Your first name and middle initial

Last name

Your social security number

If joint return, spouse’s first name and middle initial

Last name

Spouse’s social security number

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

Apt. no.

Presidential Election Campaign

Check here if you, or your

spouse if filing jointly, want $3

City, town, or post office. If you have a foreign address, also complete spaces below.

State

ZIP code

to go to this fund. Checking a

box below will not change

Foreign country name

Foreign province/state/county

Foreign postal code

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?

Yes

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:

Were born before January 2, 1957

Are blind

Spouse:

Was born before January 2, 1957

Is blind

Dependents (see instructions):

(2) Social security

(3) Relationship

(4) ✔ if qualifies for (see instructions):

If more

(1) First name

Last name

number

to you

Child tax credit

Credit for other dependents

than four

dependents,

see instructions

and check

here ▶

Attach

1

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

.

1

2

a

Tax-exempt interest . . .

2a

b Taxable interest

. . . .

.

2b

Sch. B if

3

a

Qualified dividends . . .

3a

b Ordinary dividends . . . .

.

3b

required.

4a

IRA distributions . . . .

4a

b Taxable amount

.

4b

5a

Pensions and annuities . .

5a

b Taxable amount

.

5b

Standard

6a

Social security benefits . .

6a

b Taxable amount

.

6b

Deduction for—

7

Capital gain or (loss). Attach Schedule D if required. If not required, check here .

. . . ▶

7

• Single or

8

Other income from Schedule 1, line 10

.

8

Married filing

separately,

9

Add lines 1, 2b, 3b, 4b, 5b, 6b, 7, and 8. This is your total income

▶

9

$12,550

• Married filing

10

Adjustments to income from Schedule 1, line 26

.

10

jointly or

11

Subtract line 10 from line 9. This is your adjusted gross income

. . . . . . . . .

▶

11

Qualifying

widow(er),

12

a

Standard deduction or itemized deductions (from Schedule A)

. .

12a

$25,100

b

Charitable contributions if you take the standard deduction (see instructions)

12b

• Head of

household,

c

Add lines 12a and 12b

.

12c

$18,800

• If you checked

13

Qualified business income deduction from Form 8995 or Form 8995-A

.

13

any box under

14

Add lines 12c and 13

. . . . . . . . . . . . . . . . . . . . . .

.

14

Standard

Deduction,

15

Taxable income. Subtract line 14 from line 11. If zero or less, enter -0-

.

15

see instructions.

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

Cat. No. 11320B

Form 1040 (2021)

Form 1040 (2021)

Page 2

16

Tax (see instructions). Check if any from Form(s): 1

8814

2

4972

3

. .

16

17

Amount from Schedule 2, line 3

. . . . . . . .

17

18

Add lines 16 and 17

. . . . . . . .

18

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

23

Other taxes, including self-employment tax, from Schedule 2, line 21 .

. . . . . . . .

23

24

Add lines 22 and 23. This is your total tax

. . . . .

. .

▶

24

25

Federal income tax withheld from:

a

Form(s) W-2

25a

b

Form(s) 1099

25b

c

Other forms (see instructions)

25c

d

Add lines 25a through 25c

. . . . . . . .

25d

If you have a

26

2021 estimated tax payments and amount applied from 2020 return . .

. . . . . . . .

26

27a

Earned income credit (EIC)

27a

qualifying child,

attach Sch. EIC.

Check here if you were born after January 1, 1998, 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 ▶

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

▶

32

33

Add lines 25d, 26, and 32. These are your total payments . . . .

. . . . .

. .

▶

33

Refund

34

If line 33 is more than line 24, subtract line 24 from line 33. This is the amount you overpaid

. .

34

35a

Amount of line 34 you want refunded to you. If Form 8888 is attached, check here . .

.

▶

35a

Direct deposit?

▶ b

Routing number

▶ c Type:

Checking

Savings

See instructions.

▶ d

Account number

36

Amount of line 34 you want applied to your 2022 estimated tax .

.

▶

36

Amount

37

Amount you owe. Subtract line 33 from line 24. For details on how to pay, see instructions

.

▶

37

You Owe

38

Estimated tax penalty (see instructions) . . .

. . . . .

.

▶

38

Third Party

Do

you want to allow another person to discuss this return with the IRS? See

Designee

instructions

. . . . . . . . . . . . . . . . . . .

.

▶

Yes. Complete below.

No

Designee’s

Phone

Personal identification

name ▶

no. ▶

number (PIN) ▶

Paid

Preparer’s name

Preparer’s signature

Date

PTIN

Check if:

Self-employed

Preparer

Firm’s name ▶

Phone no.

Use Only

Firm’s address ▶

Firm’s EIN

▶

Go to www.irs.gov/Form1040 for instructions and the latest information.

Form 1040 (2021)