Name:

Kelsey Ewell

CHAPTER 12 TAX RETURN ASSIGNMENT

Using the data for NOAH AND JOAN ARC (Comprehensive Problem One from Appendix D, on page
D-2 of your textbook), prepare the FEDERAL and UTAH tax returns using any method you choose.
Since you will need to prepare the Utah return, please assume the taxpayer lives in Utah, rather
than California. Using the completed returns, answer the following questions:
1. What amount of qualified dividends is reported on the 1040?

____320_____________

2. What is the net income (loss) from Schedule C?

____42,020___________

3. What is the total capital gain (loss) reported on Schedule D?

____11,050___________

4. What is the total capital gain (loss) reported on Schedule E?

____1,755____________

5. How much are total FOR AGI adjustments (1040, line 36)?

_____2,969___________

6. How much are total itemized deductions on Schedule A?

_____16,170__________

7. What amount is reported as Taxable Income?

_____48,128__________

8. What amount is reported as federal tax on line 44?

_____6,304___________

9. How much can be taken in total credits on Form 1040, line 55?

______690____________

10. How much is reported as total payments on Form 1040, line 74?

_____17,050__________

11. What is the Utah taxable income reported on Form TC-40, line 9? _____80,298__________
12. How much is the Utah taxpayer tax credit reported on the TC-40, line 20? _____944_______
13. How much is reported as withholdings/credits on the TC-40, line 39? _________0_________

SUBMISSION INSTRUCTIONS:
Using this page as a coversheet, please scan/print this page and the completed tax return to a
single PDF file and upload the return through Canvas for grading on or before the due date noted
in Canvas. Late returns will be subject to the late penalty and will only be accepted for 1 week
beyond the due date.
This assignment serves as the ePortfolio signature assignment for this course. Please upload the
return, along with a brief reflection, to your ePortfolio and provide your ePortfolio link in Canvas.

Form

1040

2015

(99)

Department of the TreasuryInternal Revenue Service

U.S. Individual Income Tax Return

OMB No. 1545-0074

, 2015, ending

IRS Use OnlyDo not write or staple in this space.

See separate instructions.

For the year Jan. 1Dec. 31, 2015, or other tax year beginning
Your first name and initial

Last name

, 20

Your social security number

Noah

Arc

4 3 4 1 1 3 3 1 1

Joan

Arc

Spouses social security number

Last name

If a joint return, spouses first name and initial

4 5 6 8 7 5 4 3 2

Apt. no.

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

4342 Josie Jo

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

Presidential Election Campaign

Check here if you, or your spouse if filing
jointly, want $3 to go to this fund. Checking
Foreign postal code
a box below will not change your tax or
refund.
You
Spouse

Santee, CA 92071
Foreign country name

Filing Status
Check only one
box.

Exemptions

Foreign province/state/county

1
2
3

6a
b
c

Income
Attach Form(s)
W-2 here. Also
attach Forms
W-2G and
1099-R if tax
was withheld.

If you did not

get a W-2,
see instructions.

Adjusted
Gross
Income

childs name here.

Spouse
.
Dependents:

(2) Dependents
social security number

Last name

(4) if child under age 17

qualifying for child tax credit
(see instructions)

(3) Dependents
relationship to you

5 9 8 0 1 2 3 4 5
5 5 4 3 3 2 4 1 1

Total number of exemptions claimed

.
8b
. .

8a

9a

.
.

320
. . .
. . .

10
11

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

Taxable interest. Attach Schedule B if required .

Tax-exempt interest. Do not include on line 8a .
Ordinary dividends. Attach Schedule B if required

.
.
.

.
.
.

10
11

Qualified dividends . . . . . . . . . . .
9b
Taxable refunds, credits, or offsets of state and local income taxes
Alimony received . . . . . . . . . . . . . . .

12
13
14

Business income or (loss). Attach Schedule C or C-EZ . . . . . . . . .

Capital gain or (loss). Attach Schedule D if required. If not required, check here
Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . .

15a
16a
17

IRA distributions .
15a
b Taxable amount
. . .
Pensions and annuities 16a
b Taxable amount
. . .
Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E

15b
16b
17

18
19
20a

Farm income or (loss). Attach Schedule F .

Unemployment compensation . . . .
Social security benefits 20a

18
19
20b

21
22

Other income. List type and amount

Combine the amounts in the far right column for lines 7 through 21. This is your total income

23

Educator expenses

24

Certain business expenses of reservists, performing artists, and

fee-basis government officials. Attach Form 2106 or 2106-EZ

25

Health savings account deduction. Attach Form 8889

24
25

26
27
28

Moving expenses. Attach Form 3903 . . . . . .

Deductible part of self-employment tax. Attach Schedule SE .
Self-employed SEP, SIMPLE, and qualified plans
. .

26
27
28

29
30
31a

Self-employed health insurance deduction

Penalty on early withdrawal of savings . .

.
.

.
.

.
.

.
.

32
33
34

Alimony paid b Recipients SSN

IRA deduction . . . . . . .
Student loan interest deduction . .
Tuition and fees. Attach Form 8917 .

29
30
31a

.
.
.

.
.
.

.
.
.

.
.
.

32
33
34

35
36
37

Domestic production activities deduction. Attach Form 8903

35
Add lines 23 through 35 . . . . . . . . . . . . .
Subtract line 36 from line 22. This is your adjusted gross income

.
.
.

.
.
.

.
.

.
.

.
.

.
.

2
2

Dependents on 6c
not entered above

8a
b
9a

Boxes checked
on 6a and 6b
No. of children
on 6c who:
lived with you
did not live with
you due to divorce
or separation
(see instructions)

Son
Daughter

Qualifying widow(er) with dependent child

Yourself. If someone can claim you as a dependent, do not check box 6a .

Billie Bob Arc

Mary Sue Arc

Head of household (with qualifying person). (See instructions.) If

the qualifying person is a child but not your dependent, enter this

Married filing separately. Enter spouses SSN above

and full name here.

(1) First name

If more than four

dependents, see
instructions and
check here

Single
Married filing jointly (even if only one had income)

Make sure the SSN(s) above

and on line 6c are correct.

.
.

.
.

. . . . . .
. . . . . .
b Taxable amount

.
.
.

.
.
.

.
.

.
.
.

Add numbers on
lines above

27,600

842

12
13
14

42,020
11,050

1,755

21
22

83,267

36
37

2,969
80,298

23

2,969

.
.

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

.
.

.
.

.
.

.
.

Cat. No. 11320B

Form

1040

(2015)

Page 2

Form 1040 (2015)

38

Amount from line 37 (adjusted gross income)

Tax and
Credits

39a

Check
if:

Standard
Deduction
for
People who
check any
box on line
39a or 39b or
who can be
claimed as a
dependent,
see
instructions.
All others:
Single or
Married filing
separately,
$6,300
Married filing
jointly or
Qualifying
widow(er),
$12,600
Head of
household,
$9,250

Other
Taxes

58
59
60a

Unreported social security and Medicare tax from Form:

b
61

First-time homebuyer credit repayment. Attach Form 5405 if required

62
63

Form 8960 c
Taxes from: a
Form 8959 b
Add lines 56 through 62. This is your total tax . .

Payments
If you have a
qualifying
child, attach
Schedule EIC.

Sign
Here

Paid
Preparer
Use Only

You were born before January 2, 1951,

Spouse was born before January 2, 1951,

Blind.
Blind.

39b

42
43

Exemptions. If line 38 is $154,950 or less, multiply $4,000 by the number on line 6d. Otherwise, see instructions
Taxable income. Subtract line 42 from line 41. If line 42 is more than line 41, enter -0- . .
Form 4972 c
Tax (see instructions). Check if any from: a
Form(s) 8814 b

44
45
46
47
48
49
50
51
52
53
54
55
56
57

64
65
66a
b
67
68
69
70
71
72

75
76a

Alternative minimum tax (see instructions). Attach Form 6251 .

Excess advance premium tax credit repayment. Attach Form 8962
Add lines 44, 45, and 46
. . . . . . .
Foreign tax credit. Attach Form 1116 if required .

.
.

.
.

.
.

.
.

.
.

.
.

.
.

.
.

.
.

.
.

.
48

49
50
51

Credit for child and dependent care expenses. Attach Form 2441

Education credits from Form 8863, line 19 . . . . .

Retirement savings contributions credit. Attach Form 8880
Child tax credit. Attach Schedule 8812, if required . . .

.
.

Self-employment tax. Attach Schedule SE

.
.

.
.

.
.

.
.

.
.

.
.

Additional tax on IRAs, other qualified retirement plans, etc. Attach Form 5329 if required

.
.

.
.

.
.

.
.

8919

Household employment taxes from Schedule H

4137
.

.
.

.
.

.
.

.
.

.
.

.
.

. . . . .
Instructions; enter code(s)

. . . . . . . . . . .
64
Federal income tax withheld from Forms W-2 and 1099 . .
5,050
2015 estimated tax payments and amount applied from 2014 return
65
12,000
Earned income credit (EIC) . . . . . . . . . . 66a

Nontaxable combat pay election

66b
Additional child tax credit. Attach Schedule 8812 .

67

American opportunity credit from Form 8863, line 8 .

Net premium tax credit. Attach Form 8962 . . . .
Amount paid with request for extension to file . . .

.
.
.

.
.
.

68
69
70

71
72
Credits from Form: a
2439 b
Reserved c
8885 d
73
Add lines 64, 65, 66a, and 67 through 73. These are your total payments .
Excess social security and tier 1 RRTA tax withheld

Credit for federal tax on fuels. Attach Form 4136

.
.

.
.

.
.

40
41
42

16,170

43

48,128

44
45
46
47

6,304

55
56
57

690
5,614
5,937

64,128
16,000

6304

58
59
60a
60b

Full-year coverage

Health care: individual responsibility (see instructions)

80,298

690

52
Residential energy credits. Attach Form 5695 . . . .
53
3800 b
8801 c
Other credits from Form: a
54
Add lines 48 through 54. These are your total credits . . . . .
Subtract line 55 from line 47. If line 55 is more than line 47, enter -0.

38

Total boxes
checked 39a
.
.

61
62
63

11,551

.
.

74

17,050

If line 74 is more than line 63, subtract line 63 from line 74. This is the amount you overpaid

75

5,499

Amount of line 75 you want refunded to you. If Form 8888 is attached, check here

76a

5,499

b
d

c Type: Checking
Routing number
Savings
0 6 7 8 4 5 6 6 8
Account number
5 6 4 5 8 5 4 6 5 4 9 6 4
Amount of line 75 you want applied to your 2016 estimated tax 77
77
78
Amount you owe. Subtract line 74 from line 63. For details on how to pay, see instructions 78
79
Estimated tax penalty (see instructions) . . . . . . .
79
Do you want to allow another person to discuss this return with the IRS (see instructions)?
Yes. Complete below.

No

Personal identification

number (PIN)

Phone
no.

Designees
name

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 complete. 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

Spouses signature. If a joint return, both must sign.

Date

Spouses occupation

If the IRS sent you an Identity Protection

PIN, enter it
here (see inst.)
PTIN
Check
if
self-employed

Joint return? See

instructions.
Keep a copy for
your records.

Itemized deductions (from Schedule A) or your standard deduction (see left margin)
Subtract line 40 from line 38
. . . . . . . . . . . . . . . . .

Third Party
Designee

40
41

Direct deposit?
See

instructions.

Amount
You Owe

If your spouse itemizes on a separate return or you were a dual-status alien, check here

73
74

Refund

Print/Type preparers name

Firms name

Preparers signature

Date

Firm's EIN

Firms address

Phone no.

www.irs.gov/form1040

Form 1040 (2015)

SCHEDULE A
(Form 1040)

OMB No. 1545-0074

Itemized Deductions

Department of the Treasury

Internal Revenue Service (99)

Information

about Schedule A and its separate instructions is at www.irs.gov/schedulea.

Attach to Form 1040.

Name(s) shown on Form 1040

2015

Attachment
Sequence No. 07
Your social security number

Noah Arc

Medical
and
Dental
Expenses
Taxes You
Paid

434-11-3311

1
2
3
4
5

6
7
8

Interest
You Paid

9
10
11

Note:
Your mortgage
interest
deduction may
be limited (see
instructions).

Caution: Do not include expenses reimbursed or paid by others.

Medical and dental expenses (see instructions) . . . . .
1
Enter amount from Form 1040, line 38
2
80,298
Multiply line 2 by 10% (.10). But if either you or your spouse was
3
born before January 2, 1951, multiply line 2 by 7.5% (.075) instead
Subtract line 3 from line 1. If line 3 is more than line 1, enter -0- . .
State and local (check only one box):
a
Income taxes, or
. . . . . . . . . . .
5
b
General sales taxes
Real estate taxes (see instructions) . . . . . . . . .
6
Personal property taxes . . . . . . . . . . . . .
7
Other taxes. List type and amount
8
Add lines 5 through 8 . . . . . . . . . . . . . . . .
Home mortgage interest and points reported to you on Form 1098 10
Home mortgage interest not reported to you on Form 1098. If paid
to the person from whom you bought the home, see instructions
and show that persons name, identifying no., and address

8030

11
12 Points not reported to you on Form 1098. See instructions for
special rules . . . . . . . . . . . . . . . . .
12
13 Mortgage insurance premiums (see instructions) . . . . .
13
14 Investment interest. Attach Form 4952 if required. (See instructions.) 14
15 Add lines 10 through 14 . . . . . . . . . . . . . . .
Gifts to
16 Gifts by cash or check. If you made any gift of $250 or more,
see instructions . . . . . . . . . . . . . . . .
16
Charity
17 Other than by cash or check. If any gift of $250 or more, see
If you made a
gift and got a
instructions. You must attach Form 8283 if over $500 . . .
17
benefit for it,
18 Carryover from prior year . . . . . . . . . . . .
18
see instructions.
19 Add lines 16 through 18 . . . . . . . . . . . . . . .

Casualty and
Theft Losses

20 Casualty or theft loss(es). Attach Form 4684. (See instructions.) .

2,370

15

11,100

2,700

1,020
1,350

11,100

2,700

19

20

Job Expenses 21 Unreimbursed employee expensesjob travel, union dues,

and Certain
job education, etc. Attach Form 2106 or 2106-EZ if required.
Miscellaneous
21
(See instructions.) Uniforms
Deductions
22 Tax preparation fees . . . . . . . . . . . . .
22

125
350

23 Other expensesinvestment, safe deposit box, etc. List type

and amount

Other
Miscellaneous
Deductions

24
25
26
27
28

23
Add lines 21 through 23 . . . . . . . . . . . .
24
Enter amount from Form 1040, line 38 25
80,298
Multiply line 25 by 2% (.02) . . . . . . . . . . .
26
Subtract line 26 from line 24. If line 26 is more than line 24, enter -0- .
Otherfrom list in instructions. List type and amount

475

1,606

27

28

29 Is Form 1040, line 38, over $154,950?

Total
No. Your deduction is not limited. Add the amounts in the far right column
Itemized
for lines 4 through 28. Also, enter this amount on Form 1040, line 40.
Deductions

.
Yes. Your deduction may be limited. See the Itemized Deductions
Worksheet in the instructions to figure the amount to enter.
30 If you elect to itemize deductions even though they are less than your standard
deduction, check here . . . . . . . . . . . . . . . . . . .

For Paperwork Reduction Act Notice, see Form 1040 instructions.

Cat. No. 17145C

29

16,170

Schedule A (Form 1040) 2015

SCHEDULE B
Department of the Treasury
Internal Revenue Service (99)

OMB No. 1545-0074

Interest and Ordinary Dividends

(Form 1040A or 1040)

Information

Attach to Form 1040A or 1040.

about Schedule B and its instructions is at www.irs.gov/scheduleb.

Name(s) shown on return

2015

Attachment
Sequence No. 08
Your social security number

Noah Arc

Part I

434-11-3311

Interest
(See instructions
on back and the
instructions for
Form 1040A, or
Form 1040,
line 8a.)
Note: If you
received a Form
1099-INT, Form
1099-OID, or
substitute
statement from
a brokerage firm,
list the firms
name as the
payer and enter
the total interest
shown on that
form.

Part II

2
3

Add the amounts on line 1 . . . . . . . . . .

Excludable interest on series EE and I U.S. savings
Attach Form 8815 . . . . . . . . . . . . .
4
Subtract line 3 from line 2. Enter the result here and
1040, line 8a . . . . . . . . . . . . . .
Note: If line 4 is over $1,500, you must complete Part III.
List name of payer
5

Ordinary
Dividends

. . . . . . . .
bonds issued after 1989.
. . . . . . . .
on Form 1040A, or Form
. . . . . . . .

Part III
Foreign
Accounts
and Trusts
(See
instructions on
back.)

3
4

Amount

Texas Utilities
Exxon

220
302

Coca-Cola

320

(See instructions
on back and the
instructions for
Form 1040A, or
Form 1040,
line 9a.)
Note: If you
received a Form
1099-DIV or
substitute
statement from
a brokerage firm,
list the firms
name as the
payer and enter
the ordinary
dividends shown
on that form.

Amount

List name of payer. If any interest is from a seller-financed mortgage and the
buyer used the property as a personal residence, see instructions on back and list
this interest first. Also, show that buyers social security number and address

Add the amounts on line 5. Enter the total here and on Form 1040A, or Form
6
1040, line 9a . . . . . . . . . . . . . . . . . . . . . .
Note: If line 6 is over $1,500, you must complete Part III.
You must complete this part if you (a) had over $1,500 of taxable interest or ordinary dividends; (b) had a
foreign account; or (c) received a distribution from, or were a grantor of, or a transferor to, a foreign trust.
7a

At any time during 2015, did you have a financial interest in or signature authority over a financial
account (such as a bank account, securities account, or brokerage account) located in a foreign
country? See instructions . . . . . . . . . . . . . . . . . . . . . . . .

If Yes, are you required to file FinCEN Form 114, Report of Foreign Bank and Financial
Accounts (FBAR), to report that financial interest or signature authority? See FinCEN Form 114
and its instructions for filing requirements and exceptions to those requirements . . . . . .
b If you are required to file FinCEN Form 114, enter the name of the foreign country where the
financial account is located
8
During 2015, did you receive a distribution from, or were you the grantor of, or transferor to, a
foreign trust? If Yes, you may have to file Form 3520. See instructions on back . . . . . .

For Paperwork Reduction Act Notice, see your tax return instructions.

Cat. No. 17146N

842

Yes No

Schedule B (Form 1040A or 1040) 2015

Page 2

Schedule B (Form 1040A or 1040) 2015

General Instructions
Section references are to the Internal Revenue Code
unless otherwise noted.

Future Developments
For the latest information about developments
related to Schedule B (Form 1040A or 1040) and its
instructions, such as legislation enacted after they
were published, go to www.irs.gov/scheduleb.

Purpose of Form
Use Schedule B if any of the following applies.
You had over $1,500 of taxable interest or ordinary
dividends.
You received interest from a seller-financed
mortgage and the buyer used the property as a
personal residence.
You have accrued interest from a bond.
You are reporting original issue discount (OID) in
an amount less than the amount shown on Form
1099-OID.
You are reducing your interest income on a bond
by the amount of amortizable bond premium.
You are claiming the exclusion of interest from
series EE or I U.S. savings bonds issued after 1989.
You received interest or ordinary dividends as a
nominee.
You had a financial interest in, or signature
authority over, a financial account in a foreign
country or you received a distribution from, or were
a grantor of, or transferor to, a foreign trust. Part III
of the schedule has questions about foreign
accounts and trusts.

Specific Instructions
You can list more than one payer on
each entry space for lines 1 and 5, but
be sure to clearly show the amount paid
next to the payer's name. Add the
separate amounts paid by the payers
listed on an entry space and enter the total in the
Amount column. If you still need more space, attach
separate statements that are the same size as the
printed schedule. Use the same format as lines 1 and
5, but show your totals on Schedule B. Be sure to put
your name and social security number (SSN) on the
statements and attach them at the end of your return.

TIP

Part I. Interest
Line 1. Report on line 1 all of your taxable interest.
Taxable interest generally should be shown on your
Forms 1099-INT, Forms 1099-OID, or substitute
statements. Include interest from series EE, H, HH,
and I U.S. savings bonds. Also include any accrued
market discount that is includible in income. List
each payers name and show the amount. Do not
report on this line any tax-exempt interest from box
8 or box 9 of Form 1099-INT. Instead, report the
amount from box 8 on line 8b of Form 1040A or
1040. If an amount is shown in box 9 of Form
1099-INT, you generally must report it on line 12 of
Form 6251. See the Instructions for Form 6251 for
more details. For more information on market
discount and other investment income see Pub. 550.
Seller-financed mortgages. If you sold your
home or other property and the buyer used the
property as a personal residence, list first any
interest the buyer paid you on a mortgage or other
form of seller financing. Be sure to show the buyers
name, address, and SSN. You must also let the
buyer know your SSN. If you do not show the
buyers name, address, and SSN, or let the buyer
know your SSN, you may have to pay a $50 penalty.
Nominees. If you received a Form 1099-INT that
includes interest you received as a nominee (that is, in
your name, but the interest actually belongs to
someone else), report the total on line 1. Do this even
if you later distributed some or all of this income to
others. Under your last entry on line 1, put a subtotal
of all interest listed on line 1. Below this subtotal, enter
"Nominee Distribution" and show the total interest you
received as a nominee. Subtract this amount from the
subtotal and enter the result on line 2.

If you received interest as a nominee,

you must give the actual owner a Form
1099-INT unless the owner is your
spouse. You must also file a Form 1096
and a Form 1099-INT with the IRS. For
more details, see the General Instructions for Certain
Information Returns and the Instructions for Forms
1099-INT and 1099-OID.

TIP

Accrued interest. When you buy bonds between

interest payment dates and pay accrued interest to
the seller, this interest is taxable to the seller. If you
received a Form 1099 for interest as a purchaser of a
bond with accrued interest, follow the rules earlier
under Nominees to see how to report the accrued
interest. But identify the amount to be subtracted as
Accrued Interest.
Original issue discount (OID). If you are reporting
OID in an amount less than the amount shown on
Form 1099-OID, follow the rules earlier under
Nominees to see how to report the OID. But identify
the amount to be subtracted as OID Adjustment.
Amortizable bond premium. If you are reducing your
interest income on a bond by the amount of amortizable
bond premium, follow the rules earlier under Nominees
to see how to report the interest. But identify the amount
to be subtracted as ABP Adjustment.
Line 3. If, during 2015, you cashed series EE or I
U.S. savings bonds issued after 1989 and you paid
qualified higher education expenses for yourself,
your spouse, or your dependents, you may be able
to exclude part or all of the interest on those bonds.
See Form 8815 for details.

Part II. Ordinary Dividends

You may have to file Form 5471 if, in
2015, you were an officer or director of
a foreign corporation. You may also
have to file Form 5471 if, in 2015, you
owned 10% or more of the total
(a) value of a foreign corporations stock, or (b)
combined voting power of all classes of a foreign
corporations stock with voting rights. For details,
see Form 5471 and its instructions.

TIP

Line 5. Report on line 5 all of your ordinary

dividends. This amount should be shown in box 1a
of your Forms 1099-DIV or substitute statements.
List each payers name and show the amount.
Nominees. If you received a Form 1099-DIV that
includes ordinary dividends you received as a
nominee (that is, in your name, but the ordinary
dividends actually belong to someone else), report
the total on line 5. Do this even if you later
distributed some or all of this income to others.
Under your last entry on line 5, put a subtotal of all
ordinary dividends listed on line 5. Below this
subtotal, enter Nominee Distribution and show the
total ordinary dividends you received as a nominee.
Subtract this amount from the subtotal and enter the
result on line 6.
If you received dividends as a nominee,
you must give the actual owner a Form
1099-DIV unless the owner is your spouse.
You must also file a Form 1096 and a Form
1099-DIV with the IRS. For more
details, see the General Instructions for Certain
Information Returns and the Instructions for Form
1099-DIV.

TIP

Part III. Foreign Accounts and

Trusts
Regardless of whether you are required
to file FinCEN Form 114 (FBAR), you
may be required to file Form 8938,
Statement of Specified Foreign
Financial Assets, with your income tax
return. Failure to file Form 8938 may result in
penalties and extension of the statute of limitations.
See www.irs.gov/form8938 for more information.

TIP

Line 7aQuestion 1. Check the Yes box if at any

time during 2015 you had a financial interest in or
signature authority over a financial account located
in a foreign country. See the definitions that follow.
Check the Yes box even if you are not required to
file FinCEN Form 114, Report of Foreign Bank and
Financial Accounts (FBAR).

Financial account. A financial account includes,

but is not limited to, a securities, brokerage, savings,
demand, checking, deposit, time deposit, or other
account maintained with a financial institution (or
other person performing the services of a financial
institution). A financial account also includes a
commodity futures or options account, an insurance
policy with a cash value (such as a whole life
insurance policy), an annuity policy with a cash
value, and shares in a mutual fund or similar pooled
fund (that is, a fund that is available to the general
public with a regular net asset value determination
and regular redemptions).
Financial account located in a foreign country.
A financial account is located in a foreign country if
the account is physically located outside of the
United States. For example, an account maintained
with a branch of a United States bank that is
physically located outside of the United States is a
foreign financial account. An account maintained
with a branch of a foreign bank that is physically
located in the United States is not a foreign financial
account.
Signature authority. Signature authority is the
authority of an individual (alone or in conjunction
with another individual) to control the disposition of
assets held in a foreign financial account by direct
communication (whether in writing or otherwise) to
the bank or other financial institution that maintains
the financial account. See the FinCEN Form 114
instructions for exceptions. Do not consider the
exceptions relating to signature authority in
answering Question 1 on line 7a.
Other definitions. For definitions of financial
interest, United States, and other relevant terms,
see the instructions for FinCEN Form 114.
Line 7aQuestion 2. See FinCEN Form 114 and its
instructions to determine whether you must file the
form. Check the Yes box if you are required to file
the form; check the No box if you are not required
to file the form.
If you checked the Yes box to Question 2 on line
7a, FinCEN Form 114 must be electronically filed
with the Financial Crimes Enforcement Network
(FinCEN) at the following website: http://bsaefiling.
fincen.treas.gov/main.html. Do not attach FinCEN
Form 114 to your tax return. To be considered
timely, FinCEN Form 114 must be received by June
30, 2016.

If you are required to file FinCEN Form

114 but do not properly do so, you may
have to pay a civil penalty up to
$10,000. A person who willfully fails to
CAUTION
report an account or provide account
identifying information may be subject to a civil
penalty equal to the greater of $100,000 or 50
percent of the balance in the account at the time of
the violation. Willful violations may also be subject to
criminal penalties.
Line 7b. If you are required to file FinCEN Form 114,
enter the name of the foreign country or countries in
the space provided on line 7b. Attach a separate
statement if you need more space.
Line 8. If you received a distribution from a foreign
trust, you must provide additional information. For
this purpose, a loan of cash or marketable securities
generally is considered to be a distribution. See
Form 3520 for details.
If you were the grantor of, or transferor to, a
foreign trust that existed during 2015, you may have
to file Form 3520.
Do not attach Form 3520 to Form 1040. Instead,
file it at the address shown in its instructions.
If you were treated as the owner of a foreign trust
under the grantor trust rules, you are also
responsible for ensuring that the foreign trust files
Form 3520-A. Form 3520-A is due on March 15,
2016, for a calendar year trust. See the instructions
for Form 3520-A for more details.

SCHEDULE C
(Form 1040)

Profit or Loss From Business

OMB No. 1545-0074

2015

(Sole Proprietorship)
about Schedule C and its separate instructions is at www.irs.gov/schedulec.
Attach to Form 1040, 1040NR, or 1041; partnerships generally must file Form 1065.

Information

Department of the Treasury

Internal Revenue Service (99)

Attachment
Sequence No. 09

Name of proprietor

Social security number (SSN)

Noah Arc
A
Principal business or profession, including product or service (see instructions)

434-11-3311
B Enter code from instructions

Pet Store
C
Business name. If no separate business name, leave blank.
The Arc
E
Business address (including suite or room no.)

D Employer ID number (EIN), (see instr.)

F
G
H

City, town or post office, state, and ZIP code

Santee, CA 92071
(2)
Accrual
(3)
Other (specify)
Accounting method:
(1) Cash
Did you materially participate in the operation of this business during 2015? If No, see instructions for limit on losses
If you started or acquired this business during 2015, check here . . . . . . . . . . . . . . . . .

I
J

Did you make any payments in 2015 that would require you to file Form(s) 1099? (see instructions) .
If "Yes," did you or will you file required Forms 1099? . . . . . . . . . . . . . .

Part I

Income

.
.

.
.

2
3

Gross receipts or sales. See instructions for line 1 and check the box if this income was reported to you on
Form W-2 and the Statutory employee box on that form was checked . . . . . . . . .
Returns and allowances . . . . . . . . . . . . . . . . . . . . . . . . .
Subtract line 2 from line 1 . . . . . . . . . . . . . . . . . . . . . . . .

4
5
6

Cost of goods sold (from line 42) . . . . . . . . . . . . . . . . . . .

Gross profit. Subtract line 4 from line 3 . . . . . . . . . . . . . . . . .
Other income, including federal and state gasoline or fuel tax credit or refund (see instructions) .

.
.
.

.
.
.

Gross income. Add lines 5 and 6 .

Advertising .

Car and truck expenses (see

instructions) . . . . .
Commissions and fees .

Part II

10
11
12
13

16
a
b
17
28
29
30

.
.

.
.

.
.

.
.

No

Yes
Yes

No
No

.
.

144,300

2
3

0
144,300

.
.
.

4
5
6

61,900
82,400
0

82,400

18

Pension and profit-sharing plans .

Rent or lease (see instructions):
Vehicles, machinery, and equipment

19
20a

Other business property . . .

Repairs and maintenance . . .
Supplies (not included in Part III) .

20b
21
22

7,600

Taxes and licenses . . . . .

Travel, meals, and entertainment:
Travel . . . . . . . . .

23

2,250

24a

25

Deductible meals and

entertainment (see instructions) .
Utilities . . . . . . . .

24b
25

200
2,650

26
27a
b

Wages (less employment credits) .

Other expenses (from line 48) . .
Reserved for future use . . .

25,100

17
1,800
Total expenses before expenses for business use of home. Add lines 8 through 27a .

26
27a
27b

28

40,380

Tentative profit or (loss). Subtract line 28 from line 7 .

29

42,020

30

31

42,020

Interest:
Mortgage (paid to banks, etc.)
Other . . . . . .
Legal and professional services

Yes

Office expense (see instructions)

9
10

11
12

b
21
22
23
24

13

a
14
15

b
780

16a
16b

Expenses for business use of your home. Do not report these expenses elsewhere. Attach Form 8829
unless using the simplified method (see instructions).
Simplified method filers only: enter the total square footage of: (a) your home:
.

. Use the Simplified

. . . . . . .

Net profit or (loss). Subtract line 30 from line 29.

If a profit, enter on both Form 1040, line 12 (or Form 1040NR, line 13) and on Schedule SE, line 2.
(If you checked the box on line 1, see instructions). Estates and trusts, enter on Form 1041, line 3.
If a loss, you must go to line 32.

32

19
20

and (b) the part of your home used for business:

Method Worksheet in the instructions to figure the amount to enter on line 30
31

18

Employee benefit programs

(other than on line 19) . .
Insurance (other than health)

15

Expenses. Enter expenses for business use of your home only on line 30.

Contract labor (see instructions)

Depletion . . . . .
Depreciation and section 179
expense
deduction
(not
included in Part III) (see
instructions) . . . . .

14

18542 Mission Read

If you have a loss, check the box that describes your investment in this activity (see instructions).
If you checked 32a, enter the loss on both Form 1040, line 12, (or Form 1040NR, line 13) and
on Schedule SE, line 2. (If you checked the box on line 1, see the line 31 instructions). Estates and
trusts, enter on Form 1041, line 3.
If you checked 32b, you must attach Form 6198. Your loss may be limited.

For Paperwork Reduction Act Notice, see the separate instructions.

Cat. No. 11334P

32a
32b

All investment is at risk.

Some investment is not
at risk.
Schedule C (Form 1040) 2015

Page 2

Schedule C (Form 1040) 2015

Part III

Cost of Goods Sold (see instructions)

33

Method(s) used to
value closing inventory:

34

Was there any change in determining quantities, costs, or valuations between opening and closing inventory?
If Yes, attach explanation . . . . . . . . . . . . . . . . . . . . . . . . .

Cost

Lower of cost or market

Other (attach explanation)

Yes

35

Inventory at beginning of year. If different from last years closing inventory, attach explanation .

35

1,000

36

Purchases less cost of items withdrawn for personal use

36

61,900

37

Cost of labor. Do not include any amounts paid to yourself .

37

38

Materials and supplies

38

39

Other costs .

39

40

Add lines 35 through 39 .

40

62,900

41

Inventory at end of year .

41

1,000

42

Cost of goods sold. Subtract line 41 from line 40. Enter the result here and on line 4 .

42

61,900

Part IV

Information on Your Vehicle. Complete this part only if you are claiming car or truck expenses on line 9
and are not required to file Form 4562 for this business. See the instructions for line 13 to find out if you must
file Form 4562.
/

43

When did you place your vehicle in service for business purposes? (month, day, year)

44

Of the total number of miles you drove your vehicle during 2015, enter the number of miles you used your vehicle for:

No

b Commuting (see instructions)

Business

c Other
Yes

No

45

Was your vehicle available for personal use during off-duty hours?

46

Do you (or your spouse) have another vehicle available for personal use?.

Yes

No

47a

Do you have evidence to support your deduction?

Yes

No

If Yes, is the evidence written?

Yes

No

Part V

48

Other Expenses. List below business expenses not included on lines 826 or line 30.

Total other expenses. Enter here and on line 27a .

48
Schedule C (Form 1040) 2015

SCHEDULE D
(Form 1040)
Department of the Treasury
Internal Revenue Service (99)

OMB No. 1545-0074

Capital Gains and Losses

Attachment
Sequence No. 12

Your social security number

Name(s) shown on return

Noah Arc

Part I

2015

Attach to Form 1040 or Form 1040NR.

Information about Schedule D and its separate instructions is at www.irs.gov/scheduled.
Use Form 8949 to list your transactions for lines 1b, 2, 3, 8b, 9, and 10.

434-11-3311

Short-Term Capital Gains and LossesAssets Held One Year or Less

See instructions for how to figure the amounts to enter on the

lines below.
This form may be easier to complete if you round off cents to
whole dollars.

(d)
Proceeds
(sales price)

(e)
Cost
(or other basis)

(g)
Adjustments
to gain or loss from
Form(s) 8949, Part I,
line 2, column (g)

(h) Gain or (loss)

Subtract column (e)
from column (d) and
combine the result with
column (g)

1a Totals for all short-term transactions reported on Form

1099-B for which basis was reported to the IRS and for
which you have no adjustments (see instructions).
However, if you choose to report all these transactions
on Form 8949, leave this line blank and go to line 1b .
1b Totals for all transactions reported on Form(s) 8949 with
Box A checked . . . . . . . . . . . . .
2 Totals for all transactions reported on Form(s) 8949 with
Box B checked . . . . . . . . . . . . .
3 Totals for all transactions reported on Form(s) 8949 with
Box C checked . . . . . . . . . . . . .

6,000

5,300

700

4 Short-term gain from Form 6252 and short-term gain or (loss) from Forms 4684, 6781, and 8824 .
5 Net short-term gain or (loss) from partnerships, S corporations, estates, and trusts from
Schedule(s) K-1 . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6 Short-term capital loss carryover. Enter the amount, if any, from line 8 of your Capital Loss Carryover
Worksheet in the instructions
. . . . . . . . . . . . . . . . . . . . . . .
7 Net short-term capital gain or (loss). Combine lines 1a through 6 in column (h). If you have any longterm capital gains or losses, go to Part II below. Otherwise, go to Part III on the back . . . . .

Part II

4
5
6

)
700

Long-Term Capital Gains and LossesAssets Held More Than One Year

See instructions for how to figure the amounts to enter on the

lines below.
This form may be easier to complete if you round off cents to
whole dollars.

(d)
Proceeds
(sales price)

(e)
Cost
(or other basis)

(g)
(h) Gain or (loss)
Adjustments
Subtract column (e)
to gain or loss from
from column (d) and
Form(s) 8949, Part II, combine the result with
line 2, column (g)
column (g)

8a Totals for all long-term transactions reported on Form

1099-B for which basis was reported to the IRS and for
which you have no adjustments (see instructions).
However, if you choose to report all these transactions
on Form 8949, leave this line blank and go to line 8b .
8b Totals for all transactions reported on Form(s) 8949 with
Box D checked . . . . . . . . . . . . .
16,700
4,000
9 Totals for all transactions reported on Form(s) 8949 with
Box E checked . . . . . . . . . . . . .
10 Totals for all transactions reported on Form(s) 8949 with
Box F checked . . . . . . . . . . . . . .
11 Gain from Form 4797, Part I; long-term gain from Forms 2439 and 6252; and long-term gain or (loss)
from Forms 4684, 6781, and 8824 . . . . . . . . . . . . . . . . . . . . . .

11

12 Net long-term gain or (loss) from partnerships, S corporations, estates, and trusts from Schedule(s) K-1

12

13 Capital gain distributions. See the instructions . . . . . . . . . . . . . . . . . .

14 Long-term capital loss carryover. Enter the amount, if any, from line 13 of your Capital Loss Carryover
Worksheet in the instructions
. . . . . . . . . . . . . . . . . . . . . . .
15 Net long-term capital gain or (loss). Combine lines 8a through 14 in column (h). Then go to Part III on
the back . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13

For Paperwork Reduction Act Notice, see your tax return instructions.

Cat. No. 11338H

12,700

14 (

2,350 )

15

10,350

Schedule D (Form 1040) 2015

Page 2

Schedule D (Form 1040) 2015

Part III
16

Summary

Combine lines 7 and 15 and enter the result

16

11,050

If line 16 is a gain, enter the amount from line 16 on Form 1040, line 13, or Form 1040NR, line
14. Then go to line 17 below.
If line 16 is a loss, skip lines 17 through 20 below. Then go to line 21. Also be sure to complete
line 22.
If line 16 is zero, skip lines 17 through 21 below and enter -0- on Form 1040, line 13, or Form
1040NR, line 14. Then go to line 22.
17

Are lines 15 and 16 both gains?

Yes. Go to line 18.
No. Skip lines 18 through 21, and go to line 22.

18

Enter the amount, if any, from line 7 of the 28% Rate Gain Worksheet in the instructions

18

19

Enter the amount, if any, from line 18 of the Unrecaptured Section 1250 Gain Worksheet in the
instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19

21 (

20

Are lines 18 and 19 both zero or blank?

Yes. Complete the Qualified Dividends and Capital Gain Tax Worksheet in the instructions
for Form 1040, line 44 (or in the instructions for Form 1040NR, line 42). Do not complete lines
21 and 22 below.
No. Complete the Schedule D Tax Worksheet in the instructions. Do not complete lines 21
and 22 below.

21

If line 16 is a loss, enter here and on Form 1040, line 13, or Form 1040NR, line 14, the smaller of:
The loss on line 16 or
($3,000), or if married filing separately, ($1,500)

Note: When figuring which amount is smaller, treat both amounts as positive numbers.
22

Do you have qualified dividends on Form 1040, line 9b, or Form 1040NR, line 10b?
Yes. Complete the Qualified Dividends and Capital Gain Tax Worksheet in the instructions
for Form 1040, line 44 (or in the instructions for Form 1040NR, line 42).
No. Complete the rest of Form 1040 or Form 1040NR.
Schedule D (Form 1040) 2015

Form

8949

Department of the Treasury

Internal Revenue Service

Sales and Other Dispositions of Capital Assets

Information about Form 8949 and its separate instructions is at www.irs.gov/form8949.

File with your Schedule D to list your transactions for lines 1b, 2, 3, 8b, 9, and 10 of Schedule D.

OMB No. 1545-0074

2015

Attachment
Sequence No. 12A

Social security number or taxpayer identification number

Name(s) shown on return

Noah Arc

434-11-3311

Before you check Box A, B, or C below, see whether you received any Form(s) 1099-B or substitute statement(s) from your broker. A substitute
statement will have the same information as Form 1099-B. Either will show whether your basis (usually your cost) was reported to the IRS by your
broker and may even tell you which box to check.

Part I

Short-Term. Transactions involving capital assets you held 1 year or less are short term. For long-term
transactions, see page 2.
Note: You may aggregate all short-term transactions reported on Form(s) 1099-B showing basis was
reported to the IRS and for which no adjustments or codes are required. Enter the totals directly on
Schedule D, line 1a; you aren't required to report these transactions on Form 8949 (see instructions).

You must check Box A, B, or C below. Check only one box. If more than one box applies for your short-term transactions,
complete a separate Form 8949, page 1, for each applicable box. If you have more short-term transactions than will fit on this page
for one or more of the boxes, complete as many forms with the same box checked as you need.

(A) Short-term transactions reported on Form(s) 1099-B showing basis was reported to the IRS (see Note above)
(B) Short-term transactions reported on Form(s) 1099-B showing basis was not reported to the IRS
(C) Short-term transactions not reported to you on Form 1099-B

1
(a)
Description of property
(Example: 100 sh. XYZ Co.)

Yellow Co.

(b)
Date acquired
(Mo., day, yr.)

(c)
Date sold or
disposed of
(Mo., day, yr.)

1/31/15

6/5/15

(d)
Proceeds
(sales price)
(see instructions)

6,000

Adjustment, if any, to gain or loss.

If you enter an amount in column (g),
(e)
(h)
enter a code in column (f).
Cost or other basis.
Gain or (loss).
See
the
separate
instructions.
See the Note below
Subtract column (e)
and see Column (e)
from column (d) and
(f)
(g)
in the separate
combine the result
Code(s) from
instructions
with column (g)
Amount of
instructions
adjustment

5,300

700

2 Totals. Add the amounts in columns (d), (e), (g), and (h) (subtract

negative amounts). Enter each total here and include on your

Schedule D, line 1b (if Box A above is checked), line 2 (if Box B
above is checked), or line 3 (if Box C above is checked)

6,000
5,300
700
Note: If you checked Box A above but the basis reported to the IRS was incorrect, enter in column (e) the basis as reported to the IRS, and enter an
adjustment in column (g) to correct the basis. See Column (g) in the separate instructions for how to figure the amount of the adjustment.
For Paperwork Reduction Act Notice, see your tax return instructions.

Cat. No. 37768Z

Form 8949 (2015)

Attachment Sequence No. 12A

Form 8949 (2015)

Name(s) shown on return. Name and SSN or taxpayer identification no. not required if shown on other side

Page 2

Social security number or taxpayer identification number

Noah Arc

434-11-3311

Before you check Box D, E, or F below, see whether you received any Form(s) 1099-B or substitute statement(s) from your broker. A substitute
statement will have the same information as Form 1099-B. Either will show whether your basis (usually your cost) was reported to the IRS by your
broker and may even tell you which box to check.

Part II

Long-Term. Transactions involving capital assets you held more than 1 year are long term. For short-term
transactions, see page 1.
Note: You may aggregate all long-term transactions reported on Form(s) 1099-B showing basis was reported
to the IRS and for which no adjustments or codes are required. Enter the totals directly on Schedule D, line
8a; you aren't required to report these transactions on Form 8949 (see instructions).

You must check Box D, E, or F below. Check only one box. If more than one box applies for your long-term transactions, complete
a separate Form 8949, page 2, for each applicable box. If you have more long-term transactions than will fit on this page for one or
more of the boxes, complete as many forms with the same box checked as you need.

(D) Long-term transactions reported on Form(s) 1099-B showing basis was reported to the IRS (see Note above)
(E) Long-term transactions reported on Form(s) 1099-B showing basis was not reported to the IRS
(F) Long-term transactions not reported to you on Form 1099-B

1
(b)
Date acquired
(Mo., day, yr.)

(c)
Date sold or
disposed of
(Mo., day, yr.)

Blue Co.

2/11/05

8/15/15

4,500

2,400

2,100

Red Co.

10/2/06

10/7/15

12,200

1,600

10,600

(a)
Description of property
(Example: 100 sh. XYZ Co.)

(d)
Proceeds
(sales price)
(see instructions)

Adjustment, if any, to gain or loss.

If you enter an amount in column (g),
(e)
(h)
enter a code in column (f).
Cost or other basis.
Gain or (loss).
See
the
separate
instructions.
See the Note below
Subtract column (e)
and see Column (e)
from column (d) and
(f)
(g)
in the separate
combine the result
Code(s) from
instructions
with column (g)
Amount of
instructions
adjustment

2 Totals. Add the amounts in columns (d), (e), (g), and (h) (subtract
negative amounts). Enter each total here and include on your
Schedule D, line 8b (if Box D above is checked), line 9 (if Box E
above is checked), or line 10 (if Box F above is checked)

16,700
4,000
12,700
Note: If you checked Box D above but the basis reported to the IRS was incorrect, enter in column (e) the basis as reported to the IRS, and enter an
adjustment in column (g) to correct the basis. See Column (g) in the separate instructions for how to figure the amount of the adjustment.
Form 8949 (2015)

SCHEDULE E
(Form 1040)
Department of the Treasury
Internal Revenue Service (99)
Name(s) shown on return

Noah Arc

Part I

Supplemental Income and Loss

OMB No. 1545-0074

(From rental real estate, royalties, partnerships, S corporations, estates, trusts, REMICs, etc.)
Attach to Form 1040, 1040NR, or Form 1041.
about Schedule E and its separate instructions is at www.irs.gov/schedulee.

Information

2015

Attachment
Sequence No. 13
Your social security number

434-11-3311
Note: If you are in the business of renting personal property, use
Schedule C or C-EZ (see instructions). If you are an individual, report farm rental income or loss from Form 4835 on page 2, line 40.

Income or Loss From Rental Real Estate and Royalties

Yes
A Did you make any payments in 2015 that would require you to file Form(s) 1099? (see instructions)
No
Yes
B If Yes, did you or will you file required Forms 1099?
No
1a Physical address of each property (street, city, state, ZIP code)
A 6431 Gary Ct., San Diego, CA 92115
B
C
Fair Rental
Personal Use
2 For each rental real estate property listed
1b
Type of Property
QJV
above, report the number of fair rental and
Days
Days
(from list below)
personal use days. Check the QJV box

A
A
7
365
0
only if you meet the requirements to file as
a
qualified
joint
venture.
See
instructions.
B
B
C
C
Type of Property:
1 Single Family Residence
3 Vacation/Short-Term Rental 5 Land
7 Self-Rental
2 Multi-Family Residence
4 Commercial
6 Royalties
8 Other (describe)
Income:
Properties:
A
B
C
3 Rents received . . . . . . . . . . . . .
3
13,800
4 Royalties received . . . . . . . . . . . .
4
Expenses:
5
Advertising . . . . . . . . . . . . . .
5
6
Auto and travel (see instructions) . . . . . . .
6
7
Cleaning and maintenance . . . . . . . . .
7
8
Commissions. . . . . . . . . . . . . .
8
9
Insurance . . . . . . . . . . . . . . .
9
575
10
Legal and other professional fees . . . . . . .
10
11
Management fees . . . . . . . . . . . .
11
12
Mortgage interest paid to banks, etc. (see instructions)
12
6,870
13
Other interest. . . . . . . . . . . . . .
13
14
Repairs. . . . . . . . . . . . . . . .
14
15
Supplies . . . . . . . . . . . . . . .
15
16
Taxes . . . . . . . . . . . . . . . .
16
1,000
17
Utilities . . . . . . . . . . . . . . . .
17
18
Depreciation expense or depletion . . . . . . .
18
3,000
Other (list)
19
19
600
20
Total expenses. Add lines 5 through 19 . . . . .
20
12,045

Subtract line 20 from line 3 (rents) and/or 4 (royalties). If

result is a (loss), see instructions to find out if you must
file Form 6198 . . . . . . . . . . . . .
21
1,755
Deductible rental real estate loss after limitation, if any,
22
)(
)(
on Form 8582 (see instructions) . . . . . . .
22 (
23a Total of all amounts reported on line 3 for all rental properties
. . . .
23a
13,800
b Total of all amounts reported on line 4 for all royalty properties . . . .
23b
0
c Total of all amounts reported on line 12 for all properties . . . . . .
23c
6,870
d Total of all amounts reported on line 18 for all properties . . . . . .
23d
3,000
e Total of all amounts reported on line 20 for all properties . . . . . .
23e
12,045
24
Income. Add positive amounts shown on line 21. Do not include any losses . . . . . . .
24
25
Losses. Add royalty losses from line 21 and rental real estate losses from line 22. Enter total losses here 25 (
21

26

Total rental real estate and royalty income or (loss). Combine lines 24 and 25. Enter the result here.
If Parts II, III, IV, and line 40 on page 2 do not apply to you, also enter this amount on Form 1040, line
17, or Form 1040NR, line 18. Otherwise, include this amount in the total on line 41 on page 2 . . . .

For Paperwork Reduction Act Notice, see the separate instructions.

Cat. No. 11344L

26

1,755
0

1,755

Schedule E (Form 1040) 2015

Attachment Sequence No. 13

Page 2
Your social security number

Schedule E (Form 1040) 2015

Name(s) shown on return. Do not enter name and social security number if shown on other side.

Noah Arc

434-11-3311

Caution. The IRS compares amounts reported on your tax return with amounts shown on Schedule(s) K-1.

Income or Loss From Partnerships and S Corporations

Part II

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 6198. See instructions.

27

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.
Yes
No

28
A
B
C
D

(h) Nonpassive loss

from Schedule K-1

. . . . . .
. . . . . .
(loss). Combine
. . . . . .

. . . . . .
. . . . . .
lines 30 and 31.
. . . . . .

. .
. .
Enter
. .

.
.
the
.

Totals
Totals
Add columns (d) and (f) of line 34a
Add columns (c) and (e) of line 34b
Total estate and trust income or
include in the total on line 41 below

Part IV
38

. . . . . . . .
. . . . . . . .
Combine lines 35 and
. . . . . . . .

(e) Deduction or loss

from Schedule K-1

. . . . .
. . . . .
36. Enter the
. . . . .

. .
. .
result
. .

. . .
. . .
here and
. . .

(f) Other income from

Schedule K-1

35
36 (

37

Income or Loss From Real Estate Mortgage Investment Conduits (REMICs)Residual Holder
(a) Name

(b) Employer identification

number

(c) Excess inclusion from

Schedules Q, line 2c
(see instructions)

(d) Taxable income (net loss)

from Schedules Q, line 1b

Combine columns (d) and (e) only. Enter the result here and include in the total on line 41 below

Part V

(e) Income from

Schedules Q, line 3b

39

Summary

40
41

Net farm rental income or (loss) from Form 4835. Also, complete line 42 below . . . . . .
Total income or (loss). Combine lines 26, 32, 37, 39, and 40. Enter the result here and on Form 1040, line 17, or Form 1040NR, line 18

42

Reconciliation of farming and fishing income. Enter your gross

farming and fishing income reported on Form 4835, line 7; Schedule K-1
(Form 1065), box 14, code B; Schedule K-1 (Form 1120S), box 17, code
V; and Schedule K-1 (Form 1041), box 14, code F (see instructions) . .

42

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 1040 or Form 1040NR from all rental real estate activities
in which you materially participated under the passive activity loss rules . .

43

43

32

Nonpassive Income and Loss

(d) Passive income
from Schedule K-1

. .
. .
(loss).
. .

(b) Employer
identification number

Passive Income and Loss

(c) Passive deduction or loss allowed
(attach Form 8582 if required)

(j) Nonpassive income

from Schedule K-1

30
31 (

(a) Name

A
B

(e) Check if
any amount is
not at risk

(i) Section 179 expense

deduction from Form 4562

Income or Loss From Estates and Trusts

33

39

(d) Employer
identification
number

Nonpassive Income and Loss

(g) Passive income

from Schedule K-1

Totals
Totals
Add columns (g) and (j) of line 29a . . . . . .
Add columns (f), (h), and (i) of line 29b . . . .
Total partnership and S corporation income or
result here and include in the total on line 41 below

Part III

A
B
34a
b
35
36
37

(c) Check if
foreign
partnership

Passive Income and Loss

(f) Passive loss allowed
(attach Form 8582 if required)

A
B
C
D
29a
b
30
31
32

(b) Enter P for

partnership; S
for S corporation

(a) Name

40
41

Schedule E (Form 1040) 2015

SCHEDULE SE
(Form 1040)
Department of the Treasury
Internal Revenue Service (99)

OMB No. 1545-0074

Self-Employment Tax

2015

Information about Schedule SE and its separate instructions is at www.irs.gov/schedulese.

Attach

Attachment
Sequence No. 17

to Form 1040 or Form 1040NR.

Name of person with self-employment income (as shown on Form 1040 or Form 1040NR)

Noah Arc

Social security number of person

with self-employment income

434-11-3311

Before you begin: To determine if you must file Schedule SE, see the instructions.

May I Use Short Schedule SE or Must I Use Long Schedule SE?

Note. Use this flowchart only if you must file Schedule SE. If unsure, see Who Must File Schedule SE in the instructions.
Did you receive wages or tips in 2015?
No

Yes

Are you a minister, member of a religious order, or Christian

Science practitioner who received IRS approval not to be taxed
on earnings from these sources, but you owe self-employment
tax on other earnings?

Yes

Was the total of your wages and tips subject to social security
or railroad retirement (tier 1) tax plus your net earnings from
self-employment more than $118,500?

No

Yes

Did you receive tips subject to social security or Medicare tax

that you did not report to your employer?

Yes

No

No

Did you receive church employee income (see instructions)

reported on Form W-2 of $108.28 or more?

No

Are you using one of the optional methods to figure your net
earnings (see instructions)?

Yes

Yes

No

Did you report any wages on Form 8919, Uncollected Social

Security and Medicare Tax on Wages?

Yes

No

You may use Short Schedule SE below

You must use Long Schedule SE on page 2

Section AShort Schedule SE. Caution. Read above to see if you can use Short Schedule SE.
1a

Net farm profit or (loss) from Schedule F, line 34, and farm partnerships, Schedule K-1 (Form
1065), box 14, code A . . . . . . . . . . . . . . . . . . . . . . . .
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 1065), box 20, code Z

3
4

Net profit or (loss) from Schedule C, line 31; Schedule C-EZ, line 3; Schedule K-1 (Form 1065),
box 14, code A (other than farming); and Schedule K-1 (Form 1065-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 . . . . . . . . . . . . . .
Combine lines 1a, 1b, and 2
. . . . . . . . . . . . . . . . . . . . .
Multiply line 3 by 92.35% (.9235). If less than $400, you do not owe self-employment tax; do
not file this schedule unless you have an amount on line 1b . . . . . . . . . . .
Note. If line 4 is less than $400 due to Conservation Reserve Program payments on line 1b,
see instructions.
Self-employment tax. If the amount on line 4 is:
$118,500 or less, multiply line 4 by 15.3% (.153). Enter the result here and on Form 1040, line 57,
or Form 1040NR, line 55
More than $118,500, multiply line 4 by 2.9% (.029). Then, add $14,694 to the result.
Enter the total here and on Form 1040, line 57, or Form 1040NR, line 55 . . . . . . .
Deduction for one-half of self-employment tax.
Multiply line 5 by 50% (.50). Enter the result here and on Form
1040, line 27, or Form 1040NR, line 27 . . . . . . . .
6
2,969

For Paperwork Reduction Act Notice, see your tax return instructions.

Cat. No. 11358Z

1a
1b (

2
3

42,020

38,805

5,937

42,020

Schedule SE (Form 1040) 2015

Page 2

Schedule SE (Form 1040) 2015

Attachment Sequence No. 17

Name of person with self-employment income (as shown on Form 1040 or Form 1040NR)

Social security number of person

with self-employment income

Section BLong 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 $400 or more of other net earnings from self-employment, check here and continue with Part I . . . . . .
1a Net farm profit or (loss) from Schedule F, line 34, and farm partnerships, Schedule K-1 (Form 1065),
1a
box 14, code A. Note. Skip lines 1a and 1b if you use the farm optional method (see instructions)
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 1065), box 20, code Z
1b (
2

Net profit or (loss) from Schedule C, line 31; Schedule C-EZ, line 3; Schedule K-1 (Form 1065),
box 14, code A (other than farming); and Schedule K-1 (Form 1065-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) . . . . . . . . . . . . . . . . . . . .

3
4a

Combine lines 1a, 1b, and 2 . . . . . . . . . . . . . . . . . . . . . .

If line 3 is more than zero, multiply line 3 by 92.35% (.9235). Otherwise, enter amount from line 3
Note. If line 4a is less than $400 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 . .
c Combine lines 4a and 4b. If less than $400, stop; you do not owe self-employment tax.
Exception. If less than $400 and you had church employee income, enter -0- and continue
5a 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 $100, enter -0- . . . . . . . . . .
6
Add lines 4c and 5b . . . . . . . . . . . . . . . . . . . . . . . .
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 2015 . . . . . .

2
3
4a
4b
4c

5b
6
7

118,500

00

4,880

00

8a

Total social security wages and tips (total of boxes 3 and 7 on

Form(s) W-2) and railroad retirement (tier 1) compensation.
If $118,500 or more, skip lines 8b through 10, and go to line 11
8a
b Unreported tips subject to social security tax (from Form 4137, line 10)
8b
c Wages subject to social security tax (from Form 8919, line 10)
8c
d Add lines 8a, 8b, and 8c . . . . . . . . . . . . . . . . . . . . . . .
9
Subtract line 8d from line 7. If zero or less, enter -0- here and on line 10 and go to line 11 .
10
Multiply the smaller of line 6 or line 9 by 12.4% (.124) . . . . . . . . . . . . .
11
Multiply line 6 by 2.9% (.029) . . . . . . . . . . . . . . . . . . . . .
12
Self-employment tax. Add lines 10 and 11. Enter here and on Form 1040, line 57, or Form 1040NR, line 55
13
Deduction for one-half of self-employment tax.
Multiply line 12 by 50% (.50). Enter the result here and on Form
13
1040, line 27, or Form 1040NR, line 27 . . . . . . . .

Part II

Optional Methods To Figure Net Earnings (see instructions)

Farm Optional Method. You may use this method only if (a) your gross farm income1 was not more
than $7,320, or (b) your net farm profits2 were less than $5,284.
14
Maximum income for optional methods . . . . . . . . . . . . . . . . . .
15
Enter the smaller of: two-thirds (2/3) of gross farm income1 (not less than zero) or $4,880. Also
include this amount on line 4b above . . . . . . . . . . . . . . . . . . .
Nonfarm Optional Method. You may use this method only if (a) your net nonfarm profits3 were less than $5,284
and also less than 72.189% of your gross nonfarm income,4 and (b) you had net earnings from self-employment
of at least $400 in 2 of the prior 3 years. Caution. You may use this method no more than five times.
16
Subtract line 15 from line 14 . . . . . . . . . . . . . . . . . . . . . .
17
Enter the smaller of: two-thirds (2/3) of gross nonfarm income4 (not less than zero) or the
amount on line 16. Also include this amount on line 4b above . . . . . . . . . . .
1

8d
9
10
11
12

From Sch. F, line 9, and Sch. K-1 (Form 1065), box 14, code B.
2
From Sch. F, line 34, and Sch. K-1 (Form 1065), box 14, code Aminus the
amount you would have entered on line 1b had you not used the optional
method.

14
15

16
17

From Sch. C, line 31; Sch. C-EZ, line 3; Sch. K-1 (Form 1065), box 14, code
A; and Sch. K-1 (Form 1065-B), box 9, code J1.
4
From Sch. C, line 7; Sch. C-EZ, line 1; Sch. K-1 (Form 1065), box 14, code
C; and Sch. K-1 (Form 1065-B), box 9, code J2.
Schedule SE (Form 1040) 2015

Form

2441

Child and Dependent Care Expenses

Department of the Treasury

Internal Revenue Service (99)

1040
1040A
..........

..........

Attach to Form 1040, Form 1040A, or Form 1040NR.

OMB No. 1545-0074

2441

Information about Form 2441 and its separate instructions is at

www.irs.gov/form2441.

Part I
1

Attachment
Sequence No. 21
Your social security number

Name(s) shown on return

Noah Ac=rc

2015

1040NR

434-11-3311

Persons or Organizations Who Provided the CareYou must complete this part.
(If you have more than two care providers, see the instructions.)

(a) Care providers

name

(b) Address
(number, street, apt. no., city, state, and ZIP code)

(c) Identifying number

(SSN or EIN)

(d) Amount paid

(see instructions)

Roundup Day Care

3,200

Complete only Part II below.

No
Did you receive
dependent care benefits?
Complete Part III on the back next.
Yes
Caution. If the care was provided in your home, you may owe employment taxes. If you do, you cannot file Form 1040A. For details,
see the instructions for Form 1040, line 60a, or Form 1040NR, line 59a.

Part II
2

Credit for Child and Dependent Care Expenses

Information about your qualifying person(s). If you have more than two qualifying persons, see the instructions.
(b) Qualifying persons social
security number

(a) Qualifying persons name

Last

First

Mary Sue

Arc

554-33-2411

3,200

Add the amounts in column (c) of line 2. Do not enter more than $3,000 for one qualifying
person or $6,000 for two or more persons. If you completed Part III, enter the amount
from line 31 . . . . . . . . . . . . . . . . . . . . . . . . . .

4
5

Enter your earned income. See instructions . . . . . . . . . . . . . . .

If married filing jointly, enter your spouses earned income (if you or your spouse was a
student or was disabled, see the instructions); all others, enter the amount from line 4 .

6
7

Enter the smallest of line 3, 4, or 5 . . . . . . .

Enter the amount from Form 1040, line 38; Form
1040A, line 22; or Form 1040NR, line 37 . . . . .

9
10
11

(c) Qualified expenses you

incurred and paid in 2015 for the
person listed in column (a)

3
4

3,000
42,020

5
6

27,600
3,000

X.

690

7
38,298
Enter on line 8 the decimal amount shown below that applies to the amount on line 7
If line 7 is:
But not
over
Over

Decimal
amount is

If line 7 is:

$015,000
15,00017,000
17,00019,000
19,00021,000
21,00023,000
23,00025,000
25,00027,000
27,00029,000

.35
.34
.33
.32
.31
.30
.29
.28

Over

But not
over

$29,00031,000
31,00033,000
33,00035,000
35,00037,000
37,00039,000
39,00041,000
41,00043,000
43,000No limit

Decimal
amount is
.27
.26
.25
.24
.23
.22
.21
.20

Multiply line 6 by the decimal amount on line 8. If you paid 2014 expenses in 2015, see
the instructions . . . . . . . . . . . . . . . . . . . . . . . . .
Tax liability limit. Enter the amount from the Credit
Limit Worksheet in the instructions. . . . . . .
10
0
Credit for child and dependent care expenses. Enter the smaller of line 9 or line 10
here and on Form 1040, line 49; Form 1040A, line 31; or Form 1040NR, line 47 . . . .

For Paperwork Reduction Act Notice, see your tax return instructions.

11

Cat. No. 11862M

690

23

Form 2441 (2015)

Page 2

Form 2441 (2015)

Part III

Dependent Care Benefits

12 Enter the total amount of dependent care benefits you received in 2015. Amounts you
received as an employee should be shown in box 10 of your Form(s) W-2. Do not include
amounts reported as wages in box 1 of Form(s) W-2. If you were self-employed or a
partner, include amounts you received under a dependent care assistance program from
your sole proprietorship or partnership . . . . . . . . . . . . . . . . . .
13 Enter the amount, if any, you carried over from 2014 and used in 2015 during the grace
period. See instructions . . . . . . . . . . . . . . . . . . . . . . .
14 Enter the amount, if any, you forfeited or carried forward to 2016. See instructions
15 Combine lines 12 through 14. See instructions . . . . . . . . . . . .
16 Enter the total amount of qualified expenses incurred
in 2015 for the care of the qualifying person(s) . . .
16
17 Enter the smaller of line 15 or 16 . . . . . . . .
18 Enter your earned income. See instructions . . . .
19 Enter the amount shown below that applies
to you.
If married filing jointly, enter your
spouses earned income (if you or your
spouse was a student or was disabled,
see the instructions for line 5).
If married filing separately, see
instructions.

.
.

.
.

.
.

12
13
14 (
15

17
18

19

All others, enter the amount from line 18.

20 Enter the smallest of line 17, 18, or 19 . . . . . .
20
21 Enter $5,000 ($2,500 if married filing separately and
you were required to enter your spouses earned
income on line 19) . . . . . . . . . . . . .
21
22 Is any amount on line 12 from your sole proprietorship or partnership? (Form 1040A filers
go to line 25.)
No. Enter -0-.
Yes. Enter the amount here . . . . . . . . . . . . . . . . . . . .
23
23 Subtract line 22 from line 15 . . . . . . . . .
24 Deductible benefits. Enter the smallest of line 20, 21, or 22. Also, include this amount on
the appropriate line(s) of your return. See instructions . . . . . . . . . . . . .

22

24

25 Excluded benefits. Form 1040 and 1040NR filers: If you checked No on line 22, enter
the smaller of line 20 or 21. Otherwise, subtract line 24 from the smaller of line 20 or line
21. If zero or less, enter -0-. Form 1040A filers: Enter the smaller of line 20 or line 21 . .

25

26 Taxable benefits. Form 1040 and 1040NR filers: Subtract line 25 from line 23. If zero or
less, enter -0-. Also, include this amount on Form 1040, line 7, or Form 1040NR, line 8. On
the dotted line next to Form 1040, line 7, or Form 1040NR, line 8, enter DCB.
Form 1040A filers: Subtract line 25 from line 15. Also, include this amount on Form 1040A,
line 7. In the space to the left of line 7, enter DCB . . . . . . . . . . . . . .

26

To claim the child and dependent care

credit, complete lines 27 through 31 below.
27 Enter $3,000 ($6,000 if two or more qualifying persons) . . . . . . . . . . . .
28 Form 1040 and 1040NR filers: Add lines 24 and 25. Form 1040A filers: Enter the amount
from line 25 . . . . . . . . . . . . . . . . . . . . . . . . . . .
29 Subtract line 28 from line 27. If zero or less, stop. You cannot take the credit.
Exception. If you paid 2014 expenses in 2015, see the instructions for line 9 . . . . .
30 Complete line 2 on the front of this form. Do not include in column (c) any benefits shown
on line 28 above. Then, add the amounts in column (c) and enter the total here. . . . .
31 Enter the smaller of line 29 or 30. Also, enter this amount on line 3 on the front of this form
and complete lines 4 through 11 . . . . . . . . . . . . . . . . . . . .

27
28
29
30
31

Form 2441 (2015)

Clear form
Utah State Tax Commission

40501

Utah Individual Income Tax Return

All State Income Tax Dollars Fund Education

9998

Amended Return - enter code:

2015

TC-40

(code 1 - 5 from instructions)

USTC ORIGINAL FORM

Your Social Security No.

434113311
Spouses Soc. Sec. No.

456875432

Your first name

Your last name

Noah

Arc

Spouses first name

Spouse's last name

Joan

Arc

If deceased,
complete
page 3,
Part 1

Address

Telephone number

4342 Josie Jo
City

State

CA

Santee
1 Filing Status - enter code
1 = Single
2
2 = Married filling jointly
3 = Married filing separately
4 = Head of household
5 = Qualifying widow(er)

2
a
b
c
d
e

ZIP+4

Exemptions - enter number

1
Yourself*
Spouse*
1
Dependents*
2
Dependents with a disability
Total exemptions (add a through d)
4

If using code 2 or 3, enter spouses name and SSN above

Foreign country (if not U.S.)

92071

* from federal return

3 Election Campaign Fund - enter code

Does not increase your tax or reduce your refund

C = Constitution
D = Democratic
Yourself
Spouse
M = Independent American

L = Libertarian
R = Republican
N = No contribution

Federal adjusted gross income from federal return

80298 .00

Additions to income from TC-40A, Part 1 (attach TC-40A, page 1)

0 .00

Total income - add line 4 and line 5

80298 .00

State tax refund included on federal form 1040, line 10, if any

0 .00

Subtractions from income from TC-40A, Part 2 (attach TC-40A, page 1)

0 .00

Utah taxable income (loss) - subtract the sum of lines 7 and 8 from line 6

80298 .00

10

4015 .00

10 Utah tax - multiply line 9 by 5% (.05) (not less than zero)

11 Exemption amount - multiply line 2e by $3,000 (if line 4 over $154,950, see instr.) 11

12000 .00

12 Federal standard or itemized deductions

12

16170 .00

13

28170 .00

14

1020 .00

15

27150 .00

16 Initial credit before phase-out - multiply line 15 by 6% (.06)

16

1629 .00

17 Enter: $13,805 (if single or married filing separately); $20,707 (if head
of household); or $27,610 (if married filing jointly or qualifying widower)
18 Income subject to phase-out - subtract line 17 from line 9 (not less than zero)

17

27610 .00

18

52688 .00

19 Phase-out amount - multiply line 18 by 1.3% (.013)

19

685 .00

13 Add line 11 and line 12

14 State income tax deducted on federal Schedule A, line 5, if any
15 Subtract line 14 from line 13

20 Taxpayer tax credit - subtract line 19 from line 16 (not less than zero)
21 If you are a qualified exempt taxpayer, enter X (complete worksheet in instr.)
22 Utah income tax - subtract line 20 from line 10 (not less than zero)

Electronic filing
is quick, easy and
free, and will
speed up your refund.
To learn more,
go to
taxexpress.utah.gov

20

944 .00

22

3071 .00

21

40502

Utah Individual Income Tax Return (continued)

SSN

434113311

Last name

TC-40
2015

Arc

Pg. 2

USTC ORIGINAL FORM

23

3071 .00

24 Apportionable nonrefundable credits from TC-40A, Part 3 (attach TC-40A, page 1)

24

.00

25 Full-year resident, subtract line 24 from line 23 (not less than zero)
Non or Part-year resident, enter the tax from TC-40B,line 38
26 Nonapportionable nonrefundable credits from TC-40A, Part 4 (attach TC-40A, page 1)

25

3071 .00

26

.00

27

3071 .00

28 Voluntary contributions from TC-40, page 3, Part 4 (attach TC-40, page 3)

28

.00

29 AMENDED RETURN ONLY - previous refund

29

.00

30 Recapture of low-income housing credit

30

.00

31 Utah use tax

31

.00

32

3071 .00

33 Utah income tax withheld shown on TC-40W, Part 1 (attach TC-40W, page 1)

33

.00

34 Credit for Utah income taxes prepaid from TC-546 and 2014 refund applied to 2015

34

.00

35 Pass-through entity withholding tax shown on TC-40W, Part 3 (attach TC-40W, page 2)

35

.00

36 Mineral production withholding tax shown on TC-40W, Part 2 (attach TC-40W, page 2)

36

.00

37 AMENDED RETURN ONLY - previous payments

37

.00

38 Refundable credits from TC-40A, Part 5 (attach TC-40A,page 2)

38

.00

39

0 .00

40

3071 .00

42

3071 .00

43

.00

23 Enter tax from TC-40, page 1, line 22

27 Subtract line 26 from line 25 (not less than zero)

32 Total tax, use tax and additions to tax (add lines 27 through 31)

39 Total withholding and refundable credits - add lines 33 through 38

40 TAX DUE - subtract line 39 from line 32 (not less than zero)
41 Penalty and interest (see instructions)
42 TOTAL DUE - PAY THIS AMOUNT - add line 40 and line 41

41

.00

43 REFUND - subtract line 32 from line 39 (not less than zero)

44 Amount of refund on line 43 to be applied to your 2016 taxes

44

.00

45 DIRECT DEPOSIT YOUR REFUND - provide account information (see instructions for foreign accounts)
Routing number
Account number

checking

Account type:

savings

Under penalties of perjury, I declare to the best of my knowledge and belief, this return and accompanying schedules are true, correct and complete.
SIGN Your signature

Date

Spouses signature (if filing jointly)

Date

HERE
Third Party

Name of designee (if any) you authorize to discuss this return

Designees telephone number

Designee PIN

Preparers signature

Preparers telephone number

Preparers PTIN

Designee

Paid

Date

Preparers

Firms name

Section

and address

Preparers EIN

Attach TC-40 page 3 if you are filing for a deceased taxpayer, filing a fiscal year return, filed IRS form 8886, are making voluntary contributions, requesting a direct deposit
to be sent to your Utah Educational Savings Plan, requesting a direct deposit to be sent to a foreign account, or are no longer entitled to a homeowners exemption.

40503

Utah Individual Income Tax Return (continued)

SSN

434113311

Last name

TC-40
2015

Arc

Pg. 3

USTC ORIGINAL FORM

Part 1 - Deceased Taxpayer Information

If the taxpayer shown on page 1 is deceased, enter the date of death here:

mm/dd/yy

If the spouse shown on page 1 is deceased, enter the date of death here:

mm/dd/yy

If you are claiming a refund for a deceased taxpayer and are not the surviving spouse, enter X:
You must complete and attach form TC-131 to the return.

Part 2 - Fiscal Year Filer

If filing a fiscal year return (a year other than January 1 through December 31), enter the fiscal year end (mm/yy)
See incometax.utah.gov/topics/fiscal-year-filing.

Part 3 - Federal Form 8886 filed

If you filed federal form 8886, Reportable Transaction Disclosure Statement, enter X:
Get form and instructions at irs.gov.

/
mm/yy

Part 4 - Voluntary Contributions (write the code and amount of each voluntary contribution)
See explanation of each contribution at incometax.utah.gov/contributions and/or the TC-40 instructions
02 Pamela Atkinson Homeless Account
03 Kurt Oscarson Childrens Organ Transplant Account
05 School District and Nonprofit School District Foundation - enter school district code
See codes at incometax.utah.gov/contributions/school-district-contributions
09 Cat and Dog Community Spay and Neuter Program
11 Canine Body Armor Account
12 Invest More for Education Account
13 Youth Development Organization Account
14 Youth Character Organization Account

Code

Sch Dist
Code

Amount

.00

.00

.00

.00
.00

Total voluntary contributions (enter the total here and on TC-40, page 2, line 28)
Part 5 - Utah Educational Savings Plan - Refund Application
To deposit your total refund into your Utah Educational Savings Plan (UESP) account(s), enter X:
Partial refunds are not allowed. UESP will divide your refund equally between all your accounts. If you do
not have a UESP individual account, UESP will send you information about how to open an account and also
return your refund without interest or earnings.
See uesp.org, or call 801-321-7188 or 1-800-418-2551.
Part 6 - Direct Deposit to Foreign Account
If you choose to direct deposit your refund to an account outside the United States and its territories, enter X:
The Tax Commission cannot transfer a refund to an account outside the United States and its territories.
By checking this box, your refund will not be direct deposited but will be sent to you by check.
Part 7 - Property Owners Residential Exemption Termination Declaration
If you are a Utah residential property owner and declare you no longer qualify to receive a residential exemption
authorized under UC 59-2-103 for your primary residence, enter X and enter the county code where the
residence is located (see instructions for county codes and additional information).

Mail
RETURNS WITH
PAYMENTS to:

Utah State Tax Commission

210 N 1950 W
Salt Lake City, UT 84134-0266

Mail
ALL OTHER
RETURNS to:

Submit page ONLY if data entered.

Attach completed schedule to your Utah Income Tax return.

Enter X

Enter code

Utah State Tax Commission

210 N 1950 W
Salt Lake City, UT 84134-0260