Form Department of the Treasury—Internal Revenue Service

1040A U.S. Individual Income Tax Return (99) 2017 IRS Use Only—Do not write or staple in this space.
Your first name and initial Last name OMB No. 1545-0074
Your social security number
Justin R Weisent 294 96 5152
If a joint return, spouse’s first name and initial Last name Spouse’s social security number
Emma M Weisent 295 96 8736
Home address (number and street). If you have a P.O. box, see instructions. Apt. no. Make sure the SSN(s) above
c
8862 Pontius Street and on line 6c are correct.
City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions). Presidential Election Campaign
Alliance OH 44601 Check here if you, or your spouse if filing
jointly, want $3 to go to this fund. Checking
Foreign country name Foreign province/state/county Foreign postal code a box below will not change your tax or
refund. You Spouse

Filing 1 Single 4 Head of household (with qualifying person). (See instructions.)

status 2 Married filing jointly (even if only one had income) If the qualifying person is a child but not your dependent,
Check only 3 Married filing separately. Enter spouse’s SSN above and enter this child’s name here. a
one box. full name here. a 5 Qualifying widow(er) (see instructions)

}
Exemptions 6a Yourself. If someone can claim you as a dependent, do not check Boxes
checked on
box 6a. 6a and 6b 2
b Spouse No. of children
on 6c who:
c Dependents: (4)  if child under
(3) Dependent’s
(2) Dependent’s social • lived with
age 17 qualifying for
If more than six security number you
relationship to you child tax credit (see
dependents, see (1) First name Last name instructions) • did not live
instructions. with you due to
divorce or
separation (see
instructions)
Dependents
on 6c not
entered above

Add numbers
on lines
d Total number of exemptions claimed. above a 2
Income
7 Wages, salaries, tips, etc. Attach Form(s) W-2. 7 58,925.
Attach
Form(s) W-2 8a Taxable interest. Attach Schedule B if required. 8a
here. Also bTax-exempt interest. Do not include on line 8a. 8b
attach
Form(s) 9a Ordinary dividends. Attach Schedule B if required. 9a
1099-R if tax bQualified dividends (see instructions). 9b
was 10 Capital gain distributions (see instructions). 10
withheld. 11a IRA 11b Taxable amount
If you did not distributions. 11a (see instructions). 11b
get a W-2, see 12a Pensions and 12b Taxable amount
instructions.
annuities. 12a (see instructions). 12b

13 Unemployment compensation and Alaska Permanent Fund dividends. 13

14a Social security 14b Taxable amount
benefits. 14a (see instructions). 14b

15 Add lines 7 through 14b (far right column). This is your total income. a 15 58,925.
Adjusted
gross 16 Educator expenses (see instructions). 16
income 17 IRA deduction (see instructions). 17
18 Student loan interest deduction (see instructions). 18 1,720.

19 Reserved for future use. 19

20 Add lines 16 through 19. These are your total adjustments. 20 1,720.

21 Subtract line 20 from line 15. This is your adjusted gross income. a 21 57,205.
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. REV 02/13/18 Intuit.cg.cfp.sp Form 1040A (2017)
BAA
Form 1040A (2017) Page 2
Tax, credits, 22 Enter the amount from line 21 (adjusted gross income). 22 57,205.
and
payments
23a Check
if: {
You were born before January 2, 1953,
Spouse was born before January 2, 1953,
Blind Total boxes
Blind checked a 23a }
b If you are married filing separately and your spouse itemizes
Standard deductions, check here a 23b
Deduction
for— 24 Enter your standard deduction. 24 12,700.
• People who 25 Subtract line 24 from line 22. If line 24 is more than line 22, enter -0-. 25 44,505.
check any
box on line 26 Exemptions. Multiply $4,050 by the number on line 6d. 26 8,100.
23a or 23b or
who can be 27 Subtract line 26 from line 25. If line 26 is more than line 25, enter -0-.
claimed as a This is your taxable income. a 27 36,405.
dependent,
see 28 Tax, including any alternative minimum tax (see instructions). 28 4,531.
instructions.
29 Excess advance premium tax credit repayment. Attach
• All others:
Single or Form 8962. 29
Married filing 30 Add lines 28 and 29. 30 4,531.
separately,
$6,350 31 Credit for child and dependent care expenses. Attach
Married filing Form 2441. 31
jointly or
Qualifying 32 Credit for the elderly or the disabled. Attach
widow(er),
$12,700 Schedule R. 32
Head of 33 Education credits from Form 8863, line 19. 33
household,
$9,350 34 Retirement savings contributions credit. Attach Form 8880. 34
35 Child tax credit. Attach Schedule 8812, if required. 35
36 Add lines 31 through 35. These are your total credits. 36
37 Subtract line 36 from line 30. If line 36 is more than line 30, enter -0-. 37 4,531.
38 Health care: individual responsibility (see instructions). Full-year coverage 38 0.
39 Add line 37 and line 38. This is your total tax. 39 4,531.
40 Federal income tax withheld from Forms W-2 and 1099. 40 4,762.
If you have
41 2017 estimated tax payments and amount applied
a qualifying from 2016 return. 41
child, attach 42a Earned income credit (EIC). 42a
Schedule
EIC. b Nontaxable combat pay election. 42b
43 Additional child tax credit. Attach Schedule 8812. 43
44 American opportunity credit from Form 8863, line 8. 44
45 Net premium tax credit. Attach Form 8962. 45
46 Add lines 40, 41, 42a, 43, 44, and 45. These are your total payments. a 46 4,762.
47 If line 46 is more than line 39, subtract line 39 from line 46.
Refund This is the amount you overpaid. 47 231.
Direct 48a Amount of line 47 you want refunded to you. If Form 8888 is attached, check here a 48a 231.
deposit?
See a b
Routing a c Type: Checking Savings
instructions number 0 4 4 0 0 0 0 3 7
and fill in
48b, 48c, a d
Account
and 48d or number 7 2 5 9 0 5 2 7 2
Form 8888. 49 Amount of line 47 you want applied to your
2018 estimated tax. 49
Amount 50 Amount you owe. Subtract line 46 from line 39. For details on how to pay,
you owe see instructions. a 50
51 Estimated tax penalty (see instructions). 51
Third party Do you want to allow another person to discuss this return with the IRS (see instructions)? Yes. Complete the following. No
Designee’s Phone Personal identification
designee name a no. a number (PIN) a

Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge
Sign and belief, they are true, correct, and accurately list all amounts and sources of income I received during the tax year. Declaration of preparer (other
than the taxpayer) is based on all information of which the preparer has any knowledge.
here Your signature Date Your occupation Daytime phone number
F

Joint return?
See instructions. Natural Resources Worker (330)614-3129
Keep a copy Spouse’s signature. If a joint return, both must sign. Date Spouse’s occupation If the IRS sent you an Identity Protection
PIN, enter it
for your records. teacher here (see inst.)
Print/Type preparer’s name Preparer’s signature Date PTIN
Paid Check a if
self-employed
preparer Firm’s name a Firm’s EIN a
Self-Prepared
use only Firm’s address a Phone no.
Go to www.irs.gov/Form1040A for instructions and the latest information. REV 02/13/18 Intuit.cg.cfp.sp Form 1040A (2017)
IT-140W
REV. 8-17  West Virginia Withholding Tax Schedule 17
Do NOT send W-2’s, 1099’s, K-1’s and/or WV/NRW-2’s with your return.
Enter WV withholding information below.
THIS FORM MUST BE FILED EVEN IF YOU HAVE NO INCOME OR WITHHOLDING.
PRIMARY LAST NAME SOCIAL
SHOWN ON FORM
IT-140
WEISENT SECURITY
NUMBER
294965152

1 A – Employer or Payer Information B – Employee or Taxpayer Information C – WV Tax Withheld

261557130 WEISENT R JUSTIN 1186 .00

Employer ID or Payer ID from W-2, 1099, K-1, and/or WV/NRW-2 Name WV WITHHOLDING

ALLSTAR ECOLOGY LLC 294965152 Check the appropriate box

Employer or Payer Name Social Security Number
X
1582 MEADOWDALE ROAD W-2 1099 K-1 WV/NRW-2
Address Enter State Abbreviation
FAIRMONT WV 265548880 26620 .00 WV (from Box #15 on W-2 or Box #13 on 1099R)
City, State, ZIP Income Subject to WV WITHHOLDING
Enter WV withholding Only

2 A – Employer or Payer Information B – Employee or Taxpayer Information C – WV Tax Withheld

261557130 WEISENT M EMMA 803 .00

Employer ID or Payer ID from W-2, 1099, K-1, and/or WV/NRW-2 Name WV WITHHOLDING

ALLSTAR ECOLOGY LLC 295968736 Check the appropriate box

Employer or Payer Name Social Security Number
X
1582 MEADOWDALE ROAD W-2 1099 K-1 WV/NRW-2
Address Enter State Abbreviation
FAIRMONT WV 265548880 19206 .00 WV (from Box #15 on W-2 or Box #13 on 1099R)
City, State, ZIP Income Subject to WV WITHHOLDING
Enter WV withholding Only

3 A – Employer or Payer Information B – Employee or Taxpayer Information C – WV Tax Withheld

.00
Employer ID or Payer ID from W-2, 1099, K-1, and/or WV/NRW-2 Name WV WITHHOLDING

Check the appropriate box

Employer or Payer Name Social Security Number

W-2 1099 K-1 WV/NRW-2

Address Enter State Abbreviation
.00 (from Box #15 on W-2 or Box #13 on 1099R)
City, State, ZIP Income Subject to WV WITHHOLDING
Enter WV withholding Only

4 A – Employer or Payer Information B – Employee or Taxpayer Information C – WV Tax Withheld

.00
Employer ID or Payer ID from W-2, 1099, K-1, and/or WV/NRW-2 Name WV WITHHOLDING

Check the appropriate box

Employer or Payer Name Social Security Number

W-2 1099 K-1 WV/NRW-2

Address Enter State Abbreviation
.00 (from Box #15 on W-2 or Box #13 on 1099R)
City, State, ZIP Income Subject to WV WITHHOLDING
Enter WV withholding Only

Total WV tax withheld from column C above.................................................... 1989 .00

If you have WV withholding on multiple pages, add the totals together and
enter the GRAND total on line 11, Form IT-140.

1555 REV 11/15/17 INTUIT.CG.CFP.SP *T O 4 0 2 0 1 7 0 3*

 State of West Virginia
Individual Income Tax Declaration
For Electronic Filing
For the year January 1 – December 31, 2017

WV-8453
Rev. 11/17
Your first name and middle Initial Last Name Your Social Security Number

2017
JUSTIN R WEISENT 294965152
If a joint return, spouse’s first name and middle initial Last name, if different Spouse’s Social Security Number
EMMA M WEISENT 295968736
Home Address (number and street) Daytime telephone number
8862 PONTIUS STREET 3306143129
City, town or post office, state and ZIP code
ALLIANCE OH 44601
Part I Tax Return Information (whole dollars only)
1. Federal Adjusted Gross Income (Form IT-140, Line 1).................................................................... 1 .00
2. West Virginia Income Tax (Form IT-140, Line 8).............................................................................. 2 .00
3. Balance Due (Form IT-140, Line 31)................................................................................................ 3 .00
4. Refund (Form IT-140, Line 30)......................................................................................................... 4 1989.00
Part II Direct Deposit or Electronic Funds Withdrawal
5. Routing transit number (RTN) 044000037 The first two numbers of the RTN must be 01 through 12 or 21 through 32

6. Depositor account number (DAN) 725905272

7. Electronic Funds Withdrawal (Checking only; No Partial Payments)

8. Type of account: X Checking Savings (Direct Deposit Only)

Part III Declaration of Taxpayer

I consent that my refund be directly deposited or my payment due be withdrawn by electronic debit as designated in Part II. I further authorize the State of West Virginia to initiate debit entries and to initiate, if necessary, credit entries as adjustments
for any entries in error into my Checking or Savings account as indicated above in Part II and the Financial Institution indicated above in Part II, to credit the same any amount(s) owed to me by the State of West Virginia. If I have filed a joint return, this
is an irrevocable appointment of the other spouse as an agent to receive the refund or authorize the electronic debit.
Under penalties of perjury, I declare that I have compared the information contained on my return with the information I have provided to my Electronic Return Originator and that the amount described in Part I above agree with the amounts shown on
the corresponding lines of my 2017 West Virginia income tax return. To the best of my knowledge and belief, my return is true, correct, and complete. I consent that my return, including this declaration and accompanying schedules and statements, be
sent to the West Virginia State Tax Department, upon request by the Department. If I have filed a joint federal and state return, I understand that, if there is an error on either return, my state return will be rejected. If the processing of my return or
refund is delayed, I authorize the State Tax Department to disclose to my ERO and /or the transmitter the reason(s) for the delay, or when the refund was sent.

Please
Sign Here Your signature Date Spouse’s signature Date

Part IV Declaration & Signature of Electronic Return Originator (ERO) & Paid Preparer
I declare that I have reviewed the above taxpayer’s return and that entries on Form WV-8453 are complete and correct to the best of my knowledge. (ERO’s who are collectors are not responsible for reviewing the taxpayer’s return; however, they
must ensure that Form WV-8453 accurately reflects the data on the return.) I have obtained the taxpayer’s signature on Form WV-8453 before submitting this return to the State Tax Department, have provided the taxpayer a copy of all forms and
information to filed with the West Virginia State Tax Department, and have followed all other requirements described in the West Virginia Handbook for Electronic Filers of Individual Income Tax Returns (Tax Year 2017). If I am also the Paid Preparer,
under penalty of perjury I declare that I have examined the above taxpayer’s return and accompanying schedules and statements, and to the best of my knowledge and belief they are true, correct, and complete. Declaration of preparer is based on
all information of which preparer has any knowledge.

ERO’s Date Check if: Your PTIN/SSN

Signature Paid Preparer
Firm Name Self-Employed
(or yours, if self-
Phone # El No.
employed) and
address Zip Code

ERO’s are instructed to retain the WV-8453 and all supporting documents for not less than three (3) years.
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 is based on all information of
which preparer has any knowledge.

Paid Preparer’s Date Check if: Your PTIN/SSN

Preparer’s Signature Self-Employed
Firm Name
Use Only Phone # El No.
(or yours, if
self-employed)
Zip Code
and address
NOTE: Part IV of this form MUST be completed in full as required.
ERO’s are required to file and hold this document and all attachments for three (3) years from date filed.
1555 REV 11/30/17 INTUIT.CG.CFP.SP
IT-140
REV 8-17
Extended
 West Virginia Personal Income Tax Return 2017
Check box ONLY if you are a Year End
Due Date
¿VFDO\HDU¿OHU
MM DD YYYY MM DD YYYY

SOCIAL Deceased Deceased

*SPOUSE’S SOCIAL
SECURITY 294965152 Prime SECURITY NUMBER 295968736 Spouse
NUMBER

Date of Death Date of Death

WEISENT JUSTIN R
Last Name 6XI¿[ Your First Name MI

EMMA M
Spouse’s Last Name – Only if different from Last Name above 6XI¿[ Spouse’s First Name MI

8862 PONTIUS STREET

First Line of Address Second Line of Address

ALLIANCE OH 44601 —
City State Zip Code
3306143129
Telephone Number: __________________________________________
Nonresident/ Part-Year
Amended Check before 4/17/18 if you wish to stop the Net Operating X Nonresident Special )RUP:9¿OHGDVDQ
Resident
return original debit (amended return only) Loss injured spouse
(See instructions on Page 15)

Exemptions: (If someone can claim you as a dependent, leave Yourself (a)
Filing Status box (a) blank.)
Enter “1” in boxes a
and b if they apply { Spouse (b)
(Check One) F/LVW\RXUGHSHQGHQWV,IPRUHWKDQ¿YHGHSHQGHQWVFRQWLQXHRQ6FKHGXOH'3
1 Single First name Last name Social Security Number 'DWHRI%LUWK 00''<<<<

2 Head of Household

3 X Married, Filing Joint

4 Married, Filing Separate

*Enter spouse’s SS# and
name in the boxes above
d. Additional exemption if surviving spouse (see page 20) Enter total number of dependents (c)
5 Widow(er) with Enter decedents SSN: ______________________<HDU6SRXVH'LHG_____________________ (d)
dependent child
e. Total Exemptions (add boxes a, b, c, and d). Enter here and on line 6 below. If box e is zero, enter $500 on line 6 below. (e)

1. Federal Adjusted Gross Income or income to claim senior citizen tax credit from Schedule SCTC-1.................. 1 .00
$GGLWLRQVWRLQFRPH OLQHRI6FKHGXOH0  2 .00
6XEWUDFWLRQVIURPLQFRPH OLQHRI6FKHGXOH0  3 .00
4. West Virginia Adjusted Gross Income (line 1 plus line 2 minus line 3)................................................................. 4 .00
5. Low-Income Earned Income Exclusion (see worksheet on page 24)................................................................... 5 .00
7RWDO([HPSWLRQVDVVKRZQDERYHRQ([HPSWLRQ%R[ H ________ x $2,000 ................................................... 6 .00
7. West Virginia Taxable Income (line 4, minus lines 5 & 6) IF LESS THAN ZERO, ENTER ZERO ....................... 7 .00
 ,QFRPH7D['XH &KHFN2QH
Tax Table Rate Schedule Nonresident/Part-year resident calculation schedule............................... 8 .00
9. Family Tax Credit if applicable (see required schedule on page 46)..................................................................... 9 .00
10. Total Taxes Due (line 8 minus line 9)......................................................... 10 .00
TAX DEPT USE ONLY
3$<0(17 CORR SCTC NRSR HEPTC
PLAN

1555 REV 11/15/17 INTUIT.CG.CFP.SP *T O 4 0 2 0 1 7 0 1*

 PRIMARY LAST NAME SOCIAL
SHOWN ON FORM SECURITY
IT-140
WEISENT NUMBER
294965152
10. Total Taxes Due (from previous page).............................................................................. 10 .00

11. West Virginia Income Tax Withheld (SEE INSTRUCTIONS) CHECK HERE IF WITHHOLDING IS FROM NRSR
(NONRESIDENT SALE OF REAL ESTATE)...................................................................................................................................... 11 1989.00
12. Estimated Tax Payments and Payments with Schedule L .................................................................................................................. 12 .00
13. Senior Citizen Tax Credit for property tax paid from Schedule SCTC-1............................................................................................... 13 .00
14. Homestead Excess Property Tax Credit for property tax paid from Schedule HEPTC-1...................................................................... 14 .00
15. Credits from Tax Credit Recap Schedule (see schedule on page 10) ................................................................................................ 15 .00
16. Amount paid with original return (amended return only) ..................................................................................................................... 16 .00
17. Payments and Credits (add lines 11 through 16) ................................................................................................................................ 17 1989.00
18. Overpayment previously refunded or credited (amended return only) ................................................................................................ 18 .00
19. Total payments and credits (line 17 minus line 18).............................................................................................................................. 19 1989.00
 3HQDOW\'XHIURP)RUP,7 CHECK IF REQUESTING WAIVER/ANNUALIZED WORKSHEET ATTACHED If you owe penalty, enter here 20 .00

21. Subtract line 20 from line 19 and enter total, (if line 20 is larger, subtract 19 from 20 add to line 10 and enter on line 22)................... 21 1989.00
%DODQFHRI,QFRPH7D['XH OLQHPLQXVOLQH ,IOLQHLVJUHDWHUWKDQOLQHVNLSWROLQH 22 .00
23. If line 21 is greater than line 10, subtract line 10 from line 21. This is your income tax overpayment.................................................. 23 1989.00
 :HVW9LUJLQLD8VH7D['XHRQRXWRIVWDWHSXUFKDVHV VHH6FKHGXOH87RQSDJH ,IWKLVDPRXQWLVJUHDWHUWKDQOLQHJRRQ
to line 25. If this amount is less than line 23, skip to line 26 X CHECK IF NO USE TAX DUE...................................................... 24 .00
25. Subtract line 23 from line 24 and add line 22, this is the total balance of tax due............................................................................. 25 .00
26. Subtract line 24 from line 23, this is your total overpayment.............................................................................................................. 26 1989.00
27. Amount of overpayment to be credited to your 2018 estimated tax..................................................................................................... 27 .00
28. West Virginia Children’s Trust Fund to help prevent child abuse and neglect.
Enter the amount of your contribution $5 $25 $100 Other $______________ ............................................ 28 .00
'HGXFWLRQVIURP\RXURYHUSD\PHQW $GGOLQHVDQG  29 .00
30. Refund due you (subtract line 29 from line 26)................................................................................................. REFUND 30 1989.00
31. Total amount due the State (line 25 plus line 28) PAY THIS AMOUNT....................................................... 3$<7+,6$02817 31 .00

Direct
Deposit X CHECKING 044000037 725905272
SAVINGS
of Refund ROUTING NUMBER ACCOUNT NUMBER
PLEASE REVIEW YOUR ACCOUNT INFORMATION FOR ACCURACY. PROVIDING INCORRECT ACCOUNT INFORMATION MAY
RESULT IN A $15.00 RETURNED PAYMENT CHARGE.
Under penalties of perjury, I declare that I have examined this return, accompanying schedules and statements, and to the best of my knowledge and
belief, it is true, correct and complete. I authorize the State Tax Department to discuss my return with my preparer. YES NO

Your Signature Date Spouse’s Signature Date Telephone Number

SELF-PREPARED
Signature of preparer other than above Date Address Telephone Number

MAIL TO:
REFUND BALANCE DUE
Preparer: Check here if WV State Tax Department WV State Tax Department
client is requesting that P.O. Box 1071 P.O. Box 3694
Preparer’s EIN IRUP127EHH¿OHG Charleston, WV 25324-1071 Charleston, WV 25336-3694
Payment Options
5HWXUQV¿OHGZLWKDEDODQFHRIWD[GXHPD\XVHDQ\RIWKHIROORZLQJSD\PHQWRSWLRQV
‡ &KHFNRU0RQH\2UGHU,I\RX¿OHGDSDSHUUHWXUQHQFORVH\RXUFKHFNRUPRQH\RUGHUZLWK\RXUUHWXUQ,I\RXHOHFWURQLFDOO\¿OHGPDLO\RXUFKHFNRUPRQH\RUGHUZLWKWKHSD\PHQWYRXFKHU,79
that is provided to you after the submission of your tax return.
‡ (OHFWURQLF)XQGV7UDQVIHU,I\RXHOHFWURQLFDOO\¿OHG\RXUUHWXUQ\RXUWD[SD\PHQWPD\EHDXWRPDWLFDOO\GHGXFWHG
IURP\RXUFKHFNLQJDFFRXQW<RXPD\HOHFWWRDXWKRUL]HWKHZLWKGUDZDOWRRFFXUDWWKHWLPHWKHUHWXUQLV¿OHGRU
GHOD\SD\PHQWDQ\WLPHEHWZHHQ¿OLQJDQGGXHGDWHRI$SULO
‡ Payment by credit card – Payments may be made using your Visa® Card, Discover® Card, American Express®
Card or MasterCard®. Visit tax.wv.gov.
1555 REV 11/15/17 INTUIT.CG.CFP.SP *T O 4 0 2 0 1 7 0 2*
 17
SCHEDULE Nonresidents/Part-Year Residents
A
(FORM IT-140) Schedule of Income
PRIMARY LAST NAME SOCIAL
SHOWN ON FORM SECURITY
IT-140 WEISENT NUMBER 294965152
PART-YEAR RESIDENTS:
ENTER PERIOD OF FROM: TO:
WEST VIRGINIA RESIDENCY MM DD YYYY MM DD YYYY

SCHEDULE A
(To Be Completed By Nonresidents and Part-Year Residents Only)
INCOME
&2/801$
$02817)520
)('(5$/5(7851
All deductions from Form 1040 &2/801% &2/801&
or 1040A not itemized on lines $//,1&20('85,1* :96285&(,1&20(
70-75 should be totaled and 3(5,2'2):9 '85,1*
entered on line 76. 5(6,'(1&< 1215(6,'(173(5,2'
56. Wages, salaries, tips (complete Form IT-140W)..................... 56 .00 .00 .00
57. Interest..................................................................................... 57 .00 .00 .00
58. Dividends................................................................................. 58 .00 .00 .00
5HIXQGVRIVWDWHDQGORFDOLQFRPHWD[ VHHOLQHRI6FKHGXOH0  59 .00 .00
60. Alimony received...................................................................... 60 .00 .00
%XVLQHVVSUR¿W RUORVV  61 .00 .00 .00
62. Capital gains (or losses).......................................................... 62 .00 .00 .00
63. Supplemental gains (or losses)............................................... 63 .00 .00 .00
64. Total taxable pensions and annuities....................................... 64 .00 .00 .00
65. Farm income (or loss)............................................................. 65 .00 .00 .00
66. Unemployment compensation insurance................................ 66 .00 .00 .00
677RWDOWD[DEOH6RFLDO6HFXULW\DQG5DLOURDG5HWLUHPHQWEHQH¿WV VHHOLQH
RI6FKHGXOH0IRU5DLOURDG5HWLUHPHQWEHQH¿WV  67 .00 .00
68. Other income from federal return (identify source)
______________________________________________ 68 .00 .00 .00
69. Total income (add lines 56 through 68)................................... 69 .00 .00 .00
ADJUSTMENTS
70. IRA deduction.......................................................................... 70 .00 .00 .00
71. Moving expenses..................................................................... 71 .00 .00 .00
72. Self-employment tax deduction............................................... 72 .00 .00 .00
73. Self-employment health insurance deduction......................... 73 .00 .00 .00
6HOI(PSOR\HG6(36,03/(DQGTXDOL¿HGSODQV 74 .00 .00 .00
75. Penalty for early withdrawal of savings................................... 75 .00 .00 .00
76. Other adjustments................................................................... 76 .00 .00 .00
77. Total adjustments (add lines 70 through 76)........................... 77 .00 .00 .00
78. Adjusted gross income (subtract line 77 from line 69 in each
column).................................................................................... 78 .00 .00 .00
79. West Virginia income (line 78, Column B plus line 78, column C)............................................................................. 79 .00
80. Income subject to West Virginia state tax but exempt from federal tax........................... 80 .00
81. Total West Virginia income (line 79 plus line 80). Enter here and on line 2 on the next page................................... 81 .00

1555 REV 11/15/17 INTUIT.CG.CFP.SP

*T O 4 0 2 0 1 7 0 7*
 17
SCHEDULE
A
(FORM IT-140)

PRIMARY LAST NAME SOCIAL

SHOWN ON FORM SECURITY
IT-140 WEISENT NUMBER 294965152

SCHEDULE A (CONTINUED)
PART I: NONRESIDENT/PART-YEAR RESIDENT TAX CALCULATION

1. Tentative Tax (apply the appropriate tax rate schedule on page 38 to the amount shown on line 7, Form IT-140)..... 1 .00

2. West Virginia Income (line 81, Schedule A)............................................................................................................. 2 .00

3. Federal Adjusted Gross Income (line 1, Form IT-140).............................................................................................. 3 .00

4. Tax (divide line 2 by line 3, round to 4 decimal places and multiply the result by line 1). Enter here and on line 8,
Form IT-140. If you are claiming a federal net operating loss carryback, you must continue to Part II................................... 4 .00
PART II: NONRESIDENT/PART-YEAR RESIDENT TAX CALCULATION FOR NET OPERATING LOSS CARRYBACK

5. Subtract line 2 Part I from your original Federal Adjusted Gross Income (line 1, Form IT-140)............................... 5 .00
6. Income Percentage (Divide line 5 by line 3 Part I and round the result to four decimal places) Note: Decimal
caQQot e[ceeG ............................................................................................................................................ 6

7. Multiply line 1 Part I by line 6................................................................................................................................... 7 .00

8. Subtract line 7 from line 1 Part I.............................................................................................................................. 8 .00

9. West Virginia Tax (Enter the smaller of line 4 Part I or line 8 Part II here and on line 8, Form IT-140).................... 9 .00
PART III: SPECIAL NONRESIDENT INCOME FOR RESIDENTS OF RECIPROCAL STATES
ELIGIBILITY: Complete this section ONLY if you were a resident of Kentucky, Maryland, Ohio, Pennsylvania or Virginia AND:
‡ :HVW9LUJLQLDVRXUFHLQFRPHZDVIURPZDJHVDQGVDODULHV
‡ :HVW9LUJLQLDLQFRPHWD[ZDVZLWKKHOGIURPVXFKZDJHVDQGVDODULHVE\\RXUHPSOR\HU V 
If you were a domiciliary resident of Pennsylvania or Virginia and spent more than 183 days in West Virginia, you are also considered a resident of West
9LUJLQLDDQGPXVW¿OH)RUP,7DVDUHVLGHQWRI:HVW9LUJLQLD
NOTE: If you were a resident of any state other than Kentucky, Ohio, Maryland, Pennsylvania, or Virginia, you are ineligible to complete Part
III. You must check the box Filing as Nonresident or Filing as a Part-Year Resident and Complete Schedule A and Part 1 to report any income
from West Virginia sources.

I declare that I was not a resident of West Virginia at any time during 2017, I was a resident of the state shown, my only income from
sources within West Virginia was from wages and salaries, and such wages and salaries were subject to income taxation by my state of
residence.
YOUR STATE OF RESIDENCE (Check one):
1. Commonwealth of Kentucky 4. Commonwealth of Pennsylvania Number of days spent in West Virginia __________________
2. State of Maryland 5. Commonwealth of Virginia Number of days spent in West Virginia __________________
3. X State of Ohio
(A) (B)
Primary Taxpayer's Social Spouse's Social Security
Security Number Number

294965152 295968736
10. Enter your total West Virginia Income from wages and salaries in the
appropriate column.......................................................................................... 10 26620 .00 19206 .00
11. Enter total amount of West Virginia Income Tax withheld from your wages
and salaries paid by your employer in 2017.................................................... 11 1186 .00 803 .00

12. Line 11, column A plus line 11 column B. Report this amount on line 11 of Form IT-140...................................... 12 1989 .00

1555 REV 11/15/17 INTUIT.CG.CFP.SP

*T O 4 0 2 0 1 7 0 8*
 DO NOT ERO MUST RETAIN THIS FORM.
E
PLEAS DO NOT SUBMIT THIS FORM TO

MA
GEORGIA DEPARTMENT OF REVENUE

IL!
UNLESS REQUESTED TO DO SO.
IRS DCN OR SUBMISSION ID GA-8453
2017

GEORGIA INDIVIDUAL INCOME TAX DECLARATION FOR ELECTRONIC FILING

SUMMARY OF AGREEMENT BETWEEN TAXPAYER AND ERO OR PAID PREPARER
First Name and Initial Last Name Social Security Number

JUSTIN R WEISENT 294-96-5152

If Joint Return, Spouse’s First Name and Initial Spouse’s Last Name Spouse’s Social Security Number
EMMA M WEISENT 295-96-8736
Home Address (number and street) Apt Number Daytime Telephone Number

8862 PONTIUS STREET 330-614-3129

City, Town or Post Office State Zip Code
ALLIANCE OH 44601
PART I TAX RETURN INFORMATION
1. FederalAdjustedGrossIncome(Form500RU)RUP;,Line8;Form500EZ,Line1).................. 1. 57205
2. GeorgiaTaxableIncome(Form500RU)RUP;,Line15;Form500EZ,Line3).......................... 2. 7899
3. NetGeorgiaTax(Form500RU)RUP;,Line22;Form500EZ,Line6)........................................ 3. 232
4. %DODQFH'XH )RUP/LQH)RUP;/LQH)RUP(=/LQH  4.
5. 5HIXQG )RUP/LQH)RUP;/LQH)RUP(=/LQH  5. 302

PART II DECLARATION OF TAXPAYER(S)

Under penalties of perjury, I declare that the information I have provided to my Electronic Return Originator (ERO) and/or Online Service
Provider and/or Transmitter and the amounts shown in Part I agree with the amounts shown on the corresponding lines of the electronic
portion of my 2017 Georgia Income Tax Return. I declare that I have examined my tax return, including accompanying schedules and
statements, and to the best of my knowledge and belief, my return is true, correct and complete. I consent that the electronic portion of my
return may be sent by my ERO/Online Service Provider/Transmitter.
SIGN
HERE TAXPAYER’S SIGNATURE Date SPOUSE’S SIGNATURE (if joint return, both must sign) Date

PRINT NAME EMAIL ADDRESS

PART III DECLARATION OF ELECTRONIC RETURNS ORIGINATOR AND PAID PREPARER

I DECLARE THAT I HAVE REVIEWED THE ABOVE TAXPAYER’S RETURN AND THAT THE ENTRIES ON THE GA-8453 ARE COMPLETE
AND CORRECT TO THE BEST OF MY KNOWLEDGE.
ERO’s Signature _____________________________________________________________ Date ______________________
ERO’s
Firm’s Name _______________________________________________________________ Check also if paid preparer
Use
Address _______________________________________________________________ FEIN/PTIN
Only
City, State, & Zip Code_________________________________________________________ SSN/TIN
IFPREPAREDBYANYPERSONOTHERTHANTHETAXPAYER,THISDECLARATIONISBASEDON ALLINFORMATIONOF WHICH
THE35(3$5(RHAS ANY KNOWLEDGE.
SELF PREPARED
Paid Preparer’s Signature _____________________________________________________ Date ______________________
Paid
Firm’s Name _______________________________________________________________ FID/TIN
Preparer’s
Use Only Address _______________________________________________________________ SSN/TIN
City, State, & Zip Code_________________________________________________________
GA-8453 (REV 0//17)
KEEP A COPY WITH YOUR RECORDS

REV 12/15/17 INTUIT.CG.CFP.SP

INTUIT 01 115 2017
 1800411518

Georgia Form 500

(Rev. 06/22/17) Page 1 .
Individual Income Tax Return
Georgia Department of Revenue
2017 (Approved software version)

Fiscal Year
Beginning

version)
Fiscal Year
Ending YOUR DRIVER’S LICENSE/STATE ID TU012279 STATE ISSUED OH

YOUR FIRST NAME MI YOUR SOCIAL SECURITY NUMBER

1. JUSTIN R 294-96-5152
LAST NAME SUFFIX
WEISENT
SPOUSE’S FIRST NAME MI SPOUSE’S SOCIAL SECURITY NUMBER
EMMA M 295-96-8736 DEPARTMENT USE ONLY

LAST NAME SUFFIX

WEISENT

ADDRESS (NUMBER AND STREET or P.O. BOX) (Use 2nd address line for Apt, Suite or Building Number) CHECK IF ADDRESS HAS CHANGED
2. 8862 PONTIUS STREET

CITY (Please insert a space if the city has multiple names) STATE ZIP CODE
3. ALLIANCE OH 44601

(COUNTRY IF FOREIGN)
Residency Status
4. Enter your Residency Status with the appropriate number................................................................................................................. 4. 3
1. FULL- YEAR RESIDENT 2. PART- YEAR RESIDENT TO 3. NONRESIDENT

Part-Year Residents and Nonresidents must omit Lines 9 thru 14 and use Form 500 Schedule 3.
Filing Status
5. Enter Filing Status with appropriate letter (See I T - 5 1 1 Tax Booklet)...................................................................................
.... .... 5. B
A. Single B.Married filing joint C.Married filing separate(Spouse’s social security number must be entered above) D. Head of Household or Qualifying Widow(er)

6. Number of exemptions (Check appropriate box(es) and enter total in 6c.) 6a. Yourself 6b. Spouse 6c. 2

Pages (1-5) are Required for Processing

REV 11/13/17 INTUIT.CG.CFP.SP
Georgia Form 500 Page 2
Individual Income Tax Return
Georgia Department of Revenue 1800411528 YOUR SOCIAL SECURITY NUMBER
2017 294-96-5152

7a. Number of Dependents (Enter details on Line 7c., and DO NOT include yourself or your spouse)..................................... 7a.

7b. Enter the total number of exemptions and dependents (Add Lines 6c and 7a) ............................................................................ 7b. 2
7c. Dependents (If you have more than 5 dependents, attach a list of additional dependents)
First Name, MI. Last Name

Social Security Number Relationship to You

First Name, MI. Last Name

Social Security Number Relationship to You

First Name, MI. Last Name

Social Security Number Relationship to You

First Name, MI. Last Name

Social Security Number Relationship to You

First Name, MI. Last Name

Social Security Number Relationship to You

INCOME COMPUTATIONS

If amount on line 8, 9, 10, 13 or 15 is negative, use the minus sign (-). Example -3,456.
8. Federal adjusted gross income (From Federal Form 1040,1040A or 1040 EZ)................................................................ 8. 57205
(Do not use FEDERAL TAXABLE INCOME) If the amount on Line 8 is $40,000 or more, or your gross income is less than your
W-2s you must include a copy of your Federal Form 1040 Pages 1 and 2.
9. Adjustments from Form 500 Schedule 1 (See IT-511 Tax Booklet )............................................................... 9.

10. Georgia adjusted gross income (Net total of Line 8 and Line 9)...................................................................... 10.

Pages (1-5) are Required for Processing REV 11/13/17 INTUIT.CG.CFP.SP

Georgia Form 500 Page 3
Individual Income Tax Return
Georgia Department of Revenue 1800411538 YOUR SOCIAL SECURITY NUMBER
2017 294-96-5152

11. Standard Deduction (Do not use FEDERAL STANDARD DEDUCTION) ...... 11a.
(See IT-511 Tax Booklet)
b. Self: 65 or over? Blind?
Total x 1,300=......... 11b.
Spouse: 65 or over? Blind?

c. Total Standard Deduction (Line 11a + Line 11b)................................. 11c.

Use EITHER Line 11c OR Line 12c (Do not write on both lines)
12. Total Itemized Deductions used in computing Federal Taxable Income. If you use itemized deductions, you must include Federal Schedule A

a. Federal Itemized Deductions (Schedule A-Form 1040) ..................... 12a.

b. Less adjustments: (See IT-511 Tax Booklet) ................................... 12b.

c. Georgia Total Itemized Deductions...................................................... 12c.

13. Subtract either Line 11c or Line 12c from Line 10; enter balance.............. 13.

14a. Enter the number from Line 6c. Multiply by $2,700 for filing status A 14a.
or D OR multiply by $3,700 for filing status B or C
14b. Enter the number from Line 7a. Multiply by $3,000............................ 14b.

14c. Add Lines 14a. and 14b. Enter total...................................................... 14c.

15. Georgia taxable income (Line 13 less Line 14c or Schedule 3, Line 14) 15. 7899

16. Tax (Use Tax Table in the IT-511 Tax Booklet).......................................... 16. 232

17. Low Income Credit 17a. 17b. ........................ 17c.

18. Other State(s) Tax Credit (Include a copy of the other state(s) return)........ 18.

19. Credits used from IND-CR Summary Worksheet ....................................... 19.

20. Total Credits Used from Schedule 2 Georgia Tax Credits .............................. 20.

21. Total Credits Used (sum of Lines 17-20) cannot exceed Line 16 ........................ 21. 0
22. Balance (Line 16 less Line 21) if zero or less than zero, enter zero ...... 22. 232
23. Georgia Income Tax Withheld on Wages and 1099s ..................... 23. 534
(Enter Tax Withheld Only and include W-2s and/or 1099s)

24. Other Georgia Income Tax Withheld................................................ 24.

(Must include G2-A, G2-FL, G2-LP and/or G2-RP)

PLEASE COMPLETE INCOME STATEMENT DETAILS ON PAGE 4. REV 11/13/17 INTUIT.CG.CFP.SP

Pages (1-5) are Required for Processing

INTUIT 02 1555 115 2017 GA 004 T1 17
Georgia Form 500 Page 4
Individual Income Tax Return
Georgia Department of Revenue 1800411548 YOUR SOCIAL SECURITY NUMBER
2017 294-96-5152

INCOME STATEMENT DETAILS Only enter income on which Georgia Tax was withheld. Enter W-2s, 1099s, and G2-As on Line 4 GA Wages/Income. For
other income statements complete Line 4 using the income reported from Form G2-RP Line 12 or 13; Form G2-LP Line 11, or for Form G2-FL enter zero.
(INCOME STATEMENT A) (INCOME STATEMENT B) (INCOME STATEMENT C)
1. WITHHOLDING TYPE: 1. WITHHOLDING TYPE: 1. WITHHOLDING TYPE:
W-2s G2-A G2-LP W-2s G2-A G2-LP W-2s G2-A G2-LP
1099s G2-FL G2-RP 1099s G2-FL G2-RP 1099s G2-FL G2-RP
2. EMPLOYER/PAYER FEDERAL 2. EMPLOYER/PAYER FEDERAL 2. EMPLOYER/PAYER FEDERAL
ID NUMBER (FEIN) SSN ID NUMBER (FEIN) SSN ID NUMBER (FEIN) SSN

581130945 586001998
3. EMPLOYER/PAYER STATE WITHHOLDING ID 3. EMPLOYER/PAYER STATE WITHHOLDING ID 3. EMPLOYER/PAYER STATE WITHHOLDING ID

3337088XU 9410384LW
4. GA WAGES / INCOME 4. GA WAGES / INCOME 4. GA WAGES / INCOME
5455 5920
5. GA TAX WITHHELD 5. GA TAX WITHHELD 5. GA TAX WITHHELD
263 271
(INCOME STATEMENT D) (INCOME STATEMENT E) (INCOME STATEMENT F)
1. WITHHOLDING TYPE: 1. WITHHOLDING TYPE: 1. WITHHOLDING TYPE:
W-2s G2-A G2-LP W-2s G2-A G2-LP W-2s G2-A G2-LP
1099s G2-FL G2-RP 1099s G2-FL G2-RP 1099s G2-FL G2-RP
2. EMPLOYER/PAYER FEDERAL 2. EMPLOYER/PAYER FEDERAL 2. EMPLOYER/PAYER FEDERAL
ID NUMBER (FEIN) SSN ID NUMBER (FEIN) SSN ID NUMBER (FEIN) SSN

3. EMPLOYER/PAYER STATE WITHHOLDING ID 3. EMPLOYER/PAYER STATE WITHHOLDING ID 3. EMPLOYER/PAYER STATE WITHHOLDING ID

4. GA WAGES / INCOME 4. GA WAGES / INCOME 4. GA WAGES / INCOME

5. GA TAX WITHHELD 5. GA TAX WITHHELD 5. GA TAX WITHHELD

Please complete the Supplemental W-2 Income Statement if additional space is needed.
25. Estimated Tax paid for 2017 and Form IT-560 ....................................... 25.

26. Total prepayment credits (Add Lines 23, 24 and 25)................................. 26. 534
27. If Line 22 exceeds Line 26, subtract Line 26 from Line 22 and enter
balance due............................................................................................... 27.
28. If Line 26 exceeds Line 22, subtract Line 22 from Line 26 and enter
overpayment ............................................................................................. 28. 302
29. Amount to be credited to 2018 ESTIMATED TAX ................................. 29. 0

Pages (1-5) are Required for Processing

Georgia Form 500 Page 5
Individual Income Tax Return
Georgia Department of Revenue 1800411558 YOUR SOCIAL SECURITY NUMBER
2017 294-96-5152

30. Georgia Wildlife Conservation Fund (No gift of less than $1.00)............. 30.

31. Georgia Fund for Children and Elderly (No gift of less than $1.00)........ 31.

32. Georgia Cancer Research Fund (No gift of less than $1.00) ................. 32.

33. Georgia Land Conservation Program (No gift of less than $1.00)........... 33.

34. Georgia National Guard Foundation (No gift of less than $1.00) ............. 34.

35. Dog & Cat Sterilization Fund (No gift of less than $1.00) ....................... 35.

36. Saving the Cure Fund (No gift of less than $1.00)................................. 36.

37. Realizing Educational Achievement Can Happen (REACH) Program ............. 37.
(No gift of less than $1.00)
38. Public Safety Memorial Grant (No gift of less than $1.00)....................... 38.

39. Form 500 UET (Estimated tax penalty) 500 UET exception attached.... 39.
40. (If you owe) Add Lines 27, 30 thru 39
MAKE CHECK PAYABLE TO GEORGIA DEPARTMENT OF REVENUE.. 40.
41. (If you are due a refund) Subtract the sum of Lines 29 thru 39 from Line 28
THIS IS YOUR REFUND......................................................................... 41. 302
Routing
41a. Direct Deposit (For U.S. Accounts Only) Type: Checking Savings Number 044000037
Account
Number 725905272
If you do not enter Direct Deposit information or if PROCESSING CENTER PROCESSING CENTER
(PAYMENT) GEORGIA DEPARTMENT OF REVENUE (REFUND and NO GEORGIA DEPARTMENT OF REVENUE
you are a first time filer a paper check will be issued.
PO BOX 740399 BALANCE DUE) PO BOX 740380
ATLANTA, GA 30374-0399 ATLANTA, GA 30374-0380

INCLUDE ALL ITEMS IN ENVELOPE, DO NOT STAPLE YOUR CHECK, W-2s, OTHER WITHHOLDING DOCUMENTS, OR TAX RETURN
I/We declare under the penalties of perjury that I/we have examined this return (including accompanying schedules and statements) and to the best of my/our knowledge
and belief, it is true, correct, and complete. If prepared by a person other than the taxpayer(s), this declaration is based on all information of which the preparer has knowledge.
Georgia Public Revenue Code Section 48-2-31 stipulates that taxes shall be paid in lawful money of the United States, free of any expense to the State of Georgia.

Taxpayer’s Signature (Check box if deceased) Spouse’s Signature (Check box if deceased)

Date Date

Taxpayer’s Phone Number REV 11/13/17 INTUIT.CG.CFP.SP

330-614-3129 I authorize DOR to discuss this return with the named preparer.

Preparer’s Phone Number

Signature of Preparer
Name of Preparer Other Than Taxpayer Preparer’s FEIN
SELF-PREPARED
Preparer’s Firm Name Preparer’s SSN/PTIN/SIDN

Pages (1-5) are Required for Processing

Georgia Form 500 Schedule 3
(Rev. 06/22/17) Page 1
Schedule 3 1807411518 YOUR SOCIAL SECURITY NUMBER
Part-Year Nonresident 294-96-5152
2017 (Approved software version) DO NOT USE LINES 9 THRU 14 OF PAGES 2 AND 3 FORM 500 or 500X
SCHEDULE 3 COMPUTATION OF GEORGIA TAXABLE INCOME FOR ONLY PART-YEAR RESIDENTS AND NONRESIDENTS.
Income earned in another state as a Georgia resident is taxable but other state(s) tax credit may apply. See IT-511 Tax Booklet.
FEDERAL INCOME AFTER GEORGIA ADJUSTMENT INCOME NOT TAXABLE TO GEORGIA GEORGIA INCOME
(COLUMN A) (COLUMN B) (COLUMN C)

1. WAGES, SALARIES, TIPS, etc 1. WAGES, SALARIES, TIPS, etc 1. WAGES, SALARIES, TIPS, etc
58925 47550 11375

2. INTERESTSAND DIVIDENDS 2. INTERESTS AND DIVIDENDS 2. INTERESTS AND DIVIDENDS

3. BUSINESS INCOME OR (LOSS) 3. BUSINESS INCOME OR (LOSS) 3. BUSINESS INCOME OR (LOSS)

4. OTHER INCOME OR (LOSS) 4. OTHER INCOME OR (LOSS) 4. OTHER INCOME OR (LOSS)

5. TOTAL INCOME: TOTAL LINES 1 THRU 4 5. TOTAL INCOME: TOTAL LINES 1 THRU 4 5. TOTAL INCOME: TOTAL LINES 1 THRU 4
58925 47550 11375

6. TOTAL ADJUSTMENTS FROM FORM 1040 6. TOTAL ADJUSTMENTS FROM FORM 1040 6. TOTAL ADJUSTMENTS FROM FORM 1040
1720 0 1720

7. TOTAL ADJUSTMENTS FROM FORM 500, 7. TOTAL ADJUSTMENTS FROM FORM 500, 7. TOTAL ADJUSTMENTS FROM FORM 500,
SCHEDULE 1 SCHEDULE 1 SCHEDULE 1

8. ADJUSTED GROSS INCOME: 8. ADJUSTED GROSS INCOME: 8. ADJUSTED GROSS INCOME:

LINE 5 PLUS OR MINUS LINES 6 AND 7 LINE 5 PLUS OR MINUS LINES 6 AND 7 LINE 5 PLUS OR MINUS LINES 6 AND 7
57205 47550 9655

% Not to exceed 100%

9. RATIO: Divide Line 8, Column C by Line 8, Column A. Enter percentage.......... 9. 16.88

10a. Itemized or Standard Deduction (See IT-511 Tax Booklet)................... 10a. 3000

10b. Additional Standard Deduction

Self: 65 or over? Blind? Spouse: 65 or over? Blind? Total x 1,300= 10b.

11. Personal Exemption from Form 500 (See IT-511 Tax Booklet)
11a. Enter the number on Line 6c. from Form 500 or 500X 2 multiply by $2,700 for 11a. 7400
filing status A or D or multiply by $3,700 for filing status B or C
11b. Enter the number on Line 7a. from Form 500 or 500X multiply by $3,000... 11b.

11c. Add Lines 11a. and 11b. Enter total..................................................................... 11c. 7400
12. Total Deductions and Exemptions: Add Lines 10a, 10b, and 11c................. 12. 10400
13. Multiply Line 12 by Ratio on Line 9 and enter result .......................................... 13. 1756
14. Georgia Taxable Income: Subtract Line 13 from Line 8, Column C
Enter here and on Line 15, Page 3 of Form 500 or Form 500X........................ 14. 7899
List the state(s) in which the income in Column B was earned and/or to which it was reported.

REV 11/13/17 INTUIT.CG.CFP.SP

1. OH 2. WV 3. 4.
Form Department of the Treasury—Internal Revenue Service
1040A U.S. Individual Income Tax Return (99) 2017 IRS Use Only—Do not write or staple in this space.
Your first name and initial Last name OMB No. 1545-0074
Your social security number
Justin R Weisent 294 96 5152
If a joint return, spouse’s first name and initial Last name Spouse’s social security number
Emma M Weisent 295 96 8736
Home address (number and street). If you have a P.O. box, see instructions. Apt. no. Make sure the SSN(s) above
c
8862 Pontius Street and on line 6c are correct.
City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions). Presidential Election Campaign
Alliance OH 44601 Check here if you, or your spouse if filing
jointly, want $3 to go to this fund. Checking
Foreign country name Foreign province/state/county Foreign postal code a box below will not change your tax or
refund. You Spouse

Filing 1 Single 4 Head of household (with qualifying person). (See instructions.)

status 2 Married filing jointly (even if only one had income) If the qualifying person is a child but not your dependent,
Check only 3 Married filing separately. Enter spouse’s SSN above and enter this child’s name here. a
one box. full name here. a 5 Qualifying widow(er) (see instructions)

}
Exemptions 6a Yourself. If someone can claim you as a dependent, do not check Boxes
checked on
box 6a. 6a and 6b 2
b Spouse No. of children
on 6c who:
c Dependents: (4)  if child under
(3) Dependent’s
(2) Dependent’s social • lived with
age 17 qualifying for
If more than six security number you
relationship to you child tax credit (see
dependents, see (1) First name Last name instructions) • did not live
instructions. with you due to
divorce or
separation (see
instructions)
Dependents
on 6c not
entered above

Add numbers
on lines
d Total number of exemptions claimed. above a 2
Income
7 Wages, salaries, tips, etc. Attach Form(s) W-2. 7 58,925.
Attach
Form(s) W-2 8a Taxable interest. Attach Schedule B if required. 8a
here. Also bTax-exempt interest. Do not include on line 8a. 8b
attach
Form(s) 9a Ordinary dividends. Attach Schedule B if required. 9a
1099-R if tax bQualified dividends (see instructions). 9b
was 10 Capital gain distributions (see instructions). 10
withheld. 11a IRA 11b Taxable amount
If you did not distributions. 11a (see instructions). 11b
get a W-2, see 12a Pensions and 12b Taxable amount
instructions.
annuities. 12a (see instructions). 12b

13 Unemployment compensation and Alaska Permanent Fund dividends. 13

14a Social security 14b Taxable amount
benefits. 14a (see instructions). 14b

15 Add lines 7 through 14b (far right column). This is your total income. a 15 58,925.
Adjusted
gross 16 Educator expenses (see instructions). 16
income 17 IRA deduction (see instructions). 17
18 Student loan interest deduction (see instructions). 18 1,720.

19 Reserved for future use. 19

20 Add lines 16 through 19. These are your total adjustments. 20 1,720.

21 Subtract line 20 from line 15. This is your adjusted gross income. a 21 57,205.
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. REV 02/13/18 Intuit.cg.cfp.sp Form 1040A (2017)
BAA
Form 1040A (2017) Page 2
Tax, credits, 22 Enter the amount from line 21 (adjusted gross income). 22 57,205.
and
payments
23a Check
if: {
You were born before January 2, 1953,
Spouse was born before January 2, 1953,
Blind Total boxes
Blind checked a 23a }
b If you are married filing separately and your spouse itemizes
Standard deductions, check here a 23b
Deduction
for— 24 Enter your standard deduction. 24 12,700.
• People who 25 Subtract line 24 from line 22. If line 24 is more than line 22, enter -0-. 25 44,505.
check any
box on line 26 Exemptions. Multiply $4,050 by the number on line 6d. 26 8,100.
23a or 23b or
who can be 27 Subtract line 26 from line 25. If line 26 is more than line 25, enter -0-.
claimed as a This is your taxable income. a 27 36,405.
dependent,
see 28 Tax, including any alternative minimum tax (see instructions). 28 4,531.
instructions.
29 Excess advance premium tax credit repayment. Attach
• All others:
Single or Form 8962. 29
Married filing 30 Add lines 28 and 29. 30 4,531.
separately,
$6,350 31 Credit for child and dependent care expenses. Attach
Married filing Form 2441. 31
jointly or
Qualifying 32 Credit for the elderly or the disabled. Attach
widow(er),
$12,700 Schedule R. 32
Head of 33 Education credits from Form 8863, line 19. 33
household,
$9,350 34 Retirement savings contributions credit. Attach Form 8880. 34
35 Child tax credit. Attach Schedule 8812, if required. 35
36 Add lines 31 through 35. These are your total credits. 36
37 Subtract line 36 from line 30. If line 36 is more than line 30, enter -0-. 37 4,531.
38 Health care: individual responsibility (see instructions). Full-year coverage 38 0.
39 Add line 37 and line 38. This is your total tax. 39 4,531.
40 Federal income tax withheld from Forms W-2 and 1099. 40 4,762.
If you have
41 2017 estimated tax payments and amount applied
a qualifying from 2016 return. 41
child, attach 42a Earned income credit (EIC). 42a
Schedule
EIC. b Nontaxable combat pay election. 42b
43 Additional child tax credit. Attach Schedule 8812. 43
44 American opportunity credit from Form 8863, line 8. 44
45 Net premium tax credit. Attach Form 8962. 45
46 Add lines 40, 41, 42a, 43, 44, and 45. These are your total payments. a 46 4,762.
47 If line 46 is more than line 39, subtract line 39 from line 46.
Refund This is the amount you overpaid. 47 231.
Direct 48a Amount of line 47 you want refunded to you. If Form 8888 is attached, check here a 48a 231.
deposit?
See a b
Routing a c Type: Checking Savings
instructions number 0 4 4 0 0 0 0 3 7
and fill in
48b, 48c, a d
Account
and 48d or number 7 2 5 9 0 5 2 7 2
Form 8888. 49 Amount of line 47 you want applied to your
2018 estimated tax. 49
Amount 50 Amount you owe. Subtract line 46 from line 39. For details on how to pay,
you owe see instructions. a 50
51 Estimated tax penalty (see instructions). 51
Third party Do you want to allow another person to discuss this return with the IRS (see instructions)? Yes. Complete the following. No
Designee’s Phone Personal identification
designee name a no. a number (PIN) a

Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge
Sign and belief, they are true, correct, and accurately list all amounts and sources of income I received during the tax year. Declaration of preparer (other
than the taxpayer) is based on all information of which the preparer has any knowledge.
here Your signature Date Your occupation Daytime phone number
F

Joint return?
See instructions. Natural Resources Worker (330)614-3129
Keep a copy Spouse’s signature. If a joint return, both must sign. Date Spouse’s occupation If the IRS sent you an Identity Protection
PIN, enter it
for your records. teacher here (see inst.)
Print/Type preparer’s name Preparer’s signature Date PTIN
Paid Check a if
self-employed
preparer Firm’s name a Firm’s EIN a
Self-Prepared
use only Firm’s address a Phone no.
Go to www.irs.gov/Form1040A for instructions and the latest information. REV 02/13/18 Intuit.cg.cfp.sp Form 1040A (2017)
 Please detach here.

OHIO IT 1040ES Rev. 7/17

Do NOT fold check or voucher.
Individual Estimated Income Tax Use UPPERCASE letters
(Voucher 1) Due l /17/Apri 2018ES to print the first three letters of

Taxpayer’s Spouse’s last name

last name (only if joint filing)
JUSTIN R WEISENT
EMMA M WEISENT WEI WEI
8862 PONTIUS STREET
ALLIANCE OH 44601 Your SSN 294 96 5152
DO NOT STAPLE OR PAPER CLIP. Spouse’s SSN
DO NOT SEND CASH. (only if joint filing) 295 96 8736
Make this payment payabl le to: Ohio Treasurer of State
Mail this voucher and payment to: Ohio Department of Taxation, P.O. Box 1460, Columbus, OH 43216-1460
Amount of
Payment
$ 246.00
Vendor’s
Registration
Number 33
REV 08/25/17 INTUIT.CG.CFP.SP 294965152 5 0118 0 295968736 3 400
 Please detach here.

OHIO IT 1040ES Rev. 7/17

Do NOT fold check or voucher.
Individual Estimated Income Tax Use UPPERCASE letters
(Voucher 2) Due 1/5,/June 2018ES to print the first three letters of

Taxpayer’s Spouse’s last name

last name (only if joint filing)
JUSTIN R WEISENT
EMMA M WEISENT WEI WEI
8862 PONTIUS STREET
ALLIANCE OH 44601 Your SSN 294 96 5152
DO NOT STAPLE OR PAPER CLIP. Spouse’s SSN
DO NOT SEND CASH. (only if joint filing) 295 96 8736
Make this payment payabl le to: Ohio Treasurer of State
Mail this voucher and payment to: Ohio Department of Taxation, P.O. Box 1460, Columbus, OH 43216-1460
Amount of
Payment
$ 246.00
Vendor’s
Registration
Number 33
REV 08/25/17 INTUIT.CG.CFP.SP 294965152 5 0218 8 295968736 3 400
 Please detach here.

OHIO IT 1040ES Rev. 7/17

Do NOT fold check or voucher.
Individual Estimated Income Tax Use UPPERCASE letters
(Voucher 3) Due em/be/Sept 2018ES to print the first three letters of

Taxpayer’s Spouse’s last name

last name (only if joint filing)
JUSTIN R WEISENT
EMMA M WEISENT WEI WEI
8862 PONTIUS STREET
ALLIANCE OH 44601 Your SSN 294 96 5152
DO NOT STAPLE OR PAPER CLIP. Spouse’s SSN
DO NOT SEND CASH. (only if joint filing) 295 96 8736
Make this payment payabl le to: Ohio Treasurer of State
Mail this voucher and payment to: Ohio Department of Taxation, P.O. Box 1460, Columbus, OH 43216-1460
Amount of
Payment
$ 246.00
Vendor’s
Registration
Number 33
REV 08/25/17 INTUIT.CG.CFP.SP 294965152 5 0318 6 295968736 3 400
 Please detach here.

OHIO IT 1040ES Rev. 7/17

Do NOT fold check or voucher.
Individual Estimated Income Tax Use UPPERCASE letters
(Voucher 4) Due ar/y /Janu 2018ES to print the first three letters of

Taxpayer’s Spouse’s last name

last name (only if joint filing)
JUSTIN R WEISENT
EMMA M WEISENT WEI WEI
8862 PONTIUS STREET
ALLIANCE OH 44601 Your SSN 294 96 5152
DO NOT STAPLE OR PAPER CLIP. Spouse’s SSN
DO NOT SEND CASH. (only if joint filing) 295 96 8736
Make this payment payabl le to: Ohio Treasurer of State
Mail this voucher and payment to: Ohio Department of Taxation, P.O. Box 1460, Columbus, OH 43216-1460
Amount of
Payment
$ 246.00
Vendor’s
Registration
Number 33
REV 08/25/17 INTUIT.CG.CFP.SP 294965152 5 0418 4 295968736 3 400
 Do not staple or paper clip. 0033

2017 Ohio IT 1040

Rev. 9/17 Individual Income Tax Return
17000133 1
02 26 18
Check here if this is an amended return. Include the Ohio IT RE (do NOT include a copy of the previously filed return).
Check here if this is a Net Operating Loss (NOL) carryback. Include Ohio Schedule IT NOL.
Taxpayer's SSN (required) If deceased Spouse’s SSN (if filing jointly) If deceased Enter school district # for
  this return (see instructions).
294 96 5152 295 96 8736
check box check box SD# 7608
First name M.I. Last name
JUSTIN R WEISENT
Spouse's first name (only if married filing jointly) M.I. Last name
EMMA M WEISENT
Address line 1 (number and street) or P.O. Box
8862 PONTIUS STREET
Address line 2 (apartment number, suite number, etc.)

City State ZIP code Ohio county (first four letters)

ALLIANCE OH 44601 STAR
Foreign country (if the mailing address is outside the U.S.) Foreign postal code

Ohio Residency Status – Check applicable box Filing Status – Check one (as reported on federal income tax return)
Full-year Part-year Nonresident Single, head of household or qualifying widow(er)
resident resident Indicate state

Married filing jointly
Check applicable box for spouse (only if married filing jointly)
Married filing separately
Full-year Part-year Nonresident
resident resident Indicate state 
Check here if you filed the federal extension 4868.
Ohio Political Party Fund
Do not staple or paper clip.

Check here if someone else is able to claim you (or your spouse if
Check here if you want $1 to go to this fund. joint return) as a dependent.
Check here if your spouse wants $1 to go to this fund (if filing jointly).
Note: Checking this box will not increase your tax or decrease your refund.

1. Federal adjusted gross income (from the federal 1040, line 37; 1040A, line 21;
1040EZ, line 4; 1040NR, line 36; or 1040NR-EZ, line 10). Include page 1 of your
federal return if the amount is zero or negative. Place a “-” in box at the right if negative................ 1. 57205 00
2a. Additions – Ohio Schedule A, line 10 (include schedule)................................................................ 2a. 00

2b. Deductions – Ohio Schedule A, line 35 (include schedule)............................................................ 2b. 00

3. Ohio adjusted gross income (line 1 plus line 2a minus line 2b).........................................................3. 57205 00
4. Exemption amount (if claiming dependent(s), include Schedule J).................................................. 4. 4100 00
Number of exemptions claimed on your federal return: 2
5. Ohio income tax base (line 3 minus line 4; if less than zero, enter zero).......................................... 5. 53105 00

6. Taxable business income – Ohio Schedule IT BUS, line 13 (include schedule)............................... 6. 00

7. Line 5 minus line 6 (if less than zero, enter zero)............................................................................. 7. 53105 00

/ /
Postmark date Code

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 0033
2017 Ohio IT 1040
Rev. 9/17 Individual Income Tax Return 2
SSN 294 96 5152 17000233
7a. Amount from line 7 on page 1......................................................................................................... 7a. 53105 00
8a. Nonbusiness income tax liability on line 7a (see instructions for tax tables)...............................................8a. 1312 00
8b. Business income tax liability – Ohio Schedule IT BUS, line 14 (include schedule).....................................8b. 00
8c. Income tax liability before credits (line 8a plus line 8b)...............................................................................8c. 1312 00

9. Ohio nonrefundable credits – Ohio Schedule of Credits, line 33 (include schedule).....................................9. 330 00
10. Tax liability after nonrefundable credits (line 8c minus line 9; if less than zero, enter zero)........................10. 982 00
11. Interest penalty on underpayment of estimated tax (include Ohio IT/SD 2210)..........................................11. 00
12. Use tax due on Internet, mail order or other out-of-state purchases (see instructions).
Check here to certify that no use tax is due..................................................................................... ....12. 00
13. Total Ohio tax liability before withholding or estimated payments (add lines 10, 11 and 12)....................13. 982 00
14. Ohio income tax withheld (W-2, box 17; W-2G, box 15; 1099-R, box 12). Include W-2(s), W-2G(s)
and 1099-R(s) with the return......................................................................................................................14. 00
15. Estimated (2017 Ohio IT 1040ES) and extension (2017 Ohio IT 40P) payments and credit
carryforward from previous year return........................................................................................................15. 00
16. Refundable credits – Ohio Schedule of Credits, line 40 (include schedule)................................................16. 00
17. Amended return only – amount previously paid with original and/or amended return..............................17. 00
18. Total Ohio tax payments (add lines 14, 15, 16 and 17).............................................................................18. 00
19. Amended return only – overpayment previously requested on original and/or amended return...............19. 00
20. Line 18 minus line 19.....................................................................................................................................20. 00
If line 20 is MORE THAN line 13, skip to line 24. OTHERWISE, continue to line 21.

21. Tax liability (line 13 minus line 20). If line 20 is negative, ignore the "-" and add line 20 to line 13..............21. 982 00
22. Interest and penalty due on late filing or late payment of tax (see instructions)...............................................................22. 00
23. Total amount due (line 21 plus line 22). Include Ohio IT 40P (if original return) or IT 40XP (if
amended return) and make check payable to “Ohio Treasurer of State”............ AMOUNT DUE23. 982 00
24. Overpayment (line 20 minus line 13)...........................................................................................................24. 00
25. Original return only – amount of line 24 to be credited toward 2018 income tax liability.............................25. 00
26. Original return only – amount of line 24 to be donated:
a. Wishes for Sick Children b. Wildlife species c. Military injury relief

00 00 00
d. Ohio History Fund e. State nature preserves f. Breast / cervical cancer

00 00 00 Total..... 26g. 00
27. REFUND (line 24 minus lines 25 and 26g)..................................................................YOUR REFUND27. 00

Sign Here (required): I have read this return. Under penalties of perjury, I declare that, to the best of my knowledge If your refund is $1.00 or less, no refund will be issued.
and belief, the return and all enclosures are true, correct and complete. If you owe $1.00 or less, no payment is necessary.

 Your signature Date (MM/DD/YY) NO Payment Included – Mail to:

Ohio Department of Taxation
 Spouse’s signature Phone number (330)614-3129 P.O. Box 2679
Columbus, OH 43270-2679
Check here to authorize your preparer to discuss this return with Taxation
Payment Included – Mail to:
SELF-PREPARED
Preparer's printed name Ohio Department of Taxation
P.O. Box 2057
Phone number Preparer's TIN (PTIN)
Columbus, OH 43270-2057

02/26/2018 02:55 AM 2017 IT 1040 – page 2 of 2

REV 12/08/17 INTUIT.CG.CFP.SP
 Do not staple or paper clip. 0033

2017 Ohio Schedule of Credits

Rev. 08/17 Nonrefundable and Refundable
17280133
SSN of primary filer
02 26 18 294 96 5152 7

. Nonrefundable Credits
1. Tax liability before credits (from Ohio IT 1040, line 8c)............................................................................... 1. 1312 00

2. Retirement income credit (limit $200 per return) (see instructions for table)............................................. 2. 00

3. Lump sum retirement credit – Ohio LS WKS, Section III, line 6 (include worksheet)............................... 3. 00
4. Senior citizen credit (must be 65 or older to claim this credit; limit $50 per return)................................ 4. 00

5. Lump sum distribution credit – Ohio LS WKS, Section IV, line 3 (include worksheet).............................. 5. 00

6. Child care and dependent care credit (see instructions for worksheet).................................................... 6. 00
7. Displaced worker training credit (see instructions for worksheet) (limit $500 per taxpayer)................... 7. 00

8. Campaign contribution credit for Ohio statewide office or General Assembly (limit $50 per taxpayer)...... 8. 0 00

9. Income-based exemption credit ($20 times the number of exemptions).................................................. 9. 0 00

10. Total (add lines 2 through 9)................................................................................................................... 10. 0 00
Do not staple or paper clip.

11. Tax less credits (line 1 minus line 10; if less than -0-, enter -0-)............................................................. 11. 1312 00
12. Joint filing credit (see instructions). 10 % times the amount on line 11 (limit $650).....................................12. 131 00

13. Earned income credit.............................................................................................................................. 13. 00

14. Ohio adoption credit (limit $10,000 per adopted child)........................................................................ 14. 00
15. Job retention credit, nonrefundable portion (include a copy of the credit certificate).............................. 15. 00
16. Credit for eligible new employees in an enterprise zone (include a copy of the credit certificate).......... 16. 00
17. Credit for purchases of grape production property................................................................................. 17. 00

18. Invest Ohio credit (include a copy of the credit certificate)..................................................................... 18. 00
19. Technology investment credit carryforward (include a copy of the credit certificate).............................. 19. 00

20. Enterprise zone day care and training credits (include a copy of the credit certificate).......................... 20. 00
21. Research and development credit (include a copy of the credit certificate)............................................ 21. 00
22. Ohio historic preservation credit, nonrefundable carryforward portion (include a copy of the credit
certificate)............................................................................................................................................... 22. 00
23. Total (add lines 12 through 22)............................................................................................................... 23. 131 00

24. Tax less additional credits (line 11 minus line 23; if less than -0-, enter -0-)............................................ 24. 1181 00

2017 Ohio Schedule of Credits – page 1 of 2

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 0033

2017 Ohio Schedule of Credits

Rev. 08/17 Nonrefundable and Refundable
SSN of primary filer 17280233

294 96 5152 8
Nonresident Credit

Date of nonresidency to State of residency

25. Enter the portion of Ohio adjusted gross income (Ohio

IT 1040, line 3) that was not earned or received in
Ohio. Include Ohio IT NRC if required................................ 25. 00
26. Enter the Ohio adjusted gross income (Ohio IT 1040,
line 3).....................................................................................26. 00
27. Divide line 25 by line 26 and enter the result here (four digits; do not round).
Multiply this factor by the amount on line 24 to calculate your nonresident credit.................................... 27. 00
Resident Credit
28. Enter the portion of Ohio adjusted gross income (Ohio
IT 1040, line 3) subjected to tax by other states or the
District of Columbia while you were an Ohio resident
(limits apply)...................................................................... 28. 9655 00

29. Enter the Ohio adjusted gross income (Ohio IT 1040,

line 3)..............................................................................29. 57205 00

30. Divide line 28 by line 29 and enter the result here (four digits; do not round). .1687
Multiply this factor by the amount on line 24 and enter
the result here.................................................................30. 199 00
.
31. Enter the 2017 income tax, less all credits other than
withholding and estimated tax payments and overpayment
carryforwards from previous years, paid to other states or
the District of Columbia (limits apply).............................. 31. 232 00
32. Enter the smaller of line 30 or line 31. This is your Ohio resident tax credit. Enter the two-letter
state abbreviation in the boxes below for each state in which income was subject to tax...................... 32. 199 00
GA
33. Total nonrefundable credits (add lines 10, 23, 27 and 32; enter here and on Ohio IT 1040, line 9)... 33. 330 00

Refundable Credits

34. Historic preservation credit (include a copy of the credit certificate)....................................................... 34. 00
35. Job creation credit and job retention credit, refundable portion (include a copy of the credit certificate)....35. 00

36. Pass-through entity credit (include a copy of the Ohio K-1s).................................................................. 36. 00

37. Motion picture production credit (include a copy of the credit certificate)............................................... 37. 00

38. Financial Institutions Tax (FIT) credit (include a copy of the Ohio K-1s)................................................. 38. 00
39. Venture capital credit (include a copy of the credit certificate)................................................................ 39. 00

40. Total refundable credits (add lines 34 through 39; enter here and on Ohio IT 1040, line 16).............. 40. 00

2017 Ohio Schedule of Credits – page 2 of 2

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