See separate instructions. Your social security number RIGHT ANGLE If a joint return, spouse's first name and initial

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1 Form Department of the Treasury - Internal Revenue Service (99) 14 U.S. Individual Income Tax Return OMB No For the year Jan. 1-Dec. 31,, or other tax year beginning,, ending, 2 Your first name and initial Last name IRS Use Only-Do not write or staple in this space. See separate instructions. Your social security number If a joint return, spouse's first name and initial Last name Spouse's social security number Home address (number and street). If you have a P.O. box, see instructions. 599 OBTUSE RD City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions). CAMBRIDGE MA Single 4 Head of household (with qualifying person). (See instructions.) Filing If the qualifying person is a child but not your dependent, enter this 2 Married filing jointly (even if only one had income) child's name here. Status 3 Married filing separately. Enter spouse's SSN above Check only one box. and full name here. 5 Qualifying widow(er) (see instructions) 6a X Yourself. If someone can claim you as a dependent, do not check box 6a... Boxes checked Exemptions } on 6a and 6b b Spouse... No. of children (4) Chk if child under c Dependents: (3) on 6c who: (2) Dependent's Dependent's age 17 qualifying social security number relationship to you for child tax credit lived with you (1) First name Last name (see instructions) did not live with you due to divorce or separation If more than four (see instructions) dependents, see Dependents on 6c instructions and not entered above check here d Total number of exemptions claimed... Income 7 Wages, salaries, tips, etc. Attach Form(s) W a Taxable interest. Attach Schedule B if required... 8a b Tax-exempt interest. Do not include on line 8a... 8b Attach Form(s) W-2 here. Also 9a Ordinary dividends. Attach Schedule B if required... attach Forms b Qualified dividends... 9b 9a W-2G and 1 Taxable refunds, credits, or offsets of state and local income taxes R if tax 11 Alimony received was withheld. 12 Business income or (loss). Attach Schedule C or C-EZ Capital gain or (loss). Attach Schedule D if required. If not required, check here 13 If you did not get a W-2, 14 Other gains or (losses). Attach Form see instructions. 15a IRA distributions... 15a b Taxable amount... 15b 16a Pensions and annuities.. 16a b Taxable amount... 16b 17 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E Farm income or (loss). Attach Schedule F Unemployment compensation a Social security benefits.. 2a b Taxable amount... 2b 21 Other income Combine the amounts in the far right column for lines 7 through 21. This is your total income Educator expenses Adjusted 24 Certain business expenses of reservists, performing artists, and Gross fee-basis government officials. Attach Form 216 or 216-EZ Income 25 Health savings account deduction. Attach Form Moving expenses. Attach Form Deductible part of self-employment tax. Attach Schedule SE. 27 1, Self-employed SEP, SIMPLE, and qualified plans Self-employed health insurance deduction Penalty on early withdrawal of savings a Alimony paid b Recipient's SSN 31a 32 IRA deduction Student loan interest deduction Reserved for future use Domestic production activities deduction. Attach Form Add lines 23 through Subtract line 36 from line 22. This is your adjusted gross income For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. EEA Make sure the SSN(s) above and on line 6c are correct. Presidential Election Campaign Check here if you, or your spouse if filing jointly, want $3 to go to this fund. Checking Foreign country name Foreign province/state/county Foreign postal code a box below will not change your tax or refund. You Spouse X Add numbers on lines above Apt. no ,5 79,94 228,494 1, ,895 Form 14 ()

2 Form 14 () Page 2 38 Amount from line 37 (adjusted gross income) ,895 Tax and 39a Check You were born before January 2, 1953, Blind. Total boxes Credits { } if: Spouse was born before January 2, 1953, Blind. checked 39a b If your spouse itemizes on a separate return or you were a dual-status alien, check here... 39b Standard 4 Itemized deductions (from Schedule A) or your standard deduction (see left margin)... 4 Deduction for - 41 Subtract line 4 from line ,825 24,7 People who 42 Exemptions. If line 38 is $156, or less, multiply $4,5 by the number on line 6d. Otherwise, see instructions.. 42 check any box on line 43 Taxable income. Subtract line 42 from line 41. If line 42 is more than line 41, enter ,5 2,2 39a or 39b or who can be 44 Tax (see instructions). Check if any from: a Form(s) 8814 b Form 4972 c 44 49,244 claimed as a 45 Alternative minimum tax (see instructions). Attach Form dependent, see 46 Excess advance premium tax credit repayment. Attach Form instructions. 47 Add lines 44, 45, and ,244 All others: 48 Foreign tax credit. Attach Form 1116 if required Single or Married filing 49 Credit for child and dependent care expenses. Attach Form separately, 5 Education credits from Form 8863, line $6,35 Married filing 51 Retirement savings contributions credit. Attach Form jointly or 52 Child tax credit. Attach Schedule 8812, if required Qualifying widow(er), 53 Residential energy credit. Attach Form $12,7 54 Other credits from Form: a 38 b 881 c 54 Head of household, 55 Add lines 48 through 54. These are your total credits $9,35 56 Subtract line 55 from line 47. If line 55 is more than line 47, enter , Self-employment tax. Attach Schedule SE ,197 Other 58 Unreported social security and Medicare tax from Form: a 4137 b Taxes 59 Additional tax on IRAs, other qualified retirement plans, etc. Attach Form 5329 if required a Household employment taxes from Schedule H... 6a b First-time homebuyer credit repayment. Attach Form 545 if required... 6b 61 Health care: individual responsibility (see instructions) Full-year coverage , Taxes from: a X Form 8959 b X Form 896 c Instructions; enter code(s) Add lines 56 through 62. This is your total tax ,18 Payments 64 Federal income tax withheld from Forms W-2 and estimated tax payments and amount applied from 216 return ,1 36, If you have a 66a Earned income credit (EIC)... 66a qualifying child, attach b Nontaxable combat pay election... 66b Schedule EIC. 67 Additional child tax credit. Attach Schedule American opportunity credit from Form 8863, line Net premium tax credit. Attach Form Amount paid with request for extension to file Excess social security and tier 1 RRTA tax withheld Credit for federal tax on fuels. Attach Form Credits from Form: a 2439 b Reserved c 8885 d Add lines 64, 65, 66a, and 67 through 73. These are your total payments ,1 Refund 75 If line 74 is more than line 63, subtract line 63 from line 74. This is the amount you overpaid a Amount of line 75 you want refunded to you. If Form 8888 is attached, check here. 76a 82 Direct deposit? b Routing number X X X X X X X X X c Type: Checking Savings See d Account number X X X X X X X X X X X X X X X X X instructions. 77 Amount of line 75 you want applied to your 218 estimated tax Amount 78 Amount you owe. Subtract line 74 from line 63. For details on how to pay, see instructions 78 You Owe 79 Estimated tax penalty (see instructions) Third Party Do you want to allow another person to discuss this return with the IRS (see instructions)? Yes. Complete below. X No Designee Designee's name Phone no. Personal identification number (PIN) Sign Here Joint return? See instructions. Keep a copy for your records. Paid Preparer Use Only EEA 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 amount and sources of income I received during the tax year. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge. Your signature Date Your occupation Daytime phone number ATTORNEY Spouse's signature. If a joint return, both must sign. Date Spouse's occupation Identity Protection PIN (see inst.) Preparer's signature Date Check if PTIN John Doe self-employed P Print/Type preparer's name Firm's name Firm's address John Doe The Tax Firm 1234 Tax Lane Anytown, US Firm's EIN Phone no. Form 14 ()

3 SCHEDULE A (Form 14) Department of the Treasury Internal Revenue Service (99) Name(s) shown on Form 14 Your mortgage interest deduction may be limited (see instructions). If you made a gift and got a benefit for it, see instructions. Itemized Deductions Attach to Form 14. Caution: Do not include expenses reimbursed or paid by others. Medical 1 Medical and dental expenses (see instructions)... 1 and 2 Enter amount from Form 14, line 38 2 Dental 3 Multiply line 2 by 1% (.1)... 3 Expenses 4 Subtract line 3 from line 1. If line 3 is more than line 1, enter Taxes You 5 State and local (check only one box): Paid a Income taxes, or ,175 b X General sales taxes 6 Real estate taxes (see instructions) ,25 7 Personal property taxes Other taxes. List type and amount Interest You Paid Note: Gifts to Charity Go to for instructions and the latest information. 8 9 Add lines 5 through Home mortgage interest and points reported to you on Form ,2 11 Home mortgage interest not reported to you on Form 198. If paid to the person from whom you bought the home, see instructions and show that person's name, identifying no., and address 12 Points not reported to you on Form 198. See instructions for special rules Reserved Investment interest. Attach Form 4952 if required. See instructions Add lines 1 through Gifts by cash or check. If you made any gift of $25 or more, see instructions ,25 17 Other than by cash or check. If any gift of $25 or more, see instructions. You must attach Form 8283 if over $ Carryover from prior year Add lines 16 through Casualty and Theft Losses 2 Casualty or theft loss(es). Attach Form See instructions... 2 Job Expenses and Certain 21 Unreimbursed employee expenses - job travel, union dues, job education, etc. Attach Form 216 or 216-EZ if required. See instr. Miscellaneous LAW JOURNAL Deductions 22 Tax preparation fees Other expenses - investment, safe deposit box, etc. List type and amount Add lines 21 through Enter amount from Form 14, line , Multiply line 25 by 2% (.2) , Subtract line 26 from line 24. If line 26 is more than line 24, enter Other Miscellaneous 28 Other - from list in instructions. List type and amount Deductions 28 Total Itemized 29 Is Form 14, line 38, over $156,? No. Your deduction is not limited. Add the amounts in the far right column Deductions for lines 4 through 28. Also, enter this amount on Form 14, line Yes. Your deduction may be limited. See the Itemized Deductions Worksheet in the instructions to figure the amount to enter. 3 If you elect to itemize deductions even though they are less than your standard deduction, check here... For Paperwork Reduction Act Notice, see the instructions for Form 14. Schedule A (Form 14) EEA 11 OMB No Attachment Sequence No. Your social security number X 7 3,375 8,2 11,25 22,825

4 Schedule E (Form 14) Attachment Sequence No. 13 Page 2 Name(s) shown on return. Do not enter name and social security number if shown on page 1. Caution: The IRS compares amounts reported on your tax return with amounts shown on Schedule(s) K-1. Part II Income or Loss From Partnerships and S Corporations Note: If you report a loss from an at-risk activity for which any amount is not at risk, you must check the box in column (e) on line 28 and attach Form See instructions A B C D A B C Passive Income and Loss Nonpassive Income and Loss D 29a Totals 79,94 b Totals 3 Add columns (g) and (j) of line 29a ,94 31 Add columns (f), (h), and (i) of line 29b ( ) 32 Total partnership and S corporation income or (loss). Combine lines 3 and 31. Enter the result here and include in the total on line 41 below ,94 Part III Income or Loss From Estates and Trusts 33 A B A B 34a Passive Income and Loss Nonpassive Income and Loss b Totals 35 Add columns (d) and (f) of line 34a Add columns (c) and (e) of line 34b ( ) 37 Total estate and trust income or (loss). Combine lines 35 and 36. Enter the result here and include in the total on line 41 below Part IV Income or Loss From Real Estate Mortgage Investment Conduits (REMICs) - Residual Holder Combine columns (d) and (e) only. Enter the result here and include in the total on line 41 below Part V Summary 4 Net farm rental income or (loss) from Form Also, complete line 42 below Total income or (loss). Combine lines 26, 32, 37, 39, and 4. Enter the result here and on Form 14, line 17, or Form 14NR, line EEA Are you reporting any loss not allowed in a prior year due to the at-risk, excess farm loss, or basis limitations, a prior year unallowed loss from a passive activity (if that loss was not reported on Form 8582), or unreimbursed partnership expenses? If you answered "Yes," see instructions before completing this section... Totals Reconciliation of farming and fishing income. Enter your gross farming and fishing income reported on Form 4835, line 7; Schedule K-1 (Form 165), box 14, code B; Schedule K-1 (Form 112S), box 17, code V; and Schedule K-1 (Form 141), box 14, code F (see instructions)... Reconciliation for real estate professionals. If you were a real estate professional (see instructions), enter the net income or (loss) you reported anywhere on Form 14 or Form 14NR from all rental real estate activities in which you materially participated under the passive activity loss rules Your social security number (b) Enter P for (c) Check if (d) Employer (e) Check if (a) Name partnership; S foreign identification any amount is for S corporation partnership number not at risk PRIME NUMBER PARTNERS P (f) Passive loss allowed (g) Passive income (h) Nonpassive loss (i) Section 179 expense (j) Nonpassive income (attach Form 8582 if required) from Schedule K-1 from Schedule K-1 deduction from Form 4562 from Schedule K-1 (a) Name Yes (b) Employer identification number (c) Passive deduction or loss allowed (d) Passive income (e) Deduction or loss (f) Other income from (attach Form 8582 if required) from Schedule K-1 from Schedule K-1 Schedule K-1 (a) Name (c) Excess inclusion from (b) Employer identification (d) Taxable income (net loss) (e) Income from Schedules Q, line 2c number (see instructions) from Schedules Q, line 1b Schedules Q, line 3b X No 79,94 79,94 Schedule E (Form 14)

5 Schedule SE (Form 14) Attachment Sequence No. 17 Page 2 Name of person with self-employment income (as shown on Form 14 or Form 14NR) Social security number of person RIGHT ANGLE with self-employment income Section B Long Schedule SE Part I Self-Employment Tax Note. If your only income subject to self-employment tax is church employee income, see instructions. Also see instructions for the definition of church employee income. A If you are a minister, member of a religious order, or Christian Science practitioner and you filed Form 4361, but you had $4 or more of other net earnings from self-employment, check here and continue with Part I... 1 a Net farm profit or (loss) from Schedule F, line 34, and farm partnerships, Schedule K-1 (Form 165), box 14, code A. Note: Skip lines 1a and 1b if you use the farm optional method (see instructions)... 1a b If you received social security retirement or disability benefits, enter the amount of Conservation Reserve Program payments included on Schedule F, line 4b, or listed on Schedule K-1 (Form 165), box 2, code Z.. 1b ( ) 2 Net profit or (loss) from Schedule C, line 31; Schedule C-EZ, line 3; Schedule K-1 (Form 165), box 14, code A (other than farming); and Schedule K-1 (Form 165-B), box 9, code J1. Ministers and members of religious orders, see instructions for types of income to report on this line. See instructions for other income to report. Note: Skip this line if you use the nonfarm optional method (see instructions) ,94 3 Combine lines 1a, 1b, and ,94 4 a If line 3 is more than zero, multiply line 3 by 92.35% (.9235). Otherwise, enter amount from line a 73,43 Note: If line 4a is less than $4 due to Conservation Reserve Program payments on line 1b, see instructions. b If you elect one or both of the optional methods, enter the total of lines 15 and 17 here... 4b c Combine lines 4a and 4b. If less than $4, stop; you don't owe self-employment tax. Exception: If less than $4 and you had church employee income, enter -- and continue... 4c 73,43 5 a Enter your church employee income from Form W-2. See instructions for definition of church employee income... 5a b Multiply line 5a by 92.35% (.9235). If less than $1, enter b 6 Add lines 4c and 5b ,43 7 Maximum amount of combined wages and self-employment earnings subject to social security tax or the 6.2% portion of the 7.65% railroad retirement (tier 1) tax for ,2. 8 a Total social security wages and tips (total of boxes 3 and 7 on Form(s) W-2) and railroad retirement (tier 1) compensation. If $127,2 or more, skip lines 8b through 1, and go to line a 118,5 b Unreported tips subject to social security tax (from Form 4137, line 1)... 8b c Wages subject to social security tax (from Form 8919, line 1)... 8c d Add lines 8a, 8b, and 8c... 8d 9 Subtract line 8d from line 7. If zero or less, enter -- here and on line 1 and go to line Multiply the smaller of line 6 or line 9 by 12.4% (.124) Multiply line 6 by 2.9% (.29) Self-employment tax. Add lines 1 and 11. Enter here and on Form 14, line 57, or Form 14NR, line Deduction for one-half of self-employment tax. Multiply line 12 by 5% (.5). Enter the result here and on Form 14, line 27, or Form 14NR, line ,599 Part II Optional Methods To Figure Net Earnings (see instructions) Farm Optional Method. You may use this method only if (a) your gross farm income 1 wasn't more 2 than $7,8, or (b) your net farm profits were less than $5, Maximum income for optional methods , Enter the smaller of: two-thirds (2/3) of gross farm income (not less than zero) or $5,2. Also include this amount on line 4b above Nonfarm Optional Method. You may use this method only if (a) your net nonfarm profits were less than $5,631 4 and also less than % of your gross nonfarm income, and (b) you had net earnings from self-employment of at least $4 in 2 of the prior 3 years. Caution: You may use this method no more than five times. 16 Subtract line 15 from line Enter the smaller of: two-thirds (2/3) of gross nonfarm income (not less than zero) or the amount on line 16. Also include this amount on line 4b above From Sch. F, line 9, and Sch. K-1 (Form 165), box 14, code B. From Sch. C, line 31; Sch. C-EZ, line 3; Sch. K-1 (Form 165), box 14, code 2 A; and Sch. K-1 (Form 165-B), box 9, code J1. From Sch. F, line 34, and Sch. K-1 (Form 165), box 14, code A - minus the 4 amount you would have entered on line 1b had you not used the optional From Sch. C, line 7; Sch. C-EZ, line 1; Sch. K-1 (Form 165), box 14, code method. C; and Sch. K-1 (Form 165-B), box 9, code J2. EEA 118,5 8,7 1,79 2,118 3,197 Schedule SE (Form 14)

6 Form 8959 Additional Medicare Tax Department of the Treasury Internal Revenue Service Name(s) shown on return If any line does not apply to you, leave it blank. See separate instructions. Attach to Form 14, 14NR, 14-PR, or 14-SS. Go to for instructions and the latest information. Part I Additional Medicare Tax on Medicare Wages 1 Medicare wages and tips from Form W-2, box 5. If you have more than one Form W-2, enter the total of the amounts from box , 2 Unreported tips from Form 4137, line Wages from Form 8919, line Add lines 1 through , 5 Enter the following amount for your filing status: Married filing jointly... $25, Married filing separately... $125, Single, Head of household, or Qualifying widow(er)... $2, 5 2, 6 Subtract line 5 from line 4. If zero or less, enter Additional Medicare Tax on Medicare wages. Multiply line 6 by.9% (.9). Enter here and go to Part II... 7 Part II Additional Medicare Tax on Self-Employment Income 8 Self-employment income from Schedule SE (Form 14), Section A, line 4, or Section B, line 6. If you had a loss, enter -- (Form 14-PR and Form 14-SS filers, see instructions.) ,43 9 Enter the following amount for your filing status: Married filing jointly... $25, Married filing separately... $125, Singe, Head of household, or Qualifying widow(er)... $2, 9 2, 1 Enter the amount from line , 11 Subtract line 1 from line 9. If zero or less, enter , 12 Subtract line 11 from line 8. If zero or less, enter Additional Medicare Tax on self-employment income. Multiply line 12 by.9% (.9). Enter here and go to Part III Part III Additional Medicare Tax on Railroad Retirement Tax Act (RRTA) Compensation 14 Railroad retirement (RRTA) compensation and tips from Form(s) W-2, box 14 (see instructions) Enter the following amount for your filing status: Married filing jointly... $25, Married filing separately... $125, Single, Head of household, or Qualifying widow(er)... $2, Subtract line 15 from line 14. If zero or less, enter Additional Medicare Tax on railroad retirement (RRTA) compensation. Multiply line 16 by.9% (.9). Enter here and go to Part IV Part IV Total Additional Medicare Tax 18 Add lines 7, 13, and 17. Also include this amount on Form 14, line 62, (Form 14NR, 14-PR, and 14-SS filers, see instructions) and go to Part V Part V Withholding Reconciliation 19 Medicare tax withheld from Form W-2, box 6. If you have OMB No Attachment Sequence No. Your social security number more than one Form W-2, enter the total of the amounts from box Enter the amount from line , 21 Multiply line 2 by 1.45% (.145). This is your regular Medicare tax withholding on Medicare wages , Subtract line 21 from line 19. If zero or less, enter --. This is your Additional Medicare Tax withholding on Medicare wages Additional Medicare Tax withholding on railroad retirement (RRTA) compensation from Form W-2, box 14 (see instructions) Total Additional Medicare Tax withholding. Add lines 22 and 23. Also include this amount with federal income tax withholding on Form 14, line 64 (Form 14NR, 14-PR, and 14-SS filers, see instructions) For Paperwork Reduction Act Notice, see your tax return instructions. Form 8959 () EEA 71 31,

7 Form 896 Net Investment Income Tax- Individuals, Estates, and Trusts Department of the Treasury Attach to your tax return. Internal Revenue Service (99) Go to for instructions and the latest information. Name(s) shown on your tax return Your social security number or EIN Part I Investment Income Section 613(g) election (see instructions) Section 613(h) election (see instructions) Regulations section (g) election (see instructions) 1 Taxable interest (see instructions) Ordinary dividends (see instructions) Annuities (see instructions) a Rental real estate, royalties, partnerships, S corporations, trusts, etc. (see instructions)... 4a 79,94 b Adjustment for net income or loss derived in the ordinary course of a non-section 1411 trade or business (see instructions)... 4b (79,94) c Combine lines 4a and 4b... 4c 5a Net gain or loss from disposition of property (see instructions)... 5a b Net gain or loss from disposition of property that is not subject to net investment income tax (see instructions)... 5b c Adjustment from disposition of partnership interest or S corporation stock (see instructions)... 5c d Combine lines 5a through 5c... 5d 6 Adjustments to investment income for certain CFCs and PFICs (see instructions) Other modifications to investment income (see instructions) Total investment income. Combine lines 1, 2, 3, 4c, 5d, 6, and Part II Investment Expenses Allocable to Investment Income and Modifications 9a Investment interest expenses (see instructions)... 9a b State, local, and foreign income tax (see instructions)... 9b c Miscellaneous investment expenses (see instructions)... 9c d Add lines 9a, 9b, and 9c... 9d 1 Additional modifications (see instructions) Total deductions and modifications. Add lines 9d and Part III Tax Computation 12 Net investment income. Subtract Part II, line 11 from Part I, line 8. Individuals complete lines Estates and trusts complete lines 18a-21. If zero or less, enter Individuals: 13 Modified adjusted gross income (see instructions) , Threshold based on filing status (see instructions) , 15 Subtract line 14 from line 13. If zero or less, enter , Enter the smaller of line 12 or line Net investment income tax for individuals. Multiply line 16 by 3.8% (.38). Enter here and include on your tax return (see instructions) Estates and Trusts: 18a Net investment income (line 12 above)... 18a b Deductions for distributions of net investment income and deductions under section 642(c) (see instructions)... 18b c Undistributed net investment income. Subtract line 18b from 18a (see instructions). If zero or less, enter c 19a Adjusted gross income (see instructions)... 19a b Highest tax bracket for estates and trusts for the year (see instructions)... 19b c Subtract line 19b from line 19a. If zero or less, enter c 2 Enter the smaller of line 18c or line 19c Net investment income tax for estates and trusts. Multiply line 2 by 3.8% (.38). Enter here and include on your tax return (see instructions) For Paperwork Reduction Act Notice, see your tax return instructions. EEA OMB No Attachment Sequence No Form 896 ()

8 Name(s) as shown on return Federal Supporting Statements DO NOT FILE. KEEP FOR YOUR RECORDS. Your Social Security Number Form 896 Line 4b Item Detail K-1: PRIME NUMBER PARTNERS (79,94) Total (79,94) 896_ATT.LD

9 14 Overflow Statement Page 1 Name(s) as shown on return Your Social Security Number RIGHT ANGLE SCHEDULE A, LINE 16 - CASH CONTRIBUTIONS DESCRIPTION AMOUNT CHARITY 1 $ 5 CHARITY 2 1,25 CHARITY 3 8,5 CHARITY 4 1, TOTAL: OVERFLOW.LD

10 Name(s) as shown on return Qualified Dividends and Capital Gain Tax Worksheet - Line 44 (Form 14) Line 28 (Form 14A) (Keep for your records) Tax ID Number Before you begin: See the instructions for line 44 to see if you can use this worksheet to figure your tax. Before completing this worksheet, complete Form 14 through line 43. If you don't have to file Schedule D and you received capital gain distributions, be sure you checked the box on line 13 of Form Enter the amount from Form 14, line 43 (Form 14A, line 27). However, if you are filing Form 2555 or 2555-EZ (relating to foreign earned income), enter the amount from line 3 of the Foreign Earned Income Tax Worksheet Enter the amount from Form 14, line 9b (Form 14A, line 9b)* Are you filing Schedule D?* Yes. Enter the smaller of line 15 or 16 of Schedule D. If either line 15 or line 16 is blank or a loss, enter X No. Enter the amount from Form 14, line 13 (or Form 14A, line 1) 4. Add lines 2 and If filing Form 4952 (used to figure investment interest expense deduction), enter any amount from line 4g of that form. Otherwise, enter Subtract line 5 from line 4. If zero or less, enter Subtract line 6 from line 1. If zero or less, enter Enter: $37,95 if single or married filing separately, $75, if married filing jointly or qualifying widow(er), $5,8 if head of household. 9. Enter the smaller of line 1 or line Enter the smaller of line 7 or line Subtract line 1 from line 9. This amount is taxed at % Enter the smaller of line 1 or line Enter the amount from line Subtract line 13 from line Enter: $418,4 if single,... $235,35 if married filing separately, $47,7 if married filing jointly or qualifying widow(er), $444,55 if head of household. 16. Enter the smaller of line 1 or line Add lines 7 and Subtract line 17 from line 16. If zero or less, enter Enter the smaller of line 14 or line Multiply line 19 by 15% (.15) Add lines 11 and Subtract line 21 from line Multiply line 22 by 2% (.2) Figure the tax on the amount on line 7. If the amount on line 7 is less than $1,, use the Tax Table to figure the tax. If the amount on line 7 is $1, or more, use the Tax Computation Worksheet Add lines 2, 23, and Figure the tax on the amount on line 1. If the amount on line 1 is less than $1,, use the Tax Table to figure the tax. If the amount on line 1 is $1, or more, use the Tax Computation Worksheet Tax on all taxable income. Enter the smaller of line 25 or line 26. Also include this amount on Form 14, line 44 (Form 14A, line 28). If you are filing Form 2555 or 2555-EZ, don't enter this amount on Form 14, line 44 (or Form 14A, line 28). Instead, enter it on line 4 of the Foreign Earned Income Tax Worksheet ,2 199,12 37,95 37,95 37,95 418,4 2,2 199, ,19 49,244 49,46 49,244 * If you are filing Form 2555 or 2555-EZ, see the footnote in the Foreign Earned Income Tax Worksheet before completing this line. WK_CGTAX.LD

11 Worksheet B Form 14 Earned Income Credit (EIC)-Lines 66a and 66b (Keep for your records) Name(s) as shown on return Tax ID Number Use this worksheet if you answered "Yes" to Step 5, question 2. Complete the parts below (Parts 1 through 3) that apply to you. Then, continue to Part 4. If you are married filing a joint return, include your spouse's amounts, if any, with yours to figure the amounts to enter in Parts 1 through 3. Part 1 1a. Enter the amount from Schedule SE, Section A, line 3, or Section B, line 3, whichever applies. Self-Employed, Members of the b. Enter any amount from Schedule SE, Section B, line 4b, and line 5a. + Clergy, and People With c. Combine lines 1a and 1b. = Church Employee Income Filing d. Enter the amount from Schedule SE, Section A, line 6, or Section B, line 13, whichever applies. - Schedule SE e. Subtract line 1d from 1c. = Part 2 Part 3 Statutory Employees Filing Schedule C or C-EZ Part 4 All Filers Using Worksheet B 2. a. Enter any net farm profit or (loss) from Schedule F, line 34, and from Self-Employed 2a farm partnerships, Schedule K-1 (Form 165), box 14, code A*. NOT Required b. Enter any net profit or (loss) from Schedule C, line 31; Schedule C-EZ, To File line 3; Schedule K-1 (Form 165), box 14, code A (other than farming); + 2b Schedule SE and Schedule K-1 (Form 165-B), box 9, code J1*. For example, your net earnings from self-employment c. Combine lines 2a and 2b. = 2c were less than $ Do not include on these lines any statutory employee income, any net profit from services performed as a notary public, any amount exempt from self-employment tax as the result of the filing and approval of Form 429 or Form 4361, or any other amounts exempt from self-employment tax. *If you have any Schedule K-1 amounts, complete the appropriate line(s) of Schedule SE, Section A. Reduce the Schedule K-1 amounts as described in the Partner's Instructions for Schedule K-1. Enter your name and social security number on Schedule SE and attach it to your return. Enter the amount from Schedule C, line 1, or Schedule C-EZ, line 1, that you are filing as a statutory employee. Combine lines 1e, 2c, and 3. This is your total self-employed income. 1a 1b 1c 1d 1e ,94 79,94 1,599 77,495 77,495 Need more information or forms? Visit IRS.gov. WK_EIC2.LD

12 Form 14 Investment Income If You Are Filing Form 14 (Keep for your records) Name(s) as shown on return Tax ID Number Interest and Dividends 1. Enter any amount from Form 14, line 8a Enter any amount from Form 14, line 8b, plus any amount on Form 8814, line 1b Enter any amount from Form 14, line 9a Enter the amount from Form 14, line 21, that is from Form 8814 if you are filing that form to report Capital Gain Net Income 5. Enter the amount from Form 14, line 13. If the amount on that line is a loss, enter Enter any gain from Form 4797, Sales of Business Property, line 7. If the 7. amount on that line is a loss, enter --. (But, if you completed lines 8 and 9 of Form 4797, enter the amount from line 9 instead.) Subtract line 6 of this worksheet from line 5 of this worksheet. (If the result is less than zero, enter --.) Royalties and Rental Income from Personal Property 8. Passive Activities 9. your child's interest and dividend income on your return. (If your child received an Alaska Permanent Fund dividend, use Worksheet 2, on the next page, to figure the amount to enter on this line.)... Enter any royalty income from Schedule E, line 4, plus any income from the rental of personal property shown on Form 14, line 21, minus any expenses from Schedule E, line 2, related to royalty income, plus any expenses from the rental of personal property deducted on Form 14, line 36 of personal property deducted on Form 14, line 36 (If the result is less than zero, enter --.) Enter the total of any net income from passive activities (such as income included on Schedule E, lines 26, 29a (col. (g)), 34a (col. (d)), or 4) and the total of any losses from passive activities (included on Schedule E, lines 26, 29b (col. (f)), 34b (col. (c)), or 4). (See instructions below for line 9.) (if zero or less, enter --.) Adjustment from EIC screen Add the amounts on lines 1, 2, 3, 4, 7, 8, 9 and 1. Enter the total. This is your Investment Income Is the amount on line 11 more than $3,45? X Yes. You cannot take the credit. No. Go to Step 3 of the Form 14 instructions for lines 66a and 66b to find out if you can take the credit (unless you are using this publication to find out if you can take the credit; in that case, go to Rule 7, next).... Instructions for line 9. In figuring the amount to enter on line 9, do not take into account any royalty income (or loss) included on line 26 of Schedule E or any amount included in your earned income. To find out if the income on line 26 or line 4 of Schedule E is from a passive activity, see the Schedule E instructions. If any of the rental real estate income (or loss) included on Schedule E, line 26, is not from a passive activity, print "NPA" and the amount of that income (or loss) on the dotted line next to line WK_EIC4.LD

13 State and Local General Sales Tax Deduction Worksheet - Line 5b (Keep for your records) Name(s) as shown on return Tax ID Number Before you begin: See the instructions for line 1 of the worksheet if you: - Lived in more than one state during, or - Had any nontaxable income in. 1. Enter your state general sales taxes from the Optional State Sales Tax Table Next. If, for all of, you lived only in Connecticut, the District of Columbia, Indiana, Kentucky, Maine, Maryland, Massachusetts, Michigan, New Jersey, or Rhode Island, skip lines 2 through 5, enter -- on line 6, and go to line 7. Otherwise, go to line 2. Did you live in Alaska, Arizona, Arkansas, Colorado, Georgia, Illinois, Louisiana, Mississippi, Missouri, New York, North Carolina, South Carolina, Tennessee, Utah, or Virginia in? No. Enter -- Yes. Enter your base local general sales taxes from the Optional Local Sales Tax Tables Did your locality impose a local general sales tax in? Residents of California and Nevada, see the instructions for line 3 of the worksheet. No. Skip lines 3 through 5, enter -- on line 6, and go to line 7. Yes. Enter your local general sales tax rate, but omit the percentage sign. For example, if your local general sales tax rate was 2.5%, enter 2.5. If your local general sales tax rate changed or you lived in more than one locality in the same state during, see the instructions for line 3 of the worksheet... Did you enter -- on line 2? No. Skip lines 4 and 5 and go to line 6. Yes. Enter your state general sales tax rate (shown in the table heading for your state), but omit the percentage sign. For example, if your state general sales tax rate is 6%, enter Divide line 3 by line 4. Enter the result as a decimal (rounded to at least three places)... Did you enter -- on line 2? No. Multiply line 2 by line 3 Yes. Multiply line 1 by line 5. If you lived in more than one locality in the same state during, see the instructions for line 6 of the worksheet Enter your state and local general sales taxes paid on specified items, if any. See the instructions for line 7 of the worksheet... Deduction for general sales taxes. Add lines 1, 6, and 7. Enter the result here and the total from all your state and local general sales tax deduction worksheets, if you completed more than one, on Schedule A, line 5. Be sure to check box b on that line... Optional Sales Tax Table Computation State: Income: Exemptions:* Amount from table: Days: Deduction: MA 226, , ,175 * "Over 5" is the maximum number of exemptions in the optional sales tax tables in Schedule A Instructions. Returns with six or more exemptions will display a "6" on this line ,175 1,175 SALESTAX.LD

14 Name(s) as shown on return Name Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec RIGHT ANGLE X X X X X X X X X X X X Total number of X's in a month. If 5 or more, enter 5 Total number of X's in a month for individuals 18 or over* One-half the number of X's in a month for individuals under 18* Add lines 2 and 3 for each month Multiply line 4 by $695 for Shared Responsibility Payment Worksheet This worksheet is a combination of Steps 2-5, Worksheets A and B, and the Shared Responsibility Payment Worksheet shown in the instructions for Form (Keep for your records) If you or another member of your tax household had neither minimum essential coverage nor a coverage exemption for any month during, use the Shared Responsibility Payment Worksheet, below, to figure your shared responsibility payment. Complete the monthly columns by placing "X's" in each month in which you or another member of your tax household had neither minimum essential coverage nor a coverage exemption Tax ID Number each month. If $2,85 or more, enter $2, Sum of the monthly amounts entered on line Enter your household income (see Household income) ,895. Enter your filing threshold (see Filing Thresholds For Most People)... 1,4. Subtract line 8 from line ,495. Multiply line 9 by 2.5% (.25)... 5, Is line 1 more than $2,85? X Yes. Multiply line 1 by the number of months for which line 1 is more than zero No. Enter the amount from line 14 of the Flat Dollar Amount Worksheet }... 64, Divide line 11 by , Multiply line 6 by $272**... 3,264. Enter the smaller of line 12 or line 13 here and on Form 14, line 61; Form 14A, line 38; or Form 14EZ, line 11. This is your shared responsibility payment... 3,264. Rounded amount will carry to main form 3,264 *For purposes of figuring the shared responsibility payment, an individual is considered under 18 for an entire month if he or she did not turn 18 before the first day of the month. An individual turns 18 on the anniversary of the day the individual was born. For example, someone born on March 1, 1999, is considered age 18 on March 1,, and therefore, is not considered age 18 for purposes of the shared responsibility payment until April. **$272 is the national average premium for a bronze level health plan available through the Martketplace for one individual and should not be changed. WK_89651.LD

15 Name(s) as shown on return Household Income Worksheets for Form 8965 and Flat Dollar Amount Worksheet (Keep for your records) Household Income Worksheet 1. Enter your adjusted gross income (AGI) from Form 14, line 38; Form 14A, line 22; or Form 14NR, line Enter any tax-exempt interest from Form 14, line 8b; Form 14A, line 8b; or Form 14NR, line 9b Enter any amounts from Form 2555, lines 45 and 5, and Form 2555-EZ, line Modified AGI. Add lines 2 through Amount from Dependents' Combined Modified AGI Worksheet, line Household income. Add lines 1, 5, and 6. Enter here and on the Shared Responsibility Payment Worksheet, line Premiums paid through a salary reduction arrangement Household income for computing Coverage Exemption "A". Add lines 7 and Non-taxable social security received by taxpayers and dependents who were required to file a return Household income for computing Coverage Exemption "G" for residents of a state that did not expand Medicaid. Add lines 7 and Dependents' Combined Modified AGI Worksheet - Line 2b 1. Enter the AGI for your dependents from Form 14, line 38; Form 14A, line 22; Form 14EZ, line 3; and Form 14NR, line Enter any tax-exempt interest for your dependents from Form 14, line 8b; Form 14A, line 8b; Form 14EZ, the amount written to the left of the line 2 entry space; and Form 14NR, line 9b Enter any amounts for your dependents from Form 2555, lines 45 and 5, and Form 2555-EZ, line Add lines 2 and Add lines 1 and 4. Enter here and on Household Income Worksheet, line The Filing Threshold for this return is... The Federal Poverty Line for this household is... Household income (Household Income Worksheet, line 11) as a percentage of Federal Poverty Line... Flat Dollar Amount Worksheet CAUTION! Do not complete this worksheet unless the amount on line 1 of the Shared Responsibility Payment Worksheet is less than $2,85. Yes No For each month, is the amount on line 5 of the Shared Responsibility Payment Worksheet Enter the amount Enter the amount less than the amount on line 1 of the Shared Responsibility Payment Worksheet?* from line 1 from line 5 1. January February March April May June July August September October November December Add the amounts in each column Add the amounts on line 13 of both columns. Enter the result on line 11 of the Shared Responsibility Payment Worksheet... *If the amount on line 1 of the Shared Responsibility Payment Worksheet is -- for any month, leave both columns of this worksheet blank for that month. WK_89652.LD Tax ID Number 226, , , ,895 1,4 11,88 1,91