1040 U.S.

Individual Income Tax Return 2021

Department of the Treasury—Internal Revenue Service (99)
Form

OMB No. 1545-0074 IRS Use Only—Do not write or staple in this space.

Filing Status ✔ Single Married filing jointly Married filing separately (MFS) 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 name if the qualifying
one box.
person is a child but not your dependent ▶
Your first name and middle initial Last name Your social security number
MARK J THOMAS 0 1 6 6 8 5 0 1 9
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
15 HENRY STREET 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
REVERE MA 02151 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):
(1) First name Last name number to you Child tax credit Credit for other dependents
If more
than four
dependents,
see instructions
and check
here ▶
1 Wages, salaries, tips, etc. Attach Form(s) W-2 . . . . . . . . . . . . . . . . 1 24000
Attach 2a Tax-exempt interest . . . 2a 2b
b Taxable interest . . . . .
Sch. B if
3a 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
Married filing 8 Other income from Schedule 1, line 10 . . . . . . . . . . . . . . . . . . 8
separately,
$12,550 9 Add lines 1, 2b, 3b, 4b, 5b, 6b, 7, and 8. This is your total income . . . . . . . . . ▶ 9 24000
• Married filing 10 Adjustments to income from Schedule 1, line 26 . . . . . . . . . . . . . . . 10
jointly or
Qualifying 11 Subtract line 10 from line 9. This is your adjusted gross income . . . . . . . . . ▶ 11 24000
widow(er),
$25,100
12a Standard deduction or itemized deductions (from Schedule A) . . 12a 12550
• Head of b Charitable contributions if you take the standard deduction (see instructions) 12b
household,
$18,800 c Add lines 12a and 12b . . . . . . . . . . . . . . . . . . . . . . . 12c 12550
• If you checked 13 Qualified business income deduction from Form 8995 or Form 8995-A . . . . . . . . . 13
any box under
Standard 14 Add lines 12c and 13 . . . . . . . . . . . . . . . . . . . . . . . 14 12550
Deduction, 15 Taxable income. Subtract line 14 from line 11. If zero or less, enter -0- . . . . . . . . .
see instructions.
15 11450

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 1178
17 Amount from Schedule 2, line 3 . . . . . . . . . . . . . . . . . . . . 17
18 Add lines 16 and 17 . . . . . . . . . . . . . . . . . . . . . . . . 18 1178
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 1178
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 1178
25 Federal income tax withheld from:
a Form(s) W-2 . . . . . . . . . . . . . . . . . . 25a 8000
b Form(s) 1099 . . . . . . . . . . . . . . . . . . 25b
c Other forms (see instructions) . . . . . . . . . . . . . 25c
d Add lines 25a through 25c . . . . . . . . . . . . . . . . . . . . . . 25d 8000
26 2021 estimated tax payments and amount applied from 2020 return . . . . . . . . . . 26
If you have a
qualifying child, 27a Earned income credit (EIC) . . . . . . . . . . . . . . 27a
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 . . . . . . . . . . 30 200
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 ▶ 32 200
33 Add lines 25d, 26, and 32. These are your total payments . . . . . . . . . . . ▶ 33 8200
34 If line 33 is more than line 24, subtract line 24 from line 33. This is the amount you overpaid . . 34 7022
Refund
35a Amount of line 34 you want refunded to you. If Form 8888 is attached, check here . . . ▶ 35a 7022
Direct deposit? ▶b Routing number 0 4 1 2 1 5 6 6 3 ▶ c Type: ✔ Checking Savings
See instructions. ▶
d Account number 1 3 4 9 2 8 3 4 9 9 7 8 8
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) ▶

Sign 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.
Here Your signature Date Your occupation If the IRS sent you an Identity
Protection PIN, enter it here
▲

Joint return? LABORER (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.) ▶
Phone no. Email address
Preparer’s name Preparer’s signature Date PTIN Check if:
Paid 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)
Recovery Rebate Credit Worksheet—Line 30
Before you begin: See the instructions for line 30 to find out if you can take this credit and for definitions and other
information needed to fill out this worksheet.
If you received Notice 1444-C, have it available.
Don’t include on line 13 any amount you received but later returned to the IRS.
If you can't take the recovery rebate credit, you don't have to repay any amount of EIP 3 on Form 1040 or
1040-SR.
1. Can you be claimed as a dependent on another person's 2021 return? If filing a joint return, go to line 2.
✔
No. Go to line 2.
Yes. STOP You can't take the credit. Don’t complete the rest of this worksheet and
don’t enter any amount on line 30.
2. Does your 2021 return include a social security number that was issued on or before the due date of your 2021
return (including extensions) for you and, if filing a joint return, your spouse?
✔
Yes. Go to line 6.
No. If you are filing a joint return, go to line 3.
If you aren't filing a joint return, go to line 5.
3. Was at least one of you a member of the U.S. Armed Forces at any time during 2021, and does at least one of you
have a social security number that was issued on or before the due date of your 2021 return (including extensions)?
Yes. Your credit is not limited. Go to line 6.
No. Go to line 4.
4. Does one of you have a social security number that was issued on or before the due date of your 2021 return
(including extensions)?
Yes. Your credit is limited. Go to line 6.
No. Go to line 5.
5. Do you have any dependents listed in the Dependents section on page 1 of Form 1040 or 1040-SR for whom you
entered a social security number that was issued on or before the due date of your 2021 return (including
extensions) or an adoption taxpayer identification number?
Yes. Enter zero on line 6 and go to line 7.
No. STOP You can’t take the credit. Don’t complete the rest of this worksheet and
don’t enter any amount on line 30.
6. Enter:
• $1,400 if single, head of household, married filing separately, or qualifying widow(er),
• $1,400 if married filing jointly and you answered “Yes” to question 4, or
• $2,800 if married filing jointly and you answered “Yes” to question 2 or 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. 1400
7. Multiply $1,400 by the number of dependents listed in the Dependents section on page 1 of Form 1040 or
1040-SR for whom you entered a social security number that was issued on or before the due date of your 2021
return (including extensions) or an adoption taxpayer identification number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.
8. Add lines 6 and 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. 1400
9. Is the amount on line 11 of Form 1040 or 1040-SR more than the amount shown below for your filing status?
• Single or Married filing separately—$75,000
• Married filing jointly or qualifying widow(er)—$150,000
• Head of household—$112,500
Yes. Enter the amount from line 11 of Form 1040 or 1040-SR and go to line 10 . . . . . . . . . . . . . . . . . . . . . . . 9.
No. Enter the amount from line 8 on line 12 and skip lines 10 and 11.
10. Is line 9 more than the amount shown below for your filing status?
• Single or married filing separately—$80,000
• Married filing jointly or qualifying widow(er)—$160,000
• Head of household—$120,000
Yes. STOP You can’t take the credit. Don’t complete the rest of this worksheet and
don’t enter any amount on line 30.
No. Subtract line 9 from the amount shown above for your filing status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.
11. Divide line 10 by the amount shown below for your filing status. Enter the result as a decimal (rounded to at least
2 places).
• Single or married filing separately—$5,000
• Married filing jointly or qualifying widow(er)—$10,000
• Head of household—$7,500 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. .
12. Multiply line 8 by line 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.1400
13. Enter the amount, if any, of EIP 3 that was issued to you. If filing a joint return, include the amount, if any, of
your spouse’s EIP 3. You may refer to Notice 1444-C or your tax account information at IRS.gov/Account for the
amount to enter here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13. 1200
14. Recovery rebate credit. Subtract line 13 from line 12. If zero or less, enter -0-. If line 13 is more than line 12,
you don’t have to pay back the difference. Enter the result here and, if more than zero, on line 30 of Form 1040 or
1040-SR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14. 200

-59- Need more information or forms? Visit IRS.gov.