2021 Tax Return

prepared by,

E-File.com
 CORRECTED (if checked)
PAYER’S name, street address, city or town, state or province, 1 Gross distribution OMB No. 1545-0119 Distributions From
country, ZIP or foreign postal code, and telephone no. Pensions, Annuities,
Retirement or
PRINCIPAL LIFE INSURANCE CO
711 HIGH STREET
$ 8943
2a Taxable amount 2021 Profit-Sharing Plans,
IRAs, Insurance
DES MOINES IA 50392 Contracts, etc.
$ 8943 Form 1099-R
2b Taxable amount Total
not determined distribution
PAYER’S TIN RECIPIENT’S TIN 3 Capital gain (included in 4 Federal income tax
box 2a) withheld

42-0127290 033-38-4944
$ $
RECIPIENT’S name 5 Employee contributions/ 6 Net unrealized
Designated Roth appreciation in
MICHAEL A CONNERY contributions or employer’s securities
insurance premiums
$ $
Street address (including apt. no.) 7 Distribution IRA/ 8 Other
code(s) SEP/
183 LOWE STREET SIMPLE This information is
7 $ % being furnished to
City or town, state or province, country, and ZIP or foreign postal code 9a Your percentage of total 9b Total employee contributions the IRS.
LEOMINSTER MA 01453 distribution %$
10 Amount allocable to IRR 11 1st year of desig. 12 FATCA filing 14 State tax withheld 15 State/Payer’s state no. 16 State distribution
within 5 years Roth contrib. requirement
$ 456 $ 8943
MA 10026067005
$ 0 $ $
Account number (see instructions) 13 Date of 17 Local tax withheld 18 Name of locality 19 Local distribution
payment $ $
$ $
Form 1099-R www.irs.gov/Form1099R Department of the Treasury - Internal Revenue Service

CORRECTED (if checked)

PAYER’S name, street address, city or town, state or province, 1 Gross distribution OMB No. 1545-0119 Distributions From
country, ZIP or foreign postal code, and telephone no. Pensions, Annuities,
Retirement or
MA TEACHERS RETIREMENT SYSTEM
$ 62993
2a Taxable amount 2021 Profit-Sharing Plans,
IRAs, Insurance
500 RUTHERFORD AVENUE SUITE 210
CHARLESTOWN MA 02129 Contracts, etc.
$ 62651 Form 1099-R
2b Taxable amount Total
not determined distribution
PAYER’S TIN RECIPIENT’S TIN 3 Capital gain (included in 4 Federal income tax
box 2a) withheld

04-6002284 020-44-7592
$ $ 12856
RECIPIENT’S name 5 Employee contributions/ 6 Net unrealized
Designated Roth appreciation in
NIKKI CONNERY contributions or employer’s securities
insurance premiums
$ 342 $
Street address (including apt. no.) 7 Distribution IRA/ 8 Other
code(s) SEP/
183 LOWE STREET SIMPLE This information is
7 $ % being furnished to
City or town, state or province, country, and ZIP or foreign postal code 9a Your percentage of total 9b Total employee contributions the IRS.
distribution %$
LEOMINSTER MA 01453 5430
10 Amount allocable to IRR 11 1st year of desig. 12 FATCA filing 14 State tax withheld 15 State/Payer’s state no. 16 State distribution
within 5 years Roth contrib. requirement
$ $
$ 0 $ $
Account number (see instructions) 13 Date of 17 Local tax withheld 18 Name of locality 19 Local distribution
payment $ $
$ $
Form 1099-R www.irs.gov/Form1099R Department of the Treasury - Internal Revenue Service

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Form 8879 IRS e-file Signature Authorization
(Rev. January 2021) OMB No. 1545-0074
a
ERO must obtain and retain completed Form 8879.
Department of the Treasury
a Go to www.irs.gov/Form8879 for the latest information.
Internal Revenue Service

F
Submission Identification Number (SID)
Taxpayer’s name Social security number

MICHAEL A CONNERY 033-38-4944

Spouse’s name Spouse’s social security number

NIKKI CONNERY 020-44-7592

Part I Tax Return Information — Tax Year Ending December 31, 2021 (Enter year you are authorizing.)
Enter whole dollars only on lines 1 through 5.
Note: Form 1040-SS filers use line 4 only. Leave lines 1, 2, 3, and 5 blank.
1 Adjusted gross income . . . . . . . . . . . . . . . . . . . . . . . . . . 1 97702
2 Total tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 7921
3 Federal income tax withheld from Form(s) W-2 and Form(s) 1099 . . . . . . . . . . . . . 3 12856
4 Amount you want refunded to you . . . . . . . . . . . . . . . . . . . . . . 4 4935
5 Amount you owe . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Part II Taxpayer Declaration and Signature Authorization (Be sure you get and keep a copy of your return)
Under penalties of perjury, I declare that I have examined a copy of the income tax return (original or amended) I am now authorizing, and to the best of
my knowledge and belief, it is true, correct, and complete. I further declare that the amounts in Part I above are the amounts from the income tax
return (original or amended) I am now authorizing. I consent to allow my intermediate service provider, transmitter, or electronic return originator (ERO)
to send my return to the IRS and to receive from the IRS (a) an acknowledgement of receipt or reason for rejection of the transmission, (b) the reason
for any delay in processing the return or refund, and (c) the date of any refund. If applicable, I authorize the U.S. Treasury and its designated Financial
Agent to initiate an ACH electronic funds withdrawal (direct debit) entry to the financial institution account indicated in the tax preparation software for
payment of my federal taxes owed on this return and/or a payment of estimated tax, and the financial institution to debit the entry to this account. This
authorization is to remain in full force and effect until I notify the U.S. Treasury Financial Agent to terminate the authorization. To revoke (cancel) a
payment, I must contact the U.S. Treasury Financial Agent at 1-888-353-4537. Payment cancellation requests must be received no later than 2
business days prior to the payment (settlement) date. I also authorize the financial institutions involved in the processing of the electronic payment of
taxes to receive confidential information necessary to answer inquiries and resolve issues related to the payment. I further acknowledge that the
personal identification number (PIN) below is my signature for the income tax return (original or amended) I am now authorizing and, if applicable, my
Electronic Funds Withdrawal Consent.
Taxpayer’s PIN: check one box only
7 9 6 6 8
I authorize to enter or generate my PIN as my
Enter five digits, but
ERO firm name don’t enter all zeros
signature on the income tax return (original or amended) I am now authorizing.
X I will enter my PIN as my signature on the income tax return (original or amended) I am now authorizing. Check this box only
if you are entering your own PIN and your return is filed using the Practitioner PIN method. The ERO must complete Part III
below.
Your signature a Date a

Spouse’s PIN: check one box only

I authorize to enter or generate my PIN 7 9 6 6 9 as my
ERO firm name Enter five digits, but
signature on the income tax return (original or amended) I am now authorizing. don’t enter all zeros

X I will enter my PIN as my signature on the income tax return (original or amended) I am now authorizing. Check this box only
if you are entering your own PIN and your return is filed using the Practitioner PIN method. The ERO must complete Part III
below.

Spouse’s signature a Date a

Practitioner PIN Method Returns Only—continue below
Part III Certification and Authentication — Practitioner PIN Method Only
ERO’s EFIN/PIN. Enter your six-digit EFIN followed by your five-digit self-selected PIN.
Don’t enter all zeros

I certify that the above numeric entry is my PIN, which is my signature for the electronic individual income tax return (original or amended) I am now
authorized to file for tax year indicated above for the taxpayer(s) indicated above. I confirm that I am submitting this return in accordance with the
requirements of the Practitioner PIN method and Pub. 1345, Handbook for Authorized IRS e-file Providers of Individual Income Tax Returns.

ERO’s signature a EFILECOM 04/10/2022 Date a

ERO Must Retain This Form — See Instructions
Don’t Submit This Form to the IRS Unless Requested To Do So
For Paperwork Reduction Act Notice, see your tax return instructions. Form 8879 (Rev. 01-2021)
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 1040-SR U.S. Tax Return for Seniors 2021
Form Department of the Treasury—Internal Revenue Service (99)
OMB No. 1545-0074 IRS Use Only—Do not write or staple in this space.

Filing Single x Married filing jointly Married filing separately (MFS)

Status Head of household (HOH) Qualifying widow(er) (QW)
Check only If you checked the MFS box, enter the name of your spouse. If you checked the HOH or QW box, enter the child’s
one box. name if the qualifying person is a child but not your dependent a
Your first name and middle initial Last name Your social security number
MICHAEL A CONNERY 033-38-4944
If joint return, spouse’s first name and middle initial Last name Spouse’s social security number
NIKKI CONNERY 020-44-7592
Home address (number and street). If you have a P.O. box, see instructions. Apt. no. Presidential Election Campaign
183 LOWE STREET Check here if you, or your
City, town, or post office. If you have a foreign address, also complete spaces below. State ZIP code spouse if filing jointly, want
$3 to go to this fund.
LEOMINSTER MA 01453 Checking a box below will
Foreign country name Foreign province/state/county Foreign postal code not change your tax or
refund. You Spouse

At any time during 2021, did you receive, sell, exchange, or otherwise dispose of any
financial interest in any virtual currency? . . . . . . . . . . . . . . . . . . . . a Yes X No
Standard Someone can claim: You as a dependent Your spouse as a dependent
Deduction Spouse itemizes on a separate return or you were a dual-status alien

Age/Blindness { You:
Spouse:
X Were born before January 2, 1957
X Was born before January 2, 1957
Are blind
Is blind
Dependents (2) Social security number (3) Relationship to (4)  if qualifies for (see instructions):
(see instructions): (1) First name Last name you Child tax credit Credit for other dependents

If more than four

dependents, see
instructions and
check here a

1 Wages, salaries, tips, etc. Attach Form(s) W-2 . . . . . . . . . . . 1

Attach
2a Tax-exempt interest . 2a b Taxable interest . . 2b 62
Schedule B
if required. 3a Qualified dividends . . 3a b Ordinary dividends . 3b
4a IRA distributions . . . 4a b Taxable amount . . 4b
5a Pensions and annuities 5a 71936 b Taxable amount . . 5b 71594
6a Social security benefits . 6a 30642 b Taxable amount . . 6b 26046
7 Capital gain or (loss). Attach Schedule D if required. If not required,
check here . . . . . . . . . . . . . . . . . . . . . . . a 7
8 Other income from Schedule 1, line 10 . . . . . . . . . . . . . . 8
9 Add lines 1, 2b, 3b, 4b, 5b, 6b, 7, and 8. This is your total income . . a 9 97702
10 Adjustments to income from Schedule 1, line 26 . . . . . . . . . . 10
11 Subtract line 10 from line 9. This is your adjusted gross income . . a 11 97702
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Form 1040-SR (2021)
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 CONNERY 033-38-4944
Form 1040-SR (2021) Page 2

Standard 12a Standard deduction or itemized deductions (from

Deduction Schedule A) . . . . . . . . . . . . . . . . . 12a 27800
See Standard
Deduction Chart b Charitable contributions if you take the standard
on the last page deduction (see instructions) . . . . . . . . . . . 12b 600
of this form.
c Add lines 12a and 12b . . . . . . . . . . . . . . . . . . . . . 12c 28400
13 Qualified business income deduction from Form 8995 or Form 8995-A . 13
14 Add lines 12c and 13 . . . . . . . . . . . . . . . . . . . . . 14 28400
15 Taxable income. Subtract line 14 from line 11. If zero or less, enter -0- . 15 69302
16 Tax (see instructions). Check if any from:
1 Form(s) 8814 2 Form 4972 3 . . . . . . . 16 7921
17 Amount from Schedule 2, line 3 . . . . . . . . . . . . . . . . . 17
18 Add lines 16 and 17 . . . . . . . . . . . . . . . . . . . . . 18 7921
19 Nonrefundable child tax credit or credit for other dependents from
Schedule 8812 . . . . . . . . . . . . . . . . . . . . . . . . 19
20 Amount from Schedule 3, line 8 . . . . . . . . . . . . . . . . . 20
21 Add lines 19 and 20 . . . . . . . . . . . . . . . . . . . . . . 21
22 Subtract line 21 from line 18. If zero or less, enter -0- . . . . . . . . 22 7921
23 Other taxes, including self-employment tax, from Schedule 2, line 21 . . 23 0
24 Add lines 22 and 23. This is your total tax . . . . . . . . . . . a 24 7921
25 Federal income tax withheld from: FORM 1099
a Form(s) W-2 . . . . . . . . . . . . . . . . . 25a
b Form(s) 1099 . . . . . . . . . . . . . . . . 25b 12856
c Other forms (see instructions) . . . . . . . . . . 25c
d Add lines 25a through 25c . . . . . . . . . . . . . . . . . . . 25d 12856
26 2021 estimated tax payments and amount applied from 2020 return . . 26
If you have
a qualifying 27a Earned income credit (EIC) . . . . . . . . . . . 27a
child, attach Check here if you were born after January 1, 1998,
Sch. EIC.
and before January 2, 2004, and you satisfy all the
other requirements for taxpayers who are at least
age 18 to claim the EIC. See instructions . . . a
b Nontaxable combat pay election . 27b
c Prior year (2019) earned income . 27c
28 Refundable child tax credit or additional child tax
credit from Schedule 8812 . . . . . . . . . . . 28
29 American opportunity credit from Form 8863, line 8 . 29
30 Recovery rebate credit. See instructions . . . . . 30
31 Amount from Schedule 3, line 15 . . . . . . . . 31
32 Add lines 27a and 28 through 31. These are your total other payments
and refundable credits . . . . . . . . . . . . . . . . . . . a 32
33 Add lines 25d, 26, and 32. These are your total payments . . . . . a 33 12856
Go to www.irs.gov/Form1040SR for instructions and the latest information. Form 1040-SR (2021)
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 CONNERY 033-38-4944
Form 1040-SR (2021) Page 3

Refund 34 If line 33 is more than line 24, subtract line 24 from line 33. This is the
amount you overpaid . . . . . . . . . . . . . . . . . . . . . 34 4935
35a Amount of line 34 you want refunded to you. If Form 8888 is attached,
check here . . . . . . . . . . . . . . . . . . . . . . . a 35a 4935
Direct deposit? a b Routing number 2 1 1 3 9 1 8 2 5 a c Type: X Checking Savings
See
instructions. ad Account number 1 3 1 0 7 3 2 1

36 Amount of line 34 you want applied to your 2022

estimated tax . . . . . . . . . . . . . . . a 36
Amount 37 Amount you owe. Subtract line 33 from line 24. For details on how to
You Owe pay, see instructions . . . . . . . . . . . . . . . . . . . . a 37
38 Estimated tax penalty (see instructions) . . . . . a 38
Third Party Do you want to allow another person to discuss this return with the IRS? See
Designee instructions . . . . . . . . . . . . . . . . . . . . . a Yes. Complete below. No
Designee’s Phone Personal identification
name a no. a number (PIN) a

Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of
Sign my knowledge and belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information
Here of which preparer has any knowledge.
Your signature Date Your occupation If the IRS sent you an Identity
Protection PIN, enter it here
F

Joint return? RETIRED (see inst.)

See instructions.
Spouse’s signature. If a joint return, both must sign. Date Spouse’s occupation If the IRS sent your spouse an
Keep a copy for
Identity Protection PIN, enter it here
your records. (see inst.)
RETIRED
Phone no. (978) 407-0494 Email address [email protected]
Preparer’s name Preparer’s signature Date PTIN Check if:
Paid
Self-employed
Preparer
Firm’s name a Phone no.
Use Only Firm’s address a Firm’s EIN a

Go to www.irs.gov/Form1040SR for instructions and the latest information. Form 1040-SR (2021)

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 CONNERY 033-38-4944
Form 1040-SR (2021) Page 4

Standard Deduction Chart*

Add the number of boxes checked in the “Age/Blindness” section of Standard Deduction on page 1 . . . . a 2

IF your filing AND the number of THEN your standard

status is. . . boxes checked is. . . deduction is. . .
1 $14,250
Single
2 15,950
1 $26,450
Married 2 27,800
filing jointly 3 29,150
4 30,500
Qualifying 1 $26,450
widow(er) 2 27,800
Head of 1 $20,500
household 2 22,200
1 $13,900
Married filing 2 15,250
separately** 3 16,600
4 17,950
* Don’t use this chart if someone can claim you (or your spouse if filing jointly) as a dependent, your spouse itemizes on a
separate return, or you were a dual-status alien. Instead, see instructions.
** You can check the boxes for your spouse if your filing status is married filing separately and your spouse had no
income, isn’t filing a return, and can’t be claimed as a dependent on another person’s return.
Go to www.irs.gov/Form1040SR for instructions and the latest information. Form 1040-SR (2021)
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SCHEDULE B OMB No. 1545-0074
Interest and Ordinary Dividends
2021
(Form 1040)
a Go to www.irs.gov/ScheduleB for instructions and the latest information.
Department of the Treasury a Attach to Form 1040 or 1040-SR.
Attachment
Internal Revenue Service (99) Sequence No. 08
Name(s) shown on return Your social security number
MICHAEL & NIKKI CONNERY 033-38-4944
Part I 1 List name of payer. If any interest is from a seller-financed mortgage and the Amount
buyer used the property as a personal residence, see the instructions and list this
Interest interest first. Also, show that buyer’s social security number and address a
(See instructions
DIGITAL FEDERAL CREDIT UNION 62
and the
Instructions for
Form 1040, line
2b.)

Note: If you 1
received a Form
1099-INT, Form
1099-OID, or
substitute
statement from
a brokerage firm,
list the firm’s
name as the
payer and enter
the total interest
shown on that
form.
2 Add the amounts on line 1 . . . . . . . . . . . . . . . . . . . 2 62
3 Excludable interest on series EE and I U.S. savings bonds issued after 1989.
Attach Form 8815 . . . . . . . . . . . . . . . . . . . . . . 3
4 Subtract line 3 from line 2. Enter the result here and on Form 1040 or 1040-SR,
line 2b . . . . . . . . . . . . . . . . . . . . . . . . a 4 62
Note: If line 4 is over $1,500, you must complete Part III. Amount
Part II 5 List name of payer a

Ordinary
Dividends
(See instructions
and the
Instructions for
Form 1040, line
3b.) 5
Note: If you
received a Form
1099-DIV or
substitute
statement from
a brokerage firm,
list the firm’s
name as the
payer and enter
the ordinary
dividends shown
on that form.
6 Add the amounts on line 5. Enter the total here and on Form 1040 or 1040-SR,
line 3b . . . . . . . . . . . . . . . . . . . . . . . . a 6
Note: If line 6 is over $1,500, you must complete Part III.
Part III You must complete this part if you (a) had over $1,500 of taxable interest or ordinary dividends; (b) had a
Yes No
foreign account; or (c) received a distribution from, or were a grantor of, or a transferor to, a foreign trust.
Foreign 7a At any time during 2021, did you have a financial interest in or signature authority over a financial
Accounts account (such as a bank account, securities account, or brokerage account) located in a foreign
and Trusts country? See instructions . . . . . . . . . . . . . . . . . . . . . . . . X
Caution: If If “Yes,” are you required to file FinCEN Form 114, Report of Foreign Bank and Financial
required, failure Accounts (FBAR), to report that financial interest or signature authority? See FinCEN Form 114
to file FinCEN and its instructions for filing requirements and exceptions to those requirements . . . . . .
Form 114 may
result in
b If you are required to file FinCEN Form 114, enter the name of the foreign country where the
substantial financial account is located a
penalties. See 8 During 2021, did you receive a distribution from, or were you the grantor of, or transferor to, a
instructions. foreign trust? If “Yes,” you may have to file Form 3520. See instructions . . . . . . . . . X
For Paperwork Reduction Act Notice, see your tax return instructions. Schedule B (Form 1040) 2021
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MICHAEL & NIKKI CONNERY 033-38-4944

Social Security Benefits Worksheet—Lines 6a and 6b Keep for Your Records

Before you begin: Figure any write-in adjustments to be entered on Schedule 1, line 24z (see the instructions for Schedule
1, line 24z).
If you are married filing separately and you lived apart from your spouse for all of 2021, enter “D” to
the right of the word “benefits” on line 6a. If you don’t, you may get a math error notice from the IRS.
Be sure you have read the Exception in the line 6a and 6b instructions to see if you can use this
worksheet instead of a publication to find out if any of your benefits are taxable.

1. Enter the total amount from box 5 of all your Forms SSA-1099 and
RRB-1099. Also enter this amount on Form 1040 or 1040-SR,
line 6a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. 30642
2. Multiply line 1 by 50% (0.50) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. 15321
3. Combine the amounts from Form 1040 or 1040-SR, lines 1, 2b, 3b, 4b, 5b, 7, and 8 . . . . . . . . . . . 3. 71656
4. Enter the amount, if any, from Form 1040 or 1040-SR, line 2a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.
5. Combine lines 2, 3, and 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. 86977
6. Enter the total of the amounts from Schedule 1, lines 11 through 20, and 23 and 25 . . . . . . . . . . . 6.
7. Is the amount on line 6 less than the amount on line 5?
No. None of your social security benefits are taxable. Enter -0- on Form 1040 or
STOP
1040-SR, line 6b.
X Yes. Subtract line 6 from line 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. 86977

8. If you are:
• Married filing jointly, enter $32,000
• Single, head of household, qualifying widow(er), or married filing
separately and you lived apart from your spouse for all of 2021,
enter $25,000 ............... 8. 32000
• Married filing separately and you lived with your spouse at any time
in 2021, skip lines 8 through 15; multiply line 7 by 85% (0.85) and
enter the result on line 16. Then, go to line 17
9. Is the amount on line 8 less than the amount on line 7?
No. None of your social security benefits are taxable. Enter -0- on Form 1040 or
STOP
1040-SR, line 6b. If you are married filing separately and you lived apart from
your spouse for all of 2021, be sure you entered “D” to the right of the word
“benefits” on line 6a.
X Yes. Subtract line 8 from line 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. 54977

10. Enter $12,000 if married filing jointly; $9,000 if single, head of household, qualifying
widow(er), or married filing separately and you lived apart from your spouse for all
of 2021 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10. 12000
11. Subtract line 10 from line 9. If zero or less, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 42977
12. Enter the smaller of line 9 or line 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. 12000
13. Enter one-half of line 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13. 6000
14. Enter the smaller of line 2 or line 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14. 6000
15. Multiply line 11 by 85% (0.85). If line 11 is zero, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15. 36530
16. Add lines 14 and 15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16. 42530
17. Multiply line 1 by 85% (0.85) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17. 26046
18. Taxable social security benefits. Enter the smaller of line 16 or line 17. Also enter this amount
on Form 1040 or 1040-SR, line 6b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18. 26046

TIP If any of your benefits are taxable for 2021 and they include a lump-sum benefit payment that was for an earlier
year, you may be able to reduce the taxable amount. See Lump-Sum Election in Pub. 915 for details.

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-31- Need more information or forms? Visit IRS.gov.

 MICHAEL & NIKKI CONNERY 033-38-4944
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 0XOWLSO\OLQHE\OLQH                                                                         2800 
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 2021
Form M-8453 Massachusetts
Individual Income Tax Declaration Department of

for Electronic Filing Revenue

Please print or type. Privacy Act Notice available upon request. For the year January 1–December 31, 2021.
Your first name and initial Last name Your Social Security number
MICHAEL A CONNERY 033-38-4944
If a joint return, spouse’s first name and initial Last name Spouse’s Social Security number
NIKKI CONNERY 020-44-7592
Present street address (and apartment number)
183 LOWE STREET
City/Town/Post Office State Zip Filing status: Single x Married filing jointly
LEOMINSTER MA, 01453- Married filing separately Head of household

Part 1. Tax Return Information for Electronic Filing

1 Total 5.0% income (from Form 1, line 10, or Form 1-NR/PY, line 12). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 8943
2 Income tax after credits (from Form 1, line 32, or Form 1-NR/PY, line 36). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Massachusetts use tax (from Form 1, line 34, or Form 1-NR/PY, line 38). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4 Massachusetts income tax withheld (from Form 1, line 38, or Form 1-NR/PY, line 42). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 456
5 Refund amount (from Form 1, line 50, or Form 1-NR/PY, line 54). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 456
6 Tax due (from Form 1, line 51, or Form 1-NR/PY, line 55). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Part 2. Declaration and Signature of Taxpayer

Under pains and penalties of perjury, I declare that I have reviewed the information on my return with the information I have provided to my Electronic
Return Originator and that the amounts above agree with the amounts shown on my 2021 Massachusetts return. To the best of my knowledge and belief
this information is true, correct and complete. I consent that my return, including this declaration and accompanying schedules, forms and statements be
sent to the Massachusetts Department of Revenue by my Electronic Return Originator. I authorize DOR to inform my Electronic Return Originator and/or
the transmitter when my electronic return has been accepted. In the event that it is rejected, I authorize DOR to identify the reasons for rejection so that
the return can be corrected and re-transmitted. If I have filed a balance due return, I understand that if DOR does not receive full and timely payment of
my tax liability, I will remain liable for the tax liability and all applicable penalties and interest.
Your signature Date Spouse’s signature (if joint return, both must sign) Date

Part 3. Declaration and Signature of Electronic Return Originator (ERO)

I declare that I have reviewed the above taxpayer’s return and that the entries on this M-8453 are complete and correct to the best of my knowledge.
(Collectors are not responsible for reviewing the taxpayer’s return; however, they must ensure that the M-8453 accurately reflects the data on the return.)
I have obtained the taxpayer’s signature before submitting this return to the Massachusetts Department of Revenue. I have provided the taxpayer with
a copy of all forms and information filed with the Massachusetts Department of Revenue. If I am also the paid preparer, under pains and penalties of
perjury I declare that I have examined the above taxpayer’s return and accompanying schedules and statements and to the best of my knowledge and
belief, they are true, correct and complete. I declare that I have verified the taxpayer’s proof of account and it agrees with the name(s) shown on this form.
This declaration of paid preparer (other than taxpayer) is based on all information of which the preparer has any knowledge. Original Forms M-8453
should not be sent to DOR, but must instead be retained by the ERO on the ERO’s business premises for a period of three years from the date the return
to which the M-8453 relates was filed.
ERO’s signature and SSN or PTIN Date EIN Check if
self-employed

Firm name (or yours, if self-employed) and address City/Town State Zip Check if also
paid preparer

Part 4. Declaration and Signature of Paid Preparer (if other than ERO)
Under pains and penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of
my knowledge and belief it is true, correct and complete. This declaration of paid preparer (other than taxpayer) is based on all information of which the
preparer has any knowledge.
Paid preparer’s signature and SSN or PTIN Date EIN Check if
self-employed

Firm name (or yours, if self-employed) and address City/Town State Zip

V#1038
 2021 Form 1
MA21001011038
Massachusetts Resident Income Tax Return
FOR FULL YEAR RESIDENTS ONLY
For the year January 1–December 31, 2021 or other taxable

Year beginning Ending

MICHAEL A CONNERY 033384944

NIKKI CONNERY 020447592
183 LOWE STREET LEOMINSTER MA 01453

Fill in if: Amended return Other jurisdiction change Federal amendment Amended return due to IRS BBA Partnership Audit
State Election Campaign Fund: $1 You $1 Spouse TOTAL
Fill in if veteran of Operations Enduring Freedom, Iraqi Freedom, Noble Eagle or Sinai Peninsula You Spouse
Fill in if name change You Spouse
Taxpayer deceased You Spouse
Fill in if under age 18 You Spouse
a. Total federal income 97702 Fill in if noncustodial parent
b. Federal adjusted gross income 97702 Fill in if filing Schedule TDS
1. Filing status (select one only): Single Fill in if filing Schedule FCI
X Married filing jointly Fill in if reporting crypto currency
Married filing separate return
Head of household You are a custodial parent who has released claim to exemption for child(ren)
2. Exemptions
a. Personal exemptions 2a 8800
b. Number of dependents. (Do not include yourself or your spouse.) Enter number × $1,000 = 2b
c. Age 65 or over before 2022 X You + X Spouse = 2 × $700 = 2c 1400
d. Blindness You + Spouse = × $2,200 = 2d
e. Medical/dental 2e
f. Adoption 2f
g. Total exemptions. Add items 2a through 2f. Enter here and on line 18 2g 10200
SIGN HERE. Under penalties of perjury, I declare that to the best of my knowledge and belief this return and enclosures are true, correct and complete.
Your signature Date Spouse’s signature Date

[email protected] 9784070494
PRIVACY ACT NOTICE AVAILABLE UPON REQUEST

04/10/2022 08:52:38 PM
 2021 Form 1, pg. 2
MA21001021038
Massachusetts Resident Income Tax Return
033384944

3. Wages, salaries, tips 3

4. Taxable pensions and annuities 4 8943
5. Mass. bank interest: a. 62 – b. exemption 200 =5
6a. Business/profession income/loss 6a
6b. Farming income/loss 6b
7. Rental, royalty and REMIC, partnership, S corp., trust income/loss 7
8a. Unemployment 8a
8b. Mass. lottery winnings 8b
9. Other income from Schedule X, line 6 9
10. TOTAL 5.0% INCOME 10 8943
11a. Amount paid to Soc. Sec. Medicare, R.R., U.S. or Mass. Retirement 11a
11b. Amount your spouse paid to Soc. Sec., Medicare, R.R., U.S. or Mass. Retirement 11b
12. Reserved for future use 12
13. Reserved for future use 13

14. Rental deduction. a. ÷ 2 = 14

15. Other deductions from Schedule Y, line 19 15
16. Total deductions. Add lines 11 through 15 16
17. 5.0% INCOME AFTER DEDUCTIONS. Subtract line 16 from line 10. Not less than “0” 17 8943
18. Exemption amount 18 10200
19. 5.0% INCOME AFTER EXEMPTIONS. Subtract line 18 from line 17. Not less than “0” 19
20. INTEREST AND DIVIDEND INCOME 20
21. TOTAL TAXABLE 5.0% INCOME. Add lines 19 and 20 21

BE SURE TO INCLUDE THIS PAGE WITH FORM 1, PAGE 1

04/10/2022 08:52:38 PM
 2021 Form 1, pg. 3
MA21001031038
Massachusetts Resident Income Tax Return
033384944

22. TAX ON 5.0% INCOME. Note: If choosing the optional 5.85% tax rate, fill in and multiply line 21 and the
amount in Schedule D, line 21 by .0585 22
23. 12% INCOME. Not less than “0.” a. × .12 = 23
24. TAX ON LONG-TERM CAPITAL GAINS. Not less than “0.” Fill in if filing Schedule D-IS 24
Fill in if any excess exemptions were used in calculating lines 20, 23 or 24
25. Credit recapture amount (from Credit Recapture Schedule) 25
26. Additional tax on installment sale 26
27. If you qualify for No Tax Status, fill in and enter “0” on line 28 X
28. TOTAL INCOME TAX. Add lines 22 through 26 28
29. Limited Income Credit 29
30. Income tax due to another state or jurisdiction 30
31. Other credits from Credit Manager Schedule 31
32. INCOME TAX AFTER CREDITS. Subtract the total of lines 29 through 31 from line 28. Not less than “0” 32
33. Voluntary Contributions
a. Endangered Wildlife Conservation 33a
b. Organ Transplant Fund 33b
c. Massachusetts Public Health HIV and Hepatitis Fund 33c
d. Massachusetts U.S. Olympic Fund 33d
e. Massachusetts Military Family Relief Fund 33e
f. Homeless Animal Prevention and Care 33f
Total. Add lines 33a through 33f 33
34. Use tax due on Internet, mail order and other out-of-state purchases 34
35. Health care penalty a. You + b. Spouse 35
36. Amended return only. Overpayment from original return 36
37. INCOME TAX AFTER CREDITS PLUS CONTRIBUTIONS AND USE TAX. Add lines 32 through 36 37

04/10/2022 08:52:38 PM
 2021 Form 1, pg. 4
MA21001041038
Massachusetts Resident Income Tax Return
033384944

38. Massachusetts income tax withheld 38 456

39. 2020 overpayment applied to your 2021 estimated tax 39
40. 2021 Massachusetts estimated tax payments 40
41. Payments made with extension 41
42. Amended return only. Payments made with original return. Not less than “0” 42
43. Earned Income Credit. a. Number of qualifying children b. Amount from U.S. return × .30 = 43
Note: You cannot claim the Earned Income Credit if your filing status is married filing separately unless you qualify
for an exception (see instructions). Fill in if you qualify for this exception
44. Senior Circuit Breaker Credit 44
45. Child under age 13, or disabled dependent/spouse credit 45
46. Dependent member(s) of household under age 12, or dependent(s) age 65 or over (not you or your spouse)
as of December 31, 2021 credit.
Not more than two. a. × $180 = 46
47. Other Refundable Credits 47
48. Excess Paid Family Leave Withholding 48
49. TOTAL. Add lines 38 through 48 49 456
50. Overpayment. Subtract line 37 from line 49 50 456
51. Amount of overpayment you want applied to your 2022 estimated tax 51
52. Refund. Subtract line 51 from line 50. Mail to: Massachusetts DOR, PO Box 7000, Boston, MA 02204 52 456

Direct deposit of refund. Type of account checking

savings
RTN # account #

53. Tax due. Pay online at www.mass.gov/dor/payonline. Mail to: Mass. DOR, PO Box 7003, Boston, MA 02204 53
Interest Penalty M-2210 amt. EX enclose
Form M-2210

May the Department of Revenue discuss this return with the preparer shown here?
I do not want preparer to file my return electronically (this may delay your refund) Paid preparer’s
Print paid preparer’s name Date Check if self-employed SSN/PTIN
04102022
Paid preparer’s signature Paid preparer’s phone Paid preparer’s EIN

BE SURE TO INCLUDE THIS PAGE WITH FORM 1, PAGE 1

04/10/2022 08:52:38 PM
MICHAEL A CONNERY 033384944

Form 1, Line 27 Massachusetts AGI Worksheet.

No Tax Status (Only If Single, Head of Household
or Married Filing Jointly)
1. Enter your total 5.0% income from Form
1, line 10. Not less than 0. (Add back any
Abandoned Building Renovation deduction
claimed on Schedule(s) C and/or E
before entering an
amount in line 1.) . . . . . . . . 8943

2. Add Schedule Y, lines

2 to 10 and line 18 . . . . . . .
3. Subtract line 2 from
8943
line 1. Not less than 0 . . . . .
4. Enter total Mass. bank interest or the inter-
est exemption amount, whichever is smaller,
from Form 1,
62
line 5a or line 5b . . . . . . . . .
Note: If Form 1, line 10 is a loss, combine
Form 1, line 10 with the smaller amount of
total Massachusetts bank interest or the in-
terest exemption amount. Enter the result in
line 4, unless the result is a loss. If the result
is a loss, enter 0.
5. Enter amount from Schedule B, line 35. If
there is no entry in Schedule B, line 35 or if
not filing Schedule B, enter
the amount from Form 1,
line 20 . . . . . . . . . . . . . . . . .
6. Enter the amount from Schedule D, line
19. Not less than 0. (If filing Schedule D-IS,
Installment Sales, see the Schedule D-IS
instructions, available at mass.gov/dor,
for the amount to enter in
line 6.) . . . . . . . . . . . . . . . . .

7. Add lines 3 through 6 . . . 9005

If you are single and the total in line 7 is

$8,000 or less, you qualify for No Tax Status.
Fill in the oval in line 27, enter 0 in line 28 and
omit lines 29 through 31. Also, enter 0 in line
32 and complete Form 1. However, if there is
an amount entered in line 25, Credit Recap-
ture Amount and/or line 26, Additional Tax on
Installment Sales, enter that amount in line
28 and complete line 31. If you are single but
do not qualify for No Tax Status, and your
total in line 7 is $14,000 or less, complete
Form 1, line 28 and see Form 1, line 29 in-
structions for the Limited Income Credit. If
you are filing as head of household or mar-
ried filing a joint return, compare line 7 with
the No Tax Status/Limited Income Credit
Chart to see if you may qualify for No Tax
Status or the Limited Income Credit.

1038
 2021 Schedule HC
MA21029011038

Schedule HC, Health Care Information, must be completed by all

full-year residents and certain part-year residents (see instructions).
Note: Schedule HC must be enclosed with your Form 1 or Form
1-NR/PY. Failure to do so will delay the processing of your return.
MICHAEL A CONNERY 033384944

1a. Date of birth 04231950 1b. Spouse’s date of birth 12101952 1c. Family size 2

2. Federal adjusted gross income 2 97702

3. Indicate the time period that you were enrolled in a Minimum Creditable Coverage (MCC) health insurance plan(s). The Form MA 1099-HC from your
insurer will indicate whether your insurance met MCC requirements. Note: MassHealth, Medicare, and health coverage for U.S. Military, including
Veterans Administration and Tri-Care, meet the MCC requirements. If you did not receive a Form MA 1099-HC from your insurer, or you had insurance
that did not meet MCC requirements, see the special section on MCC requirements in the instructions.

See instructions if, during 2021, you turned 18, you 3a You: X Full-year MCC Part-year MCC No MCC/None
were a part-year resident or a taxpayer was deceased. 3a Spouse: X Full-year MCC Part-year MCC No MCC/None
If you filled in the full-year or part-year MCC oval, go to line 4. If you filled in No MCC/None, go to line 6.

4. Indicate the health insurance plan(s) that met the Minimum Creditable Coverage (MCC) requirements in which you were enrolled in 2021, as
shown on Form MA 1099-HC (check all that apply). If you did not receive this form, fill in line(s) 4f and/or 4g and see instructions. Fill in if you were
enrolled in private insurance and MassHealth or Commonwealth Care and enter your private insurance information in line(s) 4f and/or 4g and go
to line 5.
4a. Private insurance, including ConnectorCare (completes line(s) 4f and/or 4g below) X You X Spouse
4b. MassHealth. Fill in and go to line 5 You Spouse
4c. Medicare (including a replacement or supplemental plan). Fill in and go to line 5 X You X Spouse
4d. U.S. Military (including Veterans Administration and Tri-Care). Fill in and go to line 5 You Spouse
4e. Other program (enter the program name(s) only in lines 4f and/or 4g below). Note: Health Safety Net You Spouse
is not considered insurance or minimum creditable coverage.

4f. Your Health Insurance. Complete if you answered line(s) 4a or 4e and go to line 5.
BLE CROSS BLUE SHIELD OF MA 9838267090000

4g. Spouse Health Insurance. Complete if you answered line(s) 4a or 4e and go to line 5.
BLUE CROSS BLUE SHIELD OF MA 9838267090001

5. If you had health insurance that met MCC requirements for the full-year, including private insurance, MassHealth, Commonwealth Care or ConnectorCare,
you are not subject to a penalty. Skip the remainder of this schedule and continue completing your tax return. Other wise, go to line 6.

If you had Medicare (including a replacement or supplemental plan), U.S. Military (including Veterans Administration and Tri-Care), or other government
insurance at any point during 2021, you are not subject to a penalty. Skip the remainder of this schedule and continue completing your tax return.
Otherwise, go to line 6.

04/10/2022 08:52:38 PM
 2021 Schedule HC, pg. 2
033384944 MA21029021038

You might be eligible for low- or no-cost health insurance coverage.

If you (and/or your spouse, if married filing jointly) do not have health insurance coverage, you might be eligible for health insurance coverage programs made
available by the Commonwealth of Massachusetts. By filling in the oval below, you authorize DOR to share information from your tax return and attached schedules
with the Health Connector. If you are married filing jointly, both spouses must check the box for the Health Connector to receive all of your information. The Health
Connector will assess your eligibility for those coverage options, including low- or no-cost coverage, and contact you with information. See instructions.
You: I authorize DOR to share this tax return including attached schedules with the Massachusetts Health Connector for the purpose of assessing
my eligibility for insurance affordability programs and contacting me with information about the same.
Spouse: I authorize DOR to share this tax return including attached schedules with the Massachusetts Health Connector for the purpose of assessing
my eligibility for insurance affordability programs and contacting me with information about the same.
Your Health Insurance
6. Was your income in 2021 at or below 150% of the federal poverty level? 6 Yes No
If you answer Yes, you are not subject to a penalty in 2021. Skip the remainder of this schedule and complete your tax return. If you answer No and you were enrolled
in a health insurance plan that met the MCC requirements for part, but not all, of 2021, go to line 7. If you answer No and you had no insurance or you were enrolled
in a plan that did not meet the MCC requirements during the period that the mandate applied, go to line 8a.
7. Complete this section only if you, and/or your spouse if married filing jointly, were enrolled in a health insurance plan(s) that met the Minimum Creditable
Coverage (MCC) requirements for part, but not all of 2021. Fill in below the months that met the MCC requirements, as shown on Form MA 1099-HC. If you
did not receive this form, fill in the months you were covered by a plan that met the MCC requirements at least 15 days or more. If, during 2021, you turned
18, you were a part-year resident or a taxpayer was deceased, fill in the oval(s) below for the month(s) that met the MCC requirements during the period
that the mandate applied. See instructions.
You may only fill in the month(s) you had health insurance that met MCC requirements. If you had health insurance, but it did not meet MCC requirements,
you must skip this section and go to line 8a.

Months Covered By Health Insurance

You: Jan. Feb. March April May June July Aug. Sept. Oct. Nov. Dec.
Spouse: Jan. Feb. March April May June July Aug. Sept. Oct. Nov. Dec.
If you had four or more consecutive months either with no insurance or insurance that did not meet the MCC requirements (four or more blank months in a row),
go to line 8a. Otherwise, a penalty does not apply to you in 2021. Skip the remainder of this schedule and complete your tax return.

Religious Exemption and Certificate of Exemption

8a. Religious exemption: Are you claiming an exemption from the requirement to purchase health insurance based 8a You Yes No
on your sincerely held religious beliefs that cause you to object to substantially all forms of treatment covered by
health insurance? Spouse Yes No
If you answer Yes, go to line 8b. If you answer No, go to line 9.
8b. If you are claiming a religious exemption in line 8a, did you receive medical health care during the 2021 tax year? 8b You Yes No
Spouse Yes No
If you answer No to line 8b, skip the remainder of this schedule and continue completing your tax return. If you answer Yes to line 8b, go to line 9.
9. Certificate of exemption: Have you obtained a Certificate of Exemption issued by the Massachusetts Health 9 You Yes No
Connector for the 2021 tax year? Spouse Yes No
If you answer Yes, enter the certificate number, skip the remainder of this schedule and continue completing your tax
return. If you answer No to line 9, go to line 10.

04/10/2022 08:52:38 PM
 2021 Schedule HC, pg. 3
MA21029031038

MICHAEL A CONNERY 033384944

Affordability as Determined By State Guidelines

Note: This section will require the use of worksheets and tables found in the instructions. You must complete the worksheet(s) to determine if health insurance was
affordable to you during the 2021 tax year.
10. Did your employer offer affordable health insurance that met minimum creditable coverage requirements 10 You Yes No
as determined by completing the Schedule HC Worksheet for Line 10 in the instructions? Spouse Yes No
Fill in No if your employer did not offer health insurance that met minimum creditable coverage requirements, you were not eligible for health insurance offered by
your employer, you were self-employed or you were unemployed.
11. Were you eligible for government-subsidized health insurance as determined by completing the Schedule HC 11 You Yes No
Worksheet for Line 11 in the instructions? Spouse Yes No
If you answer No, go to line 12. If you answer Yes, go to the Health Care Penalty Worksheet in the instructions to calculate your penalty amount.
12. Were you able to purchase affordable private health insurance that met minimum creditable coverage requirements 12 You Yes No
as determined by completing the Schedule HC Worksheet for Line 12 in the instructions? Spouse Yes No
If you answer No, you are not subject to a penalty. Continue completing your tax return. If you answer Yes, go to the Health Care Penalty Worksheet in the
instructions to calculate your penalty amount.

Complete Only If You Are Filing An Appeal

You must complete the Health Care Penalty Worksheet to determine your penalty amount before completing this section.
You may have grounds to appeal if you were unable to obtain affordable insurance that meets the minimum creditable coverage requirements in 2021 due to a
hardship or other circumstances. The grounds for appeal are explained in more detail in the instructions. If you believe you have grounds for appealing the penalty,
fill in the field(s) below. The appeal will be heard by the Massachusetts Health Connector. By filling in the field below, you (or your spouse if married filing jointly) are
authorizing DOR to share information from your tax return, including this schedule, with the Massachusetts Health Connector for purposes of deciding your appeal.
You will receive a follow-up letter asking you to state your grounds for appeal in writing, and submit supporting documentation. Failure to respond to
that letter within the time specified in the letter will lead to dismissal of your appeal and will result in a future assessment of a penalty. Once your
documentation is received, it will be reviewed by the Massachusetts Health Connector and you may be required to attend a hearing on your case. You will be required
to file your claims under the pains and penalties of perjury.
Note: If you are filing an appeal, make sure you have calculated the penalty amount that you are appealing, but do not assess yourself or enter a penalty amount
on your Form 1 or Form 1-NR/PY. Also, do not include any hardship documentation with your original return. You will be required to submit substantiating hardship
documentation at a later date during the appeal process.

You: I wish to appeal the penalty. I authorize DOR to share this tax return including this schedule with the Massachusetts Health Connector
for purposes of deciding this appeal.

Spouse: I wish to appeal the penalty. I authorize DOR to share this tax return including this schedule with the Massachusetts Health Connector
for purposes of deciding this appeal.

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 2021 Schedule B
MA21010011038

MICHAEL A CONNERY 033384944

Part 1. Interest and Dividend Income

1. Total interest income 1 62
2. Total ordinary dividends 2
3. Other interest and dividends not included above 3
4. Total interest and dividends 4 62
5. Total interest from Massachusetts banks 5 62
6a. Other interest and dividends to be excluded 6a
6b. Part-year/Nonresidents only 6b
7. Subtotal 7
8. Allowable deductions from your trade or business 8
9. Subtotal 9

Part 2. Short-Term Capital Gains/Losses and Long-Term Gains on Collectibles

10. Massachusetts short-term capital gains 10
11. Massachusetts long-term capital gains on collectibles and pre-1996 installment sales 11
12. Massachusetts gain on the sale, exchange or involuntary conversion of property used in a trade or business and
held for one year or less 12
13a. Add lines 10 through 12 13a
13b. Part-year/Nonresidents only 13b
13c. Subtract line 13b from line 13a. Not less than 0 13c
14. Allowable deductions from your trade or business 14
15. Subtotal 15
16. Massachusetts short-term capital losses 16
17. Massachusetts loss on the sale, exchange or involuntary conversion of property used in a trade or business and
held for one year or less 17
18. Prior short-term unused losses for years beginning after 1981 18

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 2021 Schedule B, pg. 2
033384944 MA21010021038

19a. Combine lines 15 through 18 19a

19b. Part-year/Nonresidents only 19b
19c. Exclude line 19b losses from line 19a 19c
20. Short-term losses applied against interest and dividends 20
21. Available short-term losses 21
22. Short-term losses applied against long-term gains 22
23. Short-term losses available for carryover in 2022 23
24. Short-term gains and long-term gains on collectibles 24
25. Long-term losses applied against short-term gain 25
26. Subtotal 26
27. Long-term gains deduction 27
28. Short-term gains after long-term gains deduction 28

Part 3. Adjusted Gross Interest, Dividends, Short-Term Capital Gains and Long-Term Gains on Collectibles
29. Enter the amount from line 9 29
30. Short-term losses applied against interest and dividends 30
31. Subtotal interest and dividends 31
32. Long-term losses applied against interest and dividends 32
33. Adjusted interest and dividends 33
34. Enter the amount from line 28 34
35. Adjusted gross interest, dividends and certain capital gains 35
36. Excess exemptions 36
37. Subtract line 36 from line 35 37
38. Interest and dividends taxable at 5.0% 38
39. Taxable 12% capital gains 39
40. Available short-term losses for carryover in 2022 40

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2021 Schedule INC
MA21INC011038

MICHAEL A CONNERY 033384944

Form W-2 and 1099 Information

A. FEDERAL ID NUMBER B. STATE TAX WITHHELD C. STATE WAGES/INCOME D. TAXPAYER SS WITHHELD E. SPOUSE SS WITHHELD F. SOURCE OF WITHHOLDING

42-0127290 456 8943 1099R

TOTALS 456 8943

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