see instructions): Foreign Txes Pi or Accrue (see instructions) Home Mortgge Interest in the instructions) b Other interest expense 5 Losses from foreign sources 6 A lines 2, 3g, 4, 4b, n Subtrct line 6 from line 1. Enter the result here n on line 15, pge 2 7 Prt II ountry A Gross income from sources within country ertin itemize euctions or stnr c Section 901(j) income reit is clime Foreign txes pi or ccrue for txes (you must check one) In foreign currency In U.S. ollrs (h) (i) Home mortgge interest (use the Worksheet for Vrious 6,30 6,30 1,00 68, Pi Txes withhel t source on: Txes withhel t source on: Accrue (n) Other foreign txes (j) Dte pi (l) Rents pi or (p) Rents or ccrue (k) Diviens (m) Interest n roylties ccrue (o) Diviens (q) Interest n roylties (r) Other foreign txes pi or ccrue 8 A lines A through, column (s). Enter the totl here n on line 9, pge (s) Totl foreign txes pi or ccrue ( cols. (o) through (r)) For Pperwork Reuction Act Notice, see instructions. Form 1116 (2016) e /31/

7 Figuring the reit Form 1116 (2016) Pge 2 Prt III 9 Enter the mount from line 8. These re your totl foreign txes pi or ccrue for the ctegory of income checke bove Prt I rrybck or crryover (ttch etile computtion) A lines 9 n Reuction in foreign txes (see instructions) ( ) 13 Txes reclssifie uner high tx kickout (see instructions) ombine lines 11, 12, n 13. This is the totl mount of foreign txes vilble for creit Enter the mount from line 7. This is your txble income or (loss) from sources outsie the Unite Sttes (before justments) for the ctegory of income checke bove Prt I (see instructions) Ajustments to line 15 (see instructions) ombine the mounts on lines 15 n 16. This is your net foreign source txble income. (If the result is zero or less, you hve no foreign tx creit for the ctegory of income you checke bove Prt I. Skip lines 18 through 22. However, if you re filing more thn one Form 1116, you must complete line 2) Iniviuls: Enter the mount from Form 1040, line 41; or Form 1040NR, line 39. Esttes n trusts: Enter your txble income without the euction for your exemption ution: If you figure your tx using the lower rtes on qulifie iviens or cpitl gins, see instructions. 19 Divie line 17 by line 18. If line 17 is more thn line 18, enter Iniviuls: Enter the mounts from Form 1040, lines 44 n 46. If you re nonresient lien, enter the mounts from Form 1040NR, lines 42 n 44. Esttes n trusts: Enter the mount from Form 1041, Scheule G, line 1; or the totl of Form 990-T, lines 36, 37, n ution: If you re completing line 20 for seprte ctegory e (lump-sum istributions), see instructions. 21 Multiply line 20 by line 19 (mximum mount of creit) Enter the smller of line 14 or line 21. If this is the only Form 1116 you re filing, skip lines 23 through 27 n enter this mount on line 28. Otherwise, complete the pproprite line in Prt IV (see instructions) Prt IV Summry of reits From Seprte Prts III (see instructions) smller of line 20 or line reit for txes on pssive ctegory income reit for txes on generl ctegory income reit for txes on certin income re-source by trety reit for txes on lump-sum istributions A lines 23 through 26 Enter the Reuction of creit for interntionl boycott opertions. See instructions for line 12 Subtrct line 29 from line 28. This is your foreign tx creit. Enter here n on Form 1040, line 48; 29 Form 1040NR, line 46; Form 1041, Scheule G, line 2; or Form 990-T, line , Form 1116 (2016)

8 Form 1116 Deprtment of the Tresury Internl Revenue Service (99) Nme b f Pssive ctegory income Generl ctegory income Resient of (nme of country) Foreign Tx reit (Iniviul, Estte, or Trust) Attch to Form 1040, 1040NR, 1041, or 990-T. Informtion bout Form 1116 n its seprte instructions is t ertin income re-source by trety OM No Attchment Sequence No. 19 Ientifying number s shown on pge 1 of your tx return Lump-sum istributions Note: If you pi txes to only one foreign country or U.S. possession, use column A in Prt I n line A in Prt II. If you pi txes to more thn one foreign country or U.S. possession, use seprte column n line for ech country or possession. Prt I Txble Income or Loss From Sources Outsie the Unite Sttes (for tegory hecke Above) Foreign ountry or U.S. Possession Totl g Use seprte Form 1116 for ech ctegory of income liste below. See tegories of Income in the instructions. heck only one box on ech Form Report ll mounts in U.S. ollrs except where specifie in Prt II below. 1 Enter the nme of the foreign country or U.S. possession shown bove n of the type checke bove (see instructions): A (A cols. A,, n.) A Re-source b heck if line 1 is compenstion for personl services s n employee, your totl compenstion from ll sources is $250,000 or more, n you use n lterntive bsis to etermine its source (see instructions).. Deuctions n losses (ution: See instructions.): 2 Expenses efinitely relte to the income on line 1 (ttch sttement) 3 Pro rt shre of other euctions not efinitely relte: euction (see instructions) b Other euctions (ttch sttement) c e f g A lines 3 n 3b Gross foreign source income (see instructions) Gross income from ll sources (see instructions) Divie line 3 by line 3e (see instructions) Multiply line 3c by line 3f 4 Pro rt shre of interest expense (see instructions): Foreign Txes Pi or Accrue (see instructions) Home Mortgge Interest in the instructions) b Other interest expense 5 Losses from foreign sources 6 A lines 2, 3g, 4, 4b, n Subtrct line 6 from line 1. Enter the result here n on line 15, pge 2 7 Prt II ountry A Gross income from sources within country ertin itemize euctions or stnr c Section 901(j) income reit is clime Foreign txes pi or ccrue for txes (you must check one) In foreign currency In U.S. ollrs (h) (i) Home mortgge interest (use the Worksheet for Vrious 6,30 6, , Pi Txes withhel t source on: Txes withhel t source on: Accrue (n) Other foreign txes (j) Dte pi (l) Rents pi or (p) Rents or ccrue (k) Diviens (m) Interest n roylties ccrue (o) Diviens (q) Interest n roylties (r) Other foreign txes pi or ccrue 8 A lines A through, column (s). Enter the totl here n on line 9, pge (s) Totl foreign txes pi or ccrue ( cols. (o) through (r)) For Pperwork Reuction Act Notice, see instructions. Form 1116 (2016) e /31/

9 Figuring the reit Form 1116 (2016) Pge 2 Prt III 9 Enter the mount from line 8. These re your totl foreign txes pi or ccrue for the ctegory of income checke bove Prt I rrybck or crryover (ttch etile computtion) A lines 9 n Reuction in foreign txes (see instructions) ( ) 13 Txes reclssifie uner high tx kickout (see instructions) ombine lines 11, 12, n 13. This is the totl mount of foreign txes vilble for creit Enter the mount from line 7. This is your txble income or (loss) from sources outsie the Unite Sttes (before justments) for the ctegory of income checke bove Prt I (see instructions) Ajustments to line 15 (see instructions) ombine the mounts on lines 15 n 16. This is your net foreign source txble income. (If the result is zero or less, you hve no foreign tx creit for the ctegory of income you checke bove Prt I. Skip lines 18 through 22. However, if you re filing more thn one Form 1116, you must complete line 2) Iniviuls: Enter the mount from Form 1040, line 41; or Form 1040NR, line 39. Esttes n trusts: Enter your txble income without the euction for your exemption ution: If you figure your tx using the lower rtes on qulifie iviens or cpitl gins, see instructions. 19 Divie line 17 by line 18. If line 17 is more thn line 18, enter Iniviuls: Enter the mounts from Form 1040, lines 44 n 46. If you re nonresient lien, enter the mounts from Form 1040NR, lines 42 n 44. Esttes n trusts: Enter the mount from Form 1041, Scheule G, line 1; or the totl of Form 990-T, lines 36, 37, n ution: If you re completing line 20 for seprte ctegory e (lump-sum istributions), see instructions. 21 Multiply line 20 by line 19 (mximum mount of creit) Enter the smller of line 14 or line 21. If this is the only Form 1116 you re filing, skip lines 23 through 27 n enter this mount on line 28. Otherwise, complete the pproprite line in Prt IV (see instructions) Prt IV Summry of reits From Seprte Prts III (see instructions) smller of line 20 or line reit for txes on pssive ctegory income reit for txes on generl ctegory income reit for txes on certin income re-source by trety reit for txes on lump-sum istributions A lines 23 through 26 Enter the Reuction of creit for interntionl boycott opertions. See instructions for line 12 Subtrct line 29 from line 28. This is your foreign tx creit. Enter here n on Form 1040, line 48; 29 Form 1040NR, line 46; Form 1041, Scheule G, line 2; or Form 990-T, line , Form 1116 (2016)

10 Form 1116 Deprtment of the Tresury Internl Revenue Service (99) Nme b f Pssive ctegory income Generl ctegory income Resient of (nme of country) Foreign Tx reit (Iniviul, Estte, or Trust) Attch to Form 1040, 1040NR, 1041, or 990-T. Informtion bout Form 1116 n its seprte instructions is t ertin income re-source by trety OM No Attchment Sequence No. 19 Ientifying number s shown on pge 1 of your tx return Lump-sum istributions Note: If you pi txes to only one foreign country or U.S. possession, use column A in Prt I n line A in Prt II. If you pi txes to more thn one foreign country or U.S. possession, use seprte column n line for ech country or possession. Prt I Txble Income or Loss From Sources Outsie the Unite Sttes (for tegory hecke Above) Foreign ountry or U.S. Possession Totl g Use seprte Form 1116 for ech ctegory of income liste below. See tegories of Income in the instructions. heck only one box on ech Form Report ll mounts in U.S. ollrs except where specifie in Prt II below. 1 Enter the nme of the foreign country or U.S. possession shown bove n of the type checke bove (see instructions): A (A cols. A,, n.) A Re-source 16, ,00 b heck if line 1 is compenstion for personl services s n employee, your totl compenstion from ll sources is $250,000 or more, n you use n lterntive bsis to etermine its source (see instructions).. Deuctions n losses (ution: See instructions.): 2 Expenses efinitely relte to the income on line 1 (ttch sttement) 3 Pro rt shre of other euctions not efinitely relte: euction (see instructions) b Other euctions (ttch sttement) c e f g A lines 3 n 3b Gross foreign source income (see instructions) Gross income from ll sources (see instructions) Divie line 3 by line 3e (see instructions) Multiply line 3c by line 3f 4 Pro rt shre of interest expense (see instructions): ,469. 1, ,531. Foreign Txes Pi or Accrue (see instructions) Home Mortgge Interest in the instructions) b Other interest expense 5 Losses from foreign sources 6 A lines 2, 3g, 4, 4b, n Subtrct line 6 from line 1. Enter the result here n on line 15, pge 2 7 Prt II ountry A Gross income from sources within country ertin itemize euctions or stnr c Section 901(j) income reit is clime Foreign txes pi or ccrue for txes (you must check one) In foreign currency In U.S. ollrs (h) (i) Home mortgge interest (use the Worksheet for Vrious 6,30 6,30 16,00 68, ,469. Pi Txes withhel t source on: Txes withhel t source on: Accrue (n) Other foreign txes (j) Dte pi (l) Rents pi or (p) Rents or ccrue (k) Diviens (m) Interest n roylties ccrue (o) Diviens (q) Interest n roylties (r) Other foreign txes pi or ccrue 8 A lines A through, column (s). Enter the totl here n on line 9, pge (s) Totl foreign txes pi or ccrue ( cols. (o) through (r)) For Pperwork Reuction Act Notice, see instructions. Form 1116 (2016) e /31/

11 Figuring the reit Form 1116 (2016) Pge 2 Prt III 9 Enter the mount from line 8. These re your totl foreign txes pi or ccrue for the ctegory of income checke bove Prt I rrybck or crryover (ttch etile computtion) A lines 9 n Reuction in foreign txes (see instructions) ( ) 13 Txes reclssifie uner high tx kickout (see instructions) ombine lines 11, 12, n 13. This is the totl mount of foreign txes vilble for creit Enter the mount from line 7. This is your txble income or (loss) from sources outsie the Unite Sttes (before justments) for the ctegory of income checke bove Prt I (see instructions) Ajustments to line 15 (see instructions) ombine the mounts on lines 15 n 16. This is your net foreign source txble income. (If the result is zero or less, you hve no foreign tx creit for the ctegory of income you checke bove Prt I. Skip lines 18 through 22. However, if you re filing more thn one Form 1116, you must complete line 2) Iniviuls: Enter the mount from Form 1040, line 41; or Form 1040NR, line 39. Esttes n trusts: Enter your txble income without the euction for your exemption ution: If you figure your tx using the lower rtes on qulifie iviens or cpitl gins, see instructions. 19 Divie line 17 by line 18. If line 17 is more thn line 18, enter Iniviuls: Enter the mounts from Form 1040, lines 44 n 46. If you re nonresient lien, enter the mounts from Form 1040NR, lines 42 n 44. Esttes n trusts: Enter the mount from Form 1041, Scheule G, line 1; or the totl of Form 990-T, lines 36, 37, n ution: If you re completing line 20 for seprte ctegory e (lump-sum istributions), see instructions. 21 Multiply line 20 by line 19 (mximum mount of creit) Enter the smller of line 14 or line 21. If this is the only Form 1116 you re filing, skip lines 23 through 27 n enter this mount on line 28. Otherwise, complete the pproprite line in Prt IV (see instructions) Prt IV Summry of reits From Seprte Prts III (see instructions) smller of line 20 or line reit for txes on pssive ctegory income reit for txes on generl ctegory income reit for txes on certin income re-source by trety reit for txes on lump-sum istributions A lines 23 through 26 Enter the Reuction of creit for interntionl boycott opertions. See instructions for line 12 Subtrct line 29 from line 28. This is your foreign tx creit. Enter here n on Form 1040, line 48; 29 Form 1040NR, line 46; Form 1041, Scheule G, line 2; or Form 990-T, line , , , Form 1116 (2016)

12 Form 2555 Deprtment of the Tresury Internl Revenue Service Nme shown on Form 1040 Prt I 1, Your foreign ress (incluing country) Foreign Erne Income Attch to Form 104 omplete the Foreign Erne Income Tx Worksheet in the Instructions for Form 1040 if you enter n mount on lines 45 or 5 Informtion bout Form 2555 n its seprte instructions is t For Use by U.S. itizens n Resient Aliens Only OM No Your socil security number Your occuption 3 4 Employer's nme Employer's U.S. ress b Employer's foreign ress, 5 Employer is (check A foreign entity b A U.S. compny c Self ny tht pply): A foreign ffilite of U.S. compny e Other (specify) 6 b If you in't previously file Form 2555 or 2555-EZ to clim either of the exclusions, check here n go to line 7. c Hve you ever revoke either of the exclusions? Yes No If you nswere "Yes," enter the type of exclusion n the tx yer for which the revoction ws effective. 7 Of wht country re you citizen/ntionl? 8 Di you mintin seprte foreign resience for your fmily becuse of verse living conitions t your tx home? See Secon foreign househol in the instructions Yes No b If "Yes," enter city n country of the seprte foreign resience. Also, enter the number of ys uring your tx yer tht you mintine secon househol t tht ress. 9 List your tx home(s) uring your tx yer n te(s) estblishe. Prt II Next, complete either Prt II or Prt III. If n item oesn't pply, enter "NA." If you on't give the informtion ske for, ny exclusion or euction you clim my be isllowe. Txpyers Qulifying Uner on Fie Resience Test (see instructions) 10 Dte bon fie resience begn, n ene 11 Kin of living qurters in foreign country Purchse house b Rente house or prtment c Rente room Qurters furnishe by employer 12 Di ny of your fmily live with you bro uring ny prt of the tx yer? b If "Yes," who n for wht perio? Yes No 13 Hve you submitte sttement to the uthorities of the foreign country where you clim bon fie resience tht you ren't resient of tht country? See instructions Yes No b Are you require to py income tx to the country where you clim bon fie resience? See instructions Yes No If you nswere "Yes" to 13 n "No" to 13b, you o not qulify s bon fie resient. Don't complete the rest of this prt. 14 If you were present in the Unite Sttes or its possessions uring the tx yer, complete columns () () below. Don't inclue the income from column () in Prt IV, but report it on Form 104 () Dte rrive in U.S. Generl Informtion (b) Dte left U.S. (c) Number of ys in U.S. on business 01/01/2016 ONTINUE () Income erne in U.S. on business (ttch computtion) () Dte rrive in U.S. (b) Dte left U.S. 2 (c) Number of ys in U.S. on business 2016 Attchment Sequence No. 34 () Income erne in U.S. on business (ttch computtion) 15 List ny contrctul terms or other conitions relting to the length of your employment bro. b c e Enter the type of vis uner which you entere the foreign country. Di your vis limit the length of your sty or employment in foreign country? If "Yes," ttch explntion Di you mintin home in the Unite Sttes while living bro? If "Yes," enter ress of your home, whether it ws rente, the nmes of the occupnts, n their reltionship to you. Yes Yes No No For Pperwork Reuction Act Notice, see the Form 1040 instructions. Form 2555 (2016)

13 Form 2555 (2016) Prt III Txpyers Qulifying Uner Physicl Presence Test (see instructions) Pge 2 16 The physicl presence test is bse on the 12-month perio from through 17 Enter your principl country of employment uring your tx yer. 18 If you trvele bro uring the 12-month perio entere on line 16, complete columns () (f) below. Exclue trvel between foreign countries tht in't involve trvel on or over interntionl wters, or in or over the Unite Sttes, for 24 hours or more. If you hve no trvel to report uring the perio, enter "Physiclly present in foreign country or countries for the entire 12-month perio." Don't inclue the income from column (f) below in Prt IV, but report it on Form 104 () Nme of country (incluing U.S.) (b) Dte rrive (c) Dte left () Full ys present in country (e) Number of ys in U.S. on business (f) Income erne in U.S. on business (ttch computtion) Prt IV All Txpyers Note: Enter on lines 19 through 23 ll income, incluing noncsh income, you erne n ctully or constructively receive uring your 2016 tx yer for services you performe in foreign country. If ny of the foreign erne income receive this tx yer ws erne in prior tx yer, or will be erne in lter tx yer (such s bonus), see the instructions. Don't inclue income from line 14, column (), or line 18, column (f). Report mounts in U.S. ollrs, using the exchnge rtes in effect when you ctully or constructively receive the income. If you re csh bsis txpyer, report on Form 1040 ll income you receive in 2016, no mtter when you performe the service Foreign Erne Income Amount (in U.S. ollrs) 19 Totl wges, slries, bonuses, commissions, etc Allowble shre of income for personl services performe (see instructions): In business (incluing frming) or profession b In prtnership. List prtnership's nme n ress n type of income. 21 Noncsh income (mrket vlue of property or fcilities furnishe by employer ttch sttement showing how it ws etermine): Home (loging) b 21 50,00 b Mels b c r Other property or fcilities. List type n mount. 22 Allownces, reimbursements, or expenses pi on your behlf for services you performe: ost of living n overses ifferentil b Fmily b c Euction c Home leve e Qurters e f For ny other purpose. List type n mount. 22f g A lines 22 through 22f Other foreign erne income. List type n mount. 21c 21 22g A lines 19 through 21, line 22g, n line , Totl mount of mels n loging inclue on line 24 tht is excluble (see instructions).... Subtrct line 25 from line 24. Enter the result here n on line 27 on pge 3. This is your 2016 foreign erne income ,00 Form 2555 (2016)

14 Form 2555 (2016) Prt V All Txpyers Pge 3 27 Enter the mount from line Are you climing the housing exclusion or housing euction? Yes. omplete Prt VI. No. Go to Prt VII. Prt VI Txpyers liming the Housing Exclusion n/or Deuction 27 50,00 28 Qulifie housing expenses for the tx yer (see instructions) Enter loction where housing expenses incurre (see instructions) b Enter limit on housing expenses (see instructions) Enter the smller of line 28 or line 29b Number of ys in your qulifying perio tht fll within your 2016 tx yer (see instructions) ys 32 Multiply $44.28 by the number of ys on line 31. If 366 is entere on line 31, enter $16, here Subtrct line 32 from line 3 If the result is zero or less, on't complete the rest of this prt or ny of Prt I Enter employer-provie mounts (see instructions) Divie line 34 by line 27. Enter the result s eciml (roune to t lest three plces), but on't enter more thn "1.000" Housing exclusion. Multiply line 33 by line 35. Enter the result but on't enter more thn the mount on line 34. Also, complete Prt VIII Note: The housing euction is figure in Prt I. If you choose to clim the foreign erne income exclusion, complete Prts VII n VIII before Prt I. Prt VII Txpyers liming the Foreign Erne Income Exclusion 37 Mximum foreign erne income exclusion If you complete Prt VI, enter the number from line 31. } All others, enter the number of ys in your qulifying perio tht ys fll within your 2016 tx yer (see the instructions for line 31). 39 If line 38 n the number of ys in your 2016 tx yer (usully 366) re the sme, enter 1.00 } Otherwise, ivie line 38 by the number of ys in your 2016 tx yer n enter the result 39 s eciml (roune to t lest three plces). 40 Multiply line 37 by line Subtrct line 36 from line Foreign erne income exclusion. Enter the smller of line 40 or line Prt VIII 43 A lines 36 n Deuctions llowe in figuring your juste gross income (Form 1040, line 37) tht re llocble to the exclue income. See instructions n ttch computtion Subtrct line 44 from line 43. Enter the result here n in prentheses on Form 1040, line 21. Next to the mount enter "Form 2555." On Form 1040, subtrct this mount from your income to rrive t totl income on Form 1040, line Prt I Txpyers liming the Housing Deuction omplete this prt only if () line 33 is more thn line 36 n (b) line 27 is more thn line Subtrct line 36 from line Subtrct line 43 from line Enter the smller of line 46 or line Note: If line 47 is more thn line 48 n you couln't euct ll of your 2015 housing euction becuse of the 2015 limit, use the housing euction crryover worksheet in the instructions to figure the mount to enter on line 49. Otherwise, go to line 5 49 Housing euction crryover from Housing euction. A lines 48 n 49. Enter the totl here n on Form 1040 to the left of line 36. Next to the mount on Form 1040, enter "Form 2555." A it to the totl justments reporte on tht line Txpyers liming the Housing Exclusion, Foreign Erne Income Exclusion, or oth 28 29b $101, ,30 50,00 50,00 50,00 50,00 Form 2555 (2016)

15 2016 Other Income - Supporting Detils for Form 1040, Line 21 Nme(s) shown on Form 1040 Your socil security number Enter sources of other income below: Gmbling Winnings reporte on Form W-2G Other winnings where Form W-2G not receive 4. Jury Py 5. Net Operting Loss crry forwr from Foreign erne income exclusion from Form Other Income from Scheule K-1 8. Income from personl property rentl 9. hil's income mount from Form 8814, line 12 1 MSA Distributions, Form Meicre Avntge MSA Distributions, Form Long-term re Distribution, Form Form 1099-MIS, oxes 3 n Alsk Permnent Fun iviens 15. overell ESA or Qulifie Tuition Progrm 16. ncelltion of nonbusiness ebt, Form ncelltion of business ebt, Prtnership Sch K HSA istributions n excess contributions, Form Reemployment tre justment ssistnce (RTAA) 2 Recpture of prior yer tuition n fees euction 21. Recpture of chritble contribution euction of frctionl interest in tngible personl property 22. Recpture of chritble contribution euction if no exempt use 23. Income from Foreign orportion, Form Hobby income 25. Income or loss, Form Loss on excess eferrl istribution 27. Disster relief pyments 28. Meici wiver pyments to cre provier (NOTIE ) 29. reit justment from regulr income, Form 6478 n Form Inin gming procees (from 1099-MIS) 31. Inin tribl istrib (from 1099-MIS) 32. Ntive Americn istrib (from 1099-MIS) 33. Txble istributions from ALE ccounts, Form 1099-QA 34. Airline Pyments. If rolle over to tritionl IRA, enter mount up to 90% s negtive number Totl Other Income ob -50,00-50,00 Not Applicble

16 Worksheet for Form Foreign Tx reit rryover Worksheet for Pssive tegory Income Nme(s) shown on return Prt I. rryovers from Prior Yers Your socil security number rryovers from Prior Yers for Regulr Tx Tx Yer Foreign Txes Ajustments Utilize rrybck rryover Totl rryover to 2016 (enter on line 10 of Form 1116) rryovers from Prior Yers for AMT Tx Yer Foreign Txes Ajustments Utilize rrybck rryover Totl rryover to 2016 (enter on line 10 of Form 1116 for AMT) Prt II. rryovers to 2017 rryovers to 2017 for Regulr Tx Tx Yer Foreign Txes Ajustments Utilize rrybck rryover Totl crryover to 2017 for regulr tx rryovers to 2017 for AMT Tx Yer Foreign Txes Ajustments Utilize rrybck rryover Totl crryover to 2017 for AMT