See separate instructions. Your first name and initial. Your social security number John Smith Applied For

Transcription

1 Form () 40 U.S. Individual Inome Tax Return 2016 OMB No Attah Form(s) W-2 here. Also attah Forms W-2G and -R if tax was withheld IRS Use Only - Do not write or staple in this spae. For the year Jan. 1-De. 31, 2016, or other tax year eginning, 2016, ending, 20 See separate instrutions. Your first name and initial Last name Your soial seurity numer John Smith Applied For If a joint return, spouse s first name and initial Spouse s soial seurity numer and full name here. 5 Qualifying widow(er) with dependent hild Boxes heked 6a Yourself. If someone an laim you as a dependent, do not hek ox 6a ~~~~~~~~~~~~~~~~ on 6a and 6 Spouse No. of hildren (4) if hild on 6 who: (2) Dependent s soial (3) Dependent s u Dependents: relationship to under age 17 lived with you seurity numer (1) First name Last name qualifying for hild you did not live with tax redit pmob you due to divore or separation (see instrutions) d 7 Wages, salaries, tips, et. Attah Form(s) W-2 ~~~~~~~~~~~~~~~~~~~~~~~~~~ 7 a 14 15a 16a Taxale interest. Attah Shedule B if required ~~~~~~~~~~~~~~~~~~~~~~~~~~ Tax-exempt interest. Do not inlude on line ~~~~~~~~~~~ 8 Eduator expenses ~~~~~~~~~~~~~~~~~~~~~~~ Certain usiness expenses of reservists, performing artists, and fee-asis government offiials. Attah Form 26 or 26-EZ ~~~~~~~~~~~~~~~~~ 4 a Dependents on 6 not entered aove Add numers on lines aove 20a Soial seurity enefits ~~~~ 20a Taxale amount ~~~~~~ Other inome. List type and amount See Statement 1 21, Comine the amounts in the far right olumn for lines 7 through 21. This is your total inome 22 30, a Last name Home address (numer and street). If you have a P.O. ox, see instrutions. 60 West Addison St. City, town or post offie, state, and ZIP ode. If you have a foreign address, also omplete spaes elow. Apt. no. Make sure the SSN(s) aove and on line 6 are orret. Presidential Eletion Campaign Chiago, IL 02 Chek here if you, or your spouse if filing jointly, want $3 to go to this fund. Cheking a ox elow Foreign ountry name Foreign provine/state/ounty Foreign postal ode will not hange your tax or refund. Filing Status Chek only one ox. Exemptions If more than four dependents, see instrutions and hek here Inome If you did not get a W-2, see instrutions. Adjusted Gross Inome LHA X Single Married filing jointly (even if only one had inome) Married filing separately. Enter spouse s SSN aove Alimony paid Reipient s SSN Sutrat line 36 from line 22. This is your adjusted gross inome For Dislosure, Privay At, and Paperwork Redution At Notie, see separate instrutions a You Spouse Head of household (with qualifying person). If the qualifying person is a hild ut not your dependent, enter this hild s name here. Total numer of exemptions laimed Ordinary dividends. Attah Shedule B if required ~~~~~~~~~~~~~~~~~~~~~~~~~ Qualified dividends ~~~~~~~~~~~~~~~~~~~~~~~ Taxale refunds, redits, or offsets of state and loal inome taxes~~~~~~~~~~~~~~~~~~ Alimony reeived ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Business inome or (loss). Attah Shedule C or C-EZ ~~~~~~~~~~~~~~~~~~~~~~~ Capital gain or (loss). Attah Shedule D if required. If not required, hek here ~~~~~~~ Other gains or (losses). Attah Form 477 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~ IRA distriutions ~~~~~~~ 15a Taxale amount ~~~~~~ Pensions and annuities ~~~~ 16a Taxale amount ~~~~~~ Rental real estate, royalties, partnerships, S orporations, trusts, et. Attah Shedule E Farm inome or (loss). Attah Shedule F ~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Unemployment ompensation ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Health savings aount dedution. Attah Form 888 ~~~~~~~~ Moving expenses. Attah Form 303 ~~~~~~~~~~~~~~~ Dedutile part of self-employment tax. Attah Shedule SE~~~~~~ Self-employed SEP, SIMPLE, and qualified plans ~~~~~~~~~~ Self-employed health insurane dedution ~~~~~~~~~~~~~ Penalty on early withdrawal of savings ~~~~~~~~~~~~~~~ IRA dedution Student loan interest dedution!! ~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~ Tuition and fees. Attah Form 817 ~~~~~~~~~~~~~~~~ Domesti prodution ativities dedution. Attah Form 803 ~~~~~ Add lines 23 through 35 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ; " " " " X , ,000. Form 40 (2016)

2 Form 40 (2016) Tax and Credits 3a Chek You were orn efore January 2, 152, Blind. Total oxes Standard Dedution for - if: Spouse was orn efore January 2, 152, Blind. heked ~ 3a People who If your spouse itemizes on a separate return or you were a dual-status alien, hek here ~~ 3 hek any ox on line 3a or 40 Itemized dedutions (from Shedule A) or your standard dedution (see left margin) ~~~~~~~~~~~ 40 3 orwho an e laimed as a 41 Sutrat line 40 from line 38 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 41 dependent, see instrutions. 42 Exemptions. If line 38 is $155,650 or less, multiply $4,050 y the numer on line 6d. Otherwise, see inst. ~~ Alternative minimum tax. Attah Form 6251 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ All others: Single or 46 Exess advane premium tax redit repayment. Attah Form 862 ~~~~~~~~~~~~~~~~~~~~ Married filing 47 Add lines 44, 45, and 46 separately, $6, Foreign tax redit. Attah Form 16 if required ~~~~~~~~~~~~~ 48 Married filing jointly or Qualifying widow(er), $,600 Head of household, $,300 Other Taxes Payments If you have a qualifying hild, attah Shedule EIC. Refund Diret deposit? See instrutions. Amount You Owe Third Party Designee Sign Here Joint return? See instrutions. Keep a opy for your reords. Paid Preparer Use Only Amount from line 37 (adjusted gross inome) Taxale inome. Sutrat line 42 from line 41. If line 42 is more than line 41, enter -0- ~~~~~~~~~~~ Tax. Chek if any from: a Form(s) 8814 Form 472 ~~~~~ First-time homeuyer redit repayment. Attah Form 5405 if required ~~~~~~~~~~~~~~~~~~~ 61 Health are: Individual responsiility (see instrutions) Full-year overage X ~~~~~~~~~~~ 62 Taxes from: a Form 85 Form 860 Inst.; enter ode(s) Residential energy redits. Attah Form 565 ~~~~~~~~~~~~~~ Other redits from Form: a Add lines 48 through 54. These are your total redits~~~~~~~~~~~~~~~~~~~~~~~~~~ 55 Unreported soial seurity and Mediare tax from Form: a Credits from Form: a 243 Reserved 8885 d 73 Add lines 64, 65, 66a, and 67 through 73. These are your total payments If line 74 is more than line 63, sutrat line 63 from line 74. This is the amount you overpaid~~~~~~~~~ 76a Amount of line 75 you want refunded to you. If Form 8888 is attahed, hek here Routing Aount numer Type: Cheking Savings d numer 77 Amount of line 75 you want applied to your 2017 estimated tax 77 Do you want to allow another person to disuss this return with the IRS (see instrutions)? Yes. Complete elow. No Designee s Phone Personal identifiation name no. numer (PIN) Under penalties of perjury, I delare that I have examined this return and aompanying shedules and statements, and to the est of my knowledge and elief, they are true, orret, and aurately list all amounts and soures of inome I reeived during the tax year. Delaration of preparer (other than taxpayer) is ased on all information of whih preparer has any knowledge. Your signature Date Your oupation Daytime phone numer Spouse s signature. If a joint return, oth must sign. Date Spouse s oupation If the IRS sent you an Identity Protetion PIN, enter it here Print/Type preparer s name Preparer s signature Date Chek self-employed Firm s name Firm s EIN " Phone no. Firm s address ~~~~~~~~~~~ Add lines 56 through 62. This is your total tax 66a Earned inome redit (EIC) Credit for hild and dependent are expenses. Attah Form 2441 ~~~~~~ Eduation redits from Form 8863, line 1 ~~~~~~~~~~~~~~~ Retirement savings ontriutions redit. Attah Form 8880 ~~~~~~~~ Child tax redit. Attah Shedule 88, if required ~~~~~~~~~~~~ Sutrat line 55 from line 47. If line 55 is more than line 47, enter -0- Self-employment tax. Attah Shedule SE ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Additional tax on IRAs, other qualified retirement plans, et. Attah Form 532 if required ~~~~~~~~~~ 60a Household employment taxes from Shedule H ~~~~~~~~~~~~~~~~~~~~~~~~~~~~ = John Smith rqs Federal inome tax withheld from Forms W-2 and ~~~~~~~~~~ 2016 estimated tax payments and amount applied from 2015 return ~~~~ Nontaxale omat pay eletion ~~~~~ Additional hild tax redit. Attah Shedule 88 ~~~~~~~~~~~~ Amerian opportunity redit from Form 8863, line 8 ~~~~~~~~~~~ Net premium tax redit. Attah Form 862 ~~~~~~~~~~~~~~~ Amount paid with request for extension to file ~~~~~~~~~~~~~~ Exess soial seurity and tier 1 RRTA tax withheld 66 ~~~~~~~~~~~ Credit for federal tax on fuels. Attah Form 46 ~~~~~~~~~~~~~ Amount you owe. Sutrat line 74 from line 63. For details on how to pay, see instrutions ~~~~~~~ 78 Estimated tax penalty (see instrutions) a Applied For pmo if a a PTIN Page 2 30,000. 6, ,700. 4,050. 1,650.

3 Form 8621 (Rev. Deemer 2016) Department of the Treasury Internal Revenue Servie Name of shareholder Information Return y a Shareholder of a Passive Foreign Investment Company or Qualified Eleting Fund Information aout Form 8621 and its separate instrutions is at Identifying numer (see instrutions) OMB No Attahment Sequene No. 6 John Smith Numer, street, and room or suite no. (If a P.O. ox, see instrutions.) 60 West Addison St. Applied For Shareholder tax year: alendar year 2016 or other tax year eginning, and ending,. City or town, state, and ZIP ode or ountry Chiago, IL 02 Chek type of shareholder filing the return: X Individual Corporation Partnership S Corporation Nongrantor Trust Estate Chek if any Exepted Speified Foreign Finanial Assets are Reported on this Form (see instrutions) X Name of passive foreign investment ompany (PFIC) or qualified eleting fund (QEF) Employer identifiation numer (if any) Europe Index Mutual Fund Address (Enter numer, street, ity or town, and ountry.) 221B Baker Street London United Kingdom Part I Summary of Annual Information (See instrutions.) Provide the following information with respet to all shares of the PFIC held y the shareholder: 1 Desription of eah lass of shares held y the shareholder: B 2 Chek if shares jointly owned with spouse. Date shares aquired during the taxale year, if appliale: Referene ID numer (see instrutions) Euroindex Tax year of PFIC or QEF: alendar year 2016 tax year eginning, and ending,. or other 3 Numer of shares held at the end of the taxale year: Value of shares held at the end of the taxale year (hek the appropriate ox, if appliale): (a) (e) $0-50,000 () $50,001-0,000 () $0, ,000 (d) $150, ,000 If more than $200,000, list value: 530, Type of PFIC and amount of any exess distriution or gain treated as an exess distriution under setion 1, inlusion under setion 3, or inlusion or dedution under setion 6: (a) Setion 1 $ () Setion 3 (Qualified Eleting Fund) $ () X Setion 6 (Mark to Market) $,000. Part II Eletions (See instrutions.) A Eletion To Treat the PFIC as a QEF. I, a shareholder of a PFIC, elet to treat the PFIC as a QEF. Complete lines 6a through 7 of Part III. B Eletion To Extend Time For Payment of Tax. I, a shareholder of a QEF, elet to extend the time for payment of tax on the undistriuted earnings and profits of the QEF until this eletion is terminated. Complete lines through of Part III to alulate the tax that may e deferred. Note: If any portion of line 6a or line 7a of Part III is inludile under setion 51, you may not make this eletion. Also, see setions 4() and 4(f) and the related regulations for events that terminate this eletion. C X Eletion To Mark-to-Market PFIC Stok. I, a shareholder of a PFIC, elet to mark-to-market the PFIC stok that is marketale within the meaning of setion 6(e). Complete Part IV. D E F G H Deemed Sale Eletion. I, a shareholder on the first day of a PFIC s first tax year as a QEF, elet to reognize gain on the deemed sale of my interest in the PFIC. Enter gain or loss on line 15f of Part V. Deemed Dividend Eletion. I, a shareholder on the first day of a PFIC s first tax year as a QEF that is a ontrolled foreign orporation (CFC), elet to treat an amount equal to my share of the post-186 earnings and profits of the CFC as an exess distriution. Enter this amount on line 15e of Part V. If the exess distriution is greater than zero, also omplete line 16 of Part V. Eletion To Reognize Gain on Deemed Sale of PFIC. I, a shareholder of a former PFIC or a PFIC to whih setion 7(d) applies, elet to treat as an exess distriution the gain reognized on the deemed sale of my interest in the PFIC on the last day of its last tax year as a PFIC under setion 7(a). Enter gain on line 15f of Part V. Deemed Dividend Eletion With Respet to a Setion 7(e) PFIC. I, a shareholder of a setion 7(e) PFIC, within the meaning of Regulations setion 1.7-3(a), elet to make a deemed dividend eletion with respet to the Setion 7(e) PFIC. My holding period in the stok of the Setion 7(e) PFIC inludes the CFC qualifiation date, as defined in Regulations setion 1.7-3(d). Enter the exess distriution on line 15e, Part V. If the exess distriution is greater than zero, also omplete line 16, Part V. Deemed Dividend Eletion With Respet to a Former PFIC. I, a shareholder of a former PFIC, within the meaning of Regulations setion 1.8-3(a), elet to make a deemed dividend eletion with respet to the former PFIC. My holding period in the stok of the former PFIC inludes the termination date, as defined in Regulations setion 1.8-3(d). Enter the exess distriution on line 15e, Part V. If the exess distriution is greater than zero, also omplete line 16, Part V LHA For Dislosure, Privay At, and Paperwork Redution At Notie, see separate instrutions. Form 8621 (Rev ) PFIC Smith, John PFIC1

4 Form 8621 (Rev ) Part III Inome From a Qualified Eleting Fund (QEF). All QEF shareholders omplete lines 6a through 7. If you are making Eletion B, also omplete lines through. (See instrutions.) 6 a Enter your pro rata share of the ordinary earnings of the QEF ~~~~~~~~~~~~ d e Complete lines 8 and only if you are making a setion 4 eletion (Eletion B) for the urrent tax year. Sutrat line 8d from line, and enter the differene (if zero or less, enter amount in rakets) ~~~~~~~~~~~~~ Important: If line 8e is greater than zero, and no portion of line 6a or 7a is inludile in inome under setion 51, you may make Eletion B with respet to the amount on line 8e. Sutrat line from line a. This is the deferred tax, the time for payment of whih is extended y making Eletion B Part IV Gain or (Loss) From Mark-to-Market Eletion (See instrutions.) a Enter the fair market value of your PFIC stok at the end of the tax year ~~~~~~~~~~~~~~~~~~~~~~~~ Enter the portion of line 6a that is inluded in inome under setion 51 or that may e exluded under setion 3(g) ~~~~~~~~~~~~~~~~~~~~~~~~ Sutrat line 6 from line 6a. Enter this amount on your tax return as ordinary inome 7 a Enter your pro rata share of the total net apital gain of the QEF ~~~~~~~~~~~ Enter the portion of line 7a that is inluded in inome under setion 51 or that may e exluded under setion 3(g) ~~~~~~~~~~~~~~~~~~~~~~~~ Sutrat line 7 from line 7a. This amount is a net long-term apital gain. Enter this amount in Part II of the Shedule D used for your inome tax return. (See instrutions.) 8 a Add lines 6 and 7 Enter the total amount of ash and the fair market value of other property distriuted or deemed distriuted to you during the tax year of the QEF. (See instrutions.) ~~~~ Enter the portion of line not already inluded in line 8 that is attriutale to shares in the QEF that you disposed of, pledged, or otherwise transferred during the tax year ~ Add lines 8 and 8 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ a Enter the total tax for the tax year (See instrutions.) ~~~~~~~~~~~~~~~~ Enter the total tax for the tax year determined without regard to the amount entered on line 8e ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Enter your adjusted asis in the stok at the end of the tax year Sutrat line from line a. If a gain, do not omplete lines and. Inlude this amount as ordinary inome If you sold or otherwise disposed of any setion 6 stok (see instrutions) during the tax year: a Enter the fair market value of the stok on the date of sale or disposition Enter the adjusted asis of the stok on the date of sale or disposition Sutrat line from line a. If a gain, do not omplete line 14. Inlude this amount as ordinary inome on your 14a Enter any unreversed inlusions (as defined in setion 6(d)) ~~~~~~~~~~~~~~~~~~~~~~~~~~~ Enter the loss from line, ut only to the extent of unreversed inlusions on line 14a. Inlude this amount as an ordinary Enter the amount y whih the loss on line exeeds unreversed inlusions on line 14a. Inlude this amount on your tax Note: See instrutions in ase of multiple sales or dispositions. 6a 6 7a a ~~~~~~~~~~~~~~~~~~~~~~~~~~~ on your tax return. If a loss, go to line ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Enter any unreversed inlusions (as defined in setion 6(d)) ~~~~~~~~~~~~~~~~~~~~~~~~~~~ Enter the loss from line, ut only to the extent of unreversed inlusions on line. Inlude this amount as an ordinary loss on your tax return ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~ tax return. If a loss, go to line 14 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ loss on your tax return. If the loss on line exeeds unreversed inlusions on line 14a, omplete line 14 ~~~~~~~~ return aording to the rules generally appliale for losses provided elsewhere in the Code and regulations ~~~~~~~ 6 7 8d 8e a a 14a Page 2 5, ,000.,000. Form 8621 (Rev ) PFIC Smith, John PFIC1

5 John Smith -- }}}}}}}}}} }}}}}}}}}}} ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Form 40 Misellaneous Inome Statement 1 }}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}} Desription Amount }}}}}}}}}}} }}}}}}}}}}}}}} Form 8621, line - Europe Index Mutual Fund,000. }}}}}}}}}}}}}} Total to Form 40, line 21,000. ~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Form 8621 Additional Information Statement 2 }}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}} Name of PFIC or QEF }}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}}} Europe Index Mutual Fund Numer Numer Value of of Shares Change of Shares Shares Class of at Begining in Numer Date of at End Held At Jointly Stok of Year of Shares Change of Year Year End Owned }}}}}}}}}} }}}}}}}}}} }}}}}}}}}} }}}}}}}} }}}}}}}}}} }}}}}}}}}} }}}}}}} B , Statement(s) 1, PFIC Smith, John PFIC1