April 4, 2022 Sandra: Anderson _ > {ptD { ; k 7 Department of Treasury > jaa Remittance office, RM 3413 1500 Pennsylvania Ave, NW Washington, DC 20220 202-622-2000 To whom this my concern: Enclosed is my assessment and accounting records for an American Express Account. Included in this package are the following: 1) 2021 W4- Employee Withholding Certificate 2). Statements for American Express Account form January 2021 ~ December 2021 3) 2021 Form 1040V 4) 2021 1040- U.S. Individual Income Tax Return These forms are all prepared in good faith as it is my intention to be in voluntary compliance with the IRS and its Internal Revenue Code. If there is another way you would prefer me to complete and submit this information, please let me know. If there are any errors, please inform me as to what they are so | can make the appropriate corrections. Thanks for your attention and assistance. Kind Regards, Camplokad 11 good Qe Hr Giwen Ber patent rights plirthored (eprensenaive, 2) Sendra + Prolursen, Bureficiou AlL nights reserved cea aW cova no. 1546-0074 fom W-4 Employee's Withholding Certificate 2020) | Complete Form W-4s0 that your employer can withhold the correct federal Income tax trom your Pay 2021 T Sneromiratoyerenr > Yourithheaing I subject orev Step 1; [@ tana ote sect a Enter Le Sandra Anderson ! F Personal ~ >> ante Information — er ‘eu get Carlsbad, CA 62008-5024 Skee rr |e Single or Marie ting sono Ci Married fing jointly or Qualifying widow(er) Ctead ot household (Check oly i you're unmaried and pay more than hf the costs of keeping uP a home for yours and a qualtyng indivi) Complete Steps 2-4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can Claim exemption from withholding, when to use the estimator at www.ir.gov/W4App, and privacy. Se re a eo aT tt nee ele ceisler asetainie Vaeeoatey nna ome crn cng tn uy 2, 2th Dene 2: Statement Closing Date 1/22/21 = $0.00: 2/19/21 = $754.74 : 03/29/21 = $703.14 : 05/23/21 = $25.25 : 06/22/21 = $2209.27 (07/23/21 = $1507.11 : 08/23/21 = $2356.15: 09/22/21 = $848.17 : 10/22/21 = $1187.55 : 11/22/21 = $436.51 = 12/23/21 = $2902.86 TOTAL = 12,929.75 OR $12,930 fount net poner covet po tid U cloacae arsed estesalash el Welraea| EXEMPT Seop 6: | Urder panain of pry, decreas cerita, oe beet of my knowledge and bet st, comet, ane complet. ha y Bai Sanaue: Podecon oll. cighls cesened 3 hon 1, 202 Employeo’s signature (This form isnot vail unless you sign it) Employers Rrttan ergs on Shomer | SRY Kontication Oni fect 60th Floor Y Pear NY” 10288 January, 2021 | 13.4922250 “Farias Rotana Paperwork Reduction AA NOES 9 Oe 3: Ca Na a0 Form Wo ct}Department of the Treasury 2 O 2 1 Form 1 040-V sa Internal Revenue Service Form 1040-v? statement any balan etyOu send with your check or money order or “Amount you owe" line of your 2021 Form 1040, 1040:SR, or 1080-NR * Consider Making Your Tax Payment Electronically—tt's Easy a ‘You can make electronic payments online, by phone, of from a ‘mobile device, Paying electronically is safe and secure. When you schedule your payment, you will receive immediate ‘confirmation from the IRS, Go to www.irs.gov/Payments to see all your electronic payment options. How To Fill in Form 1040-V Line 4. Enter your social security number (SSN). | you are filing a joint return, enter the SSN shown first on your return, Line 2. you are fling a joint return, enter the SSN shi ‘second on your return. “wn Line 3. Enter the amount you are paying by check or money ‘order. It paying online at www.irs.gov/Payments, don't complete LLine 4. Enter your name(s) and address exactly as shown on your return. Please print clearly. How To Prepare Your Payment * Make your check or money order payable to “United States “Treasury.” Don't send cash. Ifyou want to pay in cash, in person, see Pay by cash, later. * Make sure your name and address appear on your check or money order. * Enter your daytime phone number and your SSN on ‘check of money order you have an Indhvidual Taxpayer Tdentiication Number (TIN), enter it wherever your SSN Is requested. if you are fing a joint return, enter the SSN shown first on your return. Also, enter “2021 Form 1040," "2021 Form “1040-38.” oF "2021 Fort 1040-NF,”" whichever is appropriate, + To help us process your payment, enter the amount on the tight si of your check ike tis: § X30.XK. Don't use dashes or Tines (for example, dont ontr "$0" oF $8 100/10". Tajo um apouees a rare wa mil Print oF pe Y Detach Hore and Mall With Your ‘axpayers presenting checks. When you provid Notes nave you autntze us eer to use loa {rom your check to make a one-time electronic fund transfor from ur aecount or to process the payment as a check transaction. jen wo use information from your check to make an electronic {und transfer, funds may be withdrawn from your account as soon as the same day we receive your payment, and you will not feceive your check back from your financial Institution. No checks of $100 million or more accepted. The IRS can't Accept a single check (including a cashier's check) for amounts {of $100,000,000 ($100 milion) or more. if you are sending $100 mnilion or more by check, you will need to spread the payments ver two or more checks, with each check made out for an ‘amount less than $100 milion, Pay by cash, This is an in-person payment option for individuals provided through real partners with @ maximum of $1,000 per day Per transaction. To make a cash payment, you must fist be Teaistered online at www.offciajpayments.com/fed, our Official Payment provider. How To Send in Your 2021 Tax Return, Payment, and Form 1040-V ‘Don't staple or otherwise attach your payment or Form 1040-V to your retumn or to each other. Instead, just put them loose in the envelope. ‘Mail your 2021 tax return, payment, and Form 1040-V to the ‘address shown on the back that appiies to you, How To Pay Electronically Pay Online Pees sy mapa ot Steen mo er aincgoeearemn et : aE Inomition, goto ww. gou/Paymens, ne "1" tre fee ety sn 1 costo you, You recaive Insta conimnaton that your a Pegasus San nn cacomace The IS doesn't charge a fe for this service; the cara Processors do. The authorized eos umbors ara one at wav. gon/Baymcra sar PHONE _ Payment Voucher ‘ot staple or attach this voucher to your payment of return > Go to ww.ir.gov/Payments fr payment options and information, a TT Te aT ee 2 leone a ae am a RR ch | ame LS aa ar a oo Tor aor ‘Gut No, 208766‘1 040 Deparent ote t-te Rove Sn Filing Status U.S. Individual income Tax Return | 2O2W [owons 115.0074] ne mow Check ony Sho Marea tngjoty C) ried tg sparta (FS) (Hows of ould HOM] Cuihing widow OW one box, tYOU checked the MFS. ‘box, enter the name of your spouse. It you checked the HOH or QW box, enter the child's name if the qualifying Tao Beonins cnet a oo a oceson "een aaa ianansaaTmaao RE Te cal Home address (umber and sree}, If you have @ P.O. box, see instructions. me. nn © |emanecnreuoyes Se te Ben fice ye Fave eign airs, Conga waves bow YS BP code ipototns tea Chey a seed Sy ca oooe | eee econ Foreign country name Foreign provncaltatalouny Foran pot code ey — At any te during 2021, i you rece, sel exchange, or certs depose of any fend nrestinany vtual cureney? —Cl¥ee [Ne ‘Standard Someone can claim: [] You as a dependent [Your spouse as a dependent Deduction (1) spouse itemizes on a separate return or you wore a dual-status allen ‘Age/Biindness You: C] Were bom before January 2, 1957 [Are bind Spouse: Was bom before January2, 1987 _(1] Is bind Dependents (see instructions}: ‘@) Social securty |) Relationship (H i qualifies for (200 instructions: trore {0 Piatrane Lanta ber ‘oyeu Chita rat ropes than four T 0 o soo matching 0 o and ches i o -o here — Oo I Wages salanes, toa, ete AtachFomyW2 >. 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Mero ress onter-0- = |) lL io ‘or Disclosure, Privacy Act, and Paperwork Reduction Act Notice, eee separate iatrucione, Fem 1040 cas)‘Tax (se0 Instructions. Check any Fom Form): @ qo eed 2 Bs wr 30 ‘Amount from Schedule 2, line 3. ; . a Add tines 1 and 17 Mecano grins ‘Amount from Schedule 3, tine 8 oa Seer = Add lines 19 and 20 wee Subtract ne 2 rom ine 18, zero or ss eter-O- ; tere, eng st-enpoyment rom Scede 2 ine21 Add tines 22 and 20. his isyourtotaltax ss = 2 8 Federal income tax withheld from Form(s) W-2 wee we woe 25a Form(s) 1099. iaoeuasiseisep 4.) [ap Other forms seo instructions) sss Be ‘Add lines 25a trough 250. - Leva aS 2001 etimated tax payments and amount pple fom 2020 etm «ey w+ 26 Eamedincome credit (EIQ)... 20 Check hare you were bom ser January 1, 198, and before January 2, 2004, and you satisfy all the other requirements for taxpayers who are atleast age 16, to claim the EIC, See instructions > [] 7 or) 9 20 21 2 2 24 25 a b a 1b Nontaxable combat payelecton =. [27 2 © Proryear@09}eamedincome |. | [ate ‘28 etude chi tax cect or adonl hd tax cred rom Seheaue 8812 | 28 20 American opportunity ced rom Form 8869, tne 8 28 30 Recovery rebate cred. Se netuctions 20 31 Amount from Schedule 3, line 15. 31 sd 32 Aatines 27a and 28 hough 31. These ar your total other payments and refundable credits > | 2 133 _Addlines 254,26, and 22 These ar yourtotal payments. ee hfe Fatund Sine 2s mor than ne 24, uate 26 rome $3, Tiss the amount you overpaid. | 94 Sa Amount of tine 34 you went refunded to you It Form 6888 s attached, check here ... &D [35a 12,930 Direct deposit? Bb Routing numbe| PeType: [2] Checking [] Savings Steinincions. = lata 36 _ Amount of ine 34 you your Bnawrmied tax. > | 38 ‘Amount 37 Amount you owe. Subtract line 3S from line 24 For deta on how to pay, see instructions. > You Owe 38 _ Estimated tax penalty (see instructions)... _ >| as Third Party a.you wart o alow eo pero to Sin i wan wih Hw TR? 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