2012 Federal Return

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Department of the Treasury - Internal Revenue Service Form

1040EZ
Your first name and initial

Income Tax Return for Single and Joint Filers With No Dependents (99)
Last name

2012

OMB No. 1545-0074 Your social security number

brandon s
If a joint return, spouse's first name and initial

sly
Last name Apt. no.

593-62-7683
Spouse's social security number

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

942 Marietta St
City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions).

Make sure the SSN(s) above are correct.


Presidential Election Campaign
Check here if you, or your spouse if filing jointly, want $3 to go to this fund. Checking a box below will not change your tax or refund.

lakeland, FL 33803
Foreign country name Foreign province/county Foreign postal code

You

Spouse

Income
Attach Form(s) W-2 here.
Enclose, but do not attach, any payment.

Wages, salaries, and tips. This should be shown in box 1 of your Form(s) W-2. Attach your Form(s) W-2. Taxable interest. If the total is over $1,500, you cannot use Form 1040EZ. Unemployment compensation and Alaska permanent Fund dividends (see instructions).

1 2 3 4

15,269.

2 3 4 5

Payments, Credits, and Tax

Add lines 1, 2, and 3. This is your adjusted gross income. If someone can claim you (or your spouse if a joint return) as a dependent, check the applicable box(es) below and enter the amount from the worksheet on Page 2. You Spouse If no one can claim you (or your spouse if a joint return), enter $9,750 if single; $19,500 if married filing jointly. See instructions for explanation. 6 Subtract line 5 from line 4. If line 5 is larger than line 4, enter -0-. This is your taxable income. 7 Federal income tax withheld from Form(s) W-2 and 1099. 8a Earned income credit (EIC) (see instructions). NO b Nontaxable combat pay election. 8b 9 Add lines 7 and 8a. These are your total payments and credits. 10 Tax. Use the amount on line 6 above to find your tax in the tax table in the instructions. Then, enter the tax from the table on this line. 11a If line 9 is larger than line 10, subtract line 10 from line 9. This is your refund. If Form 8888 is attached, check here b Routing number d Account number 12 If line 10 is larger than line 9, subtract line 9 from line 10. This is the amount you owe. For details on how to pay, see instructions.
Phone no.

15,269.

5 6 7 8a 9 10

9,750. 5,519. 1,003. 1,003. 553. 450.

Refund
Have it directly deposited! See instructions and fill in 11b, 11c, and 11d or Form 8888.

11a
Savings

c Type:

Checking

Amount You Owe

12
Yes. Complete below.
Personal identification number (PIN)

0.
No

Third Party Designee

Do you want to allow another person to discuss this return with the IRS (see instructions)?
Designee's name

Sign Here
Joint return? See instructions. Keep a copy for your records.

Under penalties of perjury, I declare that I have examined this return, and to the best of my knowledge and belief, it is true, correct, and accurately lists all amounts and sources of income I received during the tax year. Declaration of preparer (other than the taxpayer) is based on all information of which the preparer has any knowledge. Your signature Date Daytime phone number Your occupation

unemployed
Spouse's signature. If a joint return, both must sign. Date Spouse's occupation Print/Type preparer's name Firm's name Firm's address Preparer's signature Date

(863)450-5708
If the IRS sent you an Identity Protection PIN, enter it here (see inst.)

Paid Preparer Use Only

if PTIN Check self-employed Firm's EIN Phone no.

For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see instructions.
UYA

Form 1040EZ (2012)

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