January 17, 2024

BROWN AND ASSOCIATE TAX ACCOUNTING

885 WALNUT STREET
MACON, GA 31201
478-305-9437

ROBERT MCELROY

3707 CASE STREET APT G2

MACON, GA 31204-0000

Dear Client,

Please find enclosed your 2023 Federal individual income tax return. We prepared your return
based on the information provided. Please review the return carefully to ensure that there are
no omissions. You should retain a copy of your return, along with any supporting documents,
for a minimum of three years from the filing date.

Your Federal return was filed electronically. The IRS was instructed to deposit your refund of
$3312 directly into an account at Refund Advantage. Once this direct deposit is received by the
bank, the bank will deposit the funds into your bank account. This deposit will be available
based on the time and date your bank receives the deposit from Refund Advantage.
As your Electronic Return Originator, we will forward your required supporting documents to
the IRS.

If you have any questions about your return, please feel free to contact our office. Remember
that we are here throughout the year to assist you with all of your financial and tax consulting
needs.

Sincerely,

BRANDON GASTIN
 U.S. Individual Income Tax Transmittal for an IRS e-file Return OMB No. 1545-0074
Form 8453 For the year January 1-December 31, 2023
Department of the Treasury
Internal Revenue Service
See instructions on back.
Go to www.irs.gov/Form8453 for the latest information.
2023
Your first name and initial Last name Your social security number
P
R
ROBERT J MCELROY JR 260-81-3375
I If a joint return, spouse’s first name and initial Last name Spouse’s social security number
N
T
Please Home address (number and street). If you have a P.O. box, see instructions. Apt. no.
print or C Important!
type. L 3707 CASE STREET G2 You must enter
E
City, town or post office, state, and ZIP code (If a foreign address, also complete spaces below.) your SSN(s) above.
A
R
L MACON GA 31204 478-739-7094
Y Foreign country name Foreign province/state/county Foreign postal code

FILE THIS FORM ONLY IF YOU ARE ATTACHING ONE OR MORE

OF THE FOLLOWING FORMS OR SUPPORTING DOCUMENTS.
Check the applicable box(es) to identify the attachments.

Form 1098-C, Contributions of Motor Vehicles, Boats, and Airplanes (or equivalent contemporaneous written
acknowledgement)

Form 2848, Power of Attorney and Declaration of Representative (or POA that states the agent is granted authority to sign the
return)

Form 3115, Application for Change in Accounting Method

Form 3468 - attach a copy of the first page of NPS Form 10-168, Historic Preservation Certification Application (Part 2- Description
of Rehabilitation), with an indication that it was received by the Department of the Interior or the State Historic Preservation Officer,
together with proof that the building is a certified historic structure (or that such status has been requested)

X Form 4136 - attach appropriate certificates and, if applicable, the appropriate reseller statements for biodiesel, renewable
diesel, and sustainable aviation fuel claims

Form 5713, International Boycott Report

Form 8283, Noncash Charitable Contributions, Section A (if any statement or qualified appraisal is required), or Section B,
Donated Property, and any related attachments (including any qualified appraisal or partnership Form 8283)

Form 8332, Release/Revocation of Release of Claim to Exemption for Child by Custodial Parent (or certain pages from a
divorce decree or separation agreement that went into effect after 1984 and before 2009) (see instructions)

Form 8858, Information Return of U.S. Persons With Respect to Foreign Disregarded Entities (FDEs) and Foreign Branches (FBs)

Form 8864 - attach the appropriate certificates and, if applicable, the appropriate reseller statements for biodiesel, renewable
diesel, and sustainable aviation fuel claims

Form 8949, Sales and Other Dispositions of Capital Assets (or a statement with the same information), if you elect not to
report your transactions electronically on Form 8949

DON’T SIGN THIS FORM.

SPA For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see your tax return instructions. 1037 CPTS 3US991 Form 8453 (2023)

Page 03
Form 8879 IRS e-file Signature Authorization
(Rev. January 2021) OMB No. 1545-0074
ERO must obtain and retain completed Form 8879.
Department of the Treasury
Internal Revenue Service Go to www.irs.gov/Form8879 for the latest information.

Submission Identification Number (SID) )

Taxpayer’s name Social security number
ROBERT J MCELROY JR 260-81-3375
Spouse’s name Spouse’s social security number

Part I Tax Return Information — Tax Year Ending December 31, 2023 (Enter year you are authorizing.)
Enter whole dollars only on lines 1 through 5.
Note: Form 1040-SS filers use line 4 only. Leave lines 1, 2, 3, and 5 blank.
1 Adjusted gross income . . . . . . . . . . . . . . . . . . . . . . . . . . 1 16,148
2 Total tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Federal income tax withheld from Form(s) W-2 and Form(s) 1099 . . . . . . . . . . . . 3 236
4 Amount you want refunded to you . . . . . . . . . . . . . . . . . . . . . . 4 3,312
5 Amount you owe . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Part II Taxpayer Declaration and Signature Authorization (Be sure you get and keep a copy of your return)
Under penalties of perjury, I declare that I have examined a copy of the income tax return (original or amended) I am now authorizing, and to the best of
my knowledge and belief, it is true, correct, and complete. I further declare that the amounts in Part I above are the amounts from the income tax
return (original or amended) I am now authorizing. I consent to allow my intermediate service provider, transmitter, or electronic return originator (ERO)
to send my return to the IRS and to receive from the IRS (a) an acknowledgement of receipt or reason for rejection of the transmission, (b) the reason
for any delay in processing the return or refund, and (c) the date of any refund. If applicable, I authorize the U.S. Treasury and its designated Financial
Agent to initiate an ACH electronic funds withdrawal (direct debit) entry to the financial institution account indicated in the tax preparation software for
payment of my federal taxes owed on this return and/or a payment of estimated tax, and the financial institution to debit the entry to this account. This
authorization is to remain in full force and effect until I notify the U.S. Treasury Financial Agent to terminate the authorization. To revoke (cancel) a
payment, I must contact the U.S. Treasury Financial Agent at 1-888-353-4537. Payment cancellation requests must be received no later than 2
business days prior to the payment (settlement) date. I also authorize the financial institutions involved in the processing of the electronic payment of
taxes to receive confidential information necessary to answer inquiries and resolve issues related to the payment. I further acknowledge that the
personal identification number (PIN) below is my signature for the income tax return (original or amended) I am now authorizing and, if applicable, my
Electronic Funds Withdrawal Consent.
Taxpayer’s PIN: check one box only
X I authorize BROWN AND ASSOCIATE TAX ACCOUNTING to enter or generate my PIN 03375 as my
ERO firm name Enter five digits, but
signature on the income tax return (original or amended) I am now authorizing. don’t enter all zeros

I will enter my PIN as my signature on the income tax return (original or amended) I am now authorizing. Check this box only
if you are entering your own PIN and your return is filed using the Practitioner PIN method. The ERO must complete Part III
below.
Your signature Date

Spouse’s PIN: check one box only

I authorize to enter or generate my PIN as my
ERO firm name Enter five digits, but
signature on the income tax return (original or amended) I am now authorizing. don’t enter all zeros

I will enter my PIN as my signature on the income tax return (original or amended) I am now authorizing. Check this box only
if you are entering your own PIN and your return is filed using the Practitioner PIN method. The ERO must complete Part III
below.

Spouse’s signature Date

Practitioner PIN Method Returns Only—continue below
Part III Certification and Authentication — Practitioner PIN Method Only
ERO’s EFIN/PIN. Enter your six-digit EFIN followed by your five-digit self-selected PIN. 67185910101
Don’t enter all zeros

I certify that the above numeric entry is my PIN, which is my signature for the electronic individual income tax return (original or amended) I am now
authorized to file for tax year indicated above for the taxpayer(s) indicated above. I confirm that I am submitting this return in accordance with the
requirements of the Practitioner PIN method and Pub. 1345, Handbook for Authorized IRS e-file Providers of Individual Income Tax Returns.

ERO’s signature Date

ERO Must Retain This Form — See Instructions
Don’t Submit This Form to the IRS Unless Requested To Do So
SPA For Paperwork Reduction Act Notice, see your tax return instructions. 1037 CPTS 3USPA1 Form 8879 (Rev. 01-2021)
Page 04
 U.S. Individual Income Tax Transmittal for an IRS e-file Return OMB No. 1545-0074
Form 8453 For the year January 1-December 31, 2023
Department of the Treasury
Internal Revenue Service
See instructions on back.
Go to www.irs.gov/Form8453 for the latest information.
2023
Your first name and initial Last name Your social security number
P
R
ROBERT J MCELROY JR 260-81-3375
I If a joint return, spouse’s first name and initial Last name Spouse’s social security number
N
T
Please Home address (number and street). If you have a P.O. box, see instructions. Apt. no.
print or C Important!
type. L 3707 CASE STREET G2 You must enter
E
City, town or post office, state, and ZIP code (If a foreign address, also complete spaces below.) your SSN(s) above.
A
R
L MACON GA 31204 478-739-7094
Y Foreign country name Foreign province/state/county Foreign postal code

FILE THIS FORM ONLY IF YOU ARE ATTACHING ONE OR MORE

OF THE FOLLOWING FORMS OR SUPPORTING DOCUMENTS.
Check the applicable box(es) to identify the attachments.

Form 1098-C, Contributions of Motor Vehicles, Boats, and Airplanes (or equivalent contemporaneous written
acknowledgement)

Form 2848, Power of Attorney and Declaration of Representative (or POA that states the agent is granted authority to sign the
return)

Form 3115, Application for Change in Accounting Method

Form 3468 - attach a copy of the first page of NPS Form 10-168, Historic Preservation Certification Application (Part 2- Description
of Rehabilitation), with an indication that it was received by the Department of the Interior or the State Historic Preservation Officer,
together with proof that the building is a certified historic structure (or that such status has been requested)

X Form 4136 - attach appropriate certificates and, if applicable, the appropriate reseller statements for biodiesel, renewable
diesel, and sustainable aviation fuel claims

Form 5713, International Boycott Report

Form 8283, Noncash Charitable Contributions, Section A (if any statement or qualified appraisal is required), or Section B,
Donated Property, and any related attachments (including any qualified appraisal or partnership Form 8283)

Form 8332, Release/Revocation of Release of Claim to Exemption for Child by Custodial Parent (or certain pages from a
divorce decree or separation agreement that went into effect after 1984 and before 2009) (see instructions)

Form 8858, Information Return of U.S. Persons With Respect to Foreign Disregarded Entities (FDEs) and Foreign Branches (FBs)

Form 8864 - attach the appropriate certificates and, if applicable, the appropriate reseller statements for biodiesel, renewable
diesel, and sustainable aviation fuel claims

Form 8949, Sales and Other Dispositions of Capital Assets (or a statement with the same information), if you elect not to
report your transactions electronically on Form 8949

DON’T SIGN THIS FORM.

SPA For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see your tax return instructions. 1037 CPTS 3US991 Form 8453 (2023)

Page 05
 Department of the Treasury—Internal Revenue Service

1040 U.S. Individual Income Tax Return 2023 OMB No. 1545-0074 IRS Use Only—Do not write or staple in this space.

For the year Jan. 1–Dec. 31, 2023, or other tax year beginning , 2023, ending , 20 See separate instructions.
Your first name and middle initial Last name Your social security number
ROBERT J MCELROY JR 260-81-3375
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.
3707 CASE STREET G2 Check here if you, or your
City, town, or post office. If you have a foreign address, also complete spaces below. State ZIP code spouse if filing jointly, want $3
to go to this fund. Checking a
MACON GA 31204 box below will not change your
Foreign country name Foreign province/state/county Foreign postal code tax or refund.
You Spouse

Filing Status X Single Head of household (HOH)

Married filing jointly (even if only one had income)
Check only
one box. Married filing separately (MFS) Qualifying surviving spouse (QSS)
If you checked the MFS box, enter the name of your spouse. If you checked the HOH or QSS box, enter the child’s name if the
qualifying person is a child but not your dependent:

Digital At any time during 2023, did you: (a) receive (as a reward, award, or payment for property or services); or (b) sell,
Assets exchange, or otherwise dispose of a digital asset (or a financial interest in a digital asset)? (See instructions.) Yes X 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, 1959 Are blind Spouse: Was born before January 2, 1959 Is blind

Dependents (see instructions): (2) Social security (3) Relationship (4) Check the box if qualifies
to you for (see instructions):
(1) First name Last name number
Child Credit for
tax credit other dependents
If more
than four
dependents,
see instructions
and check
here . .

Income 1a Total amount from Form(s) W-2, box 1 (see instructions) . . . . . . . . . . . . . 1a 16,148
b Household employee wages not reported on Form(s) W-2 . . . . . . . . . . . . . 1b
Attach Form(s)
W-2 here. Also c Tip income not reported on line 1a (see instructions). . . . . . . . . . . . . . . 1c
attach Forms d Medicaid waiver payments not reported on Form(s) W-2 (see instructions) . . . . . . . . 1d
W-2G and
1099-R if tax e Taxable dependent care benefits from Form 2441, line 26 . . . . . . . . . . . . . 1e
was withheld. f Employer-provided adoption benefits from Form 8839, line 29 . . . . . . . . . . . . 1f
If you did not g Wages from Form 8919, line 6 . . . . . . . . . . . . . . . . . . . . . 1g
get a Form
W-2, see
h Other earned income (see instructions) . . . . . . . . . . . . . . . . . . 1h
instructions. i Nontaxable combat pay election (see instructions) . . . . . . . 1i
z Add lines 1a through 1h . . . . . . . . . . . . . . . . . . . . . . . 1z 16,148
Attach Sch. B
2a Tax-exempt interest . . . 2a b Taxable interest . . . . . . 2b
if required.
3a Qualified dividends . . . 3a b Ordinary dividends . . . . . 3b
4a IRA distributions . . . . 4a b Taxable amount . . . . . . 4b
Standard
Deduction for— 5a Pensions and annuities . . 5a b Taxable amount . . . . . . 5b
| Single or Married 6a Social security benefits . . 6a b Taxable amount . . . . . . 6b
filing separately,
$13,850 c If you elect to use the lump-sum election method, check here (see instructions) . . . . .
| Married filing 7 Capital gain or (loss). Attach Schedule D if required. If not required, check here . . . . . 7
jointly or
Qualifying 8 Additional income from Schedule 1, line 10 . . . . . . . . . . . . . . . . . 8
surviving spouse, 9 Add lines 1z, 2b, 3b, 4b, 5b, 6b, 7, and 8. This is your total income . . . . . . . . . . 9 16,148
$27,700
| Head of 10 Adjustments to income from Schedule 1, line 26 . . . . . . . . . . . . . . . . 10
household, 16,148
$20,800
11 Subtract line 10 from line 9. This is your adjusted gross income . . . . . . . . . . . 11
| If you checked 12 Standard deduction or itemized deductions (from Schedule A) . . . . . . . . . . 12 13,850
any box under
Standard 13 Qualified business income deduction from Form 8995 or Form 8995-A . . . . . . . . . 13
Deduction, 14 Add lines 12 and 13 . . . . . . . . . . . . . . . . . . . . . . . . 14 13,850
see instructions.
15 Subtract line 14 from line 11. If zero or less, enter -0-. This is your taxable income . . . . . . 15 2,298
SPA For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. 1037 CPTS 3US011 Form 1040 (2023)

Page 06
Form 1040 (2023) Page 2

Tax and 16 Tax (see instructions). Check if any from Form(s): 1 8814 2 4972 3 . . 16 229
Credits 17 Amount from Schedule 2, line 3 . . . . . . . . . . . . . . . . . . . . . 17
18 Add lines 16 and 17 . . . . . . . . . . . . . . . . . . . . . . . . 18 229
19 Child tax credit or credit for other dependents from Schedule 8812 . . . . . . . . . . 19
20 Amount from Schedule 3, line 8 . . . . . . . . . . . . . . . . . . . . . 20 229
21 Add lines 19 and 20 . . . . . . . . . . . . . . . . . . . . . . . . 21 229
22 Subtract line 21 from line 18. If zero or less, enter -0- . . . . . . . . . . . . . . 22
23 Other taxes, including self-employment tax, from Schedule 2, line 21 . . . . . . . . . . 23
24 Add lines 22 and 23. This is your total tax . . . . . . . . . . . . . . . . . 24
Payments 25 Federal income tax withheld from:
a Form(s) W-2 . . . . . . . . . . . . . . . . . . 25a 236
b Form(s) 1099 . . . . . . . . . . . . . . . . . . 25b
c Other forms (see instructions) . . . . . . . . . . . . . 25c
d Add lines 25a through 25c . . . . . . . . . . . . . . . . . . . . . . 25d 236
If you have a 26 2023 estimated tax payments and amount applied from 2022 return . . . . . . . . . . 26
qualifying child,
attach Sch. EIC.
27 Earned income credit (EIC) . . . . . . . . . . . . . . 27 116
28 Additional child tax credit from Schedule 8812 . . . . . . . . 28
29 American opportunity credit from Form 8863, line 8 . . . . . . . 29 961
30 Reserved for future use . . . . . . . . . . . . . . . 30
31 Amount from Schedule 3, line 15 . . . . . . . . . . . . 31 1,999
32 Add lines 27, 28, 29, and 31. These are your total other payments and refundable credits . . 32 3,076
33 Add lines 25d, 26, and 32. These are your total payments . . . . . . . . . . . . . 33 3,312
Refund 34 If line 33 is more than line 24, subtract line 24 from line 33. This is the amount you overpaid . . . 34 3,312
35a Amount of line 34 you want refunded to you. If Form 8888 is attached, check here . . . . 35a 3,312
Direct deposit? b Routing number 291471024 c Type: X Checking Savings
See instructions.
d Account number 22431022608133754
36 Amount of line 34 you want applied to your 2024 estimated tax . . . 36
Amount 37 Subtract line 33 from line 24. This is the amount you owe.
You Owe For details on how to pay, go to www.irs.gov/Payments or see instructions . . . . . . . . 37
38 Estimated tax penalty (see instructions) . . . . . . . . . . 38
Third Do you want to allow another person to discuss this return with the IRS? See
instructions . . . . . . . . . . . . . . . . . . . . . . Yes. Complete below. No
Designee’s Phone Personal identification
name no. number (PIN)
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,
Sign 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? LABOR (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 balancetoday@yahoo.com

Preparer’s name Preparer’s signature Date PTIN Check if:
Paid BRANDON GASTIN (RTRP) P00187746 Self-employed
Preparer Firm’s name BROWN AND ASSOCIATE TAX ACCOUNTING Phone no. 478-305-9437
Use Only Firm’s address 885 WALNUT STREET MACON GA 31201 Firm’s EIN 32-0264305
SPA Go to www.irs.gov/Form1040 for instructions and the latest information. 1037 CPTS 3US012 Form 1040 (2023)

Page 07
SCHEDULE 3 OMB No. 1545-0074
(Form 1040) Additional Credits and Payments
Department of the Treasury
Attach to Form 1040, 1040-SR, or 1040-NR. 2023
Attachment
Internal Revenue Service Go to www.irs.gov/Form1040 for instructions and the latest information.
Sequence No. 03
Name(s) shown on Form 1040, 1040-SR, or 1040-NR Your social security number
ROBERT J MCELROY JR 260-81-3375
Part I Nonrefundable Credits
1 Foreign tax credit. Attach Form 1116 if required . . . . . . . . . . . . . . . 1
2 Credit for child and dependent care expenses from Form 2441, line 11. Attach Form
2441 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Education credits from Form 8863, line 19 . . . . . . . . . . . . . . . . . 3 229
4 Retirement savings contributions credit. Attach Form 8880. . . . . . . . . . . 4
5a Residential clean energy credit from Form 5695, line 15. . . . . . . . . . . . 5a
b Energy efficient home improvement credit from Form 5695, line 32 . . . . . . . 5b
6 Other nonrefundable credits:
a General business credit. Attach Form 3800 . . . . . . . . . 6a
b Credit for prior year minimum tax. Attach Form 8801 . . . . . 6b
c Adoption credit. Attach Form 8839 . . . . . . . . . . . . 6c
d Credit for the elderly or disabled. Attach Schedule R . . . . . 6d
e Reserved for future use. . . . . . . . . . . . . . . . . 6e
f Clean vehicle credit. Attach Form 8936 . . . . . . . . . . 6f
g Mortgage interest credit. Attach Form 8396 . . . . . . . . . 6g
h District of Columbia first-time homebuyer credit. Attach Form 8859 6h
i Qualified electric vehicle credit. Attach Form 8834 . . . . . . 6i
j Alternative fuel vehicle refueling property credit. Attach Form 8911 6j
k Credit to holders of tax credit bonds. Attach Form 8912 . . . . 6k
l Amount on Form 8978, line 14. See instructions . . . . . . . 6l
m Credit for previously owned clean vehicles. Attach Form 8936 . 6m
z Other nonrefundable credits. List type and amount:
6z
7 Total other nonrefundable credits. Add lines 6a through 6z . . . . . . . . . . 7
8 Add lines 1 through 4, 5a, 5b, and 7. Enter here and on Form 1040, 1040-SR, or
1040-NR, line 20 . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 229
(continued on page 2)
SPA For Paperwork Reduction Act Notice, see your tax return instructions. 1037 CPTS 3US0C1 Schedule 3 (Form 1040) 2023

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Schedule 3 (Form 1040) 2023 Page 2

Part II Other Payments and Refundable Credits

9 Net premium tax credit. Attach Form 8962 . . . . . . . . . . . . . . . . . 9
10 Amount paid with request for extension to file (see instructions). . . . . . . . . 10
11 Excess social security and tier 1 RRTA tax withheld . . . . . . . . . . . . . 11
12 Credit for federal tax on fuels. Attach Form 4136. . . . . . . . . . . . . . . 12 1,999
13 Other payments or refundable credits:
a Form 2439 . . . . . . . . . . . . . . . . . . . . . . 13a
b Credit for repayment of amounts included in income from earlier
years . . . . . . . . . . . . . . . . . . . . . . . . 13b
c Elective payment election amount from Form 3800, Part III, line
6, column (i) . . . . . . . . . . . . . . . . . . . . . 13c
d Deferred amount of net 965 tax liability (see instructions) . . . 13d
z Other payments or refundable credits. List type and amount:
13z
14 Total other payments or refundable credits. Add lines 13a through 13z . . . . . . 14
15 Add lines 9 through 12 and 14. Enter here and on Form 1040, 1040-SR, or 1040-NR,
line 31 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1,999
SPA 1037 CPTS 3US0C2 Schedule 3 (Form 1040) 2023

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 OMB No. 1545-0162
Form 4136 Credit for Federal Tax Paid on Fuels
2023
Department of the Treasury Go to www.irs.gov/Form4136 for instructions and the latest information. Attachment
Internal Revenue Service Sequence No. 79
Name (as shown on your income tax return) Taxpayer identification number
ROBERT J MCELROY JR 260-81-3375
Caution: Claimant has the name and address of the person who sold the fuel to the claimant and the dates of purchase. For
claims on lines 1c and 2b (type of use 13 or 14), 3d, 4c, and 5, claimant has not waived the right to make the claim.
For claims on lines 1c and 2b (type of use 13 or 14), claimant certifies that a certificate has not been provided to the
credit card issuer.

1 Nontaxable Use of Gasoline Note: CRN is the credit reference number.

(a) Type of use (b) Rate (c) Gallons (d) Amount of credit (e) CRN

a Off-highway business use $ .183

b Use on a farm for farming purposes .183 362
c Other nontaxable use (see Caution above line 1) 13 .183 10,921 $ 1,999
d Exported .184 411

2 Nontaxable Use of Aviation Gasoline

(a) Type of use (b) Rate (c) Gallons (d) Amount of credit (e) CRN

a Use in commercial aviation (other than foreign trade) $ .15 $ 354

b Other nontaxable use (see Caution above line 1) 324
c Exported .194 412
d LUST tax on aviation fuels used in foreign trade .001 433

3 Nontaxable Use of Undyed Diesel Fuel

Claimant certifies that the diesel fuel did not contain visible evidence of dye.
Exception. If any of the diesel fuel included in this claim did contain visible evidence of dye, attach an explanation and check here . . .

(a) Type of use (b) Rate (c) Gallons (d) Amount of credit (e) CRN

a Nontaxable use $ .243

b Use on a farm for farming purposes .243 $ 360
c Use in trains .243 353
d Use in certain intercity and local buses (see Caution
above line 1) .17 350
e Exported .244 413

4 Nontaxable Use of Undyed Kerosene (Other Than Kerosene Used in Aviation)

Claimant certifies that the kerosene did not contain visible evidence of dye.
Exception. If any of the kerosene included in this claim did contain visible evidence of dye, attach an explanation and check here . . .

(a) Type of use (b) Rate (c) Gallons (d) Amount of credit (e) CRN

a Nontaxable use taxed at $.244 $ .243

b Use on a farm for farming purposes .243 $ 346
c Use in certain intercity and local buses (see Caution
above line 1) .17 347
d Exported .244 414
e Nontaxable use taxed at $.044 .043 377
f Nontaxable use taxed at $.219 .218 369
SPA For Paperwork Reduction Act Notice, see the separate instructions. 1037 CPTS 3US231 Form 4136 (2023)

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ROBERT J MCELROY JR 260-81-3375
Form 4136 (2023) Page 2

5 Kerosene Used in Aviation

(a) Type of use (b) Rate (c) Gallons (d) Amount of credit (e) CRN

a Kerosene used in commercial aviation (other than

foreign trade) taxed at $.244 $ .200 $ 417
b Kerosene used in commercial aviation (other than
foreign trade) taxed at $.219 .175 355
c Nontaxable use (other than use by state or local
government) taxed at $.244 .243 346
d Nontaxable use (other than use by state or local
government) taxed at $.219 .218 369
e LUST tax on aviation fuels used in foreign trade .001 433

6 Sales by Registered Ultimate Vendors of Undyed Diesel Fuel Registration No.

Claimant certifies that it sold the diesel fuel at a tax-excluded price, repaid the amount of tax to the buyer, or has obtained the written consent of
the buyer to make the claim. Claimant certifies that the diesel fuel did not contain visible evidence of dye.
Exception. If any of the diesel fuel included in this claim did contain visible evidence of dye, attach an explanation and check here . .

(b) Rate (c) Gallons (d) Amount of credit (e) CRN

a Use by a state or local government $ .243 $ 360

b Use in certain intercity and local buses .17 350

7 Sales by Registered Ultimate Vendors of Undyed Kerosene

Registration No.
(Other Than Kerosene for Use in Aviation)

Claimant certifies that it sold the kerosene at a tax-excluded price, repaid the amount of tax to the buyer, or has obtained the written consent of
the buyer to make the claim. Claimant certifies that the kerosene did not contain visible evidence of dye.
Exception. If any of the kerosene included in this claim did contain visible evidence of dye, attach an explanation and check here . . .

(b) Rate (c) Gallons (d) Amount of credit (e) CRN

a Use by a state or local government $ .243

b Sales from a blocked pump .243 $ 346
c Use in certain intercity and local buses .17 347

8 Sales by Registered Ultimate Vendors of Kerosene for Use in Aviation Registration No.

Claimant sold the kerosene for use in aviation at a tax-excluded price and has not collected the amount of tax from the buyer, repaid the amount
of tax to the buyer, or has obtained the written consent of the buyer to make the claim. See the instructions for additional information to be
submitted.

(a) Type of use (b) Rate (c) Gallons (d) Amount of credit (e) CRN

a Use in commercial aviation (other than foreign trade)

taxed at $.219 $ 355
b Use in commercial aviation (other than foreign trade)
taxed at $.244 .200 417
c Nonexempt use in noncommercial aviation .025 418
d Other nontaxable uses taxed at $.244 .243 346
e Other nontaxable uses taxed at $.219 .218 369
f LUST tax on aviation fuels used in foreign trade .001 433
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ROBERT J MCELROY JR 260-81-3375
Form 4136 (2023) Page 3

9 Reserved for future use Registration No.

(b) Rate (c) Gallons (d) Amount of credit (e) CRN

of alcohol
a Reserved for future use $
b Reserved for future use
10 Biodiesel, Renewable Diesel, or Sustainable Aviation Fuel Mixture
Registration No.
Credit
Biodiesel or renewable diesel mixtures. Claimant produced a mixture by mixing biodiesel with diesel fuel or renewable diesel with liquid fuel
(other than renewable diesel). The biodiesel used to produce the biodiesel mixture met ASTM D6751 and met EPA’s registration requirements
for fuels and fuel additives. The renewable diesel used to produce the renewable diesel mixture was derived from biomass, met EPA’s
registration requirements for fuels and fuel additives, and met ASTM D975, D396, or other equivalent standard approved by the IRS.
Sustainable aviation fuel (SAF) mixtures. Claimant produced a qualified mixture by mixing SAF with kerosene. The qualified mixture was
produced by the claimant in the United States, such mixture was used by the claimant (or sold by the claimant for use) in an aircraft, such sale
or use was in the ordinary course of a trade or business of the claimant, and the transfer of such mixture to the fuel tank of such aircraft occurred
in the United States. The SAF used to produce the qualified mixture is the portion of liquid fuel that is not kerosene that (i) either (A) meets the
specifications of one of the ASTM D7566 Annexes, or (B) meets the specifications of ASTM D1655 Annex A1, (ii) is not derived from
coprocessing an applicable material (or materials derived from an applicable material) with a feedstock that is not biomass, (iii) is not derived
from palm fatty acid distillates or petroleum, and (iv) has been certified in accordance with section 40B(e) as having a lifecycle greenhouse gas
emissions reduction percentage of at least 50 percent. For all claims. Claimant has attached the appropriate certificates and, if applicable,
appropriate reseller statements. Claimant has no reason to believe that the information in the certificate or statement is false. See the
instructions for additional information and requirements.
(b) Rate (c) Number (d) Amount of credit (e) CRN
of gallons sold
or used
a Biodiesel (other than agri-biodiesel) mixtures $1.00 $ 388
b Agri-biodiesel mixtures 1.00 390
c Renewable diesel mixtures 1.00 307
d Sustainable aviation fuel mixtures (see instructions) 440

11 Nontaxable Use of Alternative Fuel

Caution: There is a reduced credit rate for use in certain intercity and local buses (type of use 5). See instructions.
(a) Type of use (b) Rate (c) Gallons, (d) Amount of credit (e) CRN
or gasoline
or diesel gallon
equivalents

a Liquefied petroleum gas (LPG) (see instructions) $ .183 $ 419

b “P Series” fuels .183 420
c Compressed natural gas (CNG) (see instructions) .183 421
d Liquefied hydrogen .183 422
e Fischer-Tropsch process liquid fuel from coal
(including peat) .243 423
f Liquid fuel derived from biomass .243 424
g Liquefied natural gas (LNG) (see instructions) .243 425
h Liquefied gas derived from biomass .183 435
SPA 1037 CPTS 3US233 Form 4136 (2023)

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ROBERT J MCELROY JR 260-81-3375
Form 4136 (2023) Page 4

12 Alternative Fuel Credit Registration No.

(b) Rate (c) Gallons, or (d) Amount of credit (e) CRN

gasoline or diesel
gallon equivalents

a Liquefied petroleum gas (LPG) (see instructions) $ .50 $ 426

b “P Series” fuels .50 427
c Compressed natural gas (CNG) (see instructions) .50 428
d Reserved for future use
e Fischer-Tropsch process liquid fuel from coal (including peat) .50 430
f Liquid fuel derived from biomass .50 431
g Liquefied natural gas (LNG) (see instructions) .50 432
h Liquefied gas derived from biomass .50 436
i Compressed gas derived from biomass .50 437

13 Registered Credit Card Issuers Registration No.

(b) Rate (c) Gallons (d) Amount of credit (e) CRN

a Diesel fuel sold for the exclusive use of a state or local government $ .243 $ 360
b Kerosene sold for the exclusive use of a state or local government .243 346
c Kerosene for use in aviation sold for the exclusive use of a state or local
government taxed at $.219 .218 369

14 Nontaxable Use of a Diesel-Water Fuel Emulsion

Caution: There is a reduced credit rate for use in certain intercity and local buses (type of use 5). See instructions.
(a) Type of use (b) Rate (c) Gallons (d) Amount of credit (e) CRN

a Nontaxable use $ .197 $ 309

b Exported .198 306

15 Diesel-Water Fuel Emulsion Blending Registration No.

(b) Rate (c) Gallons (d) Amount of credit (e) CRN

Blender credit $ .046 $ 310

16 Exported Dyed Fuels and Exported Gasoline Blendstocks

(b) Rate (c) Gallons (d) Amount of credit (e) CRN

a Exported dyed diesel fuel and exported gasoline blendstocks taxed

at $.001 $ .001 $ 415
b Exported dyed kerosene .001 416

17 Total income tax credit claimed. Add lines 1 through 16, column (d). Enter here and on
Schedule 3 (Form 1040), line 12; Form 1120, Schedule J, line 20b; Form 1120-S, line 24c;
Form 1041, Schedule G, line 17; or the proper line of other returns . . . . . . . . 17 $ 1,999
SPA 1037 CPTS 3US234 Form 4136 (2023)

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 Education Credits OMB No. 1545-0074
Form 8863 (American Opportunity and Lifetime Learning Credits)
2023
Department of the Treasury Attach to Form 1040 or 1040-SR.
Attachment
Internal Revenue Service Go to www.irs.gov/Form8863 for instructions and the latest information. Sequence No. 50
Name(s) shown on return Your social security number
ROBERT J MCELROY JR 260-81-3375

Complete a separate Part III on page 2 for each student for whom you’re claiming either credit before
you complete Parts I and II.

Part I Refundable American Opportunity Credit

1 After completing Part III for each student, enter the total of all amounts from all Parts III, line 30 . . . 1 2,403
2 Enter: $180,000 if married filing jointly; $90,000 if single, head of household, or
qualifying surviving spouse . . . . . . . . . . . . . . . . . 2 90,000
3 Enter the amount from Form 1040 or 1040-SR, line 11. But if you’re filing Form
2555 or 4563, or you’re excluding income from Puerto Rico, see Pub. 970 for
the amount to enter instead . . . . . . . . . . . . . . . . . 3 16,148
4 Subtract line 3 from line 2. If zero or less, stop; you can’t take any education
credit . . . . . . . . . . . . . . . . . . . . . . . . 4 73,852
5 Enter: $20,000 if married filing jointly; $10,000 if single, head of household, or
qualifying surviving spouse . . . . . . . . . . . . . . . . . 5 10,000
6 If line 4 is:
| Equal to or more than line 5, enter 1.000 on line 6 . . . . . . . . . . . . .
| Less than line 5, divide line 4 by line 5. Enter the result as a decimal (rounded to . . . 6 1.000
at least three places). . . . . . . . . . . . . . . . . . . . . . .
7 Multiply line 1 by line 6. Caution: If you were under age 24 at the end of the year and meet the
conditions described in the instructions, you can’t take the refundable American opportunity credit;
skip line 8, enter the amount from line 7 on line 9, and check this box . . . . . . . . . . 7 2,403
8 Refundable American opportunity credit. Multiply line 7 by 40% (0.40). Enter the amount here and
on Form 1040 or 1040-SR, line 29. Then go to line 9 below . . . . . . . . . . . . . . . 8 961
Part II Nonrefundable Education Credits
9 Subtract line 8 from line 7. Enter here and on line 2 of the Credit Limit Worksheet (see instructions) . 9 1,442
10 After completing Part III for each student, enter the total of all amounts from all Parts III, line 31. If zero,
skip lines 11 through 17, enter -0- on line 18, and go to line 19. . . . . . . . . . . . . . 10
11 Enter the smaller of line 10 or $10,000 . . . . . . . . . . . . . . . . . . . . . 11
12 Multiply line 11 by 20% (0.20) . . . . . . . . . . . . . . . . . . . . . . . . 12
13 Enter: $180,000 if married filing jointly; $90,000 if single, head of household, or
qualifying surviving spouse . . . . . . . . . . . . . . . . . 13 90,000
14 Enter the amount from Form 1040 or 1040-SR, line 11. But if you re filing Form
2555 or 4563, or you re excluding income from Puerto Rico, see Pub. 970 for
the amount to enter instead . . . . . . . . . . . . . . . . . 14 16,148
15 Subtract line 14 from line 13. If zero or less, skip lines 16 and 17, enter -0- on
line 18, and go to line 19 . . . . . . . . . . . . . . . . . . 15 73,852
16 Enter: $20,000 if married filing jointly; $10,000 if single, head of household, or
qualifying surviving spouse . . . . . . . . . . . . . . . . . 16 10,000
17 If line 15 is:
| Equal to or more than line 16, enter 1.000 on line 17 and go to line 18 . . . . . .
| Less than line 16, divide line 15 by line 16. Enter the result as a decimal (rounded to at . . . 17 1.000
least three places) . . . . . . . . . . . . . . . . . . . . . . .
18 Multiply line 12 by line 17. Enter here and on line 1 of the Credit Limit Worksheet (see instructions) . 18
19 Nonrefundable education credits. Enter the amount from line 7 of the Credit Limit Worksheet (see
instructions) here and on Schedule 3 (Form 1040), line 3 19 229
SPA For Paperwork Reduction Act Notice, see your tax return instructions. 1037 CPTS 3US511 Form 8863 (2023)

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Form 8863 (2023) Page 2
Name(s) shown on return Your social security number
ROBERT J MCELROY JR 260-81-3375

Complete Part III for each student for whom you re claiming either the American opportunity
credit or lifetime learning credit. Use additional copies of page 2 as needed for each student.

Part III Student and Educational Institution Information. See instructions.

20 Student name (as shown on page 1 of your tax return) 21 Student social security number (as shown on page 1 of
your tax return)
ROBERT MCELROY 260-81-3375
22 Educational institution information (see instructions)
a. Name of first educational institution b. Name of second educational institution (if any)
HELMS COLLEGE
(1) Address. Number and street (or P.O. box). City, town or (1) Address. Number and street (or P.O. box). City, town or
post office, state, and ZIP code. If a foreign address, see post office, state, and ZIP code. If a foreign address, see
instructions. instructions.
5171 EISENHOWER PKY
MACON GA 31206
(2) Did the student receive Form 1098-T (2) Did the student receive Form 1098-T
Yes X No Yes No
from this institution for 2023? from this institution for 2023?
(3) Did the student receive Form 1098-T (3) Did the student receive Form 1098-T
from this institution for 2022 with box Yes X No from this institution for 2022 with box Yes No
7 checked? 7 checked?
(4) Enter the institution’s employer identification number (EIN) (4) Enter the institution’s employer identification number (EIN)
if you’re claiming the American opportunity credit or if you if you’re claiming the American opportunity credit or if you
checked “Yes” in (2) or (3). You can get the EIN from Form checked “Yes” in (2) or (3). You can get the EIN from
1098-T or from the institution. Form 1098-T or from the institution.
58-1249683

23 Has the American opportunity credit been claimed for this

Yes — Stop!
student for any 4 prior tax years? X No — Go to line 24.
Go to line 31 for this student.

24 Was the student enrolled at least half-time for at least one

academic period that began or is treated as having begun
in 2023 at an eligible educational institution in a program No — Stop! Go to line 31
leading towards a postsecondary degree, certificate, or X Yes — Go to line 25.
for this student.
other recognized postsecondary educational credential?
See instructions.
25 Did the student complete the first 4 years of postsecondary
Yes — Stop!
education before 2023? See instructions. X No — Go to line 26.
Go to line 31 for this student.

26 Was the student convicted, before the end of 2023, of a

Yes — Stop! No — Complete lines 27
felony for possession or distribution of a controlled X
Go to line 31 for this student. through 30 for this student.
substance?

You can’t take the American opportunity credit and the lifetime learning credit for the same student in the same year. If you
complete lines 27 through 30 for this student, don’t complete line 31.

American Opportunity Credit

27 Adjusted qualified education expenses (see instructions). Don t enter more than $4,000 . . . . . 27 3,613
28 Subtract $2,000 from line 27. If zero or less, enter -0- . . . . . . . . . . . . . . . . . 28 1,613
29 Multiply line 28 by 25% (0.25). . . . . . . . . . . . . . . . . . . . . . . . . 29 403
30 If line 28 is zero, enter the amount from line 27. Otherwise, add $2,000 to the amount on line 29 and
enter the result. Skip line 31. Include the total of all amounts from all Parts III, line 30, on Part I, line 1 . 30 2,403
Lifetime Learning Credit
31 Adjusted qualified education expenses (see instructions). Include the total of all amounts from all Parts
III, line 31, on Part II, line 10 . . . . . . . . . . . . . . . . . . . . . . . . . 31
SPA 1037 CPTS 3US512 Form 8863 (2023)

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 OMB No. 1545-1629
EIC Checklist
Department of the Treasury
j To be completed by preparer and filed with Form 1040, 1040A, or 1040EZ. 2023
Attachment
Internal Revenue Service j Information about Form 8867 and its separate instructions is at www.irs.gov/form8867. Sequence No. 70
Taxpayer name(s) shown on return Taxpayer’s social security number
ROBERT J MCELROY JR 260-81-3375
For the definitions of Qualifying Child and Earned Income, see Pub. 596.

Part I All Taxpayers

1. Taxpayer's name: ROBERT J MCELROY JR

2. Is the taxpayer’s filing status married filing separately? . . . . . . . . . . . . . . Yes X No
j If checked "YES" on line 2, continue to line 2a
a. Did you live apart from your spouse for the last 6 months of 2023? . . . . . . . . . . . Yes No
j If checked "NO" on line 2a, continue to line 2b
b. Are you legally separated according to your state law under a written separation
agreement or a decree of separate maintenance AND you did NOT live in the same
household as your spouse at the end of 2023? . . . . . . . . . . . . . . . . . Yes No
j If checked "NO" on line 2b,STOP. EIC cannot be taken

3. Does the taxpayer (and spouse, if MFJ) have a social security number (SSN) that allows
him or her to work or is valid for EIC purposes? . . . . . . . . . . . . . . . . . X Yes No
j If checked "NO" on line 3, STOP. EIC cannot be taken
4. Is the taxpayer filing Form 2555? . . . . . . . . . . . . . . . . . . . . . . Yes X No
j If checked "YES" on line 4, STOP. EIC cannot be taken
5a. Was the taxpayer a nonresident alien for any part of 2023? . . . . . . . . . . . . . Yes X No
j If checked "YES" on line 5a, go to line 5b. Otherwise, skip line 5b and go to line 6.

b. Is the taxpayer’s filing status married filing jointly? . . . . . . . . . . . . . . . . Yes No

j If checked "YES" on line 5a and "NO" on line 5b, STOP. EIC cannot be taken
6. Is the taxpayer's investment income more than $11,000? . . . . . . . . . . . . . . Yes X No
j If you checked "YES" on line 6, STOP. EIC cannot be taken

7. Could the taxpayer be a qualifying child of another person for 2023? . . . . . . . . . . Yes X No
j If checked "YES" on line 7, STOP. EIC cannot be taken.
j Otherwise, go to Part II or Part III, whichever applies
For Paperwork Reduction Act Notice, see separate instructions. 3USEI1 Form 8867 (2023)

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ROBERT J MCELROY JR 260-81-3375
Page 2

Part II Taxpayers With a Qualifying Child

Child 1 Child 2 Child 3

8. Child’s name . . . . . . . . . . . . . . . . . . . . .

9. Is the child the taxpayer’s son, daughter, stepchild, foster child, brother,
sister, stepbrother, stepsister, half brother, half sister, or a descendant of
any of them? . . . . . . . . . . . . . . . . . . . . Yes No Yes No Yes No

10. Is either of the following true?

- The child is unmarried, or
- The child is married, can be claimed as the taxpayer's dependent, and
is not filing a joint return (or is only filing to claim a refund) . . . . . Yes No Yes No Yes No

11. Did the child live with the taxpayer in the United States for over half of
the year? . . . . . . . . . . . . . . . . . . . . . . Yes No Yes No Yes No

12. Was the child (at the end of the year)

- under age 19 and younger than the taxpayer, or
- under age 24, a full-time student, and younger than the taxpayer, or
- any age and permanently and totally disabled? . . . . . . . . . Yes No Yes No Yes No

13a. Could any other person check "Yes" on lines 9, 10, 11 and 12 for the
child? . . . . . . . . . . . . . . . . . . . . . . . Yes No Yes No Yes No

b. Enter child’s relationship to the other person . . . . . . . . . .

c. If the tie-breaker rules applied, is the child treated as the taxpayer's Yes No Yes No Yes No
qualifying child? . . . . . . . . . . . . . . . . . . . Don’t know Don’t know Don’t know

14. Does the qualifying child have an SSN that allows him or her to work
or is valid for EIC purposes? . . . . . . . . . . . . . . . . Yes No Yes No Yes No

If you checked "YES" on line 14, continue. If you checked "NO" on line 14 but qualify for
self-only EIC, continue. Otherwise, STOP. No credit is allowed.
15. Are the taxpayer’s earned income and adjusted gross income less
than the limit that applies to the taxpayer for this. year? . . . . . . . . . . . . . . . . . . Yes No
If "NO" is checked, the taxpayer CANNOT take the EIC.
If "YES" is checked, the taxpayer can take the EIC. Complete Schedule EIC.
3USEI2

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ROBERT J MCELROY JR 260-81-3375
Page 3

Part III Taxpayers Without a Qualifying Child

16 Was the taxpayer’s main home, and the main home of the taxpayer’s spouse if filing jointly, in the
United States for more than half the year? (Military personnel on extended active duty outside the
United States are considered to be living in the United States during that duty period.) See the
instructions before answering. X Yes No
If you checked "No" on line 16, stop; the taxpayer cannot take the EIC. Otherwise, continue.

17 Was the taxpayer, or the taxpayer’s spouse if filing jointly, at least age 25 but under age 65 at the
end of 2023? See the instructions before answering . . . . . . . . . . . . . . . . X Yes No
If you checked "No" on line 17, stop; the taxpayer cannot take the EIC. Otherwise, continue.

18 Is the taxpayer eligible to be claimed as a dependent on anyone else’s federal income tax return for
2023? If the taxpayer's filing status is married filing jointly, check "No" . . . . . . . . . . Yes X No
If you checked "Yes" on line 18, stop; the taxpayer cannot take the EIC. Otherwise, continue.

19 Are the taxpayer’s earned income and adjusted gross income each less than the limit that
applies to the taxpayer for 2023? See instructions . . . . . . . . . . . . . . . . X Yes No
If you checked "No" on line 19, stop; the taxpayer cannot take the EIC. If you checked "Yes"
on line 19, the taxpayer can take the EIC. If the taxpayer’s EIC was reduced or disallowed for a
year after 1996, see Pub. 596 to find out if Form 8862 must be filed. Go to line 20.

3USEI3

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 OMB No. 1545-0074
Form 8867 Paid Preparer’s Due Diligence Checklist
Earned Income Credit (EIC), American Opportunity Tax Credit (AOTC), For tax year
(Rev. November 2023)
Child Tax Credit (CTC) (including the Additional Child Tax Credit (ACTC) and 20
Credit for Other Dependents (ODC)), and Head of Household (HOH) Filing Status
Department of the Treasury To be completed by preparer and filed with Form 1040, 1040-SR, 1040-NR, 1040-PR, or 1040-SS. Attachment
Internal Revenue Service Go to www.irs.gov/Form8867 for instructions and the latest information. Sequence No. 70
Taxpayer name(s) shown on return Taxpayer identification number
ROBERT J MCELROY JR 260-81-3375
Preparer’s name Preparer tax identification number

BRANDON GASTIN P00187746

Part I Due Diligence Requirements
Please check the appropriate box for the credit(s) and/or HOH filing status claimed on the return and complete the related Parts I–V for
the benefit(s) claimed (check all that apply). X EIC CTC/ACTC/ODC X AOTC HOH
1 Did you complete the return based on information for the applicable tax year provided by the taxpayer or Yes No N/A
reasonably obtained by you? . . . . . . . . . . . . . . . . . . . . . . . . X
2 If credits are claimed on the return, did you complete the applicable EIC and/or CTC/ACTC/ODC
worksheets found in the Form 1040, 1040-SR, 1040-NR, 1040-PR, 1040-SS, or Schedule 8812 (Form
1040) instructions, and/or the AOTC worksheet found in the Form 8863 instructions, or your own
worksheet(s) that provides the same information, and all related forms and schedules for each credit
claimed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X
3 Did you satisfy the knowledge requirement? To meet the knowledge requirement, you must do both of
the following.
| Interview the taxpayer, ask questions, and contemporaneously document the taxpayer’s responses to
determine that the taxpayer is eligible to claim the credit(s) and/or HOH filing status.
| Review information to determine that the taxpayer is eligible to claim the credit(s) and/or HOH filing

status and to figure the amount(s) of any credit(s) . . . . . . . . . . . . . . . . . . X

4 Did any information provided by the taxpayer or a third party for use in preparing the return, or
information reasonably known to you, appear to be incorrect, incomplete, or inconsistent? (If “Yes,”
answer questions 4a and 4b. If “No,” go to question 5.) . . . . . . . . . . . . . . . . X
a Did you make reasonable inquiries to determine the correct, complete, and consistent information? .
b Did you contemporaneously document your inquiries? (Documentation should include the questions you
asked, whom you asked, when you asked, the information that was provided, and the impact the
information had on your preparation of the return.). . . . . . . . . . . . . . . . . .
5 Did you satisfy the record retention requirement? To meet the record retention requirement, you must
keep a copy of your documentation referenced in question 4b, a copy of this Form 8867, a copy of any
applicable worksheet(s), a record of how, when, and from whom the information used to prepare Form
8867 and any applicable worksheet(s) was obtained, and a copy of any document(s) provided by the
taxpayer that you relied on to determine eligibility for the credit(s) and/or HOH filing status or to figure
the amount(s) of the credit(s) . . . . . . . . . . . . . . . . . . . . . . . . X
List those documents provided by the taxpayer, if any, that you relied on:
NO QUALIFYING CHILD
NO DISABLED CHILDREN
NO SCHEDULE C
COLLEGE OR UNIVERSITY BURSAR STATEMENT
6 Did you ask the taxpayer whether he/she could provide documentation to substantiate eligibility for the
credit(s) and/or HOH filing status and the amount(s) of any credit(s) claimed on the return if his/her
return is selected for audit? . . . . . . . . . . . . . . . . . . . . . . . . . X
7 Did you ask the taxpayer if any of these credits were disallowed or reduced in a previous year? . . X
(If credits were disallowed or reduced, go to question 7a; if not, go to question 8.)
a Did you complete the required recertification Form 8862? . . . . . . . . . . . . . . .
8 If the taxpayer is reporting self-employment income, did you ask questions to prepare a complete and
correct Schedule C (Form 1040)? . . . . . . . . . . . . . . . . . . . . . . . X
SPA For Paperwork Reduction Act Notice, see separate instructions. 1037 CPTS 3USEJ2 Form 8867 (Rev. 11-2023)

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ROBERT J MCELROY JR 260-81-3375
Form 8867 (Rev. 11-2023) Page 2
Part II Due Diligence Questions for Returns Claiming EIC (If the return does not claim EIC, go to Part III.)
9a Have you determined that the taxpayer is eligible to claim the EIC for the number of qualifying children Yes No N/A
claimed, or is eligible to claim the EIC without a qualifying child? (If the taxpayer is claiming the EIC
and does not have a qualifying child, go to question 10.) . . . . . . . . . . . . . . X
b Did you ask the taxpayer if the child lived with the taxpayer for over half of the year, even if the taxpayer
has supported the child the entire year? . . . . . . . . . . . . . . . . . . . . .
c Did you explain to the taxpayer the rules about claiming the EIC when a child is the qualifying child of
more than one person (tiebreaker rules)? . . . . . . . . . . . . . . . . . . . .
Part III Due Diligence Questions for Returns Claiming CTC/ACTC/ODC (If the return does not claim CTC, ACTC,
or ODC, go to Part IV.)
10 Have you determined that each qualifying person for the CTC/ACTC/ODC is the taxpayer’s dependent Yes No N/A
who is a citizen, national, or resident of the United States? . . . . . . . . . . . . . . .
11 Did you explain to the taxpayer that he/she may not claim the CTC/ACTC if the child has not lived with
the taxpayer for over half of the year, even if the taxpayer has supported the child, unless the child’s
custodial parent has released a claim to exemption for the child? . . . . . . . . . . . . .
12 Did you explain to the taxpayer the rules about claiming the CTC/ACTC/ODC for a child of divorced or
separated parents (or parents who live apart), including any requirement to attach a Form 8332 or similar
statement to the return? . . . . . . . . . . . . . . . . . . . . . . . . . .
Part IV Due Diligence Questions for Returns Claiming AOTC (If the return does not claim AOTC, go to Part V.)
13 Did the taxpayer provide substantiation for the credit, such as a Form 1098-T and/or receipts for the qualified Yes No
tuition and related expenses for the claimed AOTC? . . . . . . . . . . . . . . . . . . . . X
Part V Due Diligence Questions for Claiming HOH (If the return does not claim HOH filing status, go to Part VI.)
14 Have you determined that the taxpayer was unmarried or considered unmarried on the last day of the tax year Yes No
and provided more than half of the cost of keeping up a home for the year for a qualifying person? . . . . . X
Part VI Eligibility Certification
You will have complied with all due diligence requirements for claiming the applicable credit(s) and/or HOH filing status
on the return of the taxpayer identified above if you:
A. Interview the taxpayer, ask adequate questions, contemporaneously document the taxpayer’s responses on the return or in
your notes, review adequate information to determine if the taxpayer is eligible to claim the credit(s) and/or HOH filing status
and to figure the amount(s) of the credit(s);
B. Complete this Form 8867 truthfully and accurately and complete the actions described in this checklist for any applicable
credit(s) claimed and HOH filing status, if claimed;
C. Submit Form 8867 in the manner required; and
D. Keep all five of the following records for 3 years from the latest of the dates specified in the Form 8867 instructions under
Document Retention.
1. A copy of this Form 8867.
2. The applicable worksheet(s) or your own worksheet(s) for any credit(s) claimed.
3. Copies of any documents provided by the taxpayer on which you relied to determine the taxpayer’s eligibility for the
credit(s) and/or HOH filing status and to figure the amount(s) of the credit(s).
4. A record of how, when, and from whom the information used to prepare this form and the applicable worksheet(s) was
obtained.
5. A record of any additional information you relied upon, including questions you asked and the taxpayer’s responses, to
determine the taxpayer’s eligibility for the credit(s) and/or HOH filing status and to figure the amount(s) of the credit(s).

If you have not complied with all due diligence requirements, you may have to pay a penalty for each failure to comply
related to a claim of an applicable credit or HOH filing status (see instructions for more information).

15 Do you certify that all of the answers on this Form 8867 are, to the best of your knowledge, true, correct, and Yes No
complete? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X
SPA 1037 CPTS 3USEJ2 Form 8867 (Rev. 11-2023)

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ROBERT J MCELROY JR 260-81-3375
Line 5 - List of Documents for EIC and CTC/ACTC
A. Which documents below, if any, did you rely on to determine EIC/CTC/ACTC eligibility for the qualifying child(ren)
on the return? Check all that apply. KEEP A COPY OF ANY DOCUMENTS YOU RELIED ON. If there is no
qualifying child, check box a. If there is no disabled child, check box o.
Residency of Qualifying (Child(ren)

X a No qualifying child j Indian tribal official statement

b School records or statement k Employer statement
c Landlord or property management statement l Other
d Health care provider statement
e Medical records
f Child care provider records
g Placement agency statement
h Social service records or statement m Did not rely on documents, but made notes in file
i Place of worship statement n Did not rely on any documents
Disability of Qualifying Child(ren)
X o No disabled child s Other
p Doctor statement
q Other health care provider statement
r Social services agency or program statement
t Did not rely on documents, but made notes in file
u Did not rely on any documents

B. If a Schedule C is included with this return, which documents or other information, if any, did you rely on to confirm the
existence of the business and to figure the amount of Schedule C income and expenses reported on the return? Check
all that apply. KEEP A COPY OF ANY DOCUMENTS YOU RELIED ON. If there is no Schedule C, check box a.
Documents or Other Information
X a No Schedule C i Reconstruction of income and expenses
b Business license j Other
c Forms 1099
d Records of gross receipts provided by taxpayer
e Taxpayer summary of income
f Records of expenses provided by taxpayer k Did not rely on documents, but made notes in file
g Taxpayer summary of expenses l Did not reply on any documents
h Bank statements
Line 5 - List of Documents for AOTC
A. Which documents below, if any, did you rely on to determine AOTC eligibility for the qualifying education expenses?
Check all that apply. KEEP A COPY OF ANY DOCUMENTS YOU RELIED ON. If there is no AOTC, check box a.
Documents or Other Information
a No American Opportunity Credit f Other
b Form 1098-T from college or university
c Form 1099-Q for distributions
X d College or university bursar statement
X e Taxpayer summary of expenses g Did not rely on documents, but made notes in file
h Did not rely on any documents
Line 5 - List of Documents for Head of Household
A. Which documents below, if any, did you rely on to determine Head of Household eligibility? Check all that apply.
KEEP A COPY OF ANY DOCUMENTS YOU RELIED ON. If not filing Head of Household, check box a.
Documents or Other Information
X a Not Head of Household h Other
b Divorce decree
c Separation agreement
d Bank statements
e Property tax bills
i Did not rely on documents, but made notes in file
f Rent statements
j Did not rely on any documents
g Utility bills
8USEJ3
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