Accounting

Form

1040

2011

(99)

Department of the Treasury—Internal Revenue Service

U.S. Individual Income Tax Return

For the year Jan. 1–Dec. 31, 2011, or other tax year beginning

OMB No. 1545-0074

, 2011, ending

IRS Use Only—Do not write or staple in this space.

See separate instructions.

, 20

Your first name and initial

Last name

Your social security number

If a joint return, spouse’s first name and initial

Last name

Spouse’s social security number

Apt. no.

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

▲

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

Foreign country name

Filing Status

Check only one

box.

Exemptions

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

Foreign province/county

1

4

Single

Married filing jointly (even if only one had income)

2

3

c

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

the qualifying person is a child but not your dependent, enter this

child’s name here. ▶

Married filing separately. Enter spouse’s SSN above

and full name here. ▶

6a

b

5

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

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(2) Dependent’s

social security number

Last name

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}

(4) ✓ if child under age 17

qualifying for child tax credit

(see instructions)

(3) Dependent’s

relationship to you

Dependents on 6c

not entered above

d

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8b

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