Form 1040-V ( 2015 )

IF you live in. . .

THEN use this address to send in your payment . . .

Internal Revenue Service
P.O. Box 1214
Charlotte, NC 28201-1214

Florida, Louisiana, Mississippi, Texas

Alaska, Arizona, California, Colorado, Hawaii, Idaho, Nevada,

New Mexico, Oregon, Utah, Washington, Wyoming

Internal Revenue Service

P.O. Box 7704
San Francisco, CA 94120-7704

Arkansas, Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota,

Montana, Nebraska, North Dakota, Ohio, Oklahoma,
South Dakota, Wisconsin

Internal Revenue Service

P.O. Box 802501
Cincinnati, OH 45280-2501

Alabama, Georgia, Kentucky, New Jersey, North Carolina, South

Carolina, Tennessee, Virginia

Internal Revenue Service

P.O. Box 931000
Louisville, KY 40293-1000

Connecticut, Delaware, District of Columbia, Maine, Maryland,

Massachusetts, Missouri, New Hampshire, New York,
Pennsylvania, Rhode Island, Vermont, West Virginia

Internal Revenue Service

P.O. Box 37008
Hartford, CT 06176-7008

A foreign country, American Samoa, or Puerto Rico (or are

excluding income under Internal Revenue Code 933), or use an
APO or FPO address, or file Form 2555, 2555-EZ, or 4563, or are
a dual-status alien or nonpermanent resident of Guam or the U.S.
Virgin Islands.

Internal Revenue Service

P.O. Box 1303
Charlotte, NC 28201-1303

MAIL FORM 1040-V TO THE INTERNAL REVENUE SERVICE CENTER AT THE ADDRESS LISTED BELOW.

Department of the Treasury

Internal Revenue Service
G
G
G
G

(99)

Here and Mail With Your Payment and Return d

2015

Use this voucher when making a payment with Form 1040.

Do not staple this voucher or your payment to Form 1040.
Make your check or money order payable to the 'United States Treasury.'
Write your social security number (SSN) on your check or money order.

DAVID ZUCKERMAN
RACHEL NEVITT
2383 GILMAN ROAD
HINESBURG VT 05461

Form 1040-V ( 2015

Form 1040-V Payment Voucher

Enter the amount
of your payment . . . . . . . . G
REV 06/12/16 PRO
1555

INTERNAL REVENUE SERVICE

P.O. BOX 37008
HARTFORD, CT 06176-7008

501.

d Detach

Form

1040

2015

(99)

Department of the TreasuryInternal Revenue Service

U.S. Individual Income Tax Return

For the year Jan. 1Dec. 31, 2015, or other tax year beginning
Your first name and initial

OMB No. 1545-0074

, 2015, ending

IRS Use OnlyDo not write or staple in this space.

See separate instructions.

, 20

Last name

David

Your social security number

Zuckerman
Last name

If a joint return, spouses first name and initial

Rachel

Spouses social security number

Nevitt
Apt. no.

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

2383 Gilman Road

City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions).

Presidential Election Campaign

Check here if you, or your spouse if filing
jointly, want $3 to go to this fund. Checking
Foreign postal code
a box below will not change your tax or
refund.
You
Spouse

Hinesburg VT 05461
Foreign country name

Filing Status
Check only one
box.

Exemptions

Foreign province/state/county

Single
Married filing jointly (even if only one had income)

2
3

Head of household (with qualifying person). (See instructions.) If

the qualifying person is a child but not your dependent, enter this
childs name here. a

Married filing separately. Enter spouses SSN above

and full name here. a

6a
b

Qualifying widow(er) with dependent child

Yourself. If someone can claim you as a dependent, do not check box 6a .

Spouse
.
Dependents:

(1) First name

(2) Dependents
social security number

Last name

(4)  if child under age 17

qualifying for child tax credit
(see instructions)

(3) Dependents
relationship to you

Addie

If you did not

get a W-2,
see instructions.

Adjusted
Gross
Income

2
1

Daughter

Dependents on 6c
not entered above

Attach Form(s)
W-2 here. Also
attach Forms
W-2G and
1099-R if tax
was withheld.

Boxes checked
on 6a and 6b
No. of children
on 6c who:
lived with you
did not live with
you due to divorce
or separation
(see instructions)

If more than four

dependents, see
instructions and
check here a

Income

Make sure the SSN(s) above

and on line 6c are correct.

Total number of exemptions claimed

.
8b
. .

8a

33,429.
5,049.

9a

779.
159.

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

Taxable interest. Attach Schedule B if required .

Tax-exempt interest. Do not include on line 8a .
Ordinary dividends. Attach Schedule B if required

.
.
.

.
.
.

383.

10
11

Qualified dividends . . . . . . . . . . .
9b
Taxable refunds, credits, or offsets of state and local income taxes
Alimony received . . . . . . . . . . . . . . .

.
.

.
.

10
11

12
13
14

Business income or (loss). Attach Schedule C or C-EZ . . . . . . . . .

Capital gain or (loss). Attach Schedule D if required. If not required, check here a
Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . .

12
13
14

15a
16a
17

IRA distributions .
15a
b Taxable amount
. . .
Pensions and annuities 16a
b Taxable amount
. . .
Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E

15b
16b
17

18
19
20a

Farm income or (loss). Attach Schedule F .

Unemployment compensation . . . .
Social security benefits 20a

18
19
20b

21
22

Honorarium
Other income. List type and amount
Combine the amounts in the far right column for lines 7 through 21. This is your total income

23

Educator expenses

24

Certain business expenses of reservists, performing artists, and

fee-basis government officials. Attach Form 2106 or 2106-EZ

25

Health savings account deduction. Attach Form 8889

24
25

26
27
28

Moving expenses. Attach Form 3903 . . . . . .

Deductible part of self-employment tax. Attach Schedule SE .
Self-employed SEP, SIMPLE, and qualified plans
. .

26
27
28

29
30
31a

Self-employed health insurance deduction

Penalty on early withdrawal of savings . .

.
.

.
.

.
.

.
.

32
33
34

Alimony paid b Recipients SSN a

IRA deduction . . . . . . .
Student loan interest deduction . .
Tuition and fees. Attach Form 8917 .

29
30
31a

.
.
.

.
.
.

.
.
.

.
.
.

32
33
34

35
36
37

Domestic production activities deduction. Attach Form 8903

35
Add lines 23 through 35 . . . . . . . . . . . . .
Subtract line 36 from line 22. This is your adjusted gross income

.
.
.

.
.
.

.
.

.
.

.
.

.
.

8a
b
9a

Add numbers on
lines above a

.
.

.
.

.
.

. . . . . .
. . . . . .
b Taxable amount

.
.

.
.
.

.
.
.

.
.
.
a

1,227.

24,676.

21
22

125.
65,444.

36
37

1,467.
63,977.
1040 (2015)

23

1,467.
.
.

.
.

.
.

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

.
.

.
.

.
a

REV 06/12/16 PRO

Form

Page 2
63,977.

Form 1040 (2015)

38

Amount from line 37 (adjusted gross income)

Tax and
Credits

39a

Check
if:

Standard
Deduction
for
People who
check any
box on line
39a or 39b or
who can be
claimed as a
dependent,
see
instructions.
All others:
Single or
Married filing
separately,
$6,300
Married filing
jointly or
Qualifying
widow(er),
$12,600
Head of
household,
$9,250

If you have a
qualifying
child, attach
Schedule EIC.

Blind.
Blind.

38

Total boxes
checked a 39a

Exemptions. If line 38 is $154,950 or less, multiply $4,000 by the number on line 6d. Otherwise, see instructions
Taxable income. Subtract line 42 from line 41. If line 42 is more than line 41, enter -0- . .
Form 4972 c
Tax (see instructions). Check if any from: a
Form(s) 8814 b

44
45
46

Alternative minimum tax (see instructions). Attach Form 6251 .

Excess advance premium tax credit repayment. Attach Form 8962

47
48

Add lines 44, 45, and 46

. . . . . . .
Foreign tax credit. Attach Form 1116 if required .

49
50
51

.
.

.
.

.
.

.
.

.
.

.
.

.
.

.
.

.
.

.
.

.
48

52
Residential energy credits. Attach Form 5695 . . . .
53
3800 b
8801 c
Other credits from Form: a
54
Add lines 48 through 54. These are your total credits . . . . .
Subtract line 55 from line 47. If line 55 is more than line 47, enter -0-

.
.

Self-employment tax. Attach Schedule SE

58
59
60a

Unreported social security and Medicare tax from Form:

b
61

First-time homebuyer credit repayment. Attach Form 5405 if required

64
65
66a
b
67
68
69
70
71
72

.
.

.
.

.
.

Additional tax on IRAs, other qualified retirement plans, etc. Attach Form 5329 if required

.
.

.
.

4137
.

.
.

b
.
.

.
.

.
.

.
.

.
.

67

American opportunity credit from Form 8863, line 8 .

Net premium tax credit. Attach Form 8962 . . . .
Amount paid with request for extension to file . . .

.
.
.

.
.
.

68
69
70

.
.

.
.

71
72
Credits from Form: a
2439 b
Reserved c
8885 d
73
Add lines 64, 65, 66a, and 67 through 73. These are your total payments .
Excess social security and tier 1 RRTA tax withheld

.
.

.
.

1,000.
2,213.

58
59
60a
60b

Health care: individual responsibility (see instructions) Full-year coverage

. . . . .
Form 8960 c
Taxes from: a
Form 8959 b
Instructions; enter code(s)
a
Add lines 56 through 62. This is your total tax . . . . . . . . . . . . .
1,712.
64
Federal income tax withheld from Forms W-2 and 1099 . .
2015 estimated tax payments and amount applied from 2014 return
65
Earned income credit (EIC) . . . No. . . . . . . 66a

Nontaxable combat pay election

66b
Additional child tax credit. Attach Schedule 8812 .

164.
3,213.

55
56
57

Credit for federal tax on fuels. Attach Form 4136

75
76a

.
.

.
.

44
45
46
47

1,000.

43

23,898.
40,079.
12,000.
28,079.
3,049.

40
41
42

.
.

8919

Household employment taxes from Schedule H

.
.

49
50
51

Credit for child and dependent care expenses. Attach Form 2441

Education credits from Form 8863, line 19 . . . . .

Retirement savings contributions credit. Attach Form 8880
Child tax credit. Attach Schedule 8812, if required . . .

52
53
54
55

If line 74 is more than line 63, subtract line 63 from line 74. This is the amount you overpaid

61
62
63

2,213.

74

1,712.

75

. a
76a
Routing number
Checking
Savings
X X X X X X X X X a c Type:
X X X X X X X X X X X X X X X X X
Account number
Amount of line 75 you want applied to your 2016 estimated tax a 77
77
78
Amount you owe. Subtract line 74 from line 63. For details on how to pay, see instructions a 78
79
Estimated tax penalty (see instructions) . . . . . . .
79
Do you want to allow another person to discuss this return with the IRS (see instructions)?
Yes. Complete below.
Amount of line 75 you want refunded to you. If Form 8888 is attached, check here

b
d

501.
No

Personal identification
a
number (PIN)

Phone
no. a

Designees
name 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 and belief,
they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Paid
Preparer
Use Only

42
43

Sign
Here
Joint return? See
instructions.
Keep a copy for
your records.

You were born before January 2, 1951,

Spouse was born before January 2, 1951,

39b

a

Third Party
Designee

.
.

Direct deposit?
See
a
instructions.

Amount
You Owe

Itemized deductions (from Schedule A) or your standard deduction (see left margin)
Subtract line 40 from line 38
. . . . . . . . . . . . . . . . .

73
74

Refund

40
41

62
63

Payments

If your spouse itemizes on a separate return or you were a dual-status alien, check here a

56
57

Other
Taxes

Your signature

Date

Your occupation

Daytime phone number

Spouses signature. If a joint return, both must sign.

Date

Spouses occupation

Farmer
Farmer
Print/Type preparers name

Firms name

Firms address a
www.irs.gov/form1040

Preparers signature

Date

Independent Tax Service Inc.

1 Mill ST STE 271 Burlington VT 05401

If the IRS sent you an Identity Protection

PIN, enter it
here (see inst.)
PTIN
Check
if
self-employed

03-0302688
(802)863-2271
REV 06/12/16 PRO Form 1040 (2015)
Firm's EIN
Phone no.