Form 1040 U.S. Individual Income Tax Return 2011

• Under Name, address, and SSN, see separate instructions.:
• • Your first name and initial field contains Charles
  • Last name field contains Woods
  • Your social security number field contains 123-00-4567
  • If a joint return, spouse's first name and initial field contains Lily
  • Last name field contains Woods
  • Spouse's social security number field contains 567-00-1234
  • Home address (number and street). If you have a P.O. box, see instructions. field contains 6925 Country Road
  • City, town or post office, state, and ZIP code. If you have a foreign address, see instructions. field contains Anytown, VA 22306
  • Presidential Election Campaign Check here if you, or your spouse if filing jointly, want $3 to go to this fund (see page 14) Checking a box below will not change your tax or refund.
  • • You: Yes checkbox checked
    • Spouse: Yes checkbox checked
• Under Filing Status Check only one box.:
• • 2. Married filing jointly (even if only one had income) checkbox checked
• Under Exemptions:
• • 6a. Yourself. If someone can claim you as a dependent, do not check box 6a checkbox checked
  • 6b. Spouse checkbox checked
  • Boxes checked on 6a and 6b field contains 2
  • 6d. Total number of exemptions claimed Add numbers on lines above field contains 2
• Under Income:
• • 7. Wages, salaries, tips, etc. Attach Form(s) W-2field contains 132,000
  • 13. Capital gain or (loss). Attach Schedule D if required. If not required, check here ▸ □ field contains 22,076
  • 17. Rental real estate, royalties, partnerships, S. corporations, trusts, etc. Attach Schedule Efield contains (21,094)
  • 22. Combine the amounts in the far right column for lines 7 through 21. This is your total income field contains 132,982
• Under Adjusted Gross Income:
• • 37. Subtract line 36 from line 22. This is your adjusted gross income field contains 132,982

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