Form 1040A United States Individual Income Tax Return 2012

Summary: This is an example of Form 1040A (2012) with these line items completed as would pertain to the text.

Under Label:
- Your first name and initial field contains Joshua A.
- Last name field contains Blake
- Your social security number field contains 111-00-1111
- Home address (number and street). If you have a Post Office box, see instructions. field contains 1040A Main Street
- City, town or post office, state, and ZIP code. If you have a foreign address, see instructions. field contains Hometown, Arizona 85240
- Presidential Election Campaign
- - Do you, or your spouse if filing a joint return, want $3 to go to this fund? You: Yes Note. Checking Yes will not change your tax or reduce your refund. Do you, or your spouse if filing a joint return, want $3 to go to this fund? You: Yes checkbox checked
Under Filing Status:
- 1. Single checkbox checked
Under Exemptions:
- 6d. Total number of exemptions claimed. Add numbers on line above field contains 0
Under Income:
- 7. Wages, salaries, tips, etc. Attach Form(s) W-2. field contains 1,550
- 8a. Taxable interest. Attach Schedule B if required. field contains 1,050
- 9a. Ordinary dividends. Attach Schedule B if required. field contains 1,050
- 9b. Qualified dividends (see instructions). field contains 1,050
- 10. Capital gain distributions (see instructions). field contains 700
- 15. Add lines 7 through 14b (far right column). This is your total income field contains 4,350
Under Adjusted gross income:
- 21. Subtract line 20 from line 15. This is your adjusted gross income. field contains 4,350