ind - services for cpa & tax...

INDEX 2010FORM # Description DS# FORM # Description DS#1040A Itemized deductions 3 8820 Orphan drug credit 6

1040B Dividend income (for items not found on DS 3 see DS 23) 3, 23 8824 Like-Kind exchange 10Interest income (for items not found on DS 3 see DS 24) 3, 24 8826 Disabled access credit 6

1040C Business income or loss 9 8828 Federal mortgage subsidy 61040D Capital gain or loss 3, 25 8829 Expenses for business use of home 10

1040E

Partnership income or loss 39 8834 Qualified electric vehicle cr 6Rent and royalty income or loss 16 8835 Renew electricity production credit 6S corporation income or loss 40 8839 Adoption credit 6, 11Trust and Fiduciary income or loss 41 8839 Qualified adoption expenses 11

1040ES Estimated payments 4 8844 Empowerment zone employment cr 61040F Farm income or loss 5 8845 Indian employment credit 61040H Household employment tax 14 8846 Employer FICA/Medicare paid on certain tips 43

1040OTHER Other income including income subject to SE tax 2, 5 8847 Contributions to community development corp. 61040M Making Work Pay & Government retiree credits 8 8853 MSAs and Long-term insurance accts 131040R Credit for the elderly or the disabled 22 8859 DC First-time home-buyer credit 6

1040-RET IRA contributions 7 8861 Welfare-to-work credit 6Self-employed SEP, SIMPLE, and qualified plans 7 8862 Information to claim EIC after disallowance 12

1040SE Half of SE tax (automatic) 12 8863 Education credits (automatic). Make entries on DS 1 for taxpayer & spouse, DS 2 for dependents 1, 2

Self-employment tax (automatic) 121040SE-HI Self-employed health insurance 7 8864 Biodiesel fuels credit 61040SSA Social security benefits 2 8874 New markets credit 6

1040X Amended Return 22 8880 Retirement savings contributions credit 61099-G Unemployment compensation 5 8882 Employer provided child care facilities & services 6

1099-R IRA Distributions (Date of birth must be entered) 18 8885 Health coverage credit 13Pension and annuity income 18 8889 Health savings account 11

1098-C Contribution of motor vehicle, boat, airplane 37 8896 Low sulfur diesel production credit 61099-C Cancellation of debt 37 8900 Qualified RR track maintenance credit 6

1099 Withholding

Form 1099-DIV withholding 2, 23 8901 Child tax credit (automatic). 6Form 1099-G withholding 2 8903 Domestic production activities 28Form 1099-INT withholding 2, 24 8906 Distilled spirits credit 6Other 1099 withholding 6 8907 nonconventional source fuel credit 6

1116All others use Form 1116 data sheet 32 8908 Energy efficient home credit 14Foreign tax credit. If amount paid is $300 or less ($600 or less if MFJ) 6 8909 Energy efficient appliance credit 44

8910 Alternative motor vehicle credit 441310 Deceased Taxpayer Refund Claim 8 8911 Alternative fuel vehicle refueling property credit 62106 Certain business expenses of reservists, etc 15 8915 Qualified hurricane retire plan distributions & repayments 222210 Underpayment of estimated tax 2, 14 8917 Tuition and fees deduction dependents 22439 Regulated investment co credit 6, 28 Tuition and fees deduction taxpayer, spouse 12441 Credit for child and dependent care expenses 4 8919 SS & Medicare tax on wages 63468 Investment credit 27 8923 Mine rescue team training credit 63800 General business credit 6, 43 8948 Explanation for not efiling 283903 Moving expenses 13 Alimony Alimony paid 54136 Federal tax on fuels 6 Alimony received 24137 SS & Medicare tax on unreported tips 6 EIC/8867 Earned income credit Form 8867 questions must be answeare 214255 Investment credit 6 K-1 (1041) Fiduciary income or loss K-1 received 414562 Depreciation & Amortization 19, 33 K-1 (1065) Partnership income or loss K-1 received 394684 Casualty and theft 30 K-1 (1120S) S Corporation income or loss K-1 received 404797 Other gains & losses 34 W-2 Federal income tax withheld 174868 Extension payment - Enter on ES section 4 W-2 Wages, salaries, tips, etc. 1, 174952 Investment interest expense MUST enter ln 4g 14 Accumulation distribution of trusts tax 64972 Lump-Sum Distributions 28 Amount to be applied to next year (ES section) 45329 Additional tax on IRAs & other Qualified plans 7 Credit for repayment under claim-of-right 65405 First-time homebuyer credit 8 Dependents, child care exp, education exp, etc 2,215695 Residential energy credits 26 DD Direct deposit information 155884 Work opportunity cr 6 Educator expenses. Enter total expenses in Box# 2594, 3625 56198 At-Risk Limitations 29 Excess SS & RRTA tax withheld 176251 Alternative minimum tax 26 Golden parachute payments 66252 Installment Sale income 31 Installment sales-dealers in personal property 66478 Alcohol fuel credit 6 Nonqualified deferred compensation plan 66765 Increasing research activity credit 6 Other taxes 68283 Noncash charitable contributions OVER $500 36 Other withholding 68379 Injured spouse claim and allocation 22 Penalty on early withdrawal of savings 5, 248396 Mortgage interest credit 6, 11 Penalty tax on premature distribution 68453 Electronic Filinig Information 15 Student loan interest deduction 58582 Other passive activity (Sch E Automatic) 29 Taxable state & local refund if not stored 2

8582CR Passive activity limitations 44 Uncollected tax on reported tips (W-2, Ln 13) 178586 Low income housing credit 6 SOH Sale of home worksheet 268606 Nondeductible IRA contributions 7 INVOICE Bill to taxpayer 1, 5

8609-A Annual statement low income housing 288611 Low-income housing cr 278615 Tax on investment income for dependent filers 118801 Credit for prior year minimum tax 298812 Additional child tax credit (automatic)8814 Election to report child's Interest/Dividends 12

SS# 20____

[32] IDENTIFYING NUMBER T / S AMOUNT STATE

SSN

EINSTATECODE[33]

T / S U.S. GOVT SAVINGSBONDS

TOTAL MUNI BONDSINTEREST INCOME(NOT U.S. GOVT)

EQUALIFIEDDIVIDENDS

U.S. GOVTBONDS

TOTAL MUNIBONDS

CAPITALGAINS

STCODE

X DESCRIPTION T/S AMOUNT

23 LIMITEDMISC.

STATEMENT 8U )

28 OTHER MISC.

DESCRIPTION T/S AMOUNT

STATEMENT 9

ATTACHMENT SCHEDULETAXPAYER'S NAME

B - INT INTEREST INCOME

1

SFIN

MO

FROM NAME [25] ADDRESSELLER-ANCED

RTGAGE 1DESCRIPTION (Use this area if you are attaching y

#1,500)our own schedule or total amount is under

STATEMENT 10B - DIV DIVIDEND INCOM

5

DESCRIPTION (Use this aschedule or total

ream

a if oun

you are attat is under #1

ching your o,500)

wn

[21]T / S ORD DIVIDEND

(1099 Box 1)S

STATEMENT 11 A ITEMIZED DEDUCTIONS

TA E

C

S

TION

8 OTHERTAXES

STATEMENT 6MISCELLANEOUS DED S (2% AGI LIMIT

2

UB

EMEX

1

DESCRIPTION T/S AMOUNT

NREIM-URSEDPLOYEEPENSE

STATEMENT 7

$12,500

TAXABLE INCOME . . . . . . . . . . . . . . . . . TI

Both Spouses over 65 and one is BlindBoth Spouses over 65 and BlindMarried Filing Separate - under 65

Head of Household - under 65

Widow(er) with Child - over 65 or Blind

Single - under 65Single - over 65 or BlindSingle - over 65 and BlindMarried Filing Joint - under 65One Spouse over 65 or BlindBoth Spouses over 65 or Blind

$5,700 $ 0 $6,800 $8,400

Head of Household - over 65 or Blind Widow(er) with Child - under 65

$8,500$11,400$12,500$13,600$14,700$15,800

Other income . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . .Taxable Social Security & Railroad . . . . SS & RR

INCOME TAX . . . . . . . . . . . . . . .

CREDITS

Education credits . . . . . . . . . . . . . . . . . . . 88632441

Child tax credit . . . . . . . . . . . . . . . . . . . . .

Foreign tax credit . . . . . . . . . . . . . . . . . . 1116

8880Retirement savings contribution credit . . .

Child and dependent care . . . . . . . . . . . .

Residential energy credit . . . . . . . . . . . . . 56958901

. . . . . .Business credits / Other . . . . . . . . . . . . . . 8839

Unemployment . . . . . . . . . . . . . . . . . . . . UNEMPLFarm income (loss) . . . . . . . . . . . . . . . . . SCH FRents, partnerships, etc . . . . . . . . . . . . . SCH ETaxable pension income . . . . . . . . . . . . RETIRE

Capital gain (loss) . . . . . . . . . . . . . . . . . . SCH DOther gains (losses) . . . . . . . . . . . . . . . . 4797

Ordinary dividends . . . . . . . . . . . . . . . . . DIVInterest income . . . . . . . . . . . . . . . . . . . .

Alimony received . . . . . . . . . . . . . . . . . . ALIMState refund . . . . . . . . . . . . . . . . . . . . . . STATE

13 47,45014 51,100

11 40,150

$5,700 $7,100

12 43,800

9 32,85010 36,500

7 25,5508 29,200

5 18,2506 21,900

10,9504 14,600

3,6502 7,300

TAX

CHILD CARE CREDIT TABLE

Over--

1

3

JVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW S0112S

INT

10TXCALC

2010LAST NAME

TP WAGES

$9,800

ADJUSTMENTS

Moving expense . . . . . . . . . . . . . . . . . . . . .

TRIAL CALCULATION WORKSHEET

INCOME

FEDERAL

EXEMPTIONS

STANDARD

DEDUCTIONS

1040

Spouse wages, salaries and tips . . . . .SP WAGES

PEN

AMT

$11,400

Spouse ItemizesMarried Filing Separate - over 65

Qualified dividends . . . . . . . . . . . . . . . . . DIV

IRA( )Alimony paid . . . . . . . . . . . . . . . . . . . . . . . . ALIM

Domestic production activities dedn. . . . . . 8903

Taxpayer wages, salaries and tips . . . .

( )1/2 Self-employment tax . . . . . . . . . . . . . . .

( )

SEHI100% Self-employment health insurance . .

Educator expense . . . . . . . . . . . . . . . . . . . . . . . . . . . .

( )

SE3903

SEP ( )

( )Student loan interest . . . . . . . . . . . . . . . . . .8917

( )IRA deduction . . . . . . . . . . . . . . . . . . . . . . .

( )

SEP, SIMPLE and qualified plans . . . . . . . .( )

( )

( )

Early savings withdrawal penalty . . . . . . . .

TAXES

SLITuition and fees . . . . . . . . . . . . . . . . . . . . . ( )

ADJUSTED GROSS INCOME . . . . . . . . . AGI

ITEMIZED/STANDARD DEDUCTION . . .

ALTERNATIVE MINIMUM TAX . . . . . . . .

. . . . . .

Estimated payments / Other . . . . . . . . . . . .

Self-employment tax / Other. . . . . . . . . . . . . . .

PAYMENTS

TOTAL TAX . . . . . . . . . . . . . . . . . . . . . . . FED

Federal withholding . . . . . . . . . . . . . . . . . . . W/H

( )

TAX RATE SCHEDULE CALCULATION

-- For Taxable Incomes Over $100,000 --

x

(d) Subtraction amount . . . . . . . . . . . . . . . .

(b) Multiplication amount . . . . . . . . . . . . . . .

REFUNDNET REFUND . . . . . . . . . . . .

AMOUNT DUE . . . . . . . . . . . . . . . DUE

Over--

31,000 -

(a) Taxable income . . . . . . . . . . . . . . . . . . . .

.27

35,000 -- 35,000 .25- 37,000

- 25,000

- 17,000

.30

33,000 -

- 23,00039,000 -

.34

.31- 21,000

15,000 -.33.32

- 15,000 .35

+TAX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(c) (a) x (b) . . . . . . . . . . . . . . . . . . . . . . . . . =

.20

.21- 41,000

If AGI is: Multiplier is:If AGI is: Multiplier is:

- No limit

But not over--

- 19,00019,000 -

- 31,000

But not over--

- 33,000 .26

.24

- 27,000.22

- 43,000

ES

29,000 -

23,000 -

- 29,00041,000 -

17,000 -

27,000 -

$0 -

.29

SCH CBusiness income (loss) . . . . . . . . . . . . . .

37,000 - - 39,001 .23

25,000 -

21,000 -

.28 43,000 -

EXE

TAX BALANCE (Not less than zero) . . . . . .

OTHER TAXES

8889Health savings acct deduction . . . . . . . . ..

EXEMPTIONS (_________ x $3,650) . .DED

Credit for elderly or disabled . . . . . . . . . . SCH R

2106 ( )Certain busn expenses (Reservists, etc.) .

( )

( )

DIRECT DEPOSIT, ELECTRONIC FILINGLAST NAME 2010

DIRECT DEPOSIT AND ELECTRONIC FUNDS WITHDRAWAL

GOVTSAME

ASFED

FINANCIAL INSTITUTION NAMEROUTINGNUMBER

DEPOSITORACCOUNT NUMBER

* ACCTTYPE

DD **EFW *** AMOUNT PERCENT

WITHDRAWALDATE

[25] [9] [17]

US

US

US

* ACCT TYPES: CHECKING - SAVINGS - 2009 IRA - 2010 IRA - HSA - MSA - ESA

DD ** = DIRECT DEPOSIT EFW *** = ELECTRONIC FUNDS WITHDRAWAL OF AMOUNT DUE

ELECTRONIC FILING PIN SIGNATURE INV TAXPAYER INVOICEFILE RTN ELECTRONICALLY 1189 YES INVOICE NUMBER 0330TAXPAYER PIN 0232 [5] PRINT CLIENT ID ON INVOICE 8285 YES

SPOUSE PIN 0233 [5] SUPPRESS INVOICE NUMBER 8455 YES

ACCOUNTANT PIN 0231 [5] DATE TO PRINT ON INVOICE 0379 - -TP ENTERED PIN(s) 8065 YES PRINT THIS AMOUNT ONLY 2407SIGNATURE DATE 0083 - - PRINT DETAILED INVOICE (YES) 1188INDICATED WHICH STATES TO BE FILED ELECTRONICALY. IF ALL, WRIGHT ALL

USE THIS SECTION IF YOU ARE FILING RETURN ELECTRONICALY AND HAVE CERTAIN PAPER FORMS TO SEND TO IRS I.e. CAPITAL GAINS ATTACHMENT or OTHER FORMS LISTED BELOW THAT MUST BE PAPER FILED. FORCE 8453 MUST BE CHECKED FOR THE FORM TO PRODUCE. CHECK THE BOXES FOR THE FORMS THAT WILL BE ATTACHED TO FORM 8453. EACH 8453 WILL HAVE A SPECIAL DCN NUMBER ASSIGNED TO IT THAT WILL CORRESPOND TO TAX RETURN EFILED TO IRS

EF FORM 8453 EFILE TRUNSMITTAL FORM FOR PAPER ATTACHMENTS

FORCE FORM 8453 TO PRINT 8173 YES

OPT OUT OF 1040 MeF (FEDERAL AND STATE) FOR THIS RETURN 1549 YES ALLOCATION RECORD FOR COMMUNITY PROPERTY

MILITARYINDICATOR

1 = Desert Storm 2 = Haiti 3 = Former Yugoslavia 4 = UN Operation 5 = Joint Guard 6 = Joint Forge

7 = Northern Watch 8 = Operation Allied Force 9 = Nothern Forge10 = Enduring Freedom11 = Combat Zone 2944

STATES AND MFS RETURNS ONLY

SPOUSE IS WIFE (DEFAULT = HUSBAND) 8053 YES

SPOUSE'S

WAGES 7654INTEREST INCOME 7655DIVIDENDS 7656STATE INCOME TAX REFUND 7657

PAPERDOCUMENTINDICATORS

FORM 4136 8174 YESCAPITAL GAINS 7658

SCH D-1 8172 YES FORM 5713 8366 YESPENSION INCOME 7659

REVPRC 09-20 8176 YES FORM 8283 1271 YESRENTS, ROYALTIES, PARTNERSHIPS, ESTATES, ETC. 7660

FORM 1098-C 1433 YES FORM 8332 1266 YESOTHER INCOME 7661

FORM 3115 8365 YES FORM 8858 8367 YESTOTAL INCOME 7662

(MUST BE ATTACHED

TO FORM 8453)

FORM 3468 1272 YES FORM 8864 1434 YESTOTAL PAYMENTS 7663

FORM 2848 1429 YES FORM 8885 8175 YESNAME OF PERSON SIGNING POWER OF ATTORNEY (2848)

8635 [35]

INTERMEDIATE SERVICE PROVIDER EFIN (SEIN) 4790 [6]

RAL INDICATOR 1336 YES

SUPPRESS PRINTING PREPARER SSN / EIN 8009 YES

OVERRIDE KEYFIELD [ # ] MAX CHAR

0020

-

2319

-

3264

QUALIFIED ELECTRIC VEHICLE

NEW MARKETS CREDIT

EMPLOYER-PROVIDED CHILDCARE

ALT FUEL VEHICLE REFUELING CREDIT

a

HOUSEHOLD EMPLOYMENT TAX

3890

[12]

a REGULATED INVESTMT CO. CR

2928

-

FEDERAL TAX ON FUELS CREDIT

AMT OWED TO U.S. VIRGIN ISLANDS

OTHER TAXES

LATE FILING AND LATE PAYMENT

8885

8882

28622593

1046

PENALTY AND INTEREST

0505 - -

8911

2570

COBRA PREM ASSISTANCE RECVD IN 2010 9153ADDITIONAL TAX ON HCTC ADVANCE PMTS 8885

BALANCE - NOT LESS THAN ZERO

GOLDEN PARACHUTE PAYMENTS

2547

8911 3891

FED MORTGAGE SUBSIDY

UT

47

49

48

d

71

RETIREMENT SAVINGS CONTRIBS CR

3800b

DATE OF LATE FILING

2308

3605

-

ADVANCED EARNED INC CR PMTS

HEALTH INS CR - ELIGIBLE RECIP

74

5405

OVERRIDE

8874

-

2209

23092546

70

2317

CREDIT FOR PY MINIMUM TAX

4136

73

P

A

Y

M

E

N

T

S

a

69

-

-

8834

8901

-

67

44

56

TAX DUE AMOUNT ON WHICH TO COMPUTE PENALTIES AND INTEREST

8834

5695

75

EST

CR FOR REPAYMENT UNDER CLAIM-OF-RIGHT

8880

2839

2522

ADDL TAX - CHARITABLE CONTRIB RECAP FITPP

NQDC

8611

EPP

8910

8801

7924

3261

2253

62

2565

3259

AMOUNT APPLIED TO 2011 ESTIMATED TAX 2270

OPTIONAL

ES -

- 2276

[ # ] MAX CHAR

-

LEAVE DIRECT DEPOSIT FIELDS BLANK

W-2

-

- 2460

- 2431

- B-INT

B-DIV

10TXDAT4

- W / H

8060 YES

W / H

3606

[20]

PROVIDE INFO BELOW IF AUTHORIZING IRS TO DISCUSS RETURN WITH THIRD PARTY:

NAME

3819

8828

-

BANK INFORMATION IS ENTERED ON THE EF / RAL DATA SHEET.

3260c

8839

2256

ECR2402

2439

OTHER WITHHOLDING

FICASUPPRESS PRINTING OF EXCESS FICA

3281

LOW-INCOME HOUSING CR

2667

2507

PEN TAX ON PREMATURE DISTRIBUTION

W-2

INVESTMENT CREDIT

ALTERNATIVE MOTOR VEHICLE CR

3889

2951

Sc 72

T

A

X

E

S

58

8845

R

8801

2311

2315

H

SE

-

-

-

-

2378

-

Sched------Form

Lineno.

61

1113 YES

3858

25881099G

FORM 1040 PAGE 2 MANUAL ENTRY

Lineno. DEDUCTIONS, CREDITS AND TAXES

Sched Computer developed formswill override all

data entered below.------Form CONTINUED FROM PREVIOUS COLUMN

40

43

2557

42 Exem

EXEMPTIONS _______________ X 3650

1173

3238

76

-

-

-

2574

- YES

ESTIMATED TAX PENALTY 2525

4137 2310

ADDITIONAL TAX ON IRAs, OTHER QUALIF RETIREMENT PLANS, ETC.

[20]TITLE OF SIGNER OF RETURN

SS & MEDICARE TX-UNREPORTED TIPS

5329

b

56

2399

CR FOR ELDERLY OR DISABLED

45

2510

FIRST-TIME HOMEBUYER CREDIT

8863

3600

-

2627

EDUCATION CREDIT RECAPTURE TAX

2363

ADOPTION CREDIT

23161116

b

CHILD TAX CR (PUERTO RICO INC AND RR EMPLYMNT TAX FOR CTC) ARE ON PROFORMA PG 2

ALL INFORMATION PERTAINING TO

ES TAX PMTS (DATES & AMTS,

ETC.), OVERPMTS APPLIED

AND EXT PMTS ARE ENTERED

ON THE ESTIMATES INPUT

OTHER 1099 WITHHOLDING

a

ALT MOTOR VEHICLE CR (PART II)

GENERAL BUSINESS CREDIT

QUAL ELECTRIC VEHICLE CREDIT

EDUCATION CREDITS

ALT FUEL VEHICLE REFUELING PROPERTY CREDIT (PART III)

-

46

8889 3262

50

57

CR FOR PY MINIMUM TAX

7764

51

MORTGAGE INTEREST CREDIT

8812

- 2861

2397

TAX

8396 -

-

8859

8936 9848

LUMP SUM DISTRIBUTIONS TAX

PARENTS ELECT TO REPORT CHILD INT

TAXPAYER OVER 65

OVERRIDE DEPENDENT OF ANOTHER EARNED INCOME (FOR STANDARD DED)

1101

CAPITAL GAINS TAX WORKSHEET

88148615

YES

4972

D

1102

YES

TAXABLE INCOME

-

-

FORCE ITMZED DED

TX PARENT'S RATE FRM CHILD'S INT

YES

FORCE STD DED

Exem

SPOUSE OVER 65

6251

2441

TOTAL TAX AND ALT MIN TAX

ALTERNATIVE MINIMUM TAX

RESIDENTIAL ENERGY EFFICIENT PROPERTY CREDIT

FOREIGN TAX CREDIT

CHILD AND DEPENDENT CARE CREDIT

DC FIRST-TIME HOMEBUYER CR

SOC SEC & MEDICARE TAX ON WAGES 8919

2867

QUAL PLUG-IN ELECTRIC DRIIVE MOTOR VEHICLE CREDIT

INDIAN EMPLOYMENT CR

QUALIFIED PLUG-IN ELECTRIC DRIVE MOTOR VEHICLE CREDIT

TX - FAILURE TO MAINT HDHP CVRAGE

SELF-EMPLOYMENT TAX

RECAPTURE

4255

TX ON ACCUMULATION DISTRIB OF TRUSTS

NONQUAL DEFERRED COMP PLAN

S453A

4970

UNCOLL TX ON REPORTED TIPS (W-2 ln 13)

INSTALLMENT SALES - DLRS IN PERS PROP

7831

TOTAL PAYMENTS

FEDERAL INCOME TAX WITHHELD

FORM 1099-INT WITHHOLDING

FORM 1099-DIV WITHHOLDING

FORM 1099-G WITHHOLDING

Computer developed formswill override all

data entered below.PAYMENTS

TOTAL FEDERAL TAX

AMOUNT PAID WITH FORM 1040-V

TAX DUE ( + )

THIRD PARTY DESIGNEE

REFUND ( - )

0506 - -DATE OF LATE PAYMENT

YESPREPARER IS THIRD PARTY DESIGNEE

[5]

3935

8910

9193 -

8054

2210

ADD-TO

01790180TELEPHONE NUMBER

8181

INTEREST

0569IDENTITY PROTECTION PIN

PERSONAL IDENTIFICATION NUMBER (PIN) 0181

52

c

53

C

R

E

D

I

T

S

8936 9237

3921

AMOUNT OVERPAID

8689

63 MMAKING WORK PAY CREDIT -

5405c REPMT OF 1ST-TIME HOMEBUYER CR CLAIMED IN '08 OR '09 9265

60

59

CONTINUED NEXT COLUMN

O

T

H

E

R

T

A

X

E

S

O

T

H

E

R60

Y

7 FEDERAL 1040 DATA SHEET 7LAST NAME 2010

5329 ADDITIONAL TAX ON RETIREMENT PLANS 8606 NONDEDUCTIBLE IRA CONTRIBUTIONS (CONTINUEDMULTIPLE SPOUSE'S FORM 5329 1340 YES TAXPAYER SPOUSE

FILE AS STAND-ALONE FORM (Firm data prints in Signature area)

4 IRA CONTRIBUTIONS MADE FROM 01-01-2011 TO 04-15-2011 2813 28198324 YES

PART I - TAX ON EARLY DISTRIBUTIONS6

VALUE OF TRADITIONAL, SEP, AND SIMPLE IRAs AS OF 12-31-10 2812 2818

1EARLY DISTRIBUTIONS INCLUDED IN INCOME 3086

OUTSTANDING ROLLOVERS 2787 2790EARLY DISTRIBUTIONS PENALIZED AT 25% RATE (Code "S" on Form 1099R) 2900

7TOTAL TRADITIONAL, SEP, AND SIMPLE IRA DISTRIBUTIONS RECEIVED IN CURR YEAR 2816 28222

DISTRIBUTIONS NOT SUBJECT TO ADDITIONAL 10% TAX 3092EXCEPTION AMOUNT FOR SIMPLE RETIREMENT ACCOUNTS 2901

8

TOTAL TRADITIONAL, SEP, AND SIMPLE IRAs CONVERTED TO ROTH IN CURRENT YEAR 7220 7228

EXCEPTION NUMBER 3090 [2]

3 AMOUNT SUBJECT TO ADDITIONAL TAX 3099PART II - TAX ON CERTAIN DISTRIB FROM EDUCATION ACCTS RECHARACTERIZATIONS 7221 7229

5 TAXABLE AMT FROM FM 1099-Q INCLUDED IN INCOME 7124 PART II - CONVERSIONS FROM TRADITIONAL TO ROTH IRAs

6 DISTRIBUTION NOT SUBJECT TO ADDITIONAL TAX 720116

NET AMOUNT CONVERTED FROM TRADITIONAL, SEP, AND SIMPLE IRAs IN 2010 9217 9214

PART III - TAX ON EXCESS CONTRIBUTIONS TO TRADITIONAL IRAs

9 EXCESS CONTRIBUTIONS FROM PRIOR YR FORM 5329, LINE 16 306617 BASIS IN NET CONVERSIONS 7222 7230

10 CONTRIBUTION CREDIT 306719

ELECT TO REPORT ENTIRE TAXABLE AMT IN CY (RATHER THAN 1/2 IN 2011AND 1/2 IN 2012)

1599 150811 CY TRADITIONAL IRA DISTRIB INCLUDED IN INCOME 308912 CY DISTRIBUTIONS PRIOR YEAR EXCESS CONTRIBUTIONS 306815 EXCESS CONTRIBUTIONS FOR CURRENT YEAR 3065 PART III - ROLLOVERS FROM QUAL RETIREMENT PLANS TO ROTH IRAs

17 VALUE OF TRADITIONAL IRAs ON LAST DAY OF CURRENT YEAR3084 21 ROLLOVER FROM QUAL RETIREMENT PLANS TO ROTH IRAs 9217 9214

TAX DUE 308522 BASIS IN ROLLOVER (ON LINE 21) 9215 9216

PART IV - TAX ON EXCESS CONTRIBUTIONS TO ROTH IRAs24

ELECT TO REPORT ENTIRE TAXABLE AMTIN CY (RATHER THAN 1/2 IN 2011 AND 1/2 IN2012) 1600 151918 EXCESS CONTRIBUTIONS FROM PY FORM 5329, LINE 24 7271

19 ROTH IRA CONTRIBUTION CREDIT 7272 THIS BOX MUST BE CHECKED IF THE BOX ON LINE 19 IS CHECKED

20 CURRENT YEAR DISTRIBUTIONS FROM ROTH IRAs 7273 PART IV - DISTRIBUTIONS FROM ROTH IRAs23 EXCESS CONTRIBUTIONS FOR CURRENT YEAR 3076 26 TOTAL ROTH NON QUAL DISTRIB RECVD 7223 723125 VALUE OF ROTH IRAs ON LAST DAY OF CURRENT YEAR 3077 27 QUAL FIRST-TIME HOMEBUYER DISTRIB 7649 7650

PART V - TAX ON EXCESS CONTRIBUTIONS TO COVERDELL ESAs 29 BASIS IN ROTH IRA CONTRIB 7270 726326 EXCESS CONTRIBUTIONS FROM PY FORM 5329, LINE 32 7274 31 BASIS IN ROTH IRA CONVERSIONS 7262 726727 COVERDELL ESA CONTRIBUTION CREDIT 7275 RET RETIREMENT CONTRIBUTIONS28 CURRENT YEAR DISTRIBUTIONS FROM COVERDELL ESAs 7276 TAXPAYER SPOUSE

31 EXCESS CONTRIBUTIONS FOR CURRENT YEAR 7202 IRA CONTRIBUTION 2518 251433 VALUE OF COVERDELL ESAs ON LAST DAY OF CURRENT YR 7203 COVERED BY RETIREMENT PLAN 1124 YES 1161 YES

PART VI - TAX ON EXCESS CONTRIBUTIONS TO ARCHER MSAs FORCE AMOUNT CONTRIBUTED AS DEDUCTIBLE 1174 YES

34 EXCESS CONTRIBUTIONS FROM PY FORM 5329, LINE 40 7205 TOTAL BASIS FOR 2009 AND EARLIER YRS 2815 282135 ARCHER MSA CONTRIBUTION CREDIT 7206 ROTH IRAs

36 CURRENT YEAR DISTRIBUTIONS FROM ARCHER MSA(s) 7207 PREPARE MAXIMUM ROTH IRA CONTRIBUTION WORKSHEET 8010 YES 8018 YES

39 EXCESS CONTRIBUTIONS FOR CURRENT YEAR 7204ACTUAL AMOUNT CONTRIBUTED FOR 2010 3911 3913

41 VALUE OF ARCHER MSAs ON LAST DAY OF CURRENT YR 7209 BASIS IN ROTH IRA CONTRIBUTIONS FOR 2009 AND EARLIER 3912 3914 PART VII - ADDL TAX ON EXCESS CONTRIBUTIONS TO HSAs

42 EXCESS CONTRIBUTIONS FROM PY FORM 5329, LINE 48 3569 BASIS IN ROTH IRA CONVERSIONS FOR 2009 AND EARLIER 7262 7267

47 EXCESS CONTRIBUTIONS FOR CURRENT YEAR 7142OVERRIDE SE INCOME ON WKSHT 3357 3358

49 VALUE OF HSAs ON LAST DAY OF CURRENT YEAR 7143SELF-EMPLOYED KEOGH RETIREMENT PLAN

PT VIII - TAX ON EXCESS ACCUMULATION IN QUAL RETIREMENT PLANS CODES FOR KEOGH DEDUCTION CALCULATION:

M = Money Purchase P = Profit SharingB = Print Amount as EnteredNOTE: FOR 2009, REQUIRED MINIMUM DISTRIBUTIONS ARE NOT REQUIRED TO BE MADE

FROM AN IRA OR CERTAIN EMPLOYER-PROVIDED QUALIFIED RETIREMENT PLANS THAT ARE DEFINED CONTRIBUTION PLANS. CODE 4726 4727

50

MINIMUM REQUIRED DISTRIB, IF ANY, FOR CURRENT YEAR (INCLUDING MINIMUM REQUIRED DISTRIB FOR 2009 THAT IS PERMITTED TO BE MADE IN 2010 FOR INDIVIDUAL WITH REQUIRED BEGINNING DATE OF 04-01-2010) 3074

CONTRIBUTION RATE 8161 8162COMPANY CONTRIBUTION AMOUNT 2342 2515CATCH-UP AMOUNT (INDIVIDUAL 401(k) ONL 3627 3628

51

AMOUNT ACTUALLY DISTRIBUTED TO TP IN CURRENT YEAR (PLUS ANY DISTRIB ACTUALLY MADE IN 2009 THAT WERE PERMITTED TO BE MADE IN 2010 FOR INDIVIDUAL WITH A REQUIRED BEGINNING DATE OF 04-01-2010) 3088

SELF-EMPLOYED SEP RETIREMENT PLAN

COMPANY CONTRIBUTION RATE 8163 [2] 8164 [2]

COMPANY CONTRIBUTION AMOUNT 7547 754852 WAIVER OF TAX 7093 SARSEPs ONLY:

EXPLANATION FOR WAIVER OF TAX ELECTIVE DEFERRAL 2765 2766[60] CATCH-UP AMOUNT 3629 3630

SELF-EMPLOYED SIMPLE RETIREMENT PLAN8606 NONDEDUCTIBLE IRA CONTRIBUTIONS

SIMPLE 401(k) PLAN (Default = IRA) 4488 YES 4493 YESPART I - TRADITIONAL IRAs

ELECTIVE CONTRIBUTION RATE 4486 4487TAXPAYER SPOUSE

ELECTIVE CONTRIBUTION AMOUNT 3080 30811 NONDED TRADITIONAL IRA

CONTRIBUTIONS FOR CY 2814 2820 CATCH-UP AMOUNT ($0 - $2,500) 3082 30832 TOTAL TRADITIONAL IRA BASIS

FOR 2009 AND EARLIER YRS 2815 2821COMPANY MATCHING CONTRIBUTION RATE @ 1%-3% 4453 4454COMPANY NONELECTIVE CONTRIBUTION RATE @ 2% 4455 4468OVERRIDE OPTIONAL KEYFIELD [ # ] MAX CHAR

PORTION , IF ANY, OF AMOUNT FROM FORM 2555, LINE 44 INCLUDED ON SCH E AS PARTNERSHIP INCOME OR DEDUCTED ON FORM 1040, LN 27, SCHEDULES C, C-EZ, OR F

9098

0570OWNERSHIP CODE: T=TAXPAYER, S=SPOUSE, J=JOINT

16 REPAYMENT AMOUNT

PUERTO RICO RESIDENT BUT QUALIFIES FOR SCHEDULE M MAKING WORK PAY CREDIT 1604 YES

SPOUSE IS A NONRESIDENT ALIEN OR BONA FIDE PUERTO RICO RESIDENT

9202FTHC PURCHASE DATE (FOR REPAYMENT PURPOSES)

3

YES

1552

e

12

b

15

0550 - -

PERCENT OF MAXIMUM CREDIT (FOR USE ONLY IF SOMEONE OTHER THAN SPOUSE HELD AN INTEREST)

YES

1

YES

1553

a

FIRST-TIME HOMEBUYER CREDIT, PG 2

GAIN ON SALE OF MAIN HOME

PERSON, OTHER THAN A OR B, CLAIMING REFUND FOR DECEDENT'S ESTATE

UNREIMBURSED NONFARM PTNSHP EXPENSE DEDUCTED ON SCH E

C

5 PUERTO RICO INCOME THAT IS EXCLUDED

E

DEPLETION ON OIL AND GAS PROPERTIES 9039

SSN

APARTMENT #0220

HOME ADDRESS

8650 - -

CHECK APPLICABLE BOX:

QUALIFY FOR CREDIT AS A LONG-TIME RESIDENT

0528

YES

2585

EARNED INCOME WORKSHEET

7544

CITY, STATE, ZIP CODE

CHOOSE THE SELECTION THAT APPLIES TO THE TAXPAYER

0224

1532 YES

TAXPAYER IS A NONRESIDENT ALIEN OR BONA FIDE PUERTO RICO RESIDENT

PENSION / ANNUITY FROM NONQUAL DEFERRED COMPENSATION PLAN OR NONGOVERNMENTAL SECTION 457(b) PLAN

TELEPHONE NUMBER

1310

[15]

AMOUNT FROM FORM 2555, LINE 44, ALSO DEDUCTED ON SCH C OR SCH F OR INCLUDED ON SCH E PTSHP NET INC OR (LOSS) 7546

0222 - -

0223

02210236 [20]

[35]

ENTER A, B, OR C

[45]

DECEASED TAXPAYER REFUND CLAIM

LAST NAME

FIRST NAME

NAME OF PERSON CLAIMING REFUND:

1294

1

0225

1293a

0226COMPLETE ONLY IF LINE C IS SELECTED:

B

KEYFIELDOVERRIDE

1296WILL CLAIMANT PAY OUT REFUND ACCORDING TO LAWS OF STATE WHERE DECEDENT WAS A LEGAL RESIDENT?

1295

UNREIMBURSED FARM PTNSHP EXPENSE DEDUCTED ON SCH E

AMOUNTT FROM SCH K-1 (FORM 1065-B), BOX 9

1

YES

b OVERRIDE EARNED INCOME


3

2b

AMERICAN SAMOA INCOME THAT IS EXCLUDED

HAS A COURT APPOINTED A PERSONAL REPRESENTATIVE FOR ESTATE OF DECEDENT?

9099

7543

4

PARTNERSHIP SECTION 179 EXPENSE DEDUCTION 9038

NOTE: TO VALIDATE THE AMOUNT OF ERP RECEIVED DURING 2010, VISIT www.irs.gov/individuals/article/0,,id=219514,00.html OR CALL THE AUTOMATED LINE AT 866-234-2942.

2394

YES

1531

SPOUSE AMOUNT

10DATA4

NOTE: FM 1040-SS & 1040-PR FILERS, ONLY COMPLETE LINE 10.

7541

SCHEDULE M

TP (OR SP IF MARRIED) IS MEMBER OF UNIFORMED SVCS, FOREIGN SVC, OR EMPLOYEE OF INTELLIGENCE COMMTY AND SOLD HOME OR HOME CEASED TO BE MAIN HOME, IN CONNECTION WITH GOV'T ORDERS FOR QUAL OFFICIAL EXTENDED DUTY SERVICE

[ # ] MAX CHAR

7542

REPAYMENT OF CREDIT CLAIMED FOR 2008, IF APPLICABLE, IS NOT REQUIRED TO BE REPAID UNTIL 2010. ENTER CREDIT AMOUNT AND PURCHASE DATE FOR PURPOSES OF REPAYMENT ON 2010 RETURN. THE 5405 WILL NOT PRODUCE IN 2009 IF CREDIT WAS NOT TAKEN IN 2009.

15581557

2010

ECONOMIC RECOVERY PAYMENT RECEIVED IN 2010:

LAST NAME

SCH M

NO

YES

PART III - DISPOSITION OR CHANGE OF MAIN HOME

Multiple

A

9097

SURVIVING SPOUSE REQUESTING REISSUE OF REFUND CHK

ZIP CODEA 8649

0307 -

8 FEDERAL 1040 DATA SHEET 4

8475

YES

IF NO, WILL ONE BE APPOINTED?

SOLD HOME TO UNRELATED PERSON

54051 FIRST-TIME HOMEBUYER CREDIT, PG 1

PART I - GENERAL INFORMATION

h

d

13

HOME DESTROYED, CONDEMNED, OR DISPOSED OF UNDER THREAT OF CONDEMNATION WITH NO PLANS TO ACQUIRE NEW HOME WITHIN 2 YRS OF EVENT

STATE

1566

YES

PURCHASE PRICE OF HOME

1568

7286

STREET ADDRESS OF HOME QUALIFYING FOR CREDIT

8474CITY

8473

[70]

PART II - CREDIT

U.S. FOR AT LEAST 90 DAYS DURING PERIOD BEGINNING AFTER 12-31-08, AND ENDING BEFORE 05-01-10.

C YES

TAXPAYER AMOUNT

CONVERTED HOME TO RENTAL OR BUSINESS USE OR STILL OWN HOME BUT NOT USED AS MAIN HOME

YES

0552

DID TAXPAYER ENTER INTO A BINDING CONTRACT BEFORE 05-01-10 TO PURCHASE HOME BEFORE 07-01-10?TP IS A MEMBER OF THE UNIFORMED SERVICES OR FOREIGN SERVICE, OR AN EMPLOYEE OF INTELLIGENCE COMMUNITY, & WAS ON QUALIFIED OFFICIAL EXTENDED DUTY OUTSIDE

DID TAXPAYER PURCHASE HOME FROM A RELATED PERSON OR A PERSON RELATED TO SPOUSE? 1569

1567

SHARED INTEREST (IF NOT MFS, MUST ENTER BOTH PCTs):

[66]0308HOME DESTROYED, CONDEMNED, OR DISPOSED OF UNDER THREAT OF CONDEMNATION, AND ACQD OR PLAN TO ACQUIRE NEW HOME WITHIN 2 YRS OF EVENT

1554

1551

YES

9090

YES

TAXPAYER WHO CLAIMED CREDIT DIED IN 2009

9089AMT OF THE CREDIT CLAIMED ON FM 5405 FOR 2008 OR 2009

NAME OF EX-SPOUSE

PART IV - REPAYMENT OF CREDIT

YES

1555

14

YES

PERCENT OF LINE 2 (FOR USE ONLY IF MFS OR SOMEONE OTHER THAN SPOUSE HELD AN INTEREST)

MONTH AND DAY HOME FOR WHICH CREDIT WAS CLAIMED CEASED TO BE MAIN HOME (MM-DD)

1556

1550

c

g

YES

SOLD HOME TO UNRELATED PERSON WITH NO GAIN ON SALE

54052

SOLD HOME TO UNRELATED PERSON AND HAD GAIN ON SALE

f

B

7545

1564SUPPRESS PRINTING OF SCHEDULE M WHEN CREDITS EQUAL ZERO

DATE HOME WAS ACQUIRED (VALID DATE RANGE IS AFTER 12-31-09 AND BEFORE 10-01-10. MEMBERS OF UNIFORMED SERVICES OR FOREIGN SERVICE AND EMPLOYEES OF THE INTELLIGENCE COMMUNITY HAVE AN ADDITIONAL YEAR TO PURCHASE A HOME.)

10

YES

DID DECEDENT LEAVE A WILL?

COURT-APPOINTED OR CERTIFIED PERSONAL REPRESENTATIVE

YES

TRANSFERRED HOME TO EX-SPOUSE:

D

11

C

NEW JERSEY SELF-EMPLOYED OR INDEPENDENT CONTRACTOR

0501

1565 YES

1492

OH CITYONLY

NEW YORK CITY UNINCORPORATED BUSINESS

TWO-LETTER STATE CODE

GENERAL INFORMATION

PART I - INCOME

PART II AND V - EXPENSES

OHIO WORKING CITY

0309

YES

1040ONLY

SUBJECT TO YONKERS NONRESIDENT EARNINGS TAX

1292

1245

PRINCIPAL BUSINESS CODE

1127

BEGINNING INVENTORY

2237

a

0025

THIS SECTION SHOULD NOT BE USED IN CONJUNCTION WITH FORM 4562.

YES

[2]

SUBJECT TO NYC NONRESIDENT EARNINGS TAX

IF JOINT SCH C, TAXPAYER'S OWNERSHIP PERCENTAGE

DATE FROM:

YES

1129

a

COMMUNITY PROPERTY FOR SCHEDULE SE PURPOSES YES

FORCE ESTIMATED VOUCHERS TO PRINT

[25]

STREET ADDRESS (IF DIFFERENT)

0024

[44]

[25]

0147

PRINCIPAL BUSN ACTIVITY

YESOTHER

CAR AND TRUCK EXPENSES

ADVERTISING

2489

SUPPRESS AUTOMATIC SCHEDULE SE

OTHER INTEREST

2487

1477 YES

8618 - -

[25]

PENSION AND PROFIT SHARING PLANS19

CLERGY SCHEDULE C

YES

[20]

ADDITIONAL LINES ARE AVAILABLE ON INPUT SCREEN

MEALS AND ENTERTAINMENT (FULLY DEDUCTIBLE)

1318

FORCE LONG SCHEDULE C 1117[2]

a VEHICLES, MACHINERY AND EQUIPMENT

BUSINESS OWNER (T = TP S = SP J = JOINT)

20

0510

11

12

2475

Multiple2010

CONTRACT LABOR

PART II AND V - EXPENSES (CONTINUED)

LAST NAME 9

(MAY BE USED WITH SYSTEMS 1040 AND 1041)

18

17 LEGAL AND PROFESSIONAL SERVICES

16

PROFIT OR (LOSS) FROM BUSINESS

24779

2473

YES1450

14 EMPLOYEE BENEFIT PROGRAMS 2482INSURANCE (OTHER THAN HEALTH)

b

[25]

2495

2484

2474

2488

EXPLANATION OF FORM 1098

FORM 1098 NAME / ADDRESS

[25]

OFFICE EXPENSE

[25]

B

REPAIRS AND MAINTENANCE

MORTGAGE (PAID TO BANKS, ETC.)

[11]

0022

15

21

BUSINESS NAME

1229

E

D

8619 - -8605

DATE TO:

0031EMPLOYER ID NUMBER (EIN)

4345

2476RENT ORLEASE 2491b OTHER BUSINESS PROPERTY

2672

TRAVEL, MEALS, ENTERTAINMENT:

UTILITIES

TELEPHONE (BUSINESS ONLY)

2673

G TP MATERIALLY PARTICIPATES IN OPERATION OF BUSINESS 1242 NO

F 1126 YES

2496LIMITED AMOUNT

2418

2490

22 SUPPLIES

NYC UNINCORPORATED BUSINESS TAX

TAXES AND LICENSES

TRAVEL

2578

WAGES (LESS EMPLOYMENT CREDIT)

1207

OIL AND GAS DEDUCTION

26

OTHER EXPENSES:

b

SUBJECT TO D.O.T. HOURS OF SERVICE LIMITATIONS

24972498

POSTAGE

YES

1588RETURNS AND ALLOWANCES 2262 ( )

[18]

25

YES

27

A

2

28

[45]ZIP CODE (CITY, STATE) 0026

[6]

6 OTHER INCOME

H FIRST SCHEDULE C FOR THIS BUSINESS 1290 YES

COST OF GOODS SOLD 2674 ( )

GROSS RECEIPTS OR SALES 2261

7 GROSS INCOME

ANY CHANGE IN DETERMINING QUANTITIES, COSTS, ETC.?

34

8

10

4

226335

[45]

[15]

1156OTHER

2437

PART III - COST OF GOODS SOLD

32

3576MISCELLANEOUS 2499

2629

c

OTHER EXPENSES:

AMOUNTEXPLANATION

1155 YES

YES

2268

1144 YES

2266 ( )2265

PART IV - INFORMATION ON YOUR VEHICLE

44

2264 ( )42 COST OF GOODS SOLD

41

45

[50]

MATERIALS AND SUPPLIES

YES

2269

2267

1267 NO

AVAILABLE FOR USE DURING OFF-HOURS?

TOTAL COMMUTING MILES DRIVENb

EVIDENCE TO SUPPORT DEDUCTION?

ANOTHER VEHICLE AVAILABLE FOR PERSONAL USE?

NO

YES1163

2486

43

246128570065 - -DATE VEHICLE PLACED IN SERVICE FOR BUSN PURPOSES

a

13

c TOTAL OTHER MILES DRIVEN

BUSINESS

23

AMORTIZATION (FORM 4562)

33

INVENTORY AT END OF YEAR

36

0280

OVERRIDE KEYFIELD ASSET MGR [ # ] MAX CHAR

37

OTHER COSTS

b IF "YES", IS EVIDENCE WRITTEN?

46

10CDATA1

EXPENSES FOR BUSINESS USE OF HOME FOR THIS SCHEDULE C IS FOUND ON FORM 8829, LOCATED ON UNIVERSAL DATA SHEET 2.

EXPLANATION OF CHANGE OF INVENTORY

[50]

[50]

b

47

ADD-TO

a

PURCHASES

38

39

INTEREST:

LESS: COST OF PERSONAL USE ITEMS

JVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW C1206D OPTIONAL

ACCOUNTINGMETHOD

(IF NOT CASH)

1291 YES

[45]

ACCRUAL

SPECIFY

0023

STATUTORY EMPLOYEE EARNINGS

PRINCIPAL BUSN INCL PRODUCT OR SERVICE [44]

[30]

2480DEPRECIATION AND SECTION 179 EXPENSE DEDUCTION (FORM 4562)

2478COMMISSIONS AND FEES

2479DEPLETION

30

IF A LOSS, ARE THERE AMTS NOT AT RISK? IF 'YES', ENTER AMOUNT AT RISK AND ATTACH FORM 6198.

29 TENTATIVE PROFIT (LOSS)

31

2644

TOTAL EXPENSES

NET PROFIT (LOSS)

EXPLAIN

EXPENSES FOR BUSINESS USE OF HOME (Form 8829)

COST OF LABOR (NOT PAID TO SELF)

INVENTORY METHOD (IF NOT COST)

LOWER OF COST OR MARKET

COUNTY WHERE BUSINESS RESIDES 8768

2494

24922493

TEXAS LLC 1476

1206(ENTER 100%)MEALS AND ENTERTAINMENT

SUBJECT TO LIMITATION

1

MISC INCOME GREATER THAN GROSS RECIEPTS/SALES

YES

24

YES

NYSTATEONLY

3 = Neither exchange nor disposition had tax avoidance as its purpose

PART II - ALLOWABLE DEDUCTION

3869SPECIAL COMPUTATION FOR CERTAIN DAYCARE FACILITIES:

2950

NET GAIN (LOSS) DERIVED FROM BUSN USE OF HOME PLUS GAIN (LOSS) FROM BUSN SHOWN ON SCH D OR FORM 4797

[60]

[35]

[50]

(Enter 1, 2, or 3)

8693 - [15]

1328

12

1 = Disposition was after death of either party

[70]

13

2 = Disposition was involuntary conversion

COMPLETE LINES 12, 13, AND 14 ONLY IF GIVEN UP PROPERTY WAS NOT LIKE-KIND

[70]

34353436

0030

3468

3179

16

11

DEDUCTIBLE MORTAGE INTEREST 3180QUALIFIED MORTAGE INSURANCE PREMIUM ALLOWED 2941

EXCESS MTG INTEREST

ASSET MGR

IDENTIFYING NUMBER

4414

IFLINE 9 OR 10

IS "YES",INDICATE

EXCEPTION,IF

APPLICABLE

2272

9

24

1

PART I - INFORMATION ON LIKE-KIND EXCHANGE

1 = SCHEDULE D - SHORT TERM2 = SCHEDULE D - LONG TERM3 = FORM 4797, PART I4 = FORM 4797, PART II

02180219

OWNERSHIP CODE (T / S / J)


2

4411DESCRIPTION OF LIKE-KIND PROPERTY GIVEN UP:

DESCRIPTION OF LIKE-KIND PROPERTY RECEIVED:

8687DATE PROP GIVEN UP WAS ORIGINALLY ACQUIRED 8688 - -

[35]

[35]

5

WAS EXCHANGE OF PROP GIVEN UP OR RECD MADE WITH RELATED PARTY, EITHER DIRECTLY OR INDIRECTLY?

DATE PROP WAS TRANSFERRED TO OTHER PARTY 8689 - -3

8691 - -DATE RECEIVED PROP FROM OTHER PARTY

8

STREET ADDRESS OR P.O. BOX

4415

4

7 YES

6

1324

8690 - -

15

21

CASH RECEIVED, FMV OF OTHER PROPERTY RECEIVED, PLUS NET LIABILITIES ASSUMED BY OTHER PARTY, LESS EXCHANGE EXPENSES INCURRED

10

9DURING TAX YEAR, DID RELATED PARTY SELL OR DISPOSE OF ANY PART OF EXCHANGED PROPERTY?

ADJUSTED BASIS OF OTHER PROPERTY GIVEN UP

11

DURING TAX YEAR, DID TAXPAYER SELL OR DISPOSE OF ANY PART OF PROPERTY RECEIVED?

30

DESCRIPTION OF REPLACEMENT PROPERTY:

8695

BASIS OF DIVESTED PROPERTY

33COST OF REPLACEMENT PROPERTY PURCHASED WITHIN 60 DAYS AFTER DATE OF SALE 3444

[35]

SALES PRICE OF DIVESTED PROPERTY

10UNIV22288

3443

JVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW C1021D

ORDINARY INCOME UNDER RECAPTURE RULES (TO FORM 4797, LINE 10)35

[ # ] MAX CHAROPTIONAL OVERRIDE KEYFIELD

88241

PART III - GAIN (LOSS) & BASIS OF LIKE-KIND PROPERTY REC'D

31

28

[15]

FAIR MARKET VALUE OF OTHER PROPERTY GIVEN UP

FAIR MARKET VALUE OF LIKE-KIND PROPERTY RECEIVED

29

[35]

8694

PART II - RELATED PARTY EXCHANGE INFORMATION

YES

IF "3"SELECTEDEXPLAIN

17

NAME OF RELATED PARTY 4413

RELATIONSHIP

10

DESCRIPTION OF DIVESTED PROPERTY:0324NUMBER FROM CERTIFICATE OF DIVESTITURE

16

ORDINARY INCOME UNDER RECAP RULES (Fm 4797, line 16)

18ADJUSTED BASIS OF OTHER PROPERTY GIVEN UP, NET AMOUNTS PAID TO OTHER PARTY, AND EXCHANGE EXPENSES NOT USED ON LINE 15

UNIVERSAL DATA SHEET 2

YES

EXPENSES FOR BUSINESS USE OF HOME8829

ZIP CODE

1329

MULTIPLE

3442

2010( TO BE USED WITH SYSTEMS 1040, 1041, 1065, 1120, 1120S)10

LIKE-KIND EXCHANGES - PAGE 1

3440

3438

LAST NAME

34972

4

YES

PART I - PART OF HOME USED FOR BUSINESS

3477

SPOUSE'S FORM 8829 (FOR USE WITH MFS SPLIT RETURN ONLY) 1469

3547

TOTAL AREA OF HOME

3498

AREA USED EXCLUSIVELYFOR NON-DAYCARE BUSINESS OR NON-EXCLUSIVELY FOR DAYCARE BUSINESS

TOTAL HOURS FACILITY USED FOR DAY CARE

INSURANCE

RENT

2583

3183

REAL ESTATE TAXES

34503933

DIRECT

EXPENSES

3181

CASUALTY LOSSES

27073243

2942

REPAIRS / MAINTENANCE

UTILITIES

OTHER EXPENSES

3244

3241

3808

3245

2722

21 2721

28 EXCESS CASUALTY LOSSES

37

3239

36

40 [2]

32480079DEPRECIATION PERCENTAGE

2584

3134

3247

20

34

PART III - DEPRECIATION OF HOME

41

3246CARRYOVER OF EXCESS CASUALTY LOSSES AND DEPRECIATION FROM 2008 FORM 8829, LINE 43CASUALTY LOSSES INCLUDED ON LINES 14 AND 32 (CARRY TO FORM 4684, SECTION B)

30

19

18

CARRYOVER - OPERATING EXPENSES FROM 2008 FORM 8829, LINE 42

W-2 WAGES RELATED TO BUSINESS USE OF HOME 3489

3242

2857

8

WHEN OFFICE IN HOME EXPENSES ARE BEING GENERATED FOR SCH F

OR FM 2106, A WKSHT WILL BE PREPARED THAT RESEMBLES FM 8829.

INDIRECT

EXPENSES

3469

3182

8696 - -DATE DIVESTED PROPERTY WAS SOLD

[70]

3439

PART IV - SECTION 1043 CONFLICT OF INTEREST SALES

27

26

LIKE-KIND EXCHANGES - PAGE 288242

4412

TOTAL HOURS AVAILABLE (IF STARTED OR STOPPED DAY CARE IN 2009)

8692 - -

5

PART OF HOME USED EXCLUSIVELY FOR DAYCARE

SSN

DATE PROP RECEIVED WAS IDENTIFIED

FEDERAL EINBUSINESS EXPENSES THAT ARE NOT FROM BUSINESS USE OF HOME

MULTIPLENUMBER

DEPRECIATION ALLOWABLE

3184

CARRYINFORMATION

TO:

1

ENTER 1, 2, 3, 4, or 5

5 = OTHER 0029

1 = Schedule C2 = Schedule F3 = Form 21064 = Sch K-1 (1065)5 = Schedule E

CARRY TO:

3553

SCHEDULE

E

ONLY: 9885SCHEDULE E NET INCOME RELATED TO BUSINESS USE OF HOME

ADD-TO

SMALLER OF HOME'S ADJUSTED BASIS OR ITS FAIR MARKET VALUE

VALUE OF LAND INCLUDED ON LINE 36

SCHEDULE C

ONLY:

FORM 2106

ONLY:

SCHEDULE F /

2106

ONLY:

2953

0118

[35]

ADDRESS

0164ZIP CODE

NAME OF ISSUER OF MORTGAGE CREDIT CERTIFICATE

[35]

REFINANCED MTG / REDUCTION OF MORTGAGE INTEREST

0251

CERTIFICATE CREDIT RATE PERCENT SHOWN ON MORTGAGE CREDIT CERTIFICATE (NOT INTEREST RATE ON MORTGAGE)

OVERRIDE LINE 15 TAX CALCULATION

76692637PARENTS' TAX (See instructions)

YES

MORTGAGE CREDIT CERTIFICATE NUMBER

SCHEDULE D OR SCHEDULE J (FORM 1040) WAS USED TO FIGURE PARENTS' TAX

OVERRIDE LINE 9 TAX CALCULATION

LINE 13 (2009 FORM 1040 TAXABLE INCOME)

LINE 22

LINE 15

LINE 16 (2009 RECALCULATED TAX)

LINE 17

LINE 19 (2007 FORM 1040 TAX)

LINE 20 (2008 FORM 1040 TAX)

LINE 2a (ELECTED FARM INCOME)

LINE 5 (2007 FORM 1040 TAXABLE INCOME)LINE 6

LINE 7

7252

7243

9160

LINE 10

LINE 11

3452

ALL OTHER CHILDREN'S QUALIFIED DIVIDENDS (FROM FORM 8615 LINE 5 WORKSHEET)OTHER CHILDREN'S TOTAL NET CAPITAL GAIN FROM LINE 2 OF FORM 8615 LINE 5 WORKSHEET (See instr)

TOTAL NET CAP GAIN ON ALL OTHER FORM(s) 8615 (See instr)

7241

7247

FORM 4952, LINE 4e (See instructions)

FORM 4952, LINE 4g (See instructions)

0067 - -PARENT'S SSN

CHILD'S EARNED INCOME

PARENT'S FILING STATUS CODE:

B

PORTION OF CHILD'S SCHEDULE A DIRECTLY CONNECTED WITH PRODUCTION OF INVESTMENT INC ($1,900 Addition is automatic)

8396 MORTGAGE INTEREST CREDIT

0253 - -

[35]

ADDRESS OF MAIN HOME ON WHICH CREDIT IS TAKEN IF DIFFERENT FROM FORM 1040:


0056

ISSUE DATE

2008 CREDIT CARRYFORWARD FROM 2009 FORM 8396, LINE 16


10DATA9

[22]

15 7670

OVERRIDE [ # ] MAX CHAR

2638

76723451

7668

7671

2607

2636

7253

NET CAP GAIN (SCH D, LN 15 OR 16, OR FM 1040 LN 13). If -0-or less, enter -1

LINE 19 (UNRECAPTURED 1250 GAIN)

PARENTS' TXBL INCOME (IF PARENT FILES FM 2555, ENTER LN 3 AMT FROM PARENTS' FOREIGN EARN INC WKSHT)

TTL NET INVEST INCOME FROM ALL OTHER FM 8615 (LN 5)CHILD'S ITEMIZED DEDUCTIONS DIRECTLY CONNECTED WITH PRODUCTION OF NET CAPITAL GAIN

22873454

2639

7667AMOUNT FROM PARENTS' SCHEDULE D

LINE 18 (28% RATE)

34533455

2459FORM 4952, LINE 4eFORM 4952, LINE 4g

3456

SEC 1250 GAIN (See instructions)

7245

7250

7255


7257LINE 21 (2009 FORM 1040 TAX)


LINE 14

7248

7251

7256

YESCHILD IS BETWEEN AGES OF 18 AND 24 AND QUALIFIES FOR 8615

PARENT'S QUALIFIED DIVIDENDS

AMOUNT FROM PARENTS' SCHEDULE J

7242

LINE 9 (2008 FORM 1040 TAXABLE INCOME)

TAX ON INVEST INCOME FOR DEPENDENT FILERS

2010 11

10

LAST NAME

2530

0172

FEDERAL 1040 DATA SHEET 9

7

7244

7249

15398615

2

7258

7387

2957

1

3

4

1286

C 1 = Single2 = Married Filing Jointly3 = Married Filing Separately

A


29545

6

0252

PARENT'S NAME 0066 [40]

2635

3142

4 = Head of Household5 = Qualifying Widow(er)

INTEREST PAID ON CERTIFIED INDEBTEDNESS AMOUNT

6

2

7254

LINE 2c (UNRECAPTURED SECTION 1250 GAIN)

7246

9161

9

TOTAL OF ALL OTHER SCHEDULE(s) D

28% RATE GAIN (See instructions)

LINE 2b (EXCESS CAPTIAL GAINS)

8889 HEALTH SAVINGS ACCOUNTS (HSAs)

SPOUSE'S FORM 8889 8071 YES

TWO-LETTER STATE CODE [2]

PART I - HSA CONTRIBUTIONS AND DEDUCTION

1 HIGH-DEDUCTIBLE HEALTH PLAN FOR CURRENT YEAR IS: 1 - SELF ONLY 2 - FAMILY 8072

2HSA CONTRIBUTIONS MADE FOR CY, AND THOSE MADE FROM 01/01/10 THROUGH 04/18/10. DO NOT INCLUDE EMPLOYER CONTRIBUTIONS OR CAFETERIA PLAN AMTS 7681

3 ALLOWABLE CONTRIBUTION AMOUNT OVERRIDE 7682

7686

4 AMOUNT TAXPAYER AND EMPLOYER CONTRIBUTED TO ARCHER MSAs FOR CURRENT YEAR 7683

6

HALF OF LN 5 IF TP AND SP HAVE SEPARATE HSAs AND FAMILY COVERAGE HDHP AT ANY TIME IN CURR YR, (OR SHARE OF LINE 5 IF TP AND SP CHOOSE TO DIVIDE DIFFERENTLY) 7684

a TOTAL DISTRIBUTIONS TP, AND SP IF MFJ, RECEIVED IN CURRENT YEAR FROM ALL HSAs 7687

b

7IF AGE 55 OR OLDER AND MARRIED, ENTER THE NUMBER OF MONTHS YOU OR SPOUSE HAD FAMILY COVERAGE UNDER AN HDHP WHILE NOT ENROLLED IN MEDICARE DURING CY 7685

9 EMPLOYER CONTRIB MADE TO TP HSAs FOR CY

17 a DISTRIBUTION AMOUNT NOT SUBJECT TO 10% TAX 7690

10 QUALIFIED HSA FUNDING DISTRIBUTIONS 7730PART II - HSA DISTRIBUTIONS

14

QUALIFIED HSA DISTRIBUTION 708919 PART-YEAR COVERAGE 7090

DISTRIBUTIONS INCLUDED ON LINE 14a ROLLED OVER TO ANOTHER HSA. ALSO INCLUDE ANY EXCESS CONTRIBUTIONS (AND EARNINGS FROM THEM) INCLUDED ON LINE 14a THAT WERE WITHDRAWN 7688

15 UNREIMBURSED QUALIFIED MEDICAL EXPENSES 7689

20 QUALIFIED HSA FUNDING DISTRIBUTIONS 7091

ACCOUNT BENEFICIARY DIED AND DESIGNATED BENEFICIARY IS NOT SURVIVING SPOUSE YES1263

PT III - INCOME/ADD'L TAX FAILURE TO MAINTAIN HDHP COVERAGE

18

[35]

7

c CHILD#3

NAME 4224[11]

[11]

4231

IS ADDRESS THE SAME FOR CHILD #3 AS CHILD #2 (AND DIFFERENT FROM CHILD #1'S ADDRESS?) 4220 YES

[25]

NAME 4233 [35]

[11]

YES

YES

YES

4223 YES

CHILD#3

STREET ADDR 4221 [35]

CITY, STATE, ZIP 4222

IS THIS PERSON THE SAME FOR CHILD #3 AS CHILD #2 (AND DIFFERENT FROM PERSON LIVING WITH CHILD #1?)

[15]

2107

c CHILD #3 42164 NUMBER OF DAYS CHILD LIVED WITH

TAXPAYER IN THE U.S DURING THE YEAR

2558

Multiple YES

LAST NAME

FILED FORM 4361

2423

CHILD'S ORDINARY DIVIDENDS (Incl AK Perm Fund Div)

PART II - OPTIONAL METHODS

2a

2259

2

YES

8814

1465

ADD-TO

1b

A

B

AMOUNT FROM LINE 1b SUBJECT TO AMT TAX

FIRST NAMECHILD'S

3073

CHILD'S TAXABLE INTEREST INCOME

ELECTION TO REPORT CHILD'S INTEREST / DIVIDENDS

4098

3

28632555

4099

2874

3400

2554

3401

2559

[15]

2552

21052106

2553

230377902380

2260

301677892375

7798b

HOUSING METHOD #1

FIGURE OPTIONAL METHOD

7719 7720

5 a

FAIR RENTAL VALUE OF PARSONAGE PROV BY CHURCH

SPOUSE

15 GROSS FARM INCOME

GROSS NONFARM INCOME

a

17

YES1387 YES

22232432

EXEMPT NOTARY AMOUNT3

CHAPTER 11 BANKRUPTCY INCOME

TOTAL FICA W-2 WAGES / RAILROAD RETIREMENT

8 a

CHURCH EMP INC FROM W-2

NON-FARM

CHILD'S TAXABLE INTEREST INCOME FROM NOMINEE DISTRIBUTIONS

CHILD'S ACCRUED INTEREST INCOME ADJUSTMENT

CHILD'S ABP INTEREST INCOME ADJUSTMENT

CHILD'S OID INTEREST INCOME ADJUSTMENT

CHILD'S TAX-EXEMPT INTEREST INCOME

90861

b

a

PTSHP K-1

1395 YES

1193 YES

1394 YES

1065 K-1(Box 14,Code A)

SCH C INC 2227

22312232

PTSHP K-1

OTHER NONFARM INCOME

SE SELF-EMPLOYMENT

2228SCH F INC

1

1382 ALLOCATE TAXABLE INCOME TO SPOUSE'S FORM 8814

TWO-LETTER STATE CODE 8171

0128 - -CHILD'S SOCIAL SECURITY NUMBER

1482 YES

7727

7829

ALLOW CLERGY W-2 WAGES TO BE CONSIDERED FOR EIC AND ADDITIONAL CTC

23033016EXEMPT NOTARY INCOME

75093148

VALUE OF MEALS AND LODGING PROVIDED FOR EMPLOYER'S CONVENIENCE

TP

SP [35]

OVERRIDE TOTAL TAXABLE EARNED INCOME

OVERRIDE TOTAL SELF-EMPL INCOME FOR EIC

03810382

[35]

7786 7787

7785

UTILITY ALLOWANCE, IF SEPARATE

e

7722ACTUAL EXPENSES FOR UTILITIES

HOUSING METHOD #2

37507 7716

b

g

b

d

CLG

c

HOUSING ALLOWANCE RECEIVED (INCLUDE UTILITY ALLOWANCE)a

4

a

CHILD#2

42294230

4211FAIR RENT VALUE OF HOME, INCL FURNISHINGS AND UTILITIES (REQD FOR ACCURATE CALC)

CLERGY

TAXPAYER

7721

KEYFIELDOVERRIDE

ONLY REASON FOR PRIOR DISALLOWANCE WAS INCORRECTLY REPORTED EARNED INC OR INVEST INC

2

6

IS THIS PERSON THE SAME FOR CHILD #3 AS CHILD #1?

RELATIONSHIP 4225

CHILD #1

4215

JVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW C0527D OPTIONAL

PART I - FOR ALL FILERS

8862

[ # ] MAX CHAR 10DATA2

DID ANYONE (EXCEPT SP, IF MFJ, AND DEPNS UNDER AGE 19) LIVE WITH CHILD #1 OR #2 OR #3 OVER HALF THE YEAR?

IS ADDRESS THE SAME FOR CHILD #3 AS CHILD #1?

4226

YES

b

2230

4206

4205

UNRECAPTURED SECTION 1250 CAPITAL GAINS

CHILD #2

a

12

YES

3 4270 YES

2010LAST NAME

FEDERAL 1040 DATA SHEET 2

4219[25]

IS THIS PERSON THE SAME FOR CHILD #2 AS CHILD #1?

YES

CITY, STATE, ZIP

NAME 42134214

4212

[35]

CHILD#1

b

a

c

4234RELATIONSHIP

RELATIONSHIP

TP (AND/OR SP IF MFJ) IS QUALIFYING DEPN OF ANOTHER

42174228 - -

a

b

IS ADDRESS THE SAME FOR CHILD #2 AS CHILD #1?

[25]

[35]

4210

ADDRESS IN U.S. WHERE TAXPAYER AND CHILD LIVED DURING THE YEAR

[35]

7508

CHILD#2

YESPRINT EVEN IF NOT QUALIFIED

SPOUSETAXPAYER

SECTION A - SHORT SCHEDULE SE

FARM

CONSERVATION RESERVE PROGRAM PAYMENTS

2222

2224

90852221

1065 K-1 (Box 14,Code A)

C / CEZ

F

22252226

YESALLOW CLERGY W-2 WAGES TO BE CONSIDERED FOR EARNED INCOME CREDIT AND ADDITIONAL CHILD TAX CREDIT 1482

FILED FORM 4029 1195SECTION B - LONG SCHEDULE SE

INFO TO CLAIM EIC AFTER DISALLOWANCE

4209

PART II - FILERS WITH A QUALIFYING CHILD OR CHILDREN

2422FORM 4361 EXEMPT INCOME AMOUNT

138822292433

CHILD#1

ACTUAL HOUSING EXPENSES

ACTUAL EXPENSES FOR UTILITIES

7723 77247782 77837717 77187784

UTILITY ALLOWANCE, IF ANY

7828OTHER ADJ TO SE INC (DESCRIBE BELOW)

OTHER RELATED INPUTS

CHILD'S ORDINARY DIV FROM NOMINEE DISTRIBUTIONS

CHILD'S ALASKA PERMANENT FUND DIVIDEND

CHILD'S QUALIFIED DIVIDENDS

CHILD'S CAPITAL GAIN DISTRIBUTIONS

CHILD'S CAP GAIN DISTRIB FROM NOMINEE DISTRIBUTIONS

28% RATE CAPITAL GAINS

4204 - -

PART III - FOR FILERS WITHOUT A QUALIFYING CHILD

8 DATES DURING YEAR THAT TAXPAYER'S HOME WAS IN UNITED STATES

FROM TO

4201 - - 4202 - -

CHILD #2

CHILD #3

9 IF MFJ, DATES DURING YEAR THAT SPOUSE'S HOME WAS IN U.S. 4203 - -

STREET ADDR

STREET ADDRb

CITY, STATE, ZIP

5

IF CHILD WAS BORN OR DIED DURING THE YEAR, SHOW BIRTH AND/OR DEATH DATES FOR EACH. OTHERWISE, SKIP THIS LINE.

4207 - -(1) BIRTH DATE (2) DEATH DATE

4208 - -4227 - -

c 4218 - -

CHILD #1

MEMBER OF AN INDIVIDUAL WHO FALLS UNDER ONE OF THE CATEGORIES LISTED ABOVE WHEN HE/SHE PASSED AWAY OR FILED FOR DIVORCE.

NOT ENTITLED TO MEDICARE PART A NOR ENROLLED IN MEDICARE PART B OR ENROLLED IN MEDICARE BUT FAMILY MEMBER(S) QUALIFIED FOR THE HCTC1

3075

5

ANY ARCHER MSA OR HEALTH SAVINGS ACCTS DISTRIBUTIONS USED TO PAY FOR QUAL HEALTH INS COVERAGE FOR MONTHS CHECKED ON LINE 1 9770

3

PART II - HEALTH COVERAGE TAX CREDIT

GRANT. ALSO, NO ADVANCE (MONTHLY) PAYMTS OR REIMBURSEMENT CR FROM FORM 1099-H, BOX 1

9017

9020

AUGUST

TOTAL EMPLOYER-PAID MOVING EXPENSES (W-2, box 12, code P)

4

APRIL

7104

90249023

9025

6

7123

18

MORE THAN ONE SECTION C IS ATTACHED

4

7

7283

7122

7105

7129

7500

7106

a

UNREIMB QUAL MEDICAL EXPENSES

7121

75497107

8853

05042-LTR STATE CODEPREPARE FORM 8853 8027 YES

MSAs AND LONG-TERM INSURANCE ACCTS

8681 9021

9019

8684

90229009

TOTAL EMPLOYER CONTRIB TO ARCHER MSAs FOR CY 2650

8049

90168663

9008

MAR 1

2758

8668

8675

SPOUSETAXPAYER

SP DEDUCTIBLE

90038664

JAN 1

2 2759

86789005

9007

86658676

9006APR 1

8679

86779004

SPOUSETAXPAYER

SP CoverCode

TP / FAMILYDEDUCTIBLE

ENTERCOVERTYPEFOR

EACHDATE

9015

YES

2649

JUN 1

LIMITATION WORKSHEET CALCULATIONS

JUL 1

AUG 1

19

8669

F=FamilyS=Self

N=None

86728671

SECTION B - MEDICARE ADVANTAGE MSA DISTRIBUTIONS

7281

SECTION C - LONG-TERM CARE (LTC) INSURANCE CONTRACTS

15

11

21 NUMBER OF DAYS IN LTC PERIOD

PART OF LINE 19 FROM QUALIFIED LTC INS CONTRACTS

14

24

22 7299

7296

80898088 YES

ACCELERATED DEATH BENEFITS ONLY PMTS RECD THIS YR?16

72987297

GROSS LTC PMTS RECD ON PER DIEM / OTHER PRD BASIS

bANYONE BUT TP RECEIVE PMTS ON PER DIEM OR OTHER BASIS UNDER QUALIFIED LTC INSURANCE CONTRACT?

WAS INSURED TERMINALLY ILL?

TTL UNREIMB QUAL MEDICAL EXP

8119 - -SOCIAL SECURITY NUMBER OF INSURED

17

YES

8094 YES

7295

8680

9018

LAST NAME

8066HEALTH COVERAGE TAX CREDIT

2010

SPOUSE'S FORM 8885

PART I - ARCHER MSA CONTRIBUTIONS AND DEDUCTIONS

TP / Fam Cover Code

NAME OFINSURED

a8118

FIRST NAME [15]

7282

[19]

7284

8117LAST NAME


COVERAGE EQUAL FOR ENTIRE YEAR

FEB 1

MAY 1 86673

SEP 1

NOT ENROLLED IN FED EMPL HEALTH BENEFITS PROG OR ELIGIBLE TO RECEIVE BENEFITS UNDER U.S. MILITARY HEALTH SYSTEM (TRICARE)

DECEMBER

8438

JULY

8439

84418437

SEPTEMBER

8433

8067

NOT IMPRISONED UNDER FEDERAL, STATE, OR LOCAL AUTHORITY

MARCH

8068 84358440

JUNE

8432

8434

NOVEMBER

NOT ENROLLED IN MEDICAID OR STATE CHILDREN'S HEALTH INS PROGRAM

8885

YES

CHECK BOXES FOR EACH MONTH THIS YR THAT ALL OF THE FOLLOWING STATEMENTS ARE TRUE ON FIRST DAY OF THAT MONTH:

ELIGIBLE TRADE ADJ ASSISTANCE (TAA) RECIPIENT, ALTERNATIVE TAA RECIPIENT, REEMPLOYMENT TRADE ADJ ASSISTANCE (RTAA) RECIPIENT OR PENSION BENEFIT GUARANTY CORP (PBGC) PAYEE OR QUALIFIED FAMILY

COVERED BY QUALIFIED HEALTH INS PLAN FOR WHICH TP PAID PREMIUMS OR TP PORTION OF PREMIUMS, DIRECTLY TO TP HEALTH PLAN (INCL MOS FOR WHICH TP PAID PREMIUMS TO US.S TREASURY--HCTC)

PART I - CHECK ELIGIBILITY FOR TAKING THE CREDIT

JANUARY

EMPLOYER DID NOT PAY 50% OR MORE OF COST OF COVERAGE

TP DID NOT RECEIVE 65% COBRA PREMIUM REDUCTION FROM FORMER EMPLOYER OR COBRA ADMINISTRATOR

OCTOBER

MAY

8436DEC 1 8674

90108670 8682

90268686

8683

FEBRUARY

TOTAL ARCHER MSA DISTRIB RECEIVED IN CURR YEAR

10

8050

90119012

YES

8087

WITHDRAWN BY RETURN DUE DATE

TOTAL MEDICARE ADVANTAGE MSA DISTRIBUTIONS RECEIVED IN CY

OCT 1

ARCHER MSA CONTRIB MADE FOR CY INCL FROM 01/01/10-04/15/10

COMPENSATION FROM EMPLYR MAINTAINING HDHP (IF SELF- EMP, EARNED INC FROM TRADE/ BUSN UNDER WHICH PLAN WAS ESTABLISHED)

10DATA8JVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW S0110S OVERRIDE KEYFIELD

7280

[ # ] MAX CHAR

ROLLED OVER TO ANOTHER MSADISTRIB

INCLUDEDON LINE 6a

8685

b

COSTS INCURRED FOR QUALIFIED LTC SERVICES PROVIDED FOR INSURED DURING LTC PERIODTOTAL REIMBURSEMENTS FOR QUALIFIED SERVICES PROVIDED FOR INSURED DURING LTC PERIOD

8673NOV 1

PART II - ARCHER MSA DISTRIBUTIONS

9013

YES

ACCELERATED DEATH BENEFITS RECEIVED ON A PER DIEM OR OTHER PERIODIC BASIS

ADVANCE PAYMENTS RECEIVED FOR ANY MONTHS NOT CHECKED ON LINE 1

1

SPOUSE IS POLICYHOLDER

9014

8666

YES

3903 MOVING EXPENSES

9771

STATE MOVED TO (IF DIFFERENT THAN RESIDENT STATE) 0358MILES FROM OLD HOME TO NEW WORKPLACE

MILES FROM OLD HOME TO OLD WORKPLACE

305030511341

TOTAL LODGING EXPENSES (NOT MEALS) 3053

ACTUAL VEHICLE EXPENSE

ARMED FORCES PERMANENT CHANGE OF STATION

30521TOTAL TRANSPORTATION AND STORAGE OF HOUSEHOLD GOODS AND PERSONAL EFFECTS

OWNERSHIP CODE: T - TAXPAYER S - SPOUSE J - JOINT 0205

2

TOTAL MILEAGE

QUAL HEALTH INS COVERAGE PD FOR MONTHS CHKD ON LN 1 (DO NOT INCLUDE ON LN 2 QUAL HEALTH INS PREMS PAID TO ``US TREAS HCTC" OR ANY INS PREMS ON COVG ACTUALLY PD FOR WITH NATL EMERGENCY

2

3566PARKING FEES AND TOLLS 9194

TRAVEL ANDLODGINGMOVING

EXPENSES3567

9769

16

3918

3919

a

9970

23

WORKSHEET FOR CREDIT REDUCTION STATES

(INDIANA, MICHIGAN, AND SOUTH CAROLINA)TOTAL TAXABLE FUTA WAGES PAID IN INDIANA 9968

4796

ACTIVITY NAME

ENERGY EFFICIENT HOME CREDIT FROM PARTNERSHIPS AND S CORPORATIONS

TOTAL NO. - QUAL ENERGY EFFICIENT MANUF HOMES MEETING 30% STD SOLD OR LEASED TO ANOTHER PERSON FOR USE AS RESIDENCE DURING TAX YEAR

[33]

8908

2

1040 / 1041 ONLY - FORM 8908 PASSIVE CREDIT FOR FORM 8582CRCURRENT CR

ENERGY EFFICIENT HOME CREDIT

PAID ALL STATE UNEMPLOYMENT CONTRIBUTIONS FOR 2010 BY APRIL 18, 2011 8005

HAND PREPARED ANNUALIZED INCOME INSTALLMENT WKSHT FROM LN 25

2 - Prior year return not filed or tax liability unknown (Penalty based on current year tax only) 3 - Prior year less than 12 months (Penalty based on current year tax only)

0 - Not Applicable, Enter prior year tax above (Default)1 - No Tax Liability (Whether or not return was required)

PART II - REASON FOR FILING

8105CONTRIBUTIONS PAID TO STATE UNEMPLOYMENT FUND

E FILING STATUS HAS CHANGED

C ANNUALIZED INCOME INSTALLMENT METHOD USED

b TAXABLE WAGES

T/S PRIOR YR CRWK #

January to August

7366

2917

April - MayJanuary - March

TO

STATE EXPERIENCE RATE

4419 - -

TOTAL TAXABLE FUTA WAGES PAID IN MICHIGAN 9969

c

d

STATE EXPERIENCERATE PERIOD

CONTRIBUTIONS PAID TO STATE UNEMPLOYMENT FUND

4423

+

4429

2939

4427 - -

4418

124 ITEMIZE DEDUCTION 2936

INVESTMENT INTEREST EXPENSE DEDUCTION

4421 4428

4425

3312

4420 - -

TOTAL TAXABLE FUTA WAGES PAID IN SOUTH CAROLINA

4422

17

CONTRIB NOT REQUIRED DUE TO ZERO PCT EXPERIENCE RATE

8323

NAME OF STATE 4416 [2]

Multiple

STATE #1

TOTAL CASH WAGES SUBJECT TO FUTA TAX

STATE #2COMPLETE ALL APPLICABLE LINES

FROM

a

ALL FUTA TAX WAGES ALSO TAXABLE FOR STATE UNEMPLOYMENT TAX

SECTION A

13 STATE WHERE UNEMPLOYMENT CONTRIBUTIONS WERE PAID [2]

8006 YES

8100

10

7125TOTAL CASH WAGES SUBJECT TO MEDICARE TAXES3

7 ADVANCE EARNED INCOME CREDIT (EIC) PAYMENTS, IF ANY 7128

7126

12

1 aTOTAL NO. - QUAL ENERGY EFFICIENT HOMES MEETING 50% STANDARD SOLD OR LEASED TO ANOTHER PERSON FOR USE AS RESIDENCE DURING TAX YEAR 3917

3926

TAXPAYER

PART II - ANNUALIZED SELF-EMPLOYMENT TAX

4735

4737TAXPAYER

10UNIV1OVERRIDE KEYFIELD

4471

2754

[ # ] MAX CHAR

AMOUNT7666

3171

ADD-TO

3311b

[38]

4470

4713[38]

AMOUNT


A

PAID TOTAL CASH WAGES OF $1,000 OR MORE IN ANY CALENDAR QUARTER OF PRIOR YEAR OR CURRENT YEAR

BWITHHELD FEDERAL INCOME TAX IN CURRENT YEAR FOR ANY HOUSEHOLD EMPLOYEE

AMOUNT

4469

2746


14

2210

2010

C

PAID $1,700 OR MORE TO ANY ONE HOUSEHOLD EMPLOYEE IN CURRENT YEAR

SPOUSE'S SCHEDULE H

FEDERAL ID NUMBER

LAST NAME

UNDERPAYMENT OF ESTIMATED TAX

( TO BE USED WITH SYSTEMS 1040, 1041, 1065, 1120, 1120S)

TOTAL CASH WAGES SUBJECT TO SOCIAL SECURITY TAXES

FEDERAL INCOME TAX WITHHELD, IF ANY 71275

11

H HOUSEHOLD EMPLOYMENT TAX

FILING AS STAND-ALONE (Firm data prints in signature area) YES 1187 YES

F1148 YES

YES

1146

FORCE PRINTING OF FORM 2210 / 2210F EVEN IF NO PENALTY

SUPPRESS PRINTING OF FORM 2210 / 2210F8007 YES

8106 -

PRIOR YEAR (2009) TAX

8

PART I - REQUIRED ANNUAL PAYMENT

8001 YES

PRIOR YEAR TAX OPTIONS:

2401

D

19

0260 YES

1257

2809

OVERRIDEFEDERAL

WITHHOLDINGPAYMENTS 7369

7367

YES

YES

2810

4798

22412937

2242June - August

SECOND QUARTER WITHHOLDING

SCHEDULE AI - ANNUALIZED INCOME INSTALLMENTS

PERIODS

15

17

1

ENTER ALL ES PAYMENT DATES AND AMOUNTS, OVERPAYMENT

APPLIED, AND EXTENSION PAYMENTS ON THE ESTIMATES SCREEN

TAX RATE

FOURTH QUARTER WITHHOLDING

18

FEDERAL AGI

January to MayJanuary to March January to December

2807 2808

2938

FIRST QUARTER WITHHOLDING

31743320

1

4734

2240

4797

7665

ACTUAL WAGES SUBJECT TO SOCIAL SECURITY TAX:

[38]

1040NR - INCOME NOT EFFECTIVELY CONNECTED TO U.S. TRADE / BUSINESS:

3927

2393

29404714

SPOUSE

2391

2

NET GAIN FROM DISPOSITION OF INVEST PROP

WORKSHEET ADJUSTMENTGROSS INC FROM PROP HELD FOR INVESTMENT

3925

THIRD QUARTER WITHHOLDING 7368

a

NET CAPITAL GAIN FROM DISPOSITION OF PROPERTY HELD FOR INVESTMENT

27452755

AMOUNT

5

gAMOUNT OF LINES 4b AND 4e ELECTED TO INCLUDE IN INVESTMENT INCOME

WORKSHEET ADJUSTMENT

d

INVESTMENT INTEREST EXP PAID / ACCRUED IN CY

0178

4

[38]

8002 YES

8004 YES

YES

PART II - FEDERAL UNEMPLOYMENT (FUTA) TAX

PAID UNEMPLOYMENT CONTRIBUTIONS TO ONLY ONE STATE

8003PART I - SOCIAL SECURITY, MEDICARE, AND INCOME TAXES

1

1246

YES

7131

[2]

4426 - -

SECTION B

1602 YES14

ACTUALLY WITHHELD METHOD USED

[30]

3314PRIOR YEAR AGI

1256

0512

WAIVER OF PENALTY REQUESTED

WAIVED AMOUNT

WAIVER EXPLANATION

2602

INVESTMENT EXPENSES

QUALIFIED DIVIDENDS INCLUDED ON LINE 4a

WORKSHEET ADJUSTMENT

4715

YES1107

34583175

h

TAKE SHORT METHOD CALCULATION, IF APPLICABLE

CARRY PENALTY TO FORM 1040 / 1041

PREPARE FORM 2210F (FARMER / FISHERMAN)

0047 - -DATE AMOUNT DUE IS PAID

1468 YES

1281 NO

3

16 CREDITS

SPOUSE

26NET EARNINGS FROM SELF-EMPLOYMENT FOR EACH PERIOD:

3176

4736 4738

2392

2412

DISALLOWED INVEST INT EXP FROMPY FORM 4952, LN 7

e

WORKSHEET ADJUSTMENT 4733

TTL OTHER TAXES

28

4952

(DEFAULT = YES)

(DEFAULT = NO)

ADDITIONAL LINES ARE AVAILABLE ON THE INPUT SCREEN

1210 YES

1209 YES

IF "YES", THE EVIDENCE IS WRITTEN21 YES

2238REIMBURSEMENTS RECEIVED FROM THE EMPLOYER NOT REPORTED IN BOX 1 OF FORM W-2

VEHICLE AVAILABLE FOR PERSONAL, OFF DUTY USE

ANOTHER VEHICLE IS AVAILABLE FOR PERSONAL USE

THERE IS EVIDENCE TO SUPPORT THIS DEDUCTION

+

BUSINESS EXPENSES NOT INCLUDED (NOT MEALS AND ENTERTAINMENT)

1137 YESDEPARTMENT OF TRANSPORTATION EMPLOYEE

2454

[20]

COLUMN BCOLUMN A

NOT MEALS AND ENTERTAINMENT

MEALS ANDENTERTAINMENT

2449

PART II - VEHICLE EXPENSES

PART II - VEHICLE EXPENSES, SECTIONS A-D

10

YES

1118 YES

1169 YES

1168

2444DISABLED EMPLOYEE

AVERAGE ROUND TRIP COMMUTING MILES

COMMUTING MILES INCLUDED IN TOTAL MILES

GASOLINE

VEHICLE DESCRIPTION

- - DATE PLACED IN SERVICE

TOTAL MILES DRIVEN

OIL

1211 YES

(DEFAULT = NO)

19

18

[20]

7

STEP 2 - REIMBURSEMENTS FROM EMPLOYER FOR EXPENSES IN STEP 1


CLERGY FORM 2106

5

PART I - EMPLOYEE BUSINESS EXPENSES AND REIMBURSEMENTS

OCCUPATION

STEP 1 - EXPENSES

CAR RENTAL

2441ARMED FORCES RESERVIST

STEP 3 - FIGURE EXPENSES TO DEDUCT ON SCHEDULE A

MEALS AND ENTERTAINMENT EXPENSES

2453

2215

4

Multiple20102106 EMPLOYEE BUSINESS EXPENSE

LAST NAME 15

3

2216

PARKING FEES, TOLLS, AND TRANSPORTATION, INCLUDING TRAINS, BUSES, ETC. (Not overnight or commuting)

YES0032BUSINESS EXPENSE OWNER T - TAXPAYER S - SPOUSE FORCE LONG FORM 2106

+

TRAVEL EXPENSE AWAY FORM HOME OVERNIGHT (NOT MEALS AND ENTERTAINMENT)

LODGING

[2]0391

OTHER

2440

0356

2443

QUALIFIED PERFORMING ARTIST

FEE-BASIS STATE/LOCAL GOVERNMENT EMPLOYEE

AMOUNT OF LINE 10 ALLOCATED TO ARMED FORCES RESERVIST

AMOUNT OF LINE 10 ALLOCATED TO QUALIFIED PERFORMING ARTIST 2442

1178

2450

ASSET MGROVERRIDE [ # ] MAX CHAR

2

KEYFIELDJVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW C0524D

AMOUNT OF LINE 10 ALLOCATED TO DISABLED EMPLOYEE

AMOUNT OF LINE 10 ALLOCATED TO FEE-BASIS STATE/LOCAL GOVERNMENT EMPLOYEE

20 (DEFAULT = YES)

1449 YES1343

102106IN

YES

1212

BUSINESS MILES

DEPRECIATION BEFORE LIMITATION AND SECTION 179 DEDUCTION

REPAIRS

VEHICLE INSURANCE

OTHER MAINTENANCE EXPENSES

VEHICLE RENT OR (LEASE)

INCLUSION AMOUNT

LIMITATION AMOUNT FROM TABLE IN INSTRUCTIONS

METHOD (OPTIMIZE - FORCE SMR - FORCE ACTUAL)

ADD-TO

VALUE OF EMPLOYER-PROVIDED VEHICLE (ONLY IF 100% OF ANNUAL LEASE VALUE IS INCLUDED ON FORM W-2)

COST OR OTHER BASIS

AMOUNT OF SECTION 179 DEDUCTION

DEPRECIATION METHOD (200% - 150% - STRAIGHT LINE)

DEPRECIATION PERCENTAGE

1578 YES

0533 [20] STATE

ADD-TOKEYFIELD

9906DEPLETION +

8

DEPRECIATION EXPENSE (FROM FORM 4562)

[30]

STREET ADDRESS

ZIP

0051

EXPENSES

4

YES

3350

2873

3570

3573 9904

3351

3

98789879

7

15

11

13

14

12

TAXES

ENTERNUMBER

(1 - 9) 0306

9876

16

9

6

10

1592

1175

COMMISSIONS

INSURANCE

OTHER INTEREST

2876

98949895

AUTO MILEAGE EXPENSE

989198929893

OTHER TRAVEL EXPENSES

3345

9901

9890

[ # ] MAX CHAR

DIRECT AMOUNT

3316

8377

9903

334733483349

3344

9900

9877

2

YES

A) OWNERSHIP IS LESS THAN 100%, B) RENTAL IS ONLY PARTIALLY TENANT OCCUPIED, OR C) PROPERTY IS A VACATION HOME

10EDATA1

20

ASSET MGR

2879

OPTIONAL

17


+ 3573

UTILITIES

9905

9902

18

3361

RENTS RECEIVED

ROYALTIES RECEIVED

16 1040 Schedule E-Suplemental Income & Loss

NOTE: USE INDIRECT COLUMN ONLY IF:

CITY 05310092

TOTAL AREA OF PERSONAL RESIDENCE

2010NumberLAST NAME

0068

98889889CLEANING AND MAINTENANCE

NUMBER OF DAYS HOME RENTED AT FAIR RENTAL PRICE

NUMBER OF DAYS HOME ONWED, IF NOT 365 (FOR TAX COURT METHOD)

PERCENT OF PERSONAL USE, IF NOT ENTERED ABOVE

1190

SUPPRESS CARRYING OF INTEREST AND TAXES TO SCHEDULE A

USE THE TAX COURT METHOD TO ALLOCATE INTEREST AND TAXES

NUMBER OF DAYS HOME USED PERSONALLY

0070

3346

INDIRECT AMOUNT

98869887

FINAL DISPOSITION

REAL ESTATE PRO INCOME (LOSS) IS PASSIVE FOR CA PURPOSES

YES

5

TYPEOF

ACTIVITY

1601 YES

PERCENT OF OWNERSHIP (IF NOT 100%)

RENTAL IS PART OF PERSONAL RESIDENCE

AREA IS USED FOR RENTAL PURPOSES

AMORTIZATION

OFFICE IN HOME DEDUCTION

VACATION HOME

1591 YES

0075

7 - Not rented for profit (related party or less than FMV rental)8 - Vacation home9 - Royalty (Portfolio, non passive)

4 - Nonpassive rental real estate5 - Land lease (nopassive investment income)6 - Self-rental to busn in which taxpayer(s) materially participated

1 - Passive rental real estate with active participation 2 - Passive rental real estate 3 - Real estate professional

OIL AND GAS DEDUCTION

9875

PERSONAL USE FOR MORE THAN 14 DAYS OR 10% DAYS RENTED

+

INDIRECT AMOUNT[20]

LEGAL AND OTHER PROFESSIONAL FEES

MANAGEMENT FEES

MORTGAGE INTEREST PAID TO BANKS, ETC.

QUALIFED MORTGAGE INSURANCE

+

DESCRIPTION:

REPAIRS

+ SUPPLIES

3356

33539896989798989899

3354

DIRECT AMOUNT

INCOME

1261 YES

ADVERTISING

PRINT SEC 469(ccc)(7)(a) RENTAL REAL ESTATE AGGREGATION ELECTION

3352

3355

OTHER EXPENSES:

OWNERSHIP ENTITY (1040 ONLY) [T] = Taxpayer [S] = Spouse [J] = Joint (Default)


PROPERTY KIND PROPERTY LOCATION

05321 [35]

D

D

17 W-2 WAGES AND TAX STATEMENT DATALAST NAME Multiple 2010

# W-2 WAGE AND TAX STATEMENT[T]AXPAYER OR [S]POUSE

5MEDICARE WAGES AND TIPS

12

SEE INSTR FOR BOX 12

EMPLOYEE NAME (IF DIFFERENT) 8201 [35]

7305 8227 7291

6MEDICARE TAX WITHHELD 8228 7292EMPLOYEE ADDRESS

(IF DIFFERENTf) 8202 [35] 7306 8229 7293CITY STATE ZIP (IF DIFFERENT) 8203 [35] 7

SOCIAL SECURITY TIPS 8230 72947307 "J" SICK PAY - RR 8008

a CONTROL NUMBER 8209 [14]8

ALLOCATED TIPS "L" TO FM 2106 # 8221b

EMPLOYER

FEDERAL ID NUMBER 8207 [9]7308 "P" TO FM 3903 # 8182

c

FOREIGN ADDRESS 8235 YES9

ADVANCE EIC PAYMENT "W" TO FM 8889 # 8701NAME 8204 [35] 7309

13

STATUTORY SCH C #

EMPLOYEE 8222ADDRESS 8205 [35] 10DEPENDENT CARE BENEFITS

7310 RETIREMENT PLAN 8226ZIP CODE 8199 [10] STATE 8198 [2]

11NONQUALIFIED PLANS THIRD PARTY

SICK PAY 8225CITY 8197 [20] 7311

14

OTHER

1WAGES, TIPS, OTHER COMP.

3SOCIAL SECURITY WAGES

CLERGY 8213 [8] 73137301 7303

CLERGY W-2 1448 8214 [8] 73142

FEDERAL INCOME TAX WITHHELD4

SOCIAL SECURITY TAX WITHHELDSUPPRESS CLERGY SE 1452 8215 [8] 73157302 7304

8216 [8] 7316

STATEDATA

STATE STATE IDENTIFICATION NO [16] STATE WAGES STATE TAX WITHHELD LOCAL WAGES, ETC LOCAL TAX WITHHEL LOCALITY NAME

123

NON-STANDARD INDICATOR 8223 YES MICHIGAN CITIES ONLY - WORKSTATION ADDRESS (Street and City)

CORRECTED FORM W-2 8224 YES 8231 [30]

# W-2 WAGE AND TAX STATEMENT[T]AXPAYER OR [S]POUSE

5MEDICARE WAGES AND TIPS

12

SEE INSTR FOR BOX 12

EMPLOYEE NAME (IF DIFFERENT) 8201 [35]

7305 8227 7291

6MEDICARE TAX WITHHELD 8228 7292EMPLOYEE ADDRESS

(IF DIFFERENTf) 8202 [35] 7306 8229 7293CITY STATE ZIP (IF DIFFERENT) 8203 [35] 7

SOCIAL SECURITY TIPS 8230 72947307 "J" SICK PAY - RR 8008

a CONTROL NUMBER 8209 [14]8

ALLOCATED TIPS "L" TO FM 2106 # 8221b

EMPLOYER

FEDERAL ID NUMBER 8207 [9]7308 "P" TO FM 3903 # 8182

c

FOREIGN ADDRESS 8235 YES9

ADVANCE EIC PAYMENT "W" TO FM 8889 # 8701NAME 8204 [35] 7309

13

STATUTORY SCH C #

EMPLOYEE 8222ADDRESS 8205 [35] 10DEPENDENT CARE BENEFITS

7310 RETIREMENT PLAN 8226ZIP CODE 8199 [10] STATE 8198 [2]

11NONQUALIFIED PLANS THIRD PARTY

SICK PAY 8225CITY 8197 [20] 7311

14

OTHER

1WAGES, TIPS, OTHER COMP.

3SOCIAL SECURITY WAGES

CLERGY 8213 [8] 73137301 7303

CLERGY W-2 1448 8214 [8] 73142

FEDERAL INCOME TAX WITHHELD4

SOCIAL SECURITY TAX WITHHELDSUPPRESS CLERGY SE 1452 8215 [8] 73157302 7304

8216 [8] 7316

STATEDATA

STATE STATE IDENTIFICATION NO [16] STATE WAGES STATE TAX WITHHELD LOCAL WAGES, ETC LOCAL TAX WITHHEL LOCALITY NAME

123

NON-STANDARD INDICATOR 8223 YES MICHIGAN CITIES ONLY - WORKSTATION ADDRESS (Street and City)

CORRECTED FORM W-2 8224 YES 8231 [30]

KEYFIELD [ # ] MAX CHAR

* LOCALITY NAME - Enter code NYC for New York City Residents or NYY (for New York Yonkers Residents), the wages will carry to the state and the local income tax will carry to Schedule A (Form 1040), line 5, as well as the state withholding line on the state return. If the residency for either city is part-year or nonresident, then PY or NR must be added to the city code respectively. For example, a city resident should enter NYC or NYY. If a part-year resident of either city, then enter NYCPY or NYYPY. If a nonresident of either city, then enter NYCNR or NYYNR.

10LITE9RJVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW C0528D KEYFIELD [ # ] MAX CHAR

[14]STATE

10 STATE TAX WITHHELD 7314

STATE / PAYER'S STATE NUMBER

77977937

[4]

DISTRIBUTION WAS ROLLED OVER TO: 1 = IRA 2 = ROTH

8228

8216

1 GROSS DISTRIBUTION

FEDERAL INCOME TAX WITHHELD 7302INS PREMIUMS FOR RETIRED PUBLIC SAFETY OFFICERS (PSO)

7301

11[2]8217

7

8020PARTIAL ROLLOVER AMOUNT INCL IN TOTAL TXBL INCOME

DISTRIBUTION CODE 8211

[T]AXPAYER OR [S]POUSE

QUALIFIED DISASTER DISTRIBUTION 8222

2010LAST NAME

18 1099-R DATA SHEET (use other side for IT-1099)

# #

[4]

1099R

8208

8204 [30]

FORM 1099-R

8210

4

QUALIFIED CHARITABLE DISTRIBUTION (QCD)2

YES

NAME OF PAYER

8224TAXABLE AMOUNT NOT DETERMINED

TOTAL DISTRIBUTION

7303a TAXABLE AMOUNT

8225IRA / SEP / SIMPLE

8223

QUALIFIED HEALTH SVC ACCT FUND (HSA)

b

7938

FIRST YEAR OF DESIGNATED ROTH CONTRIBUTION

1099R FORM 1099-R

NAME OF PAYER 8204

8223

[T]AXPAYER OR [S]POUSE 8208QUALIFIED DISASTER DISTRIBUTION 8222 YES

[30]

1 GROSS DISTRIBUTION 7301

2

a TAXABLE AMOUNT 7303

bTAXABLE AMOUNT NOT DETERMINED

TOTAL DISTRIBUTION 8224QUALIFIED CHARITABLE DISTRIBUTION (QCD) 7797

PARTIAL ROLLOVER AMOUNT INCL IN TOTAL TXBL INCOME

QUALIFIED HEALTH SVC ACCT FUND (HSA) 7937INS PREMIUMS FOR RETIRED PUBLIC SAFETY OFFICERS (PSO) 7938

8228 [4]

4 FEDERAL INCOME TAX WITHHELD 7302[4]

IRA / SEP / SIMPLE 8225

10 STATE TAX WITHHELD 7314

7

DISTRIBUTION CODE 8211

DISTRIBUTION WAS ROLLED OVER TO: 1 = IRA 2 = ROTH 82108020

FIRST YEAR OF DESIGNATED ROTH CONTRIBUTION

11STATE 8217 [2]

STATE / PAYER'S STATE NUMBER 8216 [14]

FORM 1099-R1099R FORM 1099-R # #

[T]AXPAYER OR [S]POUSE 8208 [T]AXPAYER OR [S]POUSE 82081099R

[30] NAME OF PAYER

QUALIFIED DISASTER DISTRIBUTION 8222 YES QUALIFIED DISASTER DISTRIBUTION

82048222 YES

[30]

1 GROSS DISTRIBUTION 7301 1 GROSS DISTRIBUTION 7301NAME OF PAYER 8204

2


2

a

TOTAL DISTRIBUTION 8224


TAXABLE AMOUNT 7303

bTAXABLE AMOUNT NOT DETERMINED 8223

bTAXABLE AMOUNT NOT DETERMINED 8223TOTAL DISTRIBUTION 8224

QUALIFIED CHARITABLE DISTRIBUTION (QCD) 7797 QUALIFIED CHARITABLE DISTRIBUTION (QCD) 77977937 QUALIFIED HEALTH SVC ACCT FUND (HSA) 7937

INS PREMIUMS FOR RETIRED PUBLIC SAFETY OFFICERS (PSO) 7938 INS PREMIUMS FOR RETIRED PUBLIC SAFETY OFFICERS (PSO) 79384 FEDERAL INCOME TAX WITHHELD 7302 4 FEDERAL INCOME TAX WITHHELD 7302

7

DISTRIBUTION CODE 8211 [4]

7

DISTRIBUTION CODE

DISTRIBUTION WAS ROLLED OVER TO: 1 = IRA 2 = ROTH 8210 DISTRIBUTION WAS ROLLED OVER TO: 1 = IRA 2 = ROTH

8211 [4]

IRA / SEP / SIMPLE 8225 IRA / SEP / SIMPLE 82258210

PARTIAL ROLLOVER AMOUNT INCL IN TOTAL TXBL INCOME 8020 PARTIAL ROLLOVER AMOUNT INCL IN TOTAL TXBL INCOME 8020FIRST YEAR OF DESIGNATED ROTH CONTRIBUTION 8228 [4] FIRST YEAR OF DESIGNATED ROTH CONTRIBUTION 8228 [4]

10 STATE TAX WITHHELD 7314 10 STATE TAX WITHHELD 7314

11STATE 8217 [2]

11STATE 8217 [2]

STATE / PAYER'S STATE NUMBER 8216 [14] STATE / PAYER'S STATE NUMBER 8216 [14]

FORM 1099-R1099R FORM 1099-R # #

[T]AXPAYER OR [S]POUSE 8208 [T]AXPAYER OR [S]POUSE 82081099R

[30] NAME OF PAYER

QUALIFIED DISASTER DISTRIBUTION 8222 YES QUALIFIED DISASTER DISTRIBUTION

82048222 YES

[30]

1 GROSS DISTRIBUTION 7301 1 GROSS DISTRIBUTION 7301NAME OF PAYER 8204

2


2

a



TAXABLE AMOUNT 7303

bTAXABLE AMOUNT NOT DETERMINED 8223

bTAXABLE AMOUNT NOT DETERMINED 8223TOTAL DISTRIBUTION 8224

QUALIFIED CHARITABLE DISTRIBUTION (QCD) 7797 QUALIFIED CHARITABLE DISTRIBUTION (QCD) 77977937 QUALIFIED HEALTH SVC ACCT FUND (HSA) 7937

INS PREMIUMS FOR RETIRED PUBLIC SAFETY OFFICERS (PSO) 7938 INS PREMIUMS FOR RETIRED PUBLIC SAFETY OFFICERS (PSO) 79384 FEDERAL INCOME TAX WITHHELD 7302 4 FEDERAL INCOME TAX WITHHELD 7302

7

DISTRIBUTION CODE 8211 [4]

7

DISTRIBUTION CODE

DISTRIBUTION WAS ROLLED OVER TO: 1 = IRA 2 = ROTH 8210 DISTRIBUTION WAS ROLLED OVER TO: 1 = IRA 2 = ROTH

8211 [4]

IRA / SEP / SIMPLE 8225 IRA / SEP / SIMPLE 82258210

PARTIAL ROLLOVER AMOUNT INCL IN TOTAL TXBL INCOME 8020 PARTIAL ROLLOVER AMOUNT INCL IN TOTAL TXBL INCOME 8020FIRST YEAR OF DESIGNATED ROTH CONTRIBUTION 8228 [4] FIRST YEAR OF DESIGNATED ROTH CONTRIBUTION 8228 [4]

10 STATE TAX WITHHELD 7314 10 STATE TAX WITHHELD 7314

11STATE 8217 [2]

11STATE 8217 [2]

STATE / PAYER'S STATE NUMBER 8216 [14] STATE / PAYER'S STATE NUMBER 8216 [14]

DESIGNATED ROTH ACCELERATED INCOME INCLUSION (FM 8606) BOX TO THE FAR LEFT OF BOX 109306 9306

DISABILITY INCOME IS EARNED INCOME 8226 YES

9a

b

NON-STANDARD INDICATOR 8227 YES

8214 [6]

TOTAL EMPLOYEE CONTRIBUTIONDESIGNATED ROTH ACCELERATED INCOME INCLUSION (FM 8606) BOX TO THE FAR LEFT OF BOX 10

FOREIGN ADDRESS

8208[T]AXPAYER OR [S]POUSE

8207 - FEDERAL IDENTIFICATION NUMBER

PERCENT OF TOTAL DISTRIBUTION

8

YES

OTHER 8212 [6] PERCENT 8213

7796

7306

8228FIRST YEAR OF DESIGNATED ROTH CONTRIBUTION

PARTIAL ROLLOVER AMOUNT INCL IN TOTAL TAXABLE INCOME

DISTRIBUTION CODE 8211 [4] IRA / SEP / SIMPLE

DISTRIBUTION ROLLED OVER TO: 1 - IRA 2 - ROTH 8210

4 FEDERAL INCOME TAX WITHHELD 7302

7

8225

5 EMPL / DESIGNATED ROTH CONTRIB OR INSURANCE PREM 73056 NET UNREALIZED APPRECIATION IN EMPLOYER SECURITIES

YES

QUALIFIED HEALTH SAVINGS ACCOUNT FUNDING (HSA) 7937INS PREMIUM FOR RETIRED PUBLIC SAFETY OFFICERS (PSO) 7938

3 CAPITAL GAIN (INCLUDED IN BOX 2a) 7304

8209

8224

a TOTAL TAXABLE AMOUNT 7303

bTAXABLE AMOUNT NOT DETERMINED

TOTAL DISTRIBUTION YES

8223

11

STATE PAYER ID NUMBER

14

NAME OF LOCALITY

8216 [16] 8218 [9]

8219

8226 YES

7307

[6]

8227 YESNON-STANDARD INDICATOR

[6]

9a

73168220 7318 7320

[16] 8221 [9]

PERCENT OF TOTAL DISTRIBUTION 8214

10

STATE STATE TAX WITHHELD

13

LOCAL TAX WITHHELD

8217 7314

73177315

[6]

b TOTAL EMPLOYEE CONTRIBUTION 7307

8 OTHER 8212 [6] PERCENT 8213

DISTRIBUTION ROLLED OVER TO: 1 - IRA 2 - ROTH 8210PARTIAL ROLLOVER AMOUNT INCL IN TOTAL TAXABLE INCOME 7796FIRST YEAR OF DESIGNATED ROTH CONTRIBUTION

6 NET UNREALIZED APPRECIATION IN EMPLOYER SECURITIES 7306

8228

DISTRIBUTION CODE 8211 [4] IRA / SEP / SIMPLE 8225 YES

4 FEDERAL INCOME TAX WITHHELD 73025 EMPL / DESIGNATED ROTH CONTRIB OR INSURANCE PREM 7305

YES

7937INS PREMIUM FOR RETIRED PUBLIC SAFETY OFFICERS (PSO) 7938

3 CAPITAL GAIN (INCLUDED IN BOX 2a) 7304

TOTAL TAXABLE AMOUNT 7303

bTAXABLE AMOUNT NOT DETERMINED 8223 YES


a

ACCOUNT NUMBER 8209 [30]


8199 [10] STATE 8198 [2]

[20]

[9]

8221

FOREIGN ADDRESS 8235

ADDRESS 8205

CITY 8197

YES

[30]

LOCAL DISTRIBUTION

AMOUNT RECEIVED TAX-FREE AFTER 1986

7309

8196

821882168219

73157319

8458

8321EXPLAIN EFFORTS TO OBTAIN FORM 1099-R

8322

STATE #2 TYPE

AGE AT STARTING DATE 8231COST IN PLAN AT STARTING DATE

7313

PREPARE SUBSTITUTE 1099-R (FORM 4852)

[9]

731715

TAXABLE PENSION

CALCULATION(SIMPLIFIED

METHOD)

[72]

8457

ANNUITY STARTING DATE 8234

18

8202 [30]

RECIP CITY STATE ZIP

IF DIFFERENT 8203 [30]

#

2010

7316

[30]CITY STATE ZIP IF DIFFERENT 8203 [30]

FEDERAL IDENTIFICATION NUMBER 8207 -

DISTRIBUTIONS - PENSIONS, ANNUITIES, ETC.

FORM 1099R

NUMBER OF MONTHS PAYMENTS MADE THIS YR 8232

ADDRESS

STATE DISTRIBUTION

8199

FOR STATE EXCLUSION PURPOSES. SEE INSTRUCTIONS

7310

[72]

7320

HOW WERE DISTRIBUTIONS FROM PENSIONS, ANNUITIES, ETC., DETERMINED?

FORM 1099R

8208

[30]RECIPIENT ADDRESS IF DIFFERENT 8202


8201

73188220

11

STATE TAX WITHHELD

821710 7314STATE

[16]

8233

LOCAL TAX WITHHELD

14

RECIPIENT NAME IF DIFFERENTRECIPIENT ADDRESS IF DIFFERENT

8205 [30]

[16]

STATE PAYER ID NUMBER

13

[30]

[ # ] MAX CHAR 101099RJVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW C0119D KEYFIELD

STATE #1 TYPE

NAME OF LOCALITY

10

YES

TABLE 1 OR TABLE 2

PAYER 8198

12

9

8201

CITY

ACCOUNT NUMBER


NAME

[9]

[30]

8235

ZIP CODE [2]

8197 [20]

[10] STATE

8204PAYER

#

YES

RECIP

RECIPIENT NAME IF DIFFERENT

[30]

7

QUALIFIED HEALTH SAVINGS ACCOUNT FUNDING (HSA)

[9]

DISABILITY INCOME IS EARNED INCOME

NAME 8204

[30]

ZIP CODE

FOR STATE EXCLUSION PURPOSES. SEE INSTRUCTIONS

STATE #1 TYPE 8457

12

STATE DISTRIBUTION

15

LOCAL DISTRIBUTION

73137319

PREPARE SUBSTITUTE 1099-R (FORM 4852) 8196 YES

9HOW WERE DISTRIBUTIONS FROM PENSIONS, ANNUITIES, ETC., DETERMINED?

8321 [72]

8233

10EXPLAIN EFFORTS TO OBTAIN FORM 1099-R

8322 [72]

TAXABLE PENSION

CALCULATION(SIMPLIFIED

METHOD)

COST IN PLAN AT STARTING DATE 7309AGE AT STARTING DATE

LAST NAME

7310ANNUITY STARTING DATE 8234NUMBER OF MONTHS PAYMENTS MADE THIS YR 8232

8231AMOUNT RECEIVED TAX-FREE AFTER 1986

7797

STATE #2 TYPE

QUALIFIED CHARITABLE DISTRIBUTION (QCD) INCLUDED IN TOTAL TAXABLE AMOUNT 7797

2 2 QUALIFIED CHARITABLE DISTRIBUTION (QCD) INCLUDED IN TOTAL TAXABLE AMOUNT

8458

TABLE 1 OR TABLE 2

FORM DESCRIPTION

YES

PRIOR STD MILEAGE RATE DEPRECIATION ALLOWANCE

COMMUTING MILEAGE

Schedule A (Points)Schedule A (Misc)Form 8829Schedule CSchedule ESchedule FForm 2106 (Auto)Form 2106 (Other)

Not ApplicableStraight LineActual CalculationLandQualified Zone PropertySec 168(l)(4) Grouped AssetCellulosic Biomass Ethanol Plant PropertySubject to Sec 168(f)(1) Election

LEASE PAYMENT EXPENSE

PARKING FEES AND TOLLS (SMR AND ACTUAL)

Qual Indian Reservation PropertyLong Prod Period, Transportation or Non-Commercial AircraftAsset Placed in Service in Short YrQual NY Liberty Zone PropertyNYC Qual Resurgence Zone PropQual Gulf Opportunity Zone Prop

Short Yr & Qual Gulf Opp Zone PropS/L & Qual Gulf Oppty Zone PropExt Qual Gulf Oppty Zone PropShort Yr & Extended Qual GOZ PropS/L & Extended Qual GOZ PropQual KS Recovery Assistance PropShort Yr & Qual KS Recov Assist

CONVENTION

HY - Half-YearMQ - Mid-QuarterMM - Mid-Month

LandResidential Real EstateRes Rental Furn & FixturesNonresidential Real EstateMachinery and EquipmentFurniture and FixturesVehiclesTrucks and VansOver 6,000 GVW Vehicles

Form 4835PT K-1 Recd - UREDo Not Carry

METHOD SELECTED

TABLE 7

Not ApplicableAutoOther Listed Property

Electric Vehicle LimitationTrucks & Vans (Higher Limitation)6000 - 14000 GVW SUV (179 Limit Only)

Not ApplicableSuppress Luxury Auto Limitations

TABLE 5

FORCE OPTIONS

TABLE 6

LISTED PROPERTY

TABLE 4 YES

3940

OTHER MILEAGE

REPAIRS

INTEREST EXPENSE

INCLUSION AMOUNT41

37

43

45

42

VALUE OF EMPLOYER-PROVIDED VEHICLE

GASOLINE AND OIL

6 STATE (1040 RETURNS ONLY)

ALL USE IS PERSONAL USE?

POLICY PROHIBITS PERSONAL USE EXCEPT COMMUTING?

51

49

48

ANOTHER VEHICLE AVAILABLE FOR PERSONAL USE?

AVAILABLE FOR PERSONAL USE DURING OFF-DUTY HOURS?

44

OTHER EXPENSE

50 PROVIDE OVER 5 VEHICLES AND RETAIN INFORMATION CONCERNING USE?MEETS QUALIFIED AUTO DEMONSTRATION REQUIREMENTS

47

33

26

YES

34

32

23

IF "YES", IS EVIDENCE WRITTEN?

30

31

27

METHOD SELECTED (TABLE 7)

28 HAVE EVIDENCE OF BUSINESS USE CLAIMED(TABLE 6)LISTED PROPERTY

29

25 AMORTIZATION PERIOD

(TABLE 5)

22

24

CURRENT AMT DEPRECIATION

AMORTIZATION CODE SECTION

FORCE OPTIONS

6,000 to 14,000 GVW SUVComputer SystemsDepreciable Computer SoftwareAmortizationImprovementsIndian ReservationWater Utility PropertyQual Leasehold ImprovementsOther / MiscellaneousNot Applicable

TABLE 2

20

(TABLE 4)

STATE SAME AS FEDERAL

COST

YES

19

(TABLE 3)DEPRECIATION METHOD

(TABLE 2)

18

PRIOR DEPRECIATION

15

QUALIFIES FOR SPECIAL DEPRECIATION ALLOWANCE

4

3

19 Computer Produced & Calculated Depreciation

2

7

- -

5

FORM DESCRIPTION

MULTIPLE FORM NUMBER

2010SOFTWARE

USERS ONLY

NAME OR CLIENT NUMBER

ASSET # ______ TABLE 3TABLE 1

21

DATE PLACED IN SERVICE

13

14

16

17

CONVENTION

- LAND

- OTHER

- SALVAGE VALUE

8

RECOVERY PERIOD

[20]

10

11

1

- PRIOR SPECIAL ALLOWANCE

(TABLE 1)

12

9

YES

OPTIONS

OptimizeForce SMRForce Actual

TABLE 8

- CURRENT SECTION 179 EXPENSE

- PRIOR SECTION 179 EXPENSE

TYPE

TYPE

PRIOR AMT DEPRECIATION

DESCRIPTION

CURRENT DEPRECIATION (MANUAL)

46 YES

QUESTIONS

YES

36

38

35

10DPDAT1JVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW S1214S OVERRIDE KEYFIELD [ # ] MAX CHAR

YES

YES

WRITTEN POLICY PROHIBITS ALL PRSNL USE, INCLUDING COMMUTING?

FEDERAL DATA

FEDERAL

OVERRIDE

LISTED PROPERTY

AUTO EXPENSE WORKSHEET

(MANUAL)

YES

YES

BUSINESS MILEAGE 01-01-2008 to 06-30-2008

(TABLE 8)OPTIONS

BUSINESS USE PERCENTAGE (e.g. 66.66)

USED PRIMARILY BY 5% OWNER OR RELATIVE? N/A

N/A

PropS/L & Qual KS Recov Assist PropQual Disaster Assistance PropertyShort Yr & Qual Disaster Assist PropS/L & Qual Disaster Assist PropCellulosic Biofuel Plant PropertyQual Reuse & Recycling Property

YES

N/A

MACRS Method:MSL - ADS Straight LineM3YR - 3 Yr 200% DB Switch to SL M5YR - 5 Yr 200% DB Switch to SLM7YR - 7 Yr 200% DB Switch to SLM10YR - 10 Yr 200% DB Switch to SLM15YR - 15 Yr 150% DB Switch to SLM20YR - 20 Yr 150% DB Switch to SLM27.5R - 27.5 Yr. SL ResidentialM39/M31.5NR - 31.5 / 39 Yr SL

Nonresidential ACRS Method:

ASL - Alternate SLA3YR - 3 Year - No longer in useA5YR - 5 Year - No longer in useA10YR - 10 YearA15PU - 15 Year Public Util.A15LIH - 15 Year Low-Income HousingA15RP - 15 Year Real PropertyA18YR - 18 YearA19YR - 19 Year

Nonrecovery Method:NRSL - Straight LineNR200 - 200% Declining BalanceNR150 - 150% Declining BalanceNR125 - 125% Declining BalanceNRAMRT - AmortizationNRSYD - Nonrecov Sum of Yrs Digits

0 - Manual Override Method

See Operations Manualto force MACRS or ACRS Tables.

SECTION 1254 - DRILLING AND DEVELOPMENT COSTS

SECTION 1255 - COST SHARE PAYMENTS (SECTION 126)

CASH RECEIVED

FAIR MARKET VALUE OF OTHER PROPERTY RECEIVEDADDITIONAL DEPRECIATION AFTER 1975

JVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW C0528D KEYFIELD 10DPDAT2

66 APPLICABLE PAYMENT PERCENT

PART II

c RAISED LIVESTOCK SOLD AT A GAIN

LONG TERM

( c)

LIABILITY ASSUMED BY OTHER PARTY

ORDINARY INCOME UNDER RECAPTURE RULES

[ # ] MAX CHAR

SECTION 1252 - SOIL, WATER, LAND CLEARING

SOIL, WATER, LAND CLEARING EXPENSE

64

APPLICABLE PERCENT AFTER 1975

SECTION 291 AMOUNT

SEC 1250 - REAL ESTATE (ACCUM DEPRECIATION ONLY)

TABLE 10

FORM 4797 PART

DESCRIPTION [19]

TABLE 9

DATE DISPOSED

(TABLE 9)

FORM 4797

TYPE OF DISPOSITION

ASSET # ______

Not DisposedSaleInstallment SaleLike-Kind Exchange

SECTION 1245 - BUSINESS ASSETS

YES

Not ApplicablePart 1 - Held Over 1 YearPart 2 - Ordinary Gains and LossesPart 3 - Section 1245Part 3 - Section 1250Part 3 - Other

59

- -

FORM 6252

68

62

ADDITIONAL DEPRECIATION AFTER 1969 AND BEFORE 1975

PART I

EXAMPLES

(a)

PART II PART III(1245)

b

7. OTHER LIVESTOCK USED IN TRADE OR BUSINESS

RAISED CATTLE AND HORSES SOLD AT A GAIN

PART II PART I

PART II PART I

PART ISOLD AT A LOSS PART II

LESS THAN12 MONTHS

SOLD AT A GAIN

SOLD AT A GAIN

c 2. DEPRECIABLE RESIDENTIAL RENTAL PROPERTY

3. FARMLAND (SEE INSTRUCTIONS)

SOLD OR EXCHANGED AT A GAIN PART II

PART II

a

b SOLD AT A LOSS

a

b

PART III(1255)

PART II PART I

PART III(1250)

5. DISPOSITION OF COST-SHARING PAYMENT PROPERTY DESCRIBED IN SECTION 126 PART II

4. ALL OTHER FARMLAND

SOLD AT A GAIN

PART I

PART II PART I


SOLD AT A LOSS

a

PAYMENTS EXCLUDED FROM INCOME

24 MONTHSOR MORE

( c)

6. CATTLE AND HORSES USED IN TRADE OR BUSINESS

SOLD OR EXCHANGED AT A GAIN

SOLD OR EXCHANGED AT A LOSS12 MONTHSOR MORE


LESS THAN24 MONTHS

(b)

OVERRIDE CALCULATION

MORTGAGE PURCHASER ASSUMES

CURRENT YEAR PRINCIPAL PAYMENTS RECEIVED

APPLICABLE PERCENT

COSTS FOR MINING, ETC.

b

54

55

SHORTTERM

(b)

a

PART II PART I

PART II PART III(1245, 1250)

73

20 SALE OF DEPRECIATED PROPERTY

EXAMPLES OF ITEMS REPORTABLE ON FORM 4797

(WHERE TO ENTER FIRST)

67

- -52

1. DEPRECIABLE TRADE OR BUSINESS PROPERTY

SOLD OR EXCHANGED AT A LOSS

a

b

EXAMPLES

(a)

53

GROSS SALES PRICE

58

60

FORM 8824

2010NAME OR CLIENT NUMBER

SOFTWARE

USERS ONLYAUTOMATICALLY PREPARES FORMS 6252, AND 4797 AND SCHEDULE D

DEPRECIATION ALLOWED

- -70

71

69

72

FEDERAL

FAIR MARKET VALUE OF LIKE-KIND PROPERTY RECEIVED

76

74

75

NET AMOUNTS PAID TO OTHER PARTY

DISPOSITION INFORMATION

57

EXPENSE OF DISPOSITION

TYPE OF DISPOSITION

CARRY TO 4797 PART (Default = Pt II, Sec 1245) (TABLE 10)56

DATE PROPERTY RECEIVED WAS IDENTIFIED

DATE PROPERTY WAS ACTUALLY RECEIVED

65

63

61

77

21 1040 ADDITIONAL DEPENDENTS / EIC / 8867LAST NAME 2010

DI DEPENDENTS

6

DEPENDENT #6 DEPENDENT #7 DEPENDENT #8 DEPENDENT # 9 DEPENDENT #10FIRST NAME & INIT [12] [12] [12] [12] [12]

LAST NAME IF DIFF [12] [12] [12] [12] [12]

BIRTHDATE [8] [8] [8] [8] [8]

SOC SEC NUMBER

RELATIONSHIP [11] [11] [11] [11] [11]

CLAIMED BY T / S

# MOS IN HOME

DISABLED

COLLEGE STUDENT

INELIGIBLE FOR CTC

CHILD CARE EXP [4] [4] [4] [4] [4]

EDUC EXP AMOUNT [4] [4] [4] [4] [4]

TYPE OF ED EXP *

HOPE PRIOR YRSSTATUS ** (ENTER 1 - 9) [1] [1] [1] [1] [1]

INSURED

KIDNAPPED* TYPE OF

EDUCATION EXP: 1 = Optimize: AOC, Lifetime, Tuition 2 = Optimize: Lifetime, Tuition Dedn

3 = Force AOC 4 = Force Lifetime

5 = Force Tuition Dedn

** STATUSOPTIONS

0 = CLAIMED 1 = NOT CLAIMING CHILD THIS YEAR

4 = NOT CLAIMED BUT QUALIFIES FOR DEPN CARE BENEFITS (DCB) 5 = NOT CLAIMED BUT QUALIFIES FOR BOTH EIC AND HOH 8 = NOT CLAIMED BUT QUALIFIES FOR

ALL THREE9 = CLAIMED BUT INELIGIBLE FOR EIC 2 = NOT CLAIMED BUT CHILD QUALIFIES FOR EIC

3 = NOT CLAIMED BUT QUALIFYING CHILD FOR 6 = NOT CLAIMED BUT QUALIFIES FOR BOTH EIC AND DCB 7 = NOT CLAIMED BUT QUALIFIES FOR HOH AND DCB

ADDITIONAL DEPENDENTS MAY BE ENTERED BY USING FIELDS 6 THROUGH 100.CHILD #6 CHILD #7 CHILD #8 CHILD #9 CHILD #10

9 IS CHILD TP'S SON, DTR, STEPCHILD, FOSTER CHILD, BRO, SIS, STEPBRO, STEPSIS, OR DESCENDENT OF THEM? (YES / NO)

10IS EITHER OFFOLLOWING

TRUE?

(1) CHILD UNMARRIED OR

(YES / NO) (2) CHILD MARRIED AND CAN BE CLAIMED AS TP DEPN?

11 DID CHILD LIVE W / TP IN U.S. OVER HALF THE YR? (YES / NO)

13

a COULD ANY OTHER PERSON ANSWER YES ON LINE 9 THROUGH 11 FOR THE CHILD? (YES / NO)

b CHILD'S RELATIONSHIP TO THE OTHER PERSON

c IF TIE-BREAKER RULES APPLY, WOULD CHILD BE TREATED AS TP's QUALIFYING CHILD? (YES / NO)

14 DOES CHILD HAVE SSN ALLOWING WORK OR IS VALID (YES / NO)

NUMBER OF CHILDREN LIVING AT HOME (DEFAULT) 2324

NUMBER OF CHILDREN NOT LIVING AT HOME DUE TO DIVORCE OR SEPARATION 2286

NUMBER OF OTHER DEPENDENTS LISTED ABOVE 2325

EIC / 8867 EARNED INCOME CREDIT QUESTIONS MUST BE ANSWERED FOR THE EIC TO BE CALCULATED INELIGIBLE FOR EARNED INCOME CREDIT 1172 YES DATE INFORMATION WAS OBTAINED 4370FORCE PRINTING OF SCHEDULE EIC WORKSHEETS 1273 YES FROM WHOM WAS INFO OBTAINED? (TP - SP - BOTH - OTHER) 4371

ELECT TO INCLUDE NONTAXABLE COMBAT PAY TAXPAYER 1409 YES IF OTHER, NAME: 4372 [35]

SPOUSE 1410 YESEXPLAIN:

1 [60]

FM 8867 - PAID PREPARER'S EARNED INCOME CREDIT CHECKLIST 2 [60]

PART I - ALL TAXPAYERS 3 [60]

3

DOES TP/SP HAVE SSN THAT ALLOWS THEM TO WORK? SSN IS NOT VALID IF "NOT VALID FOR EMPLOYMENT" IS PRINTED ON THE CARD AND NUMBER WAS ISSUED

YES NO PRINT SIGNATURE BLOCK 1527 YES

4367 0272

SIGNATURE BLOCK DISCLOSURE OVERRIDE:

1 [60] SOLELY TO APPLY FOR OR RECEIVE A FEDERALLY FUNDED BENEFIT. IT MAY BE USEFUL TO LOOK AT SOC SEC CARD TO VERIFY VALIDITY FOR EIC.

2 [60]

3 [60]

5a a WAS TP A NONRES ALIEN FOR ANY PART OF YR? 8022 1501 4 [60]

7 TP OR SP IS QUALIFYING DEPN OF ANOTHER THIS YR 1358 1502 WORKSHEET BPART II - TAXPAYERS WITH A QUALIFYING CHILD

2 b SELF-EMPLOYMENT INCOME IF UNDER $400 NECESSARY FOR EIC

TAXPAYER 2726THE EIC QUESTIONS IN THE DEPENDENT INFORMATION GRID MUST BE ANSWERED FOR ANY CHILD USED IN THE EIC CALCULATIONS.

SPOUSE 2727

4a

PENSION OR ANNUITY FROM NONQUALIFIED DEFERRED COMP PLAN OR NONGOVERNMENTAL SECTION 457(b) PLAN 7544

PART III - TAXPAYERS WITHOUT QUALIFYING CHILD16 TAXPAYER'S (OR SPOUSE'S, IF MFJ) MAIN HOME WAS

IN U.S. MORE THAN HALF THE YEAR 1517 1366 OTHER ADJUSTMENTS [40]

7844PART IV - DUE DILIGENCE REQUIREMENTS 8612

20 HAS FORM 8867 BEEN COMPLETED BASED ON INFORMATION PROVIDED BY TAXPAYER?

YES NO b OVERRIDE INVESTMENT INC FOR EIC PURPOSES 30441520 4366

22 IN COMPLIANCE WITH KNOWLEDGE REQUIREMENTS? 1521 4368

23FOLLOWING RECORDS BEEN MAINTAINED? FM 8867 - EIC WKSHTS - RECORD OF HOW, WHEN & FROM WHOM INFO TO PREPARE FORMS WAS OBTAINED 1522 4369

OPTIONAL OVERRIDE KEYFIELD ADD-TO [ # ] MAX CHAR

17 OVERPAYMENT, IF ANY, AS SHOWN ON ORIGINAL RETURN 2979

22 29648103

REFUND AMOUNT TO BE APPLIED TO FUTURE YR EST TAX

YEAR REFUND APPLIED

2

PART III - FIGURE CREDIT

TAXABLE DISABILITY INC

0373

PHYSICIAN'SADDRESS [40]

0370

0122

OTHER INCOME ALLOCATED TO OTHER SPOUSE

7375

8311

CREDIT FOR ELDERLY AND DISABLED

8

1198

1234

PART I - FILING STATUS

2387 2388NONTAXABLE VETERANS' PENSIONS, ANY OTHERS EXCLUDED FROM INCOME:

[40]

2385

03670366

SPOUSE'S PHYSICIAN INFORMATION

[30]

PRINT SCHEDULE R EVEN IF NOT QUALIFIED

ZIP CODE,CITY, STATE

0372

YES

PREVIOUSLY FILED STATEMENT AND UNABLE TO ENGAGE IN GAINFUL ACTIVITY IN CURRENT YEAR

TAXPAYER'S PHYSICIAN INFORMATION

[40]

YES

PERMANENTLY AND TOTALLY DISABLED

YES

1199

1120

YES

1197

0369

1398 YES

PART II - STATEMENT OF PERMANENT AND TOTAL DISABILITY

8083

7377

7379

7382

7378

8085

CHECK ONLY ONE BOX. INJURED SPOUSE IS:

ADDRESS FOR INJURED SPOUSE REFUND, IF DIFF FROM ADDRESS ON JOINT RETURN:8081

0526 [2]

TAXPAYER

KEYFIELD

7381

7383

[ # ] MAX CHAR

7380

ADJUSTMENTS TO INCOME

STANDARD OR ITEMIZED DEDUCTIONS

CREDITS (DO NOT INCLUDE ANY EARNED INCOME CREDIT)

OTHER TAXES

10DATA3

NUMBER OF EXEMPTIONS

20


19

8310

[30]

[10]

a

FEDERAL INCOME TAX WITHHELD

ESTIMATED PAYMENTS

[20]

14

7376

12

OVERRIDE

18

17

PART II - ITEMS ALLOCATED TO INJURED SPOUSE

13

15

2010 22 FEDERAL 1040 DATA SHEET 22

AMENDED RETURN 8379

LAST NAME

X

YES

1379

4

YES

1563

PREPARE FORM 1040X ONLY

8643 - -

1380

EXEMPTIONSTAX PAID WITH ORIGINAL RETURN, PLUS ADDITIONAL TAX PAID AFTER FILING

DATE PREPARED

PREPARE 1040X WITH FULL RETURN OR DIAGNOSTIC

b

[72]

ZIP CODE,CITY, STATE

SPOUSE

5

11

15

16

INJURED SPOUSE CLAIM AND ALLOCATION

0525

CLAIMED REFUNDABLE TAX CREDIT, SUCH AS HEALTH COVERAGE TAX CREDIT OR REFUNDABLE CREDIT FOR PRIOR YEAR MINIMUM TAX

830910

8316

9

6

YES

YES

11

STATE

ST ADDRESS

YES PRESIDENTIAL ELECTION CAMPAIGN FUND

YES

0368

[40]

0371

PHYSICIAN'SADDRESS

PHYSICIAN'SNAME

1378

[30]

SUPPRESS PRINTING OF SCHEDULE R

SPOUSE

MARRIED FILING SEPARATELY AND LIVED APART FROM SPOUSE DURING ENTIRE YEAR

[72]

1377TAXPAYER NOW WISHES TO CONTRIBUTE $3 TO FUND YES

1320

YES

TAXPAYER

R

b[30]

DIVORCED OR SEPARATED FROM SPOUSE ON MFJ RETURN AND WANT REFUND ISSUED IN THIS NAME ONLY

0524

EXPLANATION OF CHANGES

SPOUSE NOW WISHES TO CONTRIBUTE $3 TO FUND

YES

[72]

2978

FOR LINES 5-9, CHOOSE FROM THE FOLLOWING: AZ, CA, ID, LA, NV, NM, TX, WA, WI

0527

8

[2]

[2]

[2]

7

YES

CLAIMED EARNED INCOME CREDIT OR ADDITIONAL CHILD TAX CREDIT

[2]

YES

TWO-LETTER STATE CODE IF MAIN HOME WAS IN A COMMUNITY PROPERTY STATEMADE AND REPORTED PMTS, SUCH AS FED INCOME TAX WITHHOLDING OR ESTIMATED TAX PAYMENTS HAD EARNED INCOME, SUCH AS WAGES, SALARIES, OR SELF-EMPLOYMENT INCOME

SPOUSE

FILE AS STAND-ALONE FORM (Firm data prints in signature area)

[30]

8045

ZIP 8084

OTHER INCOME ALLOCATED TO INJURED SPOUSE

8082CITY

WAGES

9

3879

2386TAXPAYER

8044

[40]

[40]

PRIOR YEAR FORM 8915, LINE 8 AMOUNT

DATE RETIRED IF AFTER 12-31-1976

SPOUSE'S PHYSICIAN INFORMATION SAME AS TAXPAYER

PART I - QUALIFIED HURRICANE DISTRIBUTIONS

FROM RETIREMENT PLANS (OTHER THAN IRAs)

3878

1

PHYSICIAN'SNAME

13

1432 YES

YES

0123

4

8915

1455 YES

6

7

SPOUSE'S FORM 8915 1431QUAL HURRICANE RETIRE PLAN DISTRIB & REPAYMTS

TOTAL REPAYMENTS MADE IN CURRENT YR. (DO NOT INCL REPAYMENTS MADE ON OR BEFORE THE DUE DATE (INCL EXTENSIONS) FOR FILING PRIOR YR TAX RETURN


2

FILE AS STAND-ALONE FORM (FIRM INFORMATION WILL PRINT)

TOTAL REPAYMENTS MADE IN CURRENT YR. (DO NOT INCL REPAYMENTS MADE ON OR BEFORE THE DUE DATE (INCL EXTENSIONS) FOR FILING PRIOR YR TAX RETURN

3899PRIOR YEAR FORM 8915, LINE 1 AMOUNT

3880

3886

3417

PART II - QUALIFIED HURICANE DISTRIBUTIONS FROM

TRADITIONAL, SEP, SIMPLE, AND ROTH IRAs


23 PG 1

FOREIGN TRUST

DIVIDEND INCOME BASIC / DIVIDEND INCOME ADVANCED (WITHHOLDING, INVESTMENTS, FOREIGN, ETC.) (Shaded items are found on the Advanced grid only)

NAME OF COUNTRY [12]

8 1147 YES

00697

a 1112 YES

b

FOREIGN ACCOUNT

Dividend Income (Extended service $10 fee applies if over 3 transactions) Multiple

[33]

[20]

DIVIDEND INCOME DESCRIPTION

1 - Direct U.S. Government Obligations2 - NH Municipal Bonds3 - L/T or S/T Capital Gain included in Line 34 - Indiv Retire Acct KEOGH plans, other exempt retire plans

** NH TYPES

5

OWNERSHIP CODE (T /S /J)

% IN-STATE MUNICIPAL BONDS

ACCOUNT NUMBER

U.S. GOVERNMENT BONDS

% U.S. GOVERNMENT BONDS

TOTAL MUNICIPAL BONDS

** NH TYPE

[10]

[10]

ISSUING STATE

3

TOTAL ORDINARY DIVIDENDS

QUALIFIED DIVIDENDS1

a

b

[2]

d

b

TOTAL CAPITAL GAINS

IN-STATE MUNICIPAL BONDS

COLLECTIBLES (28%) GAIN

UNRECAPTURED SECTION 1250

POST 8-7-86 PRIVATE ACTIVITY BONDS

2

c

FEDERAL EIN

8

9

a

NONTAXABLE TO TN

- - -

STATE ID NUMBER

BANK INTEREST (MA / TN ONLY)

NONDIVIDEND DISTRIBUTION

CASH LIQUIDATING DISTRIBUTION

NONCASH LIQUIDATING DISTRIBUTION

FEDERAL TAX WITHHELD

5

6

7

[2]

4

INVESTMENT EXPENSE

ADJUSTMENT AMOUNT

* ADJUSTMENT TYPE

FOREIGN TAX PAID

FGN COUNTRY OR US POSSESSION

* ADJUSTMENT TYPES:

[12]

5 = Nominee - Out-of-State Municipal Bond Dividend; 6 = Nominee - Capital Gain Distribution; 7 = Dividend on Restricted Stock

SECTION 1202 GAIN

0 = None; 1 = Nominee - Ordinary Dividend; 2 = Nominee - U.S. Government Obligation Dividend; 3 = Nominee - Prorated Municipal Bond Dividend; 4 = Nominee - Instate Municipal Bond Dividend;

- -STATE TAX WITHHELD

CARRY TO STATE CODE

-

[ # ] MAX CHARJVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW C1108D 10BDATA2

2010

5 6 74

LAST NAME

1 2 3

5 - Liquidating Distributions6 - 100% of K-1 Int or Div Income from PT / Trust with nontransf shares subj to I&D Tax7 - Part of Int or Div Income from PT / Trust with nontransf shares NOT subj to I&D Tax8 - Allocation of non-NH res extra paid

PART III - FOREIGN ACCOUNTS AND TRUSTS

-

PART II - ORDINARY DIVIDENDS

ACCRUED MARKET DISCOUNTEF ONLY


3263

9 - Specifically exempted PR, Guam, VI Bonds10 - Distributive Share of Entity's Interest or Dividend Income indicated on Sch K-1 and included in Ptr, Benef or Shrhldr Federal Income Tax Return11 - Return of Capital

23 PG 2

FOREIGN TRUST

DIVIDEND INCOME BASIC / DIVIDEND INCOME ADVANCED (WITHHOLDING, INVESTMENTS, FOREIGN, ETC.) (Shaded items are found on the Advanced grid only)

NAME OF COUNTRY [12]

8 1147 YES

00697

a 1112 YES

b

FOREIGN ACCOUNT

Dividend Income (Extended service $10 fee applies if over 3 transactions)Multiple

[33]

[20]

DIVIDEND INCOME DESCRIPTION

1 - Direct U.S. Government Obligations2 - NH Municipal Bonds3 - L/T or S/T Capital Gain included in Line 34 - Indiv Retire Acct KEOGH plans, other exempt retire plans

** NH TYPES

5

OWNERSHIP CODE (T /S /J)


ACCOUNT NUMBER

U.S. GOVERNMENT BONDS

% U.S. GOVERNMENT BONDS

TOTAL MUNICIPAL BONDS

** NH TYPE

[10]

[10]

ISSUING STATE

3

TOTAL ORDINARY DIVIDENDS

QUALIFIED DIVIDENDS1

a

b

[2]

d

b

TOTAL CAPITAL GAINS



UNRECAPTURED SECTION 1250

POST 8-7-86 PRIVATE ACTIVITY BONDS

2

c

FEDERAL EIN

8

9

a

NONTAXABLE TO TN

- - -

STATE ID NUMBER


NONDIVIDEND DISTRIBUTION

CASH LIQUIDATING DISTRIBUTION

NONCASH LIQUIDATING DISTRIBUTION

FEDERAL TAX WITHHELD

5

6

7

[2]

4

INVESTMENT EXPENSE

ADJUSTMENT AMOUNT

* ADJUSTMENT TYPE

FOREIGN TAX PAID

FGN COUNTRY OR US POSSESSION

* ADJUSTMENT TYPES:

[12]

5 = Nominee - Out-of-State Municipal Bond Dividend; 6 = Nominee - Capital Gain Distribution; 7 = Dividend on Restricted Stock

SECTION 1202 GAIN

0 = None; 1 = Nominee - Ordinary Dividend; 2 = Nominee - U.S. Government Obligation Dividend; 3 = Nominee - Prorated Municipal Bond Dividend; 4 = Nominee - Instate Municipal Bond Dividend;

- -STATE TAX WITHHELD

CARRY TO STATE CODE

-

[ # ] MAX CHARJVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW C1108D 10BDATA2

2010

12 13 1411

LAST NAME

8 9 10


PART III - FOREIGN ACCOUNTS AND TRUSTS

-

PART II - ORDINARY DIVIDENDS

ACCRUED MARKET DISCOUNTEF ONLY


3263


24 Pg 1 INTEREST INCOME (Extended service $10 fee applies if over 3 transactions)LAST NAME Multiple 2010

PART 1 - INTEREST INCOME

1

INTEREST INCOME BASIC / INTEREST INCOME ADVANCED (FOREIGN, WITHHOLDING, INVESTMENT, ETC.) (Shaded items are found on the Advanced grid only)

INTEREST INCOME DESCRIPTION1 2 3 4 5 6 7

[33]

ACCOUNT NUMBER [20]


1 INTEREST INCOME (NOT U.S. GOVT)

2 EARLY WITHDRAWAL PENALTY

3 U.S. GOVT SAVINGS BONDS

8 TAX-EXEMPT MUNI BONDS

ISSUING STATE



9 POST 8-7-86 PRIVATE ACTIVITY BONDS

* ADJUSTMENT TYPE

ADJUSTMENT AMOUNT (+ / -)

*ADJUSTMENT TYPES

0 = None 1 = Nominee - Ordinary Interest 2 = Nominee - U.S. Government Obligation Interest 3 = Nominee - Prorated Muni Bond Interest

4 = Nominee - In-state Muni Bond Interest 5 = Nominee - Out-of-state Muni Bond Interest 6 = Accrued - Ordinary Interest 7 = Accrued - U.S. Gov't Obligation Interest

8 = Accrued - Prorated Muni Bond Interest 9 = Accrued - In-state Muni Bond Interest10 = Accrued - Out-of-state Muni Bond Interest

11 = OID Adjustment 12 = Amortizable Bond Premium 13 = U.S. Savings Bonds Previously Reported

4 FEDERAL INCOME TAX WITHHELD

FEDERAL EIN - - - - - - -

5 INVESTMENT EXPENSE

6 FOREIGN TAX PAID

7 FOREIGN COUNTRY OR US POSSESSION

STATE WITHHOLDING

CARRY TO STATE CODE

STATE ID NUMBER [10]


** NH TYPE

** NH TYPES

1 - Direct U.S. Government Obligations 2 - NH Municipal Bonds 3 - L/T or S/T Capital Gain included in Line 3 4 - Indiv Retire Acct KEOGH plans, other exempt retire plans



SELLER FINANCED-MORTGAGES

NAME [25] ADDRESS [32] ZIP CODE IDENTIFYING NUMBER T, S, J AMOUNT ST FOREIGN CITY FOREIGN PROVINCE/STATE FOREIGN COUNTRY POSTAL CODE

SSN - -

EIN -

SSN - -

EIN -

SSN - -

EIN -

SSN - -

EIN -

[ # ] MAX CHAR

24 Pg 2 INTEREST INCOME (Extended service $10 fee applies if over 3 transactions)LAST NAME Multiple 2010

PART 1 - INTEREST INCOME

1

INTEREST INCOME BASIC / INTEREST INCOME ADVANCED (FOREIGN, WITHHOLDING, INVESTMENT, ETC.) (Shaded items are found on the Advanced grid only)

INTEREST INCOME DESCRIPTION8 9 10 11 12 13 14

[33]

ACCOUNT NUMBER [20]


1 INTEREST INCOME (NOT U.S. GOVT)

2 EARLY WITHDRAWAL PENALTY

3 U.S. GOVT SAVINGS BONDS

8 TAX-EXEMPT MUNI BONDS

ISSUING STATE



9 POST 8-7-86 PRIVATE ACTIVITY BONDS

* ADJUSTMENT TYPE

ADJUSTMENT AMOUNT (+ / -)

*ADJUSTMENT TYPES

0 = None 1 = Nominee - Ordinary Interest 2 = Nominee - U.S. Government Obligation Interest 3 = Nominee - Prorated Muni Bond Interest

4 = Nominee - In-state Muni Bond Interest 5 = Nominee - Out-of-state Muni Bond Interest 6 = Accrued - Ordinary Interest 7 = Accrued - U.S. Gov't Obligation Interest

8 = Accrued - Prorated Muni Bond Interest 9 = Accrued - In-state Muni Bond Interest10 = Accrued - Out-of-state Muni Bond Interest

11 = OID Adjustment 12 = Amortizable Bond Premium 13 = U.S. Savings Bonds Previously Reported

4 FEDERAL INCOME TAX WITHHELD

FEDERAL EIN - - - - - - -

5 INVESTMENT EXPENSE

6 FOREIGN TAX PAID

7 FOREIGN COUNTRY OR US POSSESSION

STATE WITHHOLDING

CARRY TO STATE CODE

STATE ID NUMBER [10]


** NH TYPE

** NH TYPES

1 - Direct U.S. Government Obligations 2 - NH Municipal Bonds 3 - L/T or S/T Capital Gain included in Line 3 4 - Indiv Retire Acct KEOGH plans, other exempt retire plans



SELLER FINANCED-MORTGAGES

NAME [25] ADDRESS [32] ZIP CODE IDENTIFYING NUMBER T, S, J AMOUNT ST FOREIGN CITY FOREIGN PROVINCE/STATE FOREIGN COUNTRY POSTAL CODE

SSN - -

EIN -

SSN - -

EIN -

SSN - -

EIN -

SSN - -

EIN -

[ # ] MAX CHAR

SECTION 1202 EXCLUSION

3448

TOTAL UNRECAPTURED SECTION 1250 GAIN FROM SALE OR EXCHANGE OF INTEREST IN PTNSHP ATTRIBUTABLE TO UNRECAPTURED SECTION 1250 GAIN 32973296

UNRECAPTURED SECTION 1250 GAIN, IF ANY

TOTAL UNRECAPTURED SECTION 1250 GAIN INCLUDED ON LINE 26 OR LINE 37 OF FORM 6252 HELD MORE THAN 1 YEAR

CAPITAL LOSS CARRYOVER WORKSHEET

AMOUNT FROM 2008 FORM 1040, LINE 40

AMOUNT FROM 2008 FORM 8914, LINE 2

AMOUNT FROM 2008 SCHEDULE D, LINE 21

AMOUNT FROM 2008 SCHEDULE D, LINE 7 (ENTER '-' IF NEGATIVE)

REGULAR TAX

AMOUNT FROM 2008 SCHEDULE D, LINE 15 (ENTER '- ' IF NEGATIVE)

PART III - SUMMARY AND WORKSHEETS AMT TAX

337333743375

7673

38743873

3875

29032908

28% RATE GAIN WORKSHEET

21442856

290429062905

338633873388339233933394

SHORT-TERM CAPITAL LOSS CARRYOVER

5

SHORT-TERM GAIN FROM 6252, INSTALLMENT SALES

SHORT-TERM GAIN (LOSS) FROM FORM 4684, CASUALTIES AND THEFT

SHORT-TERM GAIN (LOSS) FROM FORM 6781, CONTRACTS AND STRADDLES

SHORT-TERM GAIN (LOSS) FROM FORM 8824, LIKE-KIND EXCHANGES

NET SHORT-TERM GAIN (LOSS) FROM PARTNERSHIPS, S CORPORATIONS, ESTATES AND TRUSTS (1065, 1120S, 1041 SCHEDULES K-1)

4

OVERRIDE

[25]

DETAILS ON SALES OF SHORT-TERM AND LONG-TERM CAPITAL GAINS AND LOSSES


PART I - SHORT-TERM CAPITAL GAINS AND LOSSES - ASSETS HELD 1 YEAR OR LESS

AMT GAIN / (LOSS)

[ # ] MAX CHAR

1481L/T CAPITAL LOSS CARRYOVER

LIMIT CAPITAL LOSS TO $1,500

REGULAR TAX AMT TAX

3372

7794

14

2372 3397

L/T GAIN FROM FORM 6252, INSTALLMENT SALES

L/T GAIN / (LOSS) FROM FORM 4684, CASUALTIES AND THEFT

L/T GAIN / (LOSS) FROM FORM 6781, CONTRACTS AND STRADDLES

2210GAIN FROM FORM 4797, PART I. SALES OF BUSINESS PROPERTY

L/T GAIN FROM FORM 2439, UNDISTRIBUTED CAPITAL GAIN 2736

2855L/T GAIN / (LOSS) FROM FORM 8824, LIKE-KIND EXCHANGES

NET L/T GAIN/(LOSS) SCHEDULES K-1 (1065, 1120S, AND 1041)

CAPITAL GAIN DISTRIBUTIONS (ENTER ON SCH B - DIVIDENDS DATA)

22112200

33953396

3828

2851

3385

2907

3382

GAIN OR (LOSS)

33802646

26472933

2852

0 = NONSPECIFIC 1 = 28% RATE 2 = SECTION 1202 3 = WASH SALE 4 = SECTION 1202 EZBS 5 = SECTION 1045 ROLLOVER 6 = PERSONAL 7 = QUALIFIED COMMUNITY ASSETS

STATEEIN

STCODE

FEDERALWITHHOLDING

ST TAXWITHHELD

FEDERALEIN

2208

LAST NAME

STATE COST(If Different)

1099 TRANSACTIONS PROPERTY DESCRIPTION T S J

# OFSHRS

AMT COST(If Different)TYPE DATE ACQUIRED DATE SOLD Term

COST ORBASIS

SALESPRICE

10DDATA1

AMT GAIN / (LOSS)

2724 3381

OPTIONAL

201025 Multiple

TYPES:

11

6

4

- -

7 - -

- -

- -

- -

- -

- -

- - - -

6

- -

5 - -

3 - -

- -

2731

AMT 28% RATE

33842370

PART II - LONG-TERM CAPITAL GAINS AND LOSSES - ASSETS HELD MORE THAN 1 YEAR

3383

3827

3829

7793

3826

3823

3830

38253824


28% RATE

- -

13

1

and

8

12

GAIN OR (LOSS)

UNRECAPTURED

SECTION 1250

WORKSHEET

19

12

TOTAL OF ANY AMOUNTS REPORTED ON A SCHEDULE K-1, FORM 1099-DIV, AND FORM 2439 AS "UNRECAPTURED" SECTION 1250 GAIN FROM AN ESTATE, TRUST, REAL ESTATE INVESTMENT TRUST, OR MUTUAL FUND

3831383538323833

7795

CAPITAL GAINS AND LOSSES (Extended service $10 fee applies if over 3 transactions)

TOTAL UNRECAPTURED SECTION 1250 GAIN FROM SALES (INCLUDING INSTALLMENT SALES) OR OTHER DISPOSITIONS OF SECTION 1250 HELD OVER 1 YEAR WITH NO ENTRY ON PART I OF FORM 4797 FOR YEAR OF SALE 38343299

CAPITAL GAINS AND LOSSES - (Extended service $10 fee applies if over 3 transactions)


TRANSACTIONS WILL BE SORTED ACCORDING TO DATE ACQUIRED. ACQUIRED DATES OF "VARIOUS" WILL DEFAULT TO LONG-TERM.

LAST NAME Multiple201025

ADDITIONAL INPUT LINES ARE AVAILABLE FOR TRANSACTIONS BY USING FIELD NUMBERS 51 THROUGH 9999.

FEDERALEIN

ST TAXWITHHELD

STATEEIN

10DDATA2

- - - - - - - - - - - -

14 - - - - - -

[ # ] MAX CHAR

- -

# OFSHRS

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

- - - - - - - -

Term GROSS SALESPRICE

COST OROTHER BASIS

AMT COST(If Different)

ST COST/BASIS(If Different)

STCODE

FEDERALTAX WITHHELD

484950

44454647

40414243

36373839

32333435

28293031

24252627

212223

19

17

20

18

PAGE 2

15

12

DESCRIPTION OF PROPERTY[25]

DATE ACQUIRED DATE SOLD

- - - -16

T / S/ J

11

13

PARTS IV AND V - SALES OF SHORT-TERM AND LONG-TERM CAPITAL ASSETS

1

and

8

TYPE

TYPES: 0 = NONSPECIFIC 1 = 28% RATE 2 = SECTION 1202 3 = WASH SALE 4 = SECTION 1202 EZBS 5 = SECTION 1045 ROLLOVER 6 = PERSONAL 7 = QUALIFIED COMMUNITY ASSETS

7751

METAL ROOF WITH APPROPRIATE PIGMENTED COATINGS, OR ASPHALT ROOF WITH APPROPRIATE GRANULES, THAT ARE SPECIFICALLY AND PRIMARILY DESIGNED TO REDUCE HEAT GAIN IN TAXPAYER'S HOME, AND ROOF MEETS OR EXCEEDS ENERGY STAR PROGRAM REQUIREMENTS IN EFFECT AT TIME OF PURCHASE OR INSTALLATION. 7753

NR ALIENS ONLY: U.S. REAL PROPERTY INTEREST

FULL-TIME STUDENT OVER 18 AND UNDER 24 AND DID NOT HAVE EARNED INC THAT WAS HALF OF THEIR SUPPORT

21

7758

10DAT10OPTIONAL

29

2833

2010LAST NAME

2410

ALT MIN FOREIGN TAX CREDIT (FORM 1116)

YES

AMOUNT TO OVERRIDE EXEMPTION WORKSHEETNOTE: THIS SECTION NOT APPLICABLE FOR MARRIED FILING JOINT RETURNS

SPOUSE'S FORM 5695

QUALIFIED SOLAR ELECTRIC PROPERTY COSTS

QUALIFIED SOLAR WATER HEATING PROPERTY COSTS

PART I - NONBUSINESS ENERGY PROPERTY CREDIT

8

13

30

18


7813

RESIDENTIAL ENERGY EFFICIENT PROPERTY CR

775914

7763

5695

1479 YES

12

MARRIED TAXPAYERS WITH MORE THAN ONE MAIN HOME FILING A JOINT RETURN SHOULD COMPLETE SEPARATE FORM(s) 5695 FOR EACH MAIN HOME IN PART I.

EXTERIOR WINDOWS (INCLUDING CERTAIN WINDOWS AND SKYLIGHTS)b

QUALIFIED ENERGY EFFICIENT IMPROVEMENTS:

7756

2663

8020 YES

RESEARCH AND EXPERIMENTAL COSTS

23713071

9

12

QUALIFIED SMALL BUSINESS STOCK (7% OF GAIN EXCLUDED UNDER SEC 1202) 2757

DEPLETION

2934

YES

3014

23362411

2550

3856

6251

4

26012871

2332

ALTERNATIVE MINIMUM TAX

1350

TAX REFUND

INVESTMENT INTEREST

2952

ADJUSTED ORDINARY GAIN (LOSS) FROM FORM 4797

2652

2299

MINING COSTS

POST-1986 DEPRECIATION

LOSS LIMITATIONS

24142369

3857

2600

2922

3432

2279

230624092413

2408

2750

8177

3854

9133

32

19

22

23

2400

3855ADJUSTED ORDINARY GAIN (LOSS) FROM BUSINESS OR INCOME-PRODUCING PROPERTY ON FORM 4684

ADD-TOJVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW S0110S ASSET MGROVERRIDE

CREDIT CARRYFORWARD FROM 2008 (AMOUNT FROM 2008 FORM 5695, LINE 28)

18

PART II - RESIDENTIAL ENERGY EFFICIENCY PROPERTY CREDIT

TOAL QUALIFIED FUEL CELL PROPERTY COSTS PAID BY TAXPAYER AND ALL OTHER OCCUPANTS

JOINT OCCUPANCYADJ FOR CHARITABLE CONTRIB OF CERTAIN PROPERTY

QUALIFIED SMALL WIND ENERGY PROPERTY COSTS

25

9082

20

7760

22

QUALIFIED FUEL CELL PROPERTY COSTS

QUALIFIED GEOTHERMAL HEAT PUMP PROPERTY COSTS

9081

KILOWATT CAPACITY OF PROPERTY ON LINE 18 ABOVE

ALTERNATIVE TAX NET OPERATING LOSS DEDUCTION SUBJECT TO 90% OF AMTI

10

15

17

15

16

26

24

c EXTERIOR DOORS (INCLUDING CERTAIN STORM DOORS)

ENERGY-EFFICIENT BUILDING PROPERTYQUALIFIED NATURAL GAS, PROPANE, OR OIL FURNACE OR HOT WATER BOILER

RESIDENTIAL ENERGY PROPERTY COSTS:

PASSIVE ACTIVITIES

OVERRIDE TOTAL LINE 18 AMOUNT

d

ALTERNATIVE TAX NET OPERATING LOSS DEDUCTION SUBJECT TO 100% OF AMTI

CHILD UNDER 18 AND BOTH PARENTS ARE DECEASED

FORCE PRINTING OF FORM 6251

CERTAIN HOME MORTGAGE INTEREST

7

18

14

a

INCENTIVE STOCK OPTIONS

7752

ADVANCED MAIN AIR CIRCULATING FAN USED IN A NATURAL GAS, PROPANE, OR OIL FURNACE

7755bCIRCULATION EXPENDITURES

ADJUSTED CAPITAL GAIN (LOSS) FROM SCHEDULE D

20

27

OTHER

DEPRECIATION (PRE-1987)

PATRON'S ADJUSTMENT

POLLUTION CONTROL FACILITIES

BENEFICIARIES OF ESTATES AND TRUSTS

LONG-TERM CONTRACTS

INSTALLMENT SALES

INTANGIBLE DRILLING COSTS

c

7754

2

a7750

OTHER ADJUSTED ORDINARY GAIN (LOSS) NOT REPORTED ELSEWHERE ON FORM 6251

ELECTING LARGE PARTNERSHIPS (SCH K-1 (1065-B), BOX 6)

INTEREST FROM SPECIFIED PRIVATE ACTIVITY BONDS EXEMPT FROM REGULAR TAX

0380

13

TAX SHELTER FARM ACTIVITIES

RELATED ADJUSTMENTS

HOWEVER, THEY SHOULD COMBINE AMOUNTS IN PART II ON ONE FORM BECAUSE THEMAXIMUM CREDIT LIMITS HAVE BEEN ELIMINATED AND THEREFORE DO NOT NEED TO

BE FIGURED ON SEPARATE FORMS.

PART I - NONBUSINESS ENERGY PROPERTY CREDIT

ENERGY EFFICIENCY IMPROVEMENTS OR RESIDENTIAL ENERGY PROPERTY COSTS WERE FOR TAXPAYER MAIN HOME LOCATED IN U.S.

11473 NO

TOTAL FORMS 5695, LINE 4 AMOUNTS FOR ALL OWNERS, INCLUDING TAXPAYER 78107

INSULATION MATERIAL SPECIFICALLY AND PRIMARILY DESIGNED TO REDUCE HEAT LOSS OR GAIN IN TAXPAYER'S HOME

3

PART II - RESIDENTIAL ENERGY EFFICIENCY PROPERTY CREDIT

9218AMOUNT FROM 2009 FORM 5695, LINE 117

1516 NO

SCHEDULE J CONTINUED NEXT COLUMN

2009 FORM 2555, LINE 50 (INCLUDE SPOUSES IF FILED JOINTLY) 9183

SP SATISFIES ALL REQ FOR MAX SALE OF HOME EXCLUSION

8294

12

2009 FORM 2555, LINE 45 (INCLUDE SPOUSES IF FILED JOINTLY)

DECEASED SP QUALIFIES FOR MAXIMUM SALE OF HOME EXCLUSION

PRINT WORKSHEET EVEN IF NOT REQUIRED

10

PURCHASE PRICE OF HOME SOLD

DEPRECIATION ALLOWED OR ALLOWABLE FOR PERIOD AFTER MAY 6, 1997

SCHEDULE J (CONTINUED)

2007 FORM 2555, LINE 45 (INCLUDE SPOUSES IF FILED JOINTLY) 91792007 UNALLOWED ITEMIZED DED DUE TO FOREIGN EXCLUSION 9180

NO

UNRECAPTURED SECTION 1250 GAIN

a

c

ELECTED FARM INCOME

9182

16

2009 FORM 4952, LINE 4g

7135

7698

b

8

2008 FORM 2555, LINE 45 (INCLUDE SPOUSES IF FILED JOINTLY) 9181

WORKSHEET 3 - REDUCED MAXIMUM EXCLUSION

[27]

TP SATISFIES ALL REQ FOR MAX SALE OF HOME EXCLUSION

7572

1576 YES

8291 - -

FORCE PRINTING OF SCHEDULE J

USE SCHEDULE J TAX EVEN IF REGULAR TAX IS GREATER

1315

2007 FILING STATUS IF DIFFERENT: 1 = SGL 2 = MFJ 3 = MFS 4 = HOH 5 = WIDOW(ER) 8109

2

9064

CAPITAL GAIN INCLUDED ON LINE 2a:

1447 YES

YES

1304 YES

SOH

9063

AMOUNT FROM 2009 SCHEDULE J, LINE 11; 2008 SCHEDULE J, LINE 15; 2007 SCHEDULE J, LINE 3; OR TAXABLE INCOME FROM 2007 FORM 1040, LINE 43; FORM 1040A, LINE 27; FORM 1040EZ, LINE 6, FORM 1040NR, LINE 41

8292 - -

DESCRIPTION OF PROPERTY

1265 YES

FARM INCOME AVERAGING

SALE OF HOME WORKSHEET

SPOUSE'S SALE OF HOME WORKSHEET (Default = TP)


7114

7571

PRINT SALE AND EXCLUSION OF HOME ON SCHEDULE D EVEN IF NOT REQUIRED

2

1282

7568

a

YES

756775667565

7585

7583

LEGAL FEES (INCL TITLE SEARCH, DOCUMENT PREPARATION FEES)

REDUCE MAXIMUM EXCL BECAUSE: 1) OWNERSHIP & USE TESTS NOT MET OR 2) HOME WAS SOLD WITHIN 2 YRS OF PRIOR SALE. EITHER REASON MUST BE DUE TO: 1) EMPLOYMENT PLACE CHANGED, 2) HEALTH, 3) UNFORESEEN CIRCUMSTANCES AS DEFINED IN IRS PUB 523.

OTHER INCREASES TO BASIS

AMOUNTS OWED BY SELLER BUT PAID BY TAXPAYER

b

7582

1515

8293 - - - -

11

$250,000.00 YES

OTHER DECREASES TO BASIS

75797580

$250,000.00

SPOUSE

8

d

OTHER SETTLEMENT FEES OR CLOSING COSTS

75787577

6

6

SELLING EXPENSES

[27]

ABSTRACT AND RECORDING FEES

WORKSHEET 1 - ADJUSTED BASIS OF HOME SOLD

1

7584

MAXIMUM AMOUNT

7

TAXPAYER

1

e

TITLE INSURANCE4c

8069

SURVEYS

YES

1

2

SELLING PRICE OF HOME

SELLER PAID POINTS FOR HOME PURCHASED AFTER 1990

b

f

TRANSFER OR STAMP TAXES

7573

2008 QUALIFIED DIVIDENDS

7570

75757576

7569

2008 SCHEDULE D, LINE 15

SPECIAL TAX ASSESSMENTS PAID

COSTS OF ADDITIONS AND IMPROVEMENTS

7581

WORKSHEET 2 - GAIN (LOSS) EXCLUSION AND TAXABLE GAIN

7697

7695

DEPRECIATION ALLOWED/ALLOWABLE RELATED TO HOME BUSINESS USE

8107

2008 FORM 4952, LINE 4g


8290

DATE HOME WAS ACQUIRED

7574

8349

DATE HOME WAS SOLD

8070

g

IF 2009SCHEDULE D

TAXAPPLIES:

IF GAIN FROM SALE OF ANOTHER HOME DURING 2-YEAR PERIOD ENDED ON DATE OF THIS SALE WAS EXCLUDED, ENTER DATE OF PRIOR SALE

NUMBER OF DAYS PROP WAS OWNED DURING 5-YEAR PD ENDED ON DATE OF SALE

NO. DAYS PROP WAS USED AS MAIN HOME DURING 5-YEAR PERIOD ENDED ON SALE DATE

2009 FILING STATUS IF DIFFERENT: 1 = SGL 2 = MFJ 3 = MFS 4 = HOH 5 = WIDOW(ER)

7136


a

2

7141

2007 FORM 4952, LINE 4g

7696

76927693

TAXABLE INCOME FROM 2009 SCHEDULE J, LINE 15, 2008 SCHEDULE J, LINE 3 OR 2008 FORM 1040, LINE 43; FORM 1040A, LINE 27; FORM 1040EZ, LINE 6; OR FORM 1040NR, LINE 41

2007 CAPITAL GAIN DISTRIBUTION IF TAX WAS FIGURED ON CAPITAL GAIN TAX WORKSHEET

IF 2008SCHEDULE D

TAXAPPLIES:

2008 FILING STATUS IF DIFFERENT: 1 = SGL 2 = MFJ 3 = MFS 4 = HOH 5 = WIDOW(ER)


8108


2008 CAPITAL GAIN DISTRIBUTION IF TAX WAS FIGURED ON CAPITAL GAIN TAX WKSHT

7116

7522

2007 FORM 4952, LINE 4e

7138


9

AMOUNT FROM 2009 SCHEDULE J, LINE 16; 2008 SCHEDULE J, LINE 4; OR TAX FROM 2008 FORM 1040, LINE 44*; FORM 1040A, LINE 28*; FORM 1040EZ, LINE 11; OR FORM 1040NR, LINE 42*





7115


13

7117

IF 2007SCH D

TAXAPPLIES:

19

2009 FORM 4952, LINE 4e

2009 CAPITAL GAIN DISTRIBUTION IF TAX WAS FIGURED ON CAPITAL GAIN TAX WKSHT

7139

7133

2008 FORM 4952, LINE 4e

5

OVERRIDE

7653


J

71407137

7675



7674

KEYFIELDJVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW C0719D

AMOUNT FROM 2009 SCHEDULE J, LINE 3 OR TAXABLE INCOME FROM 2009 FORM 1040, LINE 43; FORM 1040A, LINE 27; FORM 1040EZ, LINE 6; OR FORM 1040NR, LINE 41

7520

7132

7521

7694

7652

21

7118

7134

AMOUNT FROM 2009 SCHEDULE J, LINE 12; 2008 SCHEDULE J, LINE 16; 2007 SCHEDULE J, LINE 4; OR TAX FROM 2007 FORM 1040, LINE 44*; FORM 1040A, LINE 28*; FORM 1040EZ, LINE 10; OR FORM 1040NR, LINE 42*

3

* DO NOT INCLUDE ANY AMOUNT FROM FORM 4972 OR FORM 8814

AMOUNT FROM 2009 SCHEDULE J, LINE 4 OR TAX FROM 2009 FORM 1040, LINE 44*; FORM 1040A, LINE 28*; FORM 1040EZ, LINE 10; OR FORM 1040NR, LINE 42*

EXCESS, IF ANY, OF NET LONG-TERM CAP GAIN OVER NET SHORT-TERM CAPITAL LOSS

7120

ADD-TO

26 PG 2 FEDERAL 1040 DATA SHEET 26 pg 2 LAST NAME

2010

10DATA6

7119

20

[ # ] MAX CHAR

27PAGE 1

a

2868

7

3817a

ENTER THE APPLICABLE UNUSED INVESTMENT CREDIT FROM COOPERATIVES9

b QUALIFIED INVESTMENT IN PROPERTY OTHER THAN IN "a" ABOVE PLACED IN SERVICE DURING THE TAX YEAR

SEQUESTERS AT LEAST 75% OF THE PROJECT'S CARBON DIOXIDE EMISSIONS

3ADDITIONAL LINES ARE AVAILABLE ON INPUT SCREEN

QUALIFIED INVESTMENT IN ADVANCED COAL-BASED GENERATION TECHNOLOGY PROPERT PLACED IN SERVICE DURING TAX YEAR FOR PROJECTS DESCRIBED IN SECTION 48A(d)(3)(B)(ii)

a

b

1034681JVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW C1027D

5

6

c

OVERRIDE

9729

QUALIFIED INVESTMENT IN INTEGRATED GASIFICATION COMBINED CYCLE PROPERTY PLACED IN SERVICE DURING TAX YEAR FOR PROJECTS DESCRIBED IN SECTION 48A(d)(3)(b)(i)

9728

2010

[24] STREET ADDRESS

QUALIFYING ADVANCED ENERGY PROJECT CREDIT:

QUALIFYING GASIFICATION PROJECT CREDIT:QUALIFIED INVESTMENT IN QUALIFIED GASIFICATION PROPERTY PLACED IN SERVICE DURING THE TAX YEAR FOR WHICH CREDITS WERE ALLOCATED OR REALLOCATED AFTER 10/03/2008, AND THAT INCLUDE EQUIPMENT THAT SEPARATES AND

QUALIFIED INVESTMENT IN ADVANCED COAL-BASED GENERATION TECHNOLOGY PROPERTY PLACED IN SERVICE DURING TAX YEAR FOR PROJECTS DESCRIBED IN SECTION 48A(d)(3)(B)(iii)

PART I - ELECTION TO TREAT LESSEE AS PURCHASER OF INVESTMENT CREDIT PROPERTY

PROPERTY DESCRIPTION

NAME

(TO BE USED WITH SYSTEMS 1040, 1041, 1065, 1120, 1120S)

QUALIFIED INVESTMENT IN ADVANCED ENERGY PROJECT PROPERTY PLACE IN SERVICE AFTER 02/17/2009 9803

FORM 3468 INVESTMENT CREDIT

LESSOR NAME [35]INFORMATION ON PROPERTY ACQUIRED AS A LESSEE

AMOUNT[27] ZIP CODE

12

QUALIFYING ADVANCED COAL PROJECT CREDIT:

3815

PART II - QUALIFYING ADV COAL PROJECT CREDIT, QUALIFYING GASIFICATION PROJECT CREDIT, AND QUALIFYING ADV ENERGY PROJECT CREDIT

3816

PART III - REHABILITATION CREDIT AND ENERGY CREDIT

1120S/1065 ONLY QUALIFIED REHABILITATION EXPENDITURES - OTHER THAN RENTAL REAL ESTATE 8468 YES

8

11

a

ELECT TO TAKE QUALIFIED REHABILITATION EXPENDITURES INTO ACCOUNT FOR TAX YEAR IN WHICH PAID 1224 YES

REHABILITATION CREDIT EXPLANATION

[60]

[60]

[60]

b 24- OR 60-MONTH MEASURING PERIOD BEGINS 0322 - - ENDS 0323 - -c ADJUSTED BASIS OF BLDG AS OF BEGINNING DATE 3601d QUALIFIED REHABILITATION EXPENDITURES INCURRED DURING LINE 10b PERIOD 3602

QUALIFIED REHABILITATION EXPENDITURESe PRE-1936 BUILDINGS LOCATED IN THE GULF OPPORTUNITY ZONE 3902f PRE-1936 BUILDINGS AFFECTED BY A MIDWESTERN DISASTER 9735

gOTHER PRE-1936 BUILDINGS 2864

1041 ONLYFIDUCIARY PORTION 7907BENEFICIARY PORTION 7908

h CERTIFIED HISTORIC STRUCTURES LOCATED IN THE GULF OPPORTUNITY ZONE 3903i CERTIFIED HISTORIC STRUCTURES AFFECTED BY A MIDWESTERN DISASTER 9736

jOTHER CERTIFIED HISTORIC STRUCTURES 2865

1041 ONLYFIDUCIARY PORTION 7909BENEFICIARY PORTION 7910

[60]

FOR PROPERTIES ON LINES 10h, 10i, OR 10j, COMPLETE LINES 10k AND 10l

kENTER PROJECT # OR PASS-THROUGH EIN BUT NOT BOTH:

PASS-THROUGH EIN 0507 - NPS PROJECT NUMBER 0136 [18]

DATE NPS APPROVED REQUEST FOR CERTIFICATION OF COMPLETED WORK 0321 - -EXPLANATION OF PENDING APPROVAL

[60]

[60]

QUALIFYING THERAPEUTIC DISCOVERY PROJECT CREDIT:a QUALIFIED INVESTMENT IN A QUALIFYING THERAPEUTIC DISCOVERY PROJECT 9964

ADDITIONAL LINES ARE AVAILABLE ON INPUT SCREEN m REHABILITATION CREDIT FROM ELECTING LARGE PARTNERSHIP (FORM 1065-B, Sch K-1, Box 9) 2323

l

l

BASIS OF PROPERTY PLACED IN SERVICE DURING THE TAX YEAR THAT WAS ACQUIRED AFTER 10/03/2008, AND BEFORE 01/01/2009, AND THE BASIS ATTRIBUTABLE TO THE CONSTRUCTION, RECONSTRUCTION, OR ERECTION BY THE TAXPAYER AFTER 10/03/2008, AND BEFORE 01/01/2009o

BASIS OF PROPERTY PLACED IN SERVICE DURING THE TAX YEAR THAT WAS ACQUIRED AFTER 12/31/2008, AND THE BASIS ATTRIBUTABLE TO CONSTRUCTION, RECONSTRUCTION, OR ERECTION BY THE TAXPAYER AFTER 12/31/2008q

QUALIFIED SMALL WIND ENERGY PROPERTY

9733

9734

BASIS OF PROPERTY USING GEOTHERMAL ENERGY OR SOLAR ENERGY (ACQUIRED BEFORE 01/01/06, AND THE BASIS ATTRIBUTED TO CONSTRUCTION, RECONSTRUCTION, OR ERECTION BY THE TAXPAYER BEFORE 01/01/2006) PLACED IN SERVICE DURING THE TAX YEAR

a

BASIS OF PROPERTY USING SOLAR ILLUMINATION OR SOLAR ENERGY PLACED IN SERVICE DURING THE TAX YEAR THAT WAS ACQUIRED AFTER 12/31/2005, AND THE BASIS ATTRIBUTABLE TO CONSTRUCTION, RECONSTRUCTION, OR ERECTION BY THE TAXPAYER AFTER 12/31/2005

b3810

1041 ONLYFIDUCIARY PORTION

9801QUALIFIED INVESTMENT CREDIT FACILITY PROPERTY

s BASIS OF PROPERTY PLACED IN SERVICE DURING THE TAX YEAR 9802

BASIS OF PROPERTY PLACED IN SERVICE DURING THE TAX YEAR THAT WAS ACQUIRED AFTER 10/03/2008, AND THE BASIS ATTRIBUTABLE TO CONSTRUCTION, RECONSTRUCTION, OR ERECTION BY THE TAXPAYER AFTER 10/03/2008r

COMBINED HEAT AND POWER SYSTEM PROPERTY. CAUTION: CREDIT CANNOT BE CLAIMED IF ELECTRICAL CAPACITY IS MORE THAN 50 MEGAWATTS OR 67,000 HORSEPOWER.

9730

m ELECTRICAL CAPACITY (ENTER EITHER MEGAWATTS OR HORSEPOWER) MEGAWATTS 9731HORSEPOWER 9732

GEOTHERMAL HEAT PUMP SYSTEMS

QUALFIED MICROTURBINE PROPERTY

9726j KILOWATT CAPACITY OF PROPERTY ON LINE 11i 9727

BASIS OF PERPERTY PLACE INSERVICE DUING THE TAX YEAR THAT WAS ACQUIRED AFTER 12/31/2005, AND THE BASIS ATTRIBUTABLE TO CONSTRUCTION, OR ERECTION BY THE TAXPAYER AFTER 12/31/2005i

3813g APPLICABLE KILOWATT CAPACITY OF PROPERTY ON LINE 11f 3814

BASIS OF PROPERTY PLACED IN SERVICE DURING THE TAX YEAR THAT WAS ACQUIRED AFTER 10/03/2008, AND THE BASIS ATTRIBUTABLE TO CONSTRUCTION, RECONSTRUCTION, OR ERECTION BY THE TAXPAYER AFTER 10/03/2008f

QUALIFIED FUEL CELL PROPERTY

3811d APPLICABLE KILOWATT CAPACITY OF PROPERTY ON LINE 11c 3812

BASIS OF PROPERTY PLACED IN SERVICE DURING THE TAX YEAR THAT WAS ACQUIRED AFTER 12/31/2005, AND BEFORE 10/04/2008, AND THE BASIS ATTRIBUTABLE TO CONSTRUCTION, RECONSTRUCTION, OR ERECTION BY THE TAXPAYER AFTER 12/31/2005, AND BEFORE 10/04/2008c

1041 ONLYFIDUCIARY PORTION 7911BENEFICIARY PORTION

18 CARRYFORWARD OF REHAB CREDIT THAT ORIGINATED AFTER 2007 AND ENERGY CREDIT THAT ORIGINATED IN A TAX YR THAT BEGAN AFTER 10/03/2008 9737

[33] WK # PRIOR YEAR CRCURRENT CREDIT

12

27PAGE 2

ENERGY CREDIT

3809

BASIS OF PROPERTY PLACED IN SERVICE DURING THE TAX YEAR THAT WAS ACQUIRED AFTER 10/03/2008, AND THE BASIS ATTRIBUTABLE TO CONSTRUCTION, RECONSTRUCTION, OR ERECTION BY THE TAXPAYER AFTER 10/03/2008

7912

7913BENEFICIARY PORTION 7914

PASSIVE ACTIVITY CREDITS INCLUDED ON LINE 13

9751

1040 / 1041 ONLY - FORM 6478 PASSIVE CREDIT FOR FORM 8582CR

T/S


1034682[ # ] MAX CHAROVERRIDEJVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW C1027D

CARRYBACK OF REHABILITATION AND ENERGY CREDITS FROM 2009

9750

APPLICABLE UNUSED INVERSTMENT CREDIT FROM COOPERATIVES

15

9748


ACTIVITY NAME

PART III - REHABILITATION CREDIT AND ENERGY CREDIT (CONTINUED)

19

13

9749

2010NAME

FORM 3468 INVESTMENT CREDIT

17 PASSIVE ACTIVITY CREDIT ALLOWED FOR 2009

KEYFIELD

TAX PAID BY REGULATED INVESTMENT COMPANY

d

JVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW C0113D OVERRIDE

NO

TOTAL UNDISTRIBUTED LONG TERM CAPITAL GAIN

DIVIDE DEDUCTIONS BETWEEN CAP GAINS & ORDINARY INCOME 1283 YES 1284

2614 YES

2512 YES 2616 YES

2524 YES

2523 YES 2612 YES

2549 YES 2615 YES

YES

2239 YES 2613 YES

YES

1040 ONLY: SPOUSE'S FORM 2439 (DEFAULT = TP)

1228 YES 1276 YES

1223 YES

[35]RIC /REIT

045504560457ADDRESS

0458ZIP CODE

DEATH BENEFIT EXCLUSION FOR BENEFICIARY OF PARTICIPANT WHO DIED BEFORE 08-21-1996

8

6

ORDINARY INCOME FROM FORM 1099-R, BOX 2a

2

7893

0454RIC / REIT IDENTIFICATION NUMBER

1280 YES

CURRENT ACTUARIAL VALUE OF ANNUITY (FORM 1099-R, BOX 8)FEDERAL ESTATE TAX ATTRIBUTABLE TO LUMP-SUM DISTRIBUTION

18

9

AMT (IF DIFFERENT)

7894

[22] 0460

b

[12]

7891 7892

CITY

DISTRIBUTION PAID AS A BENEFICIARY OF PLAN PARTICIPANT WHO WAS BORN BEFORE 01-02-1936

CAPITAL GAIN PORTION FROM FORM 1099-R, BOX 3

2439

YES

0453

11

4

TAXPAYER WAS: a) PLAN PARTICIPANT WHO RECEIVED DISTRIBUTION, b) WAS BORN BEFORE 01-02-36, AND c) HAS BEEN IN PLAN AT LEAST 5 YRS BEFORE DISTRIBUTION

YESUSE PART II - CAPITAL GAIN ELECTION ((DO NOT OPTOMIZE)

2010

0459[35]

YES

UNIVERSAL DATA SHEET

BUILDING IDENTIFICATION NUMBER

NAME

LUMP-SUM DISTRIBUTIONS

DATE BUILDING PLACED IN SERVICE3

1275

SECTION 42(e) REHABILITATION EXPENDITURES

YES

1323

THIS FORM 8609-A IS FOR:

8453

1428

E

4972


TAXPAYER SPOUSE

28

8609-A

[ # ] MAX CHAR ADD-TO

0452

[11]

[35]

ST

0451

3785

3

7

DEDNS / LOSSES ALLOCABLE TO DPGR

4 3783

3782

3784

FORM W-2 WAGES (SEE INSTRUCTIONS FOR CALCULATION METHODS)16

9719

11 INCOME LIMITATION (NOT FOR 1040)

9 AMOUNT ALLOC TO BENEFICIARIES OF ESTATE/TRUST 97183672

19

FORM W-2 WAGES FROM ESTATE, TRUSTS, AND CERTAIN PARTNERSHIPS AND S CORPORATIONS

17

1

2

QUALIFIED PRODUCTION ACTIVITY INCOME ESTATES, TRUST, CERTAIN PARTNERSHIPS, AND S CORPS

COST OF GOODS SOLD & OTHER DEDUCTIONS/LOSSES RATABLY APPORTIONED TO DPGR (SB SIMPLIFIED METHOD)

ALLOCABLE COST OF GOODS SOLD 3781

YES14203780

DOMESTIC PRODUCTION ACTIVITIES DEDUCTION

DOMESTIC PRODUCTION GROSS RECEIPTS (DPGR)

8903

3787

23DOMESTIC PRODUCTION ACTIVITIES DEDUCTION FROM COOPERATIVES (FORM 1099-PATR, BOX 6) 3786

24 EXPANDED AFFILIATED GROUP ALLOCATION

3871

AMOUNT ALLOC TO BENEFICIARIES OF ESTATE/TRUST

8634

Multiple

[9]A

PART I - COMPLIANCE INFORMATION

8095

1427

8452

WAS THERE A DECREASE IN QUALIFIED BASIS OF BUILDING THIS TAX YEAR?

BUILDING QUALIFIES AS PART OF QUALIFIED LOW-INCOME HOUSING PROJECT AND MEETS SEC 42 REQUIREMENTS

B

D

ORIGINAL FORM 8609 MAINTAINED IN TAXPAYER'S RECORDS?

7

1

A NEWLY CONSTRUCTED OR EXISTING BUILDING

3

2 LOW-INCOME PERCENTAGE

4

5

C

PART II - COMPUTATION OF CREDIT

QUALIFIED BASIS OF LOW-INCOME BUILDING IS -0- YES

8097NO. OF MONTHS OWNED IF LESS THAN 12 MONTHS

8011

QUALIFIED BASIS OF BUILDING FROM PREVIOUS YEARS' SCHEDULE A, LINE 3

7195

7198PERCENT OF INTEREST IN THIS BUILDING IF LESS THAN 100%

7194

CREDIT PERCENTAGE FROM FORM 8609, PART I, LINE 2

7193ORIGINAL QUALIFIED BASIS OF BUILDING AT CLOSE OF FIRST YEAR FROM FORM 8609, PART II, LINE 8a

AMOUNT FROM PREVIOUS YEARS' SCHEDULE A, LINE 2 (PCT)

14 TOTAL OF ALL FEDERAL GRANTS FOR THIS BUILDING

MODIFIED PERCENTAGE

17 PRO RATA REDUCTION FOR INCREASED CREDIT IN PRIOR YEAR

PROPORTIONATE SHARE OF CREDIT16

11 AMOUNT FROM PREVIOUS YEARS' SCHEDULE A, LINE 1

ELIGIBLE BASIS OF BUILDING FROM FORM 8609, PART II, LINE 7b

SECTION 1202 GAIN

USING SMALL BUSINESS SIMPLIFIED OVERALL METHOD

c


ENTIRE CREDIT WAS CLAIMED IN PRIOR TAX YEARS

1

YES

NAME

7889

0503

7895

0519 - -

a

ANNUAL STATEMENT LOW-INC HOUSING CRC

17890

7191

YES

CORRECTED FORM 2439


NOTICE TO SHAREHOLDER OF UNDISTRIB LT CAP GAIN

7888UNRECAPTURED SECTION 1250 GAIN

NAME

8096

719780988110

EXPLANATION FOR NOT FILING ELECTRONICALLY

VOID FORM 2439

8099

7359

10UNIV4

%

8454 YES

%

%

%7192

%

89487887 CHECK APPLICABLE BOX TO INDICATE REASON RETURN IS NOT BEING FILED

ELECTRONICALLY

15 AMOUNT ON FORM 8609, PART I, LINE 1b

7199

REGULAR TAX

YES4201TP (BOTH IF MFJ) CHOSE TO FILE THIS RETURN ON PAPER. TP, NOT PREPARER, WILL SEND PAPER RETURN TO IRS.

1603 YES

PRINT A SIGNED STATEMENT FOR PREPARER'S RECORDS, INDICATING TP's CHOICE TO PAPER FILE THE RETURN. TO REPLACE WITH OWN WORDING, ENTER STATEMENT BELOW

YESPREPARER RECEIVED WAIVER FROM REQUIREMENT TO ELECTRONICALLY FILE TAX RETURN. 4202

STATEMENT FOR TAXPAYER'S CHOICE TO PAPER FILE RETURN

2

4204APPROVAL LETTER DATE

YES

4

RETURN WAS REJECTED BY IRS E-FILE AND REJECT CONDITION COULD NOT BE RESOLVED 4206 YES

NUMBER OF ATTEMPTS TO RESOLVE REJECT

YESPREPARER IS MEMBER OF RECOGNIZED RELIGIOUS GROUP CONSCIENTIOUSLY OPPOSED TO FILING ELECTRONICALLY

FORM 42105

4211SCHEDULE

4205

4208

PREPARER IS INELIGIBLE TO E-FILE BECAUSE IRS E-FILE DOES NOT ACCEPT FOREIGN PREPARERS WITHOUT SOC SEC NUMBERS WHO LIVE AND WORK ABROAD.

a

PREPARER INELIGIBLE TO PARTICIPATE IN IRS E-FILE DUE TO AN IRS SANCTION.b 4213

3

PREPARER'S E-FILE SOFTWARE PACKAGE DOES NOT SUPPORT FORM OR SCHEDULE ATTACHED TO RETURN 4209

YES

OTHER. DESCRIBE CIRCUMSTANCES BELOW YES4214

CHECK APPLICABLE BOX AND PROVIDE ADDITIONAL INFORMATION IF REQUESTED:

YES4212

c

6

WAIVER REFERENCE NUMBER [25]4203

REJECT CODE 4207 [25]

8283

GAIN (LOSS) FRO SALE BEING REPORTED ON:

AMOUNT

ISSUER'S NAME (IF FINANCED WITH TAX-EXEMPT BONDS):

MULTIPLE

4490 - -DATE OF ISSUE

RECAPTURE OF LOW-INCOME HOUSING CREDIT

2

SECTION 42(j)(5) PARTNERSHIP

RECAPTURE AMOUNT FROM FLOW-THRU ENTITIES 29158

CREDITS ATTRIB TO ADDITIONS TO QUALIFIED BASIS

7

1309 YES

FLOW-THROUGH ENTITY EXCEPT ELECTING LARGE PARTNERSHIP OR SECTION 42(j)(5) PARTNERSHIP

(4)

TOTAL PRIOR YR CREDITS FROM FORM 8586 FOR BUILDING

[35]

AMOUNT AT RISK:

b 1308

a

ZIP CODE

0100 - -

[35]

YES

AMOUNT (AUTOMATIC IF AT EFFECTIVE DATE)

2756 PY SCHEDULE D TAX WORKSHEET, LINE 13 OR PY SCHEDULE D (FORM 1041), LINE 22

30

8284 YES

[50]

IF PY SCHEDULE D TAX WORKSHEET WAS COMPLETED, AMOUNT FROM LINE 10 OF THAT WORKSHEET

AMOUNT FROM:

DECREASES SINCE:

2619

8470 YES

STREETADDRESS

[50]

0038 -

EFFECTIVE DATE

INCREASES AT EFFECTIVE DATE

29279

2913

NAME OF ISSUE

PT III - LINE 11 COMPUTATION USING MAX CAPITAL GAIN RATES

AMOUNT FROM:

F

[9]4491

E

NET RECAPTURE (LINE 7 OR 8 LESS LINE 9)

11 INTEREST ON NET RECAPTURE AMOUNT (LINE 10)

10

2481

10UNIV3JVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW C0728D OPTIONAL OVERRIDE [ # ] MAX CHAR

SECTION 42(j)(5) PARTNERSHIPS ONLY

16 INTEREST ON RECAPTURE AMOUNT - FLOW-THRU ENTITIES 2427

MINIMUM TAX FOREIGN TAX CREDIT ON EXCLUSION ITEMS

(2)

37

2295

AMOUNT FROM:

1439

PY QUALIFIED DIVIDENDS AND CAPITAL GAIN TAX WORKSHEET, LINE 7 OR

2762

PRIOR YEAR MINIMUM TAX CREDIT CARRYFORWARD19

12

FORM 1040 MINIMUM TAX CREDIT NOL DEDUCTION

16

2988

AMOUNT FOR CHILD UNDER 24

2741

2795AMOUNT FROM PRIOR YEAR FORM 6251, LINE 36, OR PRIOR YEAR FORM 1041, SCHEDULE I, LINE 56

9

AMOUNT FROM PRIOR YEAR FORM 6251, LINE 35, OR PRIOR YEAR FORM 1041, SCHEDULE I, LINE 55

2738

1040 ONLY - FILED FORM 2555 OR 2555-EZ IN PRIOR YEAR 1430

TAXABLE INCOME FROM PY FORM 6251, LINES 1, 6, 7, AND 11

3

PART II - MINIMUM TAX CREDIT AND CARRYFORWARD TO 2010

14 2742

3419

YES

29

D

C

8611

BUILDINGADDRESS

BUILDING ID NUMBER (BIN)

15

OTHER INCOME AND GAINS FROM SCHEDULES K-1 NOT INCLUDED ABOVE

INCREASES SINCE:


PERCENTAGE DECREASE IN QUALIFIED BASIS

IF RECAPTURE IS PASSED THROUGH FROM A FLOW-THROUGH ENTITY (PTSHP,S-CORP, ESTATE OR TRUST), SKIP LINES 1 THROUGH 7 AND GO TO LINE 8.

0021

0027

7939

20

YES1194

1 2737

31

PY TAX WAS FIGURED USING SCH D TAX WKSHT (1040 ONLY)

1040 ONLY - THERE WAS MIN TAX OR CARRYFORWARD FROM 2007 TO 2008

26

32549126

PRIOR YEAR UNALLOWED QUAL ELECTRIC VEHICLE CREDIT

PART I - CURRENT YEAR PROFIT (LOSS) FROM ACTIVITY

2462

6198

1

[25]

NAME

b 2464FORM 4797

2008 FILING STATUS, IF DIFFERENT (1 - 2 - 3 - 4 - 5)

2

5

2463

AT-RISK LIMITATIONS

2467

2

OTHER FORM OR SCHEDULE


8801

ADJUSTMENTS AND PREFERENCE ITEMS TREATED AS EXCLUSION ITEMS

* * * FOR USE WITH 1040 AND 1041 * * *

ORDINARY INCOME (LOSS) FROM ACTIVITY THIS YEAR

CREDIT FOR PRIOR YEAR MINIMUM TAX

SCHEDULE D

DECREASES FOR THE TAX YEAR

2801

0285DESCRIPTIONOF ACTIVITY

Multiple

2466

9

ADJUSTED BASIS IN ACTIVITY ON FIRST DAY OF TAX YEAR 2468PART II - SIMPLIFIED COMPUTATION

a

OTHER DEDUCTIONS AND LOSSES (INCLUDING INVESTMENT INTEREST EXPENSE ALLOWED)4

3

2465c

6

11 INVESTMENT IN ACTIVITY AT EFFECTIVE DATE

1306 YES

7 INCREASES FOR THE TAX YEAR

2470

280212

14

FROM 2009 FORM 6198, LINE 19bb

b AT END OF 2009 TAX YEAR

a

AT END OF 2009 TAX YEAR

YES

2796

PART I - NET MINIMUM TAX ON EXCLUSION ITEMS

PART III - DETAILED COMPUTATION

2471

FORCE PRINTING OF FORM 8801

DECREASES AT EFFECTIVE DATE

a AT EFFECTIVE DATE

2469

EFFECTIVE DATE

2804

16

1040 ONLY- PY FORM 2555, LINES 45 AND 50, OR PY FORM 2555-EZ, LINE 18

YES

2803

1305

1307

AMOUNT

YES

1

DATE PLACED IN SERVICE

(1)4489

1310

(3)

CUSIP NUMBER

18

2805

3 - YR 13 = .2004 - YR 14 = .133

5 - YR 15 = .067

4492

2912

40278

[2]01376

PY SCHEDULE D (FORM 1040), LINE 19 OR PY SCHEDULE D (FORM 1041), LINE 14b, COLUMN (2)

PY SCHEDULE D TAX WORKSHEET, LINE 14 OR PY SCHEDULE D (FORM 1041), LINE 23

55 2009 FM 8801, LINE 59

2009 FM 8801, LINES 18 & 20 (IF ZERO OR LESS LEAVE BLANK)50

49 2008 FM 8801, LINES 18 & 20 (IF ZERO OR LESS LEAVE BLANK)

32

UNUSED CR ATTRIBUTABLE TO ADDITIONS TO QUAL BASIS

2916

PART IV - TENTATIVE REFUNDABLE CREDIT

7941

UNUSED CREDIT ATTRIBUTABLE TO THIS BUILDING

CREDIT RECAPTURE PERCENTAGE:

AMOUNT OF ACCELERATED PORTION RECAPTURED

7940

YES

1 - YRS 2-11 = .333 2 - YR 12 = .267

YES

2760

11

3420PRIOR YEAR 1040NR ONLY - NET GAIN ON DISPOSITION OF U.S. REAL PROPERTY INTERESTS10

PY QUALIFIED DIVIDENDS AND CAPITAL GAIN TAX WORKSHEET, LINE 6 OR

IF QUALIFIED DIVIDENDS / CAPITAL GAIN TAX WORKSHEET, SCHEDULE D TAX WKSHTOR PART V OF SCHEDULE D (FORM 1041) WAS NOT COMPLETED IN PRIOR YEAR

SEE F-1 HELP BEFORE COMPLETING THIS SECTION.

4376 - -TAXPAYER SSN TAXPAYER EIN

1526 YES

ACTUAL RECOVERY

POTENTIAL INSURANCE / SIPC RECOVERY

TAXPAYER CLAIMING REV. PROC. 2009-20 THEFT LOSS DEDUCTION FROM A SPECIFIED FRAUDULENT ARRANGEMENT

QUALIFY FOR REV. PROC. 2009-20 THEFT LOSS DEDUCTION FROM FRAUDULENT ARRANGEMENT

ENTER TAX YEARS AND DATES FOR WHICH RETURNS WERE FILED:

KEYFIELD

TAXPAYER AGREES TO ALL ADJUSTMENTS NECESSARY TO COMPLY WITH REV. PROC. 2009-20 OF RETURN(S) HAVE ALREADY BEEN FILED THAT DO NOT SATISFY THE CONDITIONS IN REV. PROC. 2009-20

TWO-LETTER STATE CODEOWNERSHIP CODE -1040 ONLY (T=TAXPAYER S=SPOUSE J =JOINT)

YES

4383 - -

4387 - -4389 - -

STATE

1546

YES

4399 -

INCOME REPORTED IN PRIOR YEARS

REV. PROC. 2009-20 THEFT LOSS DEDUCTION

0529

PART II - COMPUTATION OF DEDUCTION

98069807

YES

FAIR MKTVALUE

BEFORE


FAIR MKTVALUEAFTER

CASUALTY &THEFT GROUP

NUMBER

22

DATEACQUIRED

CASUALTY &THEFT GROUP

NUMBER

GROUP CASUALTY #1 IS ATTRIBUTABLE TO LOSS IN A FEDERALLY DECLARED DISASTER AREA THAT OCCURRED AFTER 2007 AND BEFORE 2010

2010NAME

30

STATE

46841

DESCRIPTION / LOCATION

FORM 4684 DATA SHEET (TO BE USED WITH SYSTEMS 1040, 1041, 1065, 1120, 1120S)

COST ORBASIS

- -

GROUP

28%RATE

PROPERTY

STATE

T/S

- -

FAIR MARKETVALUE AFTER

IMPORTANT

FAIR MARKETVALUE BEFORE

COST OR BASIS

DESCRIPTION FOR CASUALTIES AND THEFTS

INSURANCE OR OTHER

REIMBURSE-MENT

HELDUNDER

1 YR

46842

- -

GROUP DESCRIPTION FOR CASUALTIES AND THEFTS

- -

T/S

INSURANCEOR OTHER

REIMBURSE-MENT

[30]

DATEACQUIREDDESCRIPTION / LOCATION

YES

HELDUNDER

1 YR

28%RATEPROP

INCOMEPRODUCINGPROPERTY(1 = Income,

2 = Empl Prop)

CASUALTY OR THEFT GAINS FROM FORM 4797, LINE 32

NAME

4381

154243754377

1543


37 3441

4379

IF TAXPAYER HAS OTHER CASUALTIES NOT RELATED TO REV. PROC. 2009-20, ASSIGN THEM A GROUP NUMBER OTHER THAN GROUP 1.

4343

1

43731541

- -

- - - -

4 WITHDRAWALS

THEFT LOSS TERM 1= LONG TERM 2=SHORT TERM

INITIAL INVESTMENT

SUBSEQUENT INVESTMENTS

INSTRUCTIONS: ENTER THE INOFRMATION REQUESTED BELOW. NOTE: IF TAXPAYER IS CLAIMING A REV. PROC. 2009-20 THEFT LOSS DEDUCTION, IT WILL BE ASSIGNED GROUP #1.

- -

6

CITY

PART III - REQUIRED STATEMENTS AND DECLARATIONS

9808

1

2

3

7 9810

9809

YES

TAX YEAR

4382

PERCENTAGE OF QUALIFIED INVESTMENT 1=95% OF LINE 5 WITH NO 3rd-PARTY RECOVERY 2=75% OF LINE 5 WITH POTENTIAL 3rd-PARTY RECOVERY

8 9811

2

3 TAXPAYER IS A QUALIFIED INVESTOR AS DEFINED IN SECTION 4.03 OF REV. PROC. 2009-20

ZIP

DATE RETURN FILED

1544 YES

4385 - -

CASUALTY AND THEFT OF PERSONAL PROPERTY - PAGE 1

CASUALTY AND THEFT OF BUSINESS & INCOME-PRODUCING PROPERTY - PAGE 2

1545

FRAUDULENT ARRANGEMENT CONDUCTED BY:

4

4386

5

4380

[30]

4384

TAXPAYER HAS WRITTEN DOCUMENTATION TO SUPPORT AMOUNTS REPORTED IN PART II

STREET ADDRESS[18]

104684INJVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW C0121D OVERRIDE [ # ] MAX CHAR

1

4374

4388

TAXPAYER DOES NOT INTEND TO PURSUE ANY POTENTIAL THIRD-PARTY RECOVERY

288528862887

36

33

31

30

(DO NOT COMPLETE IF FINAL PAYMENT IS RECEIVED THIS YEAR)

SELLING PRICE OF PROPERTY SOLD BY RELATED PARTY

CONTRACT PRICE FROM LINE 18 FOR YEAR OF FIRST SALE

TOTAL PAYMENTS RECEIVED BY END OF 2008 TAX YEAR (NOT 28% RATE)

7664

36373636PORTION OF LINE 35 THAT IS ORDINARY INCOME UNDER RECAPTURE RULES

PAYMENTS RECEIVED THAT QUALIFY FOR 28% RATE (NOT FOR 1120)

36333634 7896

38673868 7897

3635

2889

FEDERALAMT MIN IF

DIFFERENT

STATE IF

DIFFERENT

2891

19

21

[70]

[70]

2626

2890

3864

8388 YES

344725

2902PAYMENTS RECEIVED DURING YEAR (NOT 28%) (NO INTEREST PAYMENTS)

PAYMENTS RECEIVED THAT QUALIFY FOR 28% RATE (Not applicable for 1120)

3446CURRENT YEAR INTEREST PAYMENTS RECEIVED

3865

e

23

[35]8400 - 27

8169 YESDID RELATED PARTY RESELL OR DISPOSE OF PROPERTY DURING TAX YEAR?28

26

IT CAN BE ESTABLISHED TO SATISFACTION OF IRS THAT TAX AVOIDANCE WAS NOT A PRINCIPAL PURPOSE FOR EITHER OF THE DISPOSITIONS

DATE OF DISPOSITION

8299 YES


8195 YES

298389 YES

[70]

SECOND DISPOSITION OCCURRED AFTER DEATH OF ORIGINAL SELLER OR BUYER

8398 - -

EXPLAIN:

a

d

b

[25]

c

IF LINE 28 IS YES, COMPLETE LINES 30 - 36 UNLESS ONE OF THE FOLLOWING APPLY:

SECOND DISPOSITION MORE THAN 2 YEARS AFTER FIRST DISPOSITION

FIRST DISPOSITION WAS SALE OR EXCHANGE OF STOCK TO ISSUING CORPORATION

SECOND DISPOSITION WAS INVOLUNTARY CONVERSION AND THREAT OF CONVERSION OCCURRED AFTER FIRST DISPOSITION

8170 YES

ZIP CODE

TOTAL UNRECAPTURED SECTION 1250 GAIN

NAME 8394

8396

3866PART III - RELATED PARTY INSTALLMENT SALE INCOME

SOCIAL SECURITY NUMBER

STREET ADDRESS

RELATED PARTY:

FEDERAL EIN

0043 8545 0174GROSS PROFIT PERCENTAGE (AFTER YEAR OF SALE)

[35]8397

PAYMENTS RECEIVED IN PRIOR YEARS

PRIOR YEAR INTEREST PAYMENTS RECEIVED

PORTION THAT IS TAXABLE AS ORDINARY INCOME

2883SELLING PRICE

12

11

STATE IF

DIFFERENT

6

9

2659

2884

a2

YES

STATE IF

DIFFERENT

PROPERTY WAS SOLD TO RELATED PARTY AFTER 05-14-1980

[45]

PART I - GROSS PROFIT AND CONTRACT PRICE (YEAR OF SALE ONLY)

PROPERTY SOLD TO RELATED PARTY WAS A MARKETABLE SECURITY YES

2010

KEYFIELD [ # ] MAX CHAR

LAST NAME

02160095

YES

1165

AMT MIN IF

DIFFERENT

106252OVERRIDE

31 INSTALLMENT SALE INCOME( TO BE USED WITH SYSTEMS 1040, 1041, 1065, 1120, 1120S)

8425

IF MAIN HOME, AMOUNT OF EXCLUDED GAIN

FEDERAL

b

DESCRIPTION

1164

Multiple


3

4

8424

2533

8395 - -

YES

INCOME RECAPTURE FROM CA SCHEDULE D-1, PART III

0096 - -0097 - -DATE SOLD

DATE ACQUIRED

AMT MIN IF

DIFFERENTFEDERAL

8

15

5

3860 26213861 2624

38622625

MORTGAGES, DEBTS, AND OTHER LIABILITIES PURCHASER ASSUMES

COST OR OTHER BASIS OF PROPERTY SOLD

DEPRECIATION ALLOWED OR ALLOWABLE

COMMISSIONS AND OTHER EXPENSES OF SALE

INCOME RECAPTURE FROM FORM 4797, LINE 31

3863PART II - INSTALLMENT SALE INCOME

CARRY TO FORM 4797 (SCHEDULE D IS AUTOMATIC)

SHORT TERM GAIN

02171040 ONLY: OWNERSHIP CODE [T] = Taxpayer [S] = Spouse [J] = Joint (Default)

1040 ONLY: TWO-LETTER STATE CODE

1

2628

OVERRIDE [ # ] MAX CHAR

FOREIGN QUALIFIED DIVIDENDS AND CAPITAL GAINS (LOSSES) (SEE WORKSHEET FOR LINE 1a ABOVE)

6

5

32743275

AMT LOSSES FROM FOREIGN SOURCES

TOTAL AMT HTKO DEDUCTIONS

JVA COPYRIGHT FORMS(SOFTWARE ONLY) - 2010 TW C0524D

[60]EXPLAIN OTHER DEDUCTIONS

d

[60]

[60]

[60]

7064

[60]

1 - Passive category income 2 - General category income 3 - Section 901 (j) income

[60]

YES

aFOREIGN SOURCE QUALIFIED DIVIDENDS

7096

[60]

EXPENSES DEFINITELY RELATED TO LINE 1a INCOME

LAST NAME

7095

[30]

[11]4494 NAME OF FOREIGN COUNTRY OR UNITED STATES POSSESSION

7 - HTKO (general category) (See Helps for completing Form 1116 with high taxed income (HTKO)

4 - Certain income re-sourced treaty5 - Lump-sum distributions6 - HTKO (passive category)

RESIDENT OF (NAME OF COUNTRY)

YES

f

ENTERNUMBER (1 - 5)

2503

1

g

FOREIGN QUALIFIED DIVIDENDS AND CAPITAL GAINS (LOSSES) WORKSHEET

0127

Multiple2010FORM 1116 FOREIGN TAX CREDIT

7101

ENTRIES ARE USED TO CALCULATE ADJUSTMENTS FOR FOREIGN QUALIFIED DIVIDENDS, AS WELL AS WORKSHEET A OR WORKSHEET B AMOUNTS THAT CARRY TO FORM 1116, LINES 1a AND 5. WORKSHEETS A AND B CAN ONLY BE USED IF THERE ARE NO MORE THAN TWO CATEGORIES OF FOREIGN

FOREIGN SOURCE CAPITAL GAINS ADJUSTMENT FOR FORM 1116, LINE 1a

0270OWNERSHIP CODE (T / S / J)

101116IN

e

INCOME FROM A REGULATED INVESTMENT COMPANY (RIC)

7102

8642

FOREIGN SOURCE QUALIFIED DIVIDENDS INCLUDED ON FORM 4952, LINE 4g

ALTERNATIVE METHOD TO SOURCE COMPENSATION EXPLANATION

TYPE OF INCOME

3251

GROSS AMT INCOME FROM SOURCES WITHIN THE COUNTRY

7094

FOREIGN SOURCE LONG-TERM CAPITAL GAINS AND LOSSES (IF NEGATIVE, ENTER AS NEGATIVE)

1474

[60]

[30]


FOREIGN CAPITAL GAINS INCLUDED ON FM 4952, LINE 4gFOREIGN SOURCE SHORT-TERM CAPITAL GAINS AND LOSSES (IF NEGATIVE, ENTER AS NEGATIVE)

7099

1285 YES

1125 YES

SUPPRESS PRINTING OF FORM 1116 AMT

ELECT TO USE SIMPLIFIED FOREIGN TAX CREDIT LIMITATION FOR ALTERNATIVE MINIMUM TAX PURPOSES

0059

3250GROSS INCOME FROM WITHIN THE COUNTRY

7061

7100FOREIGN SOURCE CAPITAL GAIN DISTRIBUTIONS

PART I - TAXABLE INCOME FROM SOURCES OUTSIDE THE UNITED STATES

7097

SOURCE CAPITAL GAINS OR LOSSES. IF THERE ARE MORE THAN TWO, MANUAL CALCULATIONS ARE REQUIRED AND THE RESULTS ARE ENTERED IN THE OVERRIDE FIELDS BELOW.

OTHER DEDUCTIONS

b

LINE 1a IS COMPENSATION FOR PERSONAL SERVICES AS EMPLOYEE, TOTAL COMPENSATION FROM ALL SOURCES IS $250,000 OR MORE, AND AN ALTERNATIVE METHOD WAS USED TO DETERMINE ITS SOURCE.

a7063

FOREIGN SOURCE QUALIFIED DIVIDENDS ADJUSTMENT FOR FORM 1116, LINE 1aFOREIGN SOURCE CAPITAL LOSS ADJUSTMENT FOR FORM 1116, LINE 5

7098

3256

3253

AMT EXPENSES DEFINITELY RELATED LINE 1a INCOME

3418

7062

3252

7065

3257 7069

b


AMT OTHER DEDUCTIONS

GROSS FOREIGN SOURCE INCOME


3298

AMT GROSS FOREIGN SOURCE INCOME

AMT ITEMIZED OR STANDARD DEDUCTION

32557066

LOSSES FROM FOREIGN SOURCES

TOTAL HTKO DEDUCTIONS

7068

7067OTHER INTEREST EXPENSE

a

2

PRO RATA SHARE OF OTHER DEDUCTIONS NOT DEFINITELY RELATED:

ALLOCABLE EXPENSES EXPLANATION

[60]

b3

ITEMIZED OR STANDARD DEDUCTION

AMT OTHER INTEREST EXPENSE

PAGE 1 32

GROSS INCOME FROM ALL SOURCES

AMT GROSS INCOME FROM ALL SOURCES

PRO RATA SHARE OF INTEREST EXPENSE:

4HOME MORTGAGE INTEREST

AMT HOME MORTGAGE INTEREST

3742

2009

2005

3760 3762

ALT MINIMUM

TAX

2010 3755

32PAGE 2

ALTERNATIVE MINIMUM TAX ADJUSTMENT TO TAXABLE INCOME (LOSS)

3746

3752 3753

2006

37473754

USED CREDIT

3735

32723273

8

2008

FOREIGN TAX CREDIT CARRYOVER STATEMENT

3739 3740 374137432007

REDUCTION IN FOREIGN TAXES (EXPLAIN BELOW)

7083

2654

EXPLANATION FOR REDUCTION IN FOREIGN TAXES


37443748 3749

CARRYBACK TO PRIOR YEAR

(SEE NOTE ON SCREEN*)USED CREDIT

FORM 1041 ONLY

OVERRIDE

[60]

[60]

[ # ] MAX CHAR

16

JVA COPYRIGHT FORMS(SOFTWARE ONLY) - 2010 TW S0111S

10

8111

REGULAR

TAX

373837362005 3737

3750

FOREIGN TAX

PAID / ACCRUED

REDUCTION IN

FOREIGN TAXES

CARRYBACK TO PRIOR YEAR

(SEE NOTE ON SCREEN*)

FOREIGN TAX

PAID / ACCRUED

REDUCTION IN

FOREIGN TAXES

3745

2007

2008

2006

3756

3751

3768

FORM 1116 FOREIGN TAX CREDIT

PART III - FIGURING THE CREDIT

q

n

7080

101116IN2

2010LAST NAME Multiple

[60]

REGULAR TAX


AMT TAX

3277

EXPLANATION FOR CARRYBACK BEING UTILITZED IN CURRENT YEAR

2009

37762010

3278

3772 3774

THESE ENTRIES ARE FOR CARRYBACK AMOUNT UTILIZED IN THE CURRENT YEAR (USUALLY FOR AMENDED RETURNS OR IF THE PRIOR YEAR RETURN WAS NOT FILED BEFORE SUBSEQUENT RETURNS). FOR INSTANCE, IF AN AMOUNT IS UTILIZED IN THE 2009 RETURN FROM A 2010 CARRYBACK, ENTER THE APPLICABLE AMOUNT IN THIS SECTION.

IN FOREIGN

CURRENCY

TAXES WITHHELDAT SOURCE ON:

k

l

o

p

CARRYBACK OR CARRYOVER (USE WORKSHEET BELOW)

r

m

DIVIDENDS

3267326832693270

RENTS AND ROYALTIES

INTEREST

OTHER FOREIGN TAXES PAID OR ACCRUED

DIVIDENDS

RENTS AND ROYALTIES

INTEREST

OTHER FOREIGN TAXES PAID OR ACCRUED

TOTAL FOREIGN ALT MIN TAXES PAID OR ACCRUED FOR COLUMN (s)

IN U.S.

DOLLARS

TAXES WITHHELDAT SOURCE ON:

7081AMT CARRYOVER OR CARRYBACK

3773

37643763

3769

3759

3775

3757

3765

3758

3766 37673770 3771

3761

17

288831723173

70822653

[60]

ADJUSTMENTS TO TAXABLE INCOME (LOSS) OUTSIDE U.S.

PERCENT OF FOREIGN TAXES PASSED THROUGH TO BENEFICIARIES

15

12

28

PART IV - SUMMARY OF CREDITS

2656REDUCTION OF CREDIT FOR INTERNATIONAL BOYCOTT OPERATIONS

PART II - FOREIGN TAXES PAID OR ACCRUED

1171 YES

3266

CREDIT IS CLAIMED FOR TAXES: ACCRUED (DEFAULT = PAID)

0035 - -DATE PAID OR ACCRUED

i

j

[60]

[60]

AMOUNT FROM FORM 4972, LINES 6 AND 12, THAT ARE FROM FOREIGN SOURCES (OPTION 5 ONLY)

AMOUNT FROM FORM 1040, LINE 41 (SEE FEDERAL INSTRUCTIONS FOR WORKSHEET AMOUNT)

ALTERNATIVE MINIMUM TAX WORKSHEET AMOUNT OVERRIDE FOR LINE 17

2655

[60]

ALTERNATIVE MINIMUM TAX REDUCTION IN FOREIGN TAXES

3271

EXPLANATION FOR ADJUSTMENTS TO TAXABLE INCOME


[60]

[60]

NOTE: ENTRIES FOR THE YEARS FROM 2000 TO 2004 OF REGULAR TAX AND ALTERNATIVE MINIMUM TAX ARE FOUND ON THE INPUT SCREENS.

APPLICABLE FORM OR SCHEDULE

CLASS LIFE ADS12 - YEAR ADS40 - YEAR ADS

23 4550FOR ASSETS PLACED IN SERVICE DURING THE CURRENT YEAR, SECTION 263A COSTS

(b) Cost (Business Use Only)[20]

GDS AND ADS FOR ASSETS PLACED IN SERVICE IN TAX YEARS BEFORE 2010

(d) Recovery Period

( c) Elected Cost


PropertyClassification Types:

3 - YEAR PROPERTY5 - YEAR PROPERTY7 - YEAR PROPERTY

10 - YEAR PROPERTY15 - YEAR PROPERTY20 - YEAR PROPERTY

25 - YEAR PROPERTYRESIDENTIAL RENTAL PROPNONRESIDENTIAL REAL PROP

3

OPTIONAL

2

[60]

4547 YES1317

(g) DepreciationDeduction

(e) ConventionHY / MM / MQ

[20]

4548PROPERTY SUBJECT TO SECTION 168(f)(1) ELECTION EF EXPLANATION

ELECTION MADE UNDER SECTION 168(I)(4) TO GROUP ASSETS PLACED IN SERVICE THIS YEAR

( c) Basis for Depr(Busn Use Only.

See Instr)

COST OF QUALIFED KANSAS RECOVERY ASSISTANCE PROPERTY

COST OF QUALIFIED DISASTER ASSISTANCE PROPERTY

TOTAL COST OF SECTION 179 PROPERTY PLACED IN SERVICE

(a) Classification ofProperty

(See Types Below)

18

(b) *Date in Service(Only applicable to

Res rental, Nonres realproperty & 40-yr ADS)

(f) Method:200 DB / 150 DB /

DB / SL

SECTION A

17

15


6

BUSINESS INCOME LIMITATION FOR TAX YEAR (Automatic only if using Asset Manager) (LESSER OF BUSINESS INCOME OR LINE 5)

16

[60]

(a) Description of Property

14

[60]

PROPERTY SUBJECT TO SECTION 168(f)(1) ELECTION EF EXPLANATION


OTHER DEPRECIATION (INCLUDING ACRS)

45764512

CARRYOVER OF DISALLOWED DEDUCTION FROM PRIOR YEAR

2137SPECIAL DEPRECIATION ALLOWANCE FOR QUALIFIED PROPERTY (OTHER THAN LISTED PROPERTY PLACED IN SERVICE DURING THE TAX YEAR

SECTION B - ASSETS PLACED IN SERVICE DURING 2010 USING GEN'L DEPRECIATION SYSTEM OR ALT DEPRECIATION SYSTEM

13

SCHEDULE E AND FORM 8825 DEPRECIATION APPORTIONMENT

SECTION 179 PROPERTY

4552 4553

2

4554

4505772577267731

10

11

Do not use this section for automobiles, certain vehicles, computers and property used for entertainment, recreation or amusement.Instead, use Part V, Listed Property section on page 2.

4589

COST OF QUALIFIED ZONE PROPERTY (QUALIFIED BUSINESS ONLY)

COST OF QUALIFIED EXTENDED GULF OPPORTUNITY ZONE PROPERTY

PROPERTY A PROPERTY B PROPERTY C

ADDITIONAL SCHEDULE

OR FORM

NUMBER

27 - Form 990-EZ Line 14

4549

PROP D (Fm 8825 ONLY)

4577CARRYOVER OF DISALLOWED DEDUCTION TO 2011 (Automatic only if using Asset Manager)

4559

45024501

32 - Form 990-T Sch E33 - Form 990-T Sch I

9 - Form 1065

34 - Form 990-T Sch J35 - PT K-1 Recv'd Unreimb Exp Wksht18 - Other Rental Wksht

CARRY THIS FORM 4562 TO:

1045621OVERRIDE [ # ] MAX CHAR

Asset Description

1

2010(MAY BE USED WITH SYSTEMS 1040, 1041, 1065, 1120 AND 1120S)

LAST NAME Multiple4562 DEPRECIATION AND AMORTIZATION 33

PAGE 1

23 - Beneficiaries - Non-passive24 - Beneficiaries - Passive

Enter Number (1 - 35)

1

25 - Form 99026 - Form 990-PF

1 - Sch A (Points)2 - Form 88293 - Schedule C4 - Schedule E5 - Schedule F6 - Reserved

28 - Form 990-EZ Line 1629 - Form 990-T

21 - PT Sch K Other Dedns22 - CS Sch K Other Dedns

10 - Form 1065 (Sch A)11 - Form 8825 12 - Form 112013 - Form 1120 (Sch A)14 - Form 1120S15 - Form 1120S (Sch A)16 - Form 483517 - Do not carry

19 - Sec 179 Summary20 - Schedule A Misc

30 - Form 990-T Sch A31 - Form 990-T Sch C

7 - Fm 2106 (Other)8 - Form 1041

PART I - SECTION 179 EXPENSES

PART II - SPECIAL DEPRECIATION ALLOWANCE AND OTHER DEPRECIATION

PART III - MACRS DEPRECIATION

PART IV - SUMMARY


45678910

TREAT ALL USE OF VEHICLES BY EMPLOYEES AS PERSONAL USE

37

39

1250 YES

MEETS ALL QUALIFICATIONS TO PREPARE SECTION C

A WRITTEN POLICY STATEMENT MAINTAINED THAT PROHIBITS ALL PERSONAL USE, INCLUDING COMMUTING

A WRITTEN POLICY STATEMENT MAINTAINED THAT PROHIBITS PERSONAL USE OF VEHICLES, EXCEPT COMMUTING

8184 YES

1249 YES

ADDITIONAL LINES ARE AVAILABLE ON INPUT SCREENSECTION C - QUESTIONS FOR EMPLOYERS WHO PROVIDE VEHICLES FOR EMPLOYEES

12 - - 11 - - 10 - - 9 - - 8 - - 7 - - 6 - - 5 - -

- -

2141

BusinessMiles

(Ln 30)

CommuteMiles

(Ln 31)

PrsnlMiles

(Ln 32)

(i) Elected section

179 cost

BUSINESS USE CLAIMED

IF "YES," EVIDENCE IS WRITTEN

SPECIAL DEPRECIATION ALLOWANCE FOR QUALIFIED LISTED PROPERTY PLACED IN SERVICE DURING THE TAX YEAR AND USED MORE THAN 50% IN A QUALIFIED BUSINESS USE

FORM 4562 DEPRECIATION AND AMORTIZATION

IF USING THE STANDARD MILEAGE RATE OR DEDUCTING VEHICLE LEASE EXPENSE, COMPLETE COLUMNS (a) THORUGH ( c) OF SECTION A, ALL OF SECTION B, AND SECTION C IFAPPLICABLE

1045622

PROPERTY D (Form 8825 ONLY)PROPERTY CSCHEDULE E AND FORM 8825 APPORTIONMENT

(d) Code (f) Amortization for this year

(e) Amortizationperiod or %

(MAY BE USED WITH SYSTEMS 1040, 1041, 1065, 1120 AND 1120S)

38

SECTION B - LINE 26 OR 27 AND LINES 30-36 LISTED PROPERTY / VEHICLE INFORMATION

(f)Recovery

period

33PAGE 2

SECTION A - DEPRECIATION AND OTHER INFORMATION

25

Prsnl Use

(Ln 34)

Con-vention

[12]

( c) Busnuse %

(g)Method

(h)Depreciation

deduction

(e) Depreciation Basis(busn/investment)

(d) Cost or other

basis

JVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW C0525D [ # ] MAX CHAR

- - - -

24 a 1214

(b) Date placed

in service

(a) Type ofProperty

(List vehicles first)

1

b

2010

1215 NO

Multiple

NO

40

4 - -

(a) Property Description

AMORTIZATION OF COSTS DURING CURRENT YEAR

[21]( c) Amortizable Amount

23

LAST NAME

PART V - LISTED PROPERTY

OtherVehicle(Ln 36)

5%Owner(Ln 35)

PART VI - AMORTIZATION

- - - - - -

(b) Date acquired

42

PROPERTY B

41

PROVIDE MORE THAN 5 VEHICLES AND RETAIN INFORMATION ON THEM

MEET REQUIREMENTS CONCERNING QUALIFIED AUTOMOBILE DEMONSTRATION USE

1251 YES

1252 YES

1253 YES

4555 4556 4557 4599SCHEDULE E / FORM 8825 AMORTIZATION APPORTIONMENT

434551AMORTIZATION OF COSTS THAT BEGAN BEFORE CURRENT TAX YEAR

PROPERTY A

3846

OTHER RENTAL

38503851

NET GAIN OR (LOSS) FROM FORM 4684, LINES 35 AND 42a

ORDINARY GAIN FROM INSTALLMENT SALES FROM FORM 6252, LINE 25 OR 36

ORDINARY GAIN OR (LOSS) FROM LIKE-KIND EXCHANGES FROM FORM 8824

TOTAL ORDINARY GAIN OR (LOSS)

PART OF LINE 17 THAT IS RELATED TO INCOME FOR FORM 8825 (1065 / 1120S ONLY)FORM 1065 AND1120S ONLY 3433


3849

27433845

3844

AMT GAIN OR (LOSS)

(1040 ONLY)

3

34PAGE 1

SALES OF BUSINESS PROPERTY (LINE 2 OR 10)

2841GROSS PROCEEDS FROM SALES OR EXCHANGES REPORTED ON FORM(S) 1099-S OR 1099-B INCLUDED ON LINES 2, 10 OR 20

(d)Gross Sales

Price

1047971JVA COPYRIGHT FORMS(SOFTWARE ONLY) - 2010 TW M0504A OPTIONAL OVERRIDE

PART Ib

3. FARMLAND (SEE INSTR)

SOLD OR EXCHANGED AT A LOSS

SOLD OR EXCHANGED AT A LOSSb

a

a

PART II PART I

PART II PART I

6 GAIN, IF ANY, FROM LINE 32, FROM OTHER THAN CASULATY OR THEFT

7 LONG-TERM GAIN TO SCHEDULE D LOSS CARRIES TO LINE 11

PART III(1245, 1250)

- -

2301

GAIN OR (LOSS)

3291

PTI orII

- -

- -

(b)Date Acquired

(MM-DD-YYYY)

- -


27792778

- -

FROM 2008

FROM 2007

FROM 2004

2799

a

UNRECAPTURED NET SECTION 1231 LOSS FROM PRIOR YEARS (NOT APPLICABLE TO S CORPORATIONS AND PARTNERSHIPS EXCEPT ELECTING LARGE PARTNERSHIPS)

4

1

PART I - SALE OR EXCHANGE OF PROPERTY USED IN TRADE OR BUSINESS

6 - -

- -

- -

1

PART II

LESS THAN12 MONTHS

PART II

PART II

SOLD AT A LOSS

SOLD AT A GAIN

RAISED CATTLE AND HORSES SOLD AT A GAIN

SOLD AT A LOSS

c

7. OTHER LIVESTOCK USED IN TRADE OR BUSINESS

PART I

RAISED LIVESTOCK SOLD AT A GAIN

b

PART III(1252)

SOLD AT A GAINa

PART III(1255)

5. DISPOSITION OF COST-SHARING PAYMENT PROPERTY DESCRIBED IN SECTION 126

12 MONTHSOR MOREPART III (1245)

PART I

PART I

SOLD AT A GAIN

SOLD AT A LOSS

PART II

PART IIb

1. DEPRECIABLE TRADE OR BUSINESS PROPERTY 2. DEPRECIABLE RESIDENTIAL RENTAL PROPERTY

PART II

EXAMPLES(a)

SHORTTERM

(b)


PART II

PART II

4. ALL OTHER FARMLAND

PART III(1250)

LESS THAN24 MONTHS

(b)

24 MONTHSOR MORE

( c )

PART II

PART I

PART I

PART III(1245)

PART II

PART IIb

a PART II

GAIN, IF ANY, FROM LINE 7 ABOVE, OR AMOUNT FROM LINE 8, IF APPLICABLE

EXAMPLES(a)

6. CATTLE AND HORSES USED IN TRADE OR BUSINESS c

4

5

GAIN, IF ANY, FROM LINE 31

PRIOR YEAR NET SECTION 1231 CARRYOVER LOSS WORKSHEET

PART II - ORDINARY GAINS AND LOSSES

11

3848

[18]

TSJ

(e)Depreciation

Allowed (or Allowable)

(c)Date Sold

(MM-DD-YYYY)

2

(a)Description of

Property

- -

- -

LONGTERM( c )

EXAMPLES OF ITEMS REPORTABLE ON THIS FORM AND WHERE TO ENTER FIRST

17

16

GAIN OR (LOSS)AMT GAIN OR (LOSS)

(1040 ONLY)

12

13

14

7

- -

GAIN, IF ANY FROM FORM 4684, LINE 43

8

S CORPORATION, PARTNERSHIP AND FIDUCIARY GAIN OR (LOSS)

STATE S CORPORATION, PARTNERSHIP AND FIDUCIARY GAIN OR (LOSS) IF DIFFERENT

- -

3847SECTION 1231 GAIN OR (LOSS) FROM LIKE-KIND EXCHANGES FROM FORM 8824

- -

- -

- -

3

5

4797 SALES OF BUSINESS PROPERTY(MAY BE USED WITH SYSTEM 1040, 1041, 1065, 1120, AND 1120S)

StateDepreciation(if different)

- -

AMT Cost or Other Basis(if different)

2010MultipleLAST NAME

AMTDepreciation(if different)

LOSS, IF ANY, FROM LINE 7 ABOVE

STATE(f)

Cost orOther Basis

36717680

3667

ADD-TO

SECTION 1231 GAIN FROM INSTALLMENT SALES FROM FORM 6252, LINE 26 OR 37

2777

REGULAR AMT

15

FROM 2005

7676767776787679

8 366836693670

27832302

FROM 2006

2782

19

3561

MORTGAGE PURCHASER ASSUMES

PRINCIPAL PAYMENTS RECEIVED THIS YEAR

INTEREST PAYMENTS RECEIVED

EXPENSE OF DISPOSITION

IF THE SALE IS A RELATED PARTY INSTALLMENT SALE, SEE FORM 6252 DATA SHEET.

2405TWO-LETTER STATE CODE

27683467

4338

No Entry = OTHER INCOME line of return or Schedule K,(if applicable.)

4339

4340

4335

MULTIPLE NUMBER OF FORM OR SCHEDULE INDICATED ABOVE (I. E. SCHEDULE C, #2)

2767

SECTION 1252 PROPERTY - SOIL, WATER, LAND CLEAR (PARTNERSHIPS - SKIP THIS SECTION)

a

ADDITIONAL DEPRECIATION BETWEEN 1969 AND 1976

SECTION 1254 PROPERTY - INTANGIBLE DRILLING AND DEVELOPMENT COSTS

3842

3888GROSS SALES PRICE

COST OR OTHER BASIS PLUS EXPENSE OF SALE

DEPRECIATION (OR DEPLETION)

ADJUSTED BASIS (LINE 21 LESS LINE 22)

TOTAL GAIN (LINE 20 LESS LINE 23)

2846

b27

INTANGIBLE DRILLING AND DEVELOPMENT COSTS, EXPENDITURES FOR DEVELOPMENT OF MINES, OTHER NATURAL DEPOSITS, MINING EXPLORATION COSTS AND DEPLETION

SECTI0N 280f(b)(2)SECTION 179

a

SOIL, WATER AND LAND CLEARING EXPENSE

LINE 27a TIMES APPLICABLE PERCENTAGE

ENTER 1, 2, 3, OR 4

2406

22

23

24

2845

2775 3852

d

4333ADDITIONAL DEPRECIATION AFTER 1975

APPLICABLE PERCENTAGE MULTIPLIED BY THE SMALLER OF LINES 24 AND 26a26 4334

a 4332DEPRECIATION ALLOWED (SEE INSTRUCTIONS)25 3840 2843

AMT (IF DIFF)

21

COMPUTATION OF GAIN

43293838

OWNERSHIP [T] = TP [S] = SP [J] = JT (Default)


[1]

SECTION 1245 PROPERTY - BUSINESS ASSETS

43304331 3839

YES

2842

20

CARRY TO SCHEDULE E

b

a 3841SECTION 1250 PROPERTY - DEPRECIABLE REAL PROPERTY

0201

FEDERAL

1040ONLY

2010PAGE 2

4797 SALES OF BUSINESS PROPERTYLAST NAME Multiple

0203PASSIVE

ACTIVITIES[2]0204

KEYFIELD

[50]

4327 - -

28

[2]0202

STATE (IF DIFF)

MULTIPLE

1047972JVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW M0504A [ # ] MAX CHAROPTIONAL

4326 - -DATE ACQUIRED

EXPENSE DEDNS

AUTOMATICALLY CREATE FORM 6252 FOR THIS PROPERTY

4342

DATE SOLD

SECTION 1255 - COST SHARE PAY (SECTION 126)

29

STATE, IF DIFFERENT

PART IV - RECAPTURE OF AMOUNTS UNDER SECTIONS 179 AND 280F(b)(2)

FEDERAL

RECOVERY DEDNS

PART III - GAIN FROM DISPOSITION OF PROPERTY UNDER SECTIONS 1245, 1250, 1252, 1254, AND 1255

34

32

1 = Schedule C, Line 62 = Schedule F, Line 103 = Form 4835, Line 64 = DO NOT CARRY

DESCRIPTION OF SECTION 1245, 1250, 12152, 1254, OR 1255 PROPERTY. NOTE: ENTER "S1250" AT BEGINNING OF DESCRIPTION IF SECTION 1250 PROPERTY.

24382831 2895 2404

(MAY BE USED WITH SYSTEM 1040, 1041, 1065, 1120, AND 1120S)

2439

a APPLICABLE PERCENTAGE EXCLUDED FROM INCOME UNDER SECTION 126 (SEE INSTRUCTIONS) 4341

2609 2403

PORTION OF LINE 32 FROM CASUALTY AND THEFT (ON FORM 4684)

33

34SECTION 179 EXPENSE DEDUCTION OR DEPRECIATION ALLOWABLE IN PRIOR YEARS

RECOMPUTED DEPRECIATION

CARRY RECAPTURED AMOUNTTO FORM OR SCHEDULE:

2608

2

IF CONDITIONS WERE ATTACHED TO ANY CONTRIBUTION LISTED IN PART I, ANSWER THE FOLLOWING QUESTIONS:

RESTRICTION (TEMPORARY OR PERMANENT) ON DONEE'S RIGHT TO USE OR DISPOSE OF DONATED PROPERTY?

RESTRICTION EF EXPLANATION

1301 YES

2379

[25] 0314

METHOD USED TO DETERMINEFAIR MARKET VALUE



[20] [20] [20] [20] [20]

[35]

DESCRIPTION OF DONATION

CITY, STATE , ZIP CITY, STATE , ZIP CITY, STATE , ZIP

[30][30]

DONEE ORGANIZATION

[35]

[30]

[35]

SECTION A - DONATIONS OF $5,000 OR LESS PER ITEM AND CERTAIN PUBLICLY TRADED SECURITIES

[25]

DONEE ORGANIZATION

[30]

* TYPE OF CONTRIBUTION: 1 = (50%) NONCASH CONTRIB 2 = (30%) NONCASH CONTRIB 3 = (30%) CAPITAL GAIN PROP 4 = (20%) CAPITAL GAIN PROP

[25][25][25] [25]

OWNERSHIP (T - S - J) OWNERSHIP (T - S - J)

CITY [15]ADDRESS

OWNERSHIP (T - S - J)

DONEE ORGANIZATION

QUALIFIED CONSERVATION OR REDUCED FMV EF EXPLANATION


- - - -


1082831


D EC

1302

TOTAL AMOUNT CLAIMED AS DEDUCTION FOR PROPERTY IN PART I FOR THIS TAX YEAR


8283 NONCASH CHARITABLE CONTRIBUTIONS

[ # ] MAX CHAR


ENTER LETTER FROM PART I WHICH IDENTIFIES THE PROPERTY

A B

[35]

NAME/ADDRESS OF ORGANIZATION TO WHICH ANY SUCH CONTRIB WAS MADE IN A PRIOR YEAR (COMPLETE ONLY IF DIFFERENT FROM DONOR ORGANIZATION ABOVE)

0315

(1)

(2) TOTAL AMOUNT CLAIMED AS DEDUCTION FOR ANY PRIOR YEARS

[30]

[25]e

NAME OF CHARITABLE ORGANIZATION

STATE

ZIP CODE


NAME OF PERSON (NOT DONEE ORGANIZATION) HAVING ACTUAL POSSESSION OF PROPERTY

36PAGE 1

d

TYPE OF CONTRIBUTION *

a

DATE ACQUIRED BY DONOR

IF LESS THAN ENTIRE INTEREST IN THE PROPERTY IS CONTRIBUTED DURING THE YEAR, COMPLETE THE FOLLOWING:

PART I - INFORMATION ON DONATED PROPERTY (ENTER VEHICLES ON FORM 1098-C SCREEN)

PART II - PARTIAL INTEREST AND RESTRICTED USE PROPERTY

DATE CONTRIBUTED DATE CONTRIBUTED

LOCATION OF TANGIBLE PROPERTY

DATE CONTRIBUTED

FAIR MARKET VALUE FAIR MARKET VALUE

b

0261

0258



STREET ADDRESS OF ABOVE

[35][35]

[30]


STREET ADDRESS OF ABOVE

[30]

- -- -


DONEE ORGANIZATION

CITY, STATE , ZIP

TYPE OF CONTRIBUTION *TYPE OF CONTRIBUTION * TYPE OF CONTRIBUTION *

[30][30][30]

CITY, STATE , ZIP

DONEE ORGANIZATION


DATE CONTRIBUTED DATE CONTRIBUTED

- - - -

FAIR MARKET VALUE FAIR MARKET VALUE

HOW ACQUIRED HOW ACQUIRED

DONOR'S COST OR BASIS

HOW ACQUIRED HOW ACQUIREDHOW ACQUIRED


- -

- - - -DATE ACQUIRED BY DONOR



FAIR MARKET VALUE

STREET ADDRESS OF ABOVE STREET ADDRESS OF ABOVE STREET ADDRESS OF ABOVE

- -

QUALIFIED CONSERVATION/REDUCED FMV



DONOR'S COST OR BASIS DONOR'S COST OR BASIS


ANYONE ELSE GIVEN RIGHT TO INCOME OR POSSESSION OF PROPERTY, INCLUDING RIGHT TO VOTE DONATED SECURITIES, OR ACQUIRE PROP BY PURCHASE OR OTHERWISE, OR DESIGNATE PERSON HAVING SUCH INCOME, PSEESEEION, OR RIGHT TO ACQUIRE?



[60]

[60]

[60]

[60]

[60]

YES

0262

0256(A - B - C- D - E)

2501

ANY RESTRICTION LIMITING DONATED PROPERTY FOR A PARTICULAR USE?

RESTRICTION ON USE EF EXPLANATION

3

c

1303 YES

GIVE RIGHTS EF EXPLANATION

[25]


0312 0313

b

DONATED PROPERY OF $5,000 OR LESS AND CERTAIN PUBLICLY TRADED SECURITIES


1


a

c

[60]

[60]

[60]

[8][8][8][8]

[8][8][8][8][8]

[8]

[8][8][8][8][8]

[8]

[10]

DATE ACQUIRED

[25]

[10][10]

APPRAISED FAIR MARKET VALUE

IF TANGIBLE PROPERTY, PHYSICAL CONDITION

[30]

SECTION B - DONATED PROPERTY OVER $5,000 (EXCEPT CERTAIN PUBLICLY TRADED SECURITIES)

[ # ] MAX CHAR

PART I - INFORMATION ON DONATED PROPERTY (ENTER VEHICLES ON FORM 1098-C SCREEN)

[25][25][25]

[33] [33]

BUSINESS ADDRESS [30]

[18]

0318TITLE 0268

YES

NO1279DOES ORGANIZATION INTEND TO USE PROPERTY FOR UNRELATED USE?

03160276

0265 - EMPLOYER IDENTIFICATION NUMBER

0319 CITY 0267[20]

[18] STATE

AVG TRADING PRICE OF SECURITIES(SEE INSTRUCTIONS)

STATE

A B C


AMOUNT CLAIMED AS DEDUCTION

36PAGE 2

LAST NAMENONCASH CHARITABLE CONTRIBUTIONS, CONT'D

Multiple

40176

TYPE OF PROPERTY (1 THROUGH 9)

2010

FOR BARGAIN SALES,AMOUNT RECEIVED


DONATED PROPERTYDESCRIPTION



DATE ACQUIRED

[11]

D



APPRAISER INFORMATION:

0275ZIP CODE

[13]


PART III - DECLARATION OF APPRAISER


1082832

0271

0317 CITY

1 [17]



[13] [13]


DATE ACQUIRED


DATE ACQUIRED


[10]

[33] [33]

1 = Art (Contribution of $20,000 or more)2 = Art (Contribution under $20,000)3 = Collectibles

4 = Qualified Conservation Contribution5 = Other Real Estate6 = Intellectual Property

7 = Equipment8 = Securities9 = Other




1 = (50%) NONCASH CONTRIBUTION 2 = (30%) NONCASH CONTRIBUTION 3 = (30%) CAPITAL GAIN PROPERTY 4 = (20%) CAPITAL GAIN PROPERTY


DONOR'S COST OR BASISDONOR'S COST OR BASIS DONOR'S COST OR BASIS

HOW ACQUIRED



[10] - -

[10]


HOW ACQUIRED

0266ZIP CODE

TYPE OF CONTRIBUTION * TYPE OF CONTRIBUTION * TYPE OF CONTRIBUTION *

* TYPE OF

CONTRIBUTION


0269 - - 0448 - PART IV - DONEE ACKNOWLEDGMENT (TO BE COMPLETED BY CHARITABLE ORGANIZATION)

SOCIAL SECURITY NUMBER EMPLOYER IDENTIFICATION NUMBER

[11][11] [11]

OR

1312

[30]

[13][13]

0263 - -DATE QUALIFIED ORGANIZATION RECEIVED DONATED PROPERTY DESCRIBED IN PART I ABOVE


DESCRIPTION

0274

HOW ACQUIRED

[8] [8] [8]FOR BARGAIN SALES,AMOUNT RECEIVED

HOW ACQUIRED

[10]- - - - [10] - -

[13] [13]

[13]

LETTER (A - D)

[13]

LAST NAME

ADDRESS


CHARITABLE ORGANIZATION (DONEE) NAME 0264

DONATED PROPERTY OVER $5,000 (EXCEPT CERTAIN PUBLICLY TRADED SECURITIES

5

PART II - TAXPAYER (DONOR) STATEMENT

LIST ANY ITEM(S) INCLUDED IN SECTION B, PART I, SEPARATELY IDENTIFIED AS VALUED AT NO MORE THAN $500 PER ITEM

[13][13][13]

0557 DATE SIGNED 0558 - -TITLE

05560555FIRST NAME

STATE 0318 TITLE 0268EMPLOYER IDENTIFICATION NUMBER 0265 -

CHARITABLE ORGANIZATION NAME 0264ADDRESS 0266ZIP CODE 0319 CITY 0267

DATE ORGANIZATION RECEIVED PROPERTY DESCRIBED IN PART I ABOVE 0263 - -DOES ORGANIZATION INTEND TO USE PROPERTY FOR UNRELATED USE?

1312 YES

1279 NO

SSN 0269 - - OR EIN 0448 - DONEE ACKNOWLEDGEMENT (COMPLETED BY CHARITABLE ORGANIZATION)

ZIP CODE 0317 CITY 0276 STATE 0316

TITLE 0557DATE SIGNED 8002 - -BUSINESS ADDRESS 0275

DECLARATION OF APPRAISER

0275

SSN EINOR

DATE SIGNED

TITLE 05578002 - -

BUSINESS ADDRESS

03180265 -

TITLE 0268EMPLOYER IDENTIFICATION NUMBER

ZIP CODE 0319 CITY

STATE

0267ADDRESS

02640266

0263 - -1312 YES

1279 NO

DATE ORGANIZATION RECEIVED PROPERTY DESCRIBED IN PART I ABOVE

0317 CITY 0276 STATE

CHARITABLE ORGANIZATION NAME

DOES ORGANIZATION INTEND TO USE PROPERTY FOR UNRELATED USE?

FIRST NAME 0555LAST NAME 0556

03160269 - - 0448 - DONEE ACKNOWLEDGEMENT (COMPLETED BY CHARITABLE ORGANIZATION)

ZIP CODE

INFORMATION TO BE COMPLETED FOR VEHICLES OVER $5,000:

DECLARATION OF APPRAISER

FIRST NAME 0555LAST NAME

CORRECTED FORM 1098-C 8704CORRECTED FORM 1098-C 8704

YEAR 8733 MAKE & MODEL 8715

0556

6

8726 YES7

INFORMATION TO BE COMPLETED FOR VEHICLES OVER $5,000:

c

8728 YES

DESCRIPTION OF GOODS AND SERVICES PROVIDED:

8725

8724 YESGOODS AND SERVICES CONSISTED SOLELY OF INTANGIBLE RELIGIOUS BENEFITS

TYPE OF CONTRIBUTION: 1 - 50% NONCASH CONTRIB 3 - 30% CAPITAL GAIN PROP 2 - 30% NONCASH CONTRIB 4 -20% CAPITAL GAIN PROP

8720 YESDESCRIPTION OF IMPROVEMENTS OR SIGNIFICANT INTERVENING USE:

8721 [80]

9841 YES

VALUE OF GOODS AND SERVICES PROVIDED

8727

[80]

b

WERE GOODS AND SERVICES PROVIDED IN EXCHANGE FOR VEHICLE? 8722

DONOR MAY NOT CLAIM DEDUCTION OF MORE THAN $500

a

DESCRIPTION OF PHYSICAL CONDITION OF ITEM (IF DEDUCTION EXCEEDS $5,000):

8732

5

a

b

8719 YESVEHICLE WILL NOT BE TRANSFERRED

VEHICLE WILL BE TRANSFERRED FOR LESS THAN FMV

a

b DATE OF SALE

GROSS PROCEEDS FROM SALEc

4

87153

DATE OF CONTRIBUTION 8714

9840

VEHICLE OR OTHER ID NUMBER 8716 YES8717VEHICLE WAS SOLD IN ARM'S LENGTH TRANSACTION

[30]

LAST NAME

WAS THIS ITEM ORDINARY INCOME PROPERTY OR LIMITED TO ITS COST BASIS FOR DEDUCTION PURPOSES?


COST OR OTHER BASIS OF ITEM

8729[9]

STATE

YEAR, MAKE AND MODEL OF VEHICLE:

DONEE'S PAYER'S CITY

8705

9843

[14]DONEE'S PHONE NUMBER 8712

2YEAR 8733 MAKE & MODEL

8718

HOW WAS ITEM ACQUIRED?

DONEE'S PAYER'S ZIP

DONEE'S NAME (CONTINUED) 8707 [30]

[9]

1 DATE OF CONTRIBUTION 8714

FAIR MARKET VALUE ON DATE OF CONTRIBUTION

METHOD USED TO DETERMINE FMV

87309842

YES

DONEE'S STREET ADDRESS 8708 [30]

DONEE'S STREET ADDRESS

8706

8707

8708

DONEE'S NAME (CONTINUED)

DONEE'S NAME


DONEE

DONEE'S NAME [30]

DONEE

8706 [30]

[14]

DONEE'S PAYER'S ZIP 8711 [10] STATE 8709 [2]

DONEE'S PAYER'S CITY 8710 [20]

DONEE'S PHONE NUMBER 8712

2YEAR, MAKE AND MODEL OF VEHICLE:

8709

3 VEHICLE OR OTHER ID NUMBER 8716 [23]

1

DONEE'S FEDERAL ID NUMBER 8713 -

8717 YES

b DATE OF SALE 8718c GROSS PROCEEDS FROM SALE 9840

8721 [80]

VEHICLE WILL BE TRANSFERRED FOR LESS THAN FMV 8720 YES

c

VEHICLE WILL NOT BE TRANSFERRED 8719

cc

DESCRIPTION OF GOODS AND SERVICES PROVIDED:

8725

8724 YES

YES

b

b

8727

4a VEHICLE WAS SOLD IN ARM'S LENGTH TRANSACTION

5

a

7 DONOR MAY NOT CLAIM DEDUCTION OF MORE THAN $500

DESCRIPTION OF IMPROVEMENTS OR SIGNIFICANT INTERVENING USE:

DATE ACQUIRED BY DONOR 8729HOW WAS ITEM ACQUIRED?

8726 YES

6

WERE GOODS AND SERVICES PROVIDED IN EXCHANGE FOR VEHICLE? 8722 YESa

8730 [9]

COST OR OTHER BASIS OF ITEM 9842

[80]GOODS AND SERVICES CONSISTED SOLELY OF INTANGIBLE RELIGIOUS BENEFITS

1 - 50% NONCASH CONTRIB 3 - 30% CAPITAL GAIN PROP 2 - 30% NONCASH CONTRIB 4 -20% CAPITAL GAIN PROPWAS THIS ITEM ORDINARY INCOME PROPERTY OR LIMITED TO ITS COST BASIS FOR DEDUCTION PURPOSES? 8728 YES

101098C[ # ] MAX CHARJVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW C0524D KEYFIELD

METHOD USED TO DETERMINE FMV 8731 [20]DESCRIPTION OF PHYSICAL CONDITION OF ITEM (IF DEDUCTION EXCEEDS $5,000):

[20]8731

TYPE OF CONTRIBUTION:

37 PG 1

# FORM 1098-C

8713 -

VALUE OF GOODS AND SERVICES PROVIDED 9841

20101098 -C MOTOR VEHICLES, BOATS, AIRPLANE CONTRIBUTIONS

#

8705FORM 1098-C


[2][10]8711

[9]

[20]8710

DONEE'S FEDERAL ID NUMBER

YES

[23]

[30]

[30]

8732 [30]

FAIR MARKET VALUE ON DATE OF CONTRIBUTION 9843

DEBT DESCRIPTION

8210 [30]

[30]

[30]

3 INTEREST IF INCLUDED IN BOX 2 7304

[30]

[30]

[30]

8204 [35]

DEBT DESCRIPTION

8210

8205[2][10]8199

[30]

#

2010

[4]

CANCELLATION OF DEBT

8208

8209

FORM 1099-C

[9]

[22]8197

37 PG 2

# FORM 1099-C

8207

7304INTEREST IF INCLUDED IN BOX 23

DATE CANCELED

8223BANKRUPTCY6 YES

5 8735BANKRUPTCY

8198STATE 8198

7307

1

7303AMOUNT OF DEBT CANCELED2

4

[4]

4

8223 YES

7

5 DEBTOR PERSONALLY LIABLE FOR REPAYMENT OF DEBT 8735 YES

6

1 DATE CANCELED 82092 AMOUNT OF DEBT CANCELED 7303

[10] [2]

CREDITOR'S PAYER'S CITY 8197 [22]

STATECREDITOR'S PAYER'S ZIP

CREDITOR'S PAYER'S CITY

[9]

8204 [35]CREDITOR'S PAYER'S ADDRESS 8205 [35]

CREDITOR'S PAYER'S ZIP 8199

8202CITY STATE ZIP (IF DIFFERENT) 8203

DEBTOR'S ADDRESS (IF DIFFERENT)

CREDITOR'S PAYER'S ADDRESS

CREDITOR'S FEDERAL ID NUMBER 8207CREDITOR'S PAYER'S NAME

[35]

CREDITOR'S FEDERAL ID NUMBERCREDITOR'S PAYER'S NAME

DEBTOR'S NAME (IF DIFFERENT)

[T]AXPAYER OR [S]POUSE [T]AXPAYER OR [S]POUSE

DEBTOR DEBTOR

8201DEBTOR'S NAME (IF DIFFERENT) [30]

LAST NAME

CITY STATE ZIP (IF DIFFERENT)

8201

8202

8203CREDITOR

8208

CREDITOR

DEBTOR'S ADDRESS (IF DIFFERENT)

ENTER MULTIPLE # OF FORM (IF CARRYING TO SCH C, E, F OR FM 4835) IF THERE IS ONLY ONE MULTIPLE, ENTER '1' 8737

YESDEBTOR PERSONALLY LIABLE FOR REPAYMENT OF DEBT

CARRY TAXABLE DEBT

CANCELLATION INCOME TO:

1 = 1040, LINE 21 2 = SCH C, LINE 6 3 = SCH E, LINE 3

7307FAIR MARKET VALUE OF PROPERTY

EXCEPTIONS TO DEBT CANCELLATION INCOME

QUALIFYING STUDENT LOAN DEBTS 9138

7

4 = SCH F, LINE 105 = FORM 4835, LINE 6 8736

DEBT CANCELED (IF NOT EQUAL TO FM 1099-C, BOX 2) 9136

OTHER EXCEPTIONS 9140

AMOUNT OF BOX 3 INTEREST OTHERWISE DEDUCTIBLE 9137

EXCLUSIONS FROM INCOME

ENTER AMOUNTS REQUIRED FOR ANY EXCLUSION(S) THAT APPLY TO THISCANCELED DEBT:

BANKRUPTCY 9141

CANCELLATION OF DEBTS AS GIFTS

9142

8738 YES

9139

9143

AMOUNT DISCHARGED IN BANKRUPTCY

CANCELED DEBT SECURED BY PRINCIPAL RESTOTAL DEBT ON PRINCIPAL RES IMMEDIATELY BEFORE FORECLOSURE, SHORT SALE, ABANDONMENT, OTHER PROPERTY TRANSFER

QUALIFIED REAL PROPERTY BUSINESS DEBT EXCLUDED

9144EXTENT OF INSOLVENCY (VALUE OF DEBTS IN EXCESS OF VALUE OF ASSETS)AMOUNT OF INSOLVENCY EXCLUSION APPLIED TO DEBT

AMT OF PRINCIPAL RES EXCLUSION APPLIED

DEBT AMOUNT NOT QUALIFIED FOR EXCLUSION

IF CANCELED DEBT WAS NONRECOURSE DEBT, BALANCE OF DEBT IMMEDIATELY BEFORE PROPERTY WAS TRANSFERRED 9151

INSOLVENCY9145

9146

GAIN OR LOSS FROM FORECLOSURE

IF CANCELED DEBT WAS RECOURSE DEBT, FAIR MKT VALUE OF PROPERTY FORECLOSED 9150

FAIR MARKET VALUE OF PROPERTYCARRY TAXABLE

DEBT CANCELLATION

INCOME TO:

1 = 1040, LINE 21 2 = SCH C, LINE 6 3 = SCH E, LINE 3

4 = SCH F, LINE 105 = FORM 4835, LINE 6

AMOUNT OF BOX 3 INTEREST OTHERWISE DEDUCTIBLE

91479148

8736

DEBT CANCELED (IF NOT EQUAL TO FM 1099-C, BOX 2) 9136

ADJUSTED BASIS OF PROPERTY GIVEN UP 9152

QUALIFIEDPRINCIPAL

RESIDENCEDEBT:

QUALIFIED FARM DEBT EXCLUDED

9137EXCEPTIONS TO DEBT CANCELLATION INCOME

QUALIFYING STUDENT LOAN DEBTS 9138CANCELLATION OF DEBTS AS GIFTS 9139

9144

OTHER EXCEPTIONS 9140EXCLUSIONS FROM INCOME

ENTER AMOUNTS REQUIRED FOR ANY EXCLUSION(S) THAT APPLY TO THISCANCELED DEBT:

BANKRUPTCY AMOUNT DISCHARGED IN BANKRUPTCY 9141

9147

QUALIFIEDPRINCIPAL

RESIDENCEDEBT:

CANCELED DEBT SECURED BY PRINCIPAL RES 8738 YESTOTAL DEBT ON PRINCIPAL RES IMMEDIATELY BEFORE FORECLOSURE, SHORT SALE, ABANDONMENT, OTHER PROPERTY TRANSFER 9142DEBT AMOUNT NOT QUALIFIED FOR EXCLUSION 9143AMT OF PRINCIPAL RES EXCLUSION APPLIED

QUALIFIED REAL PROPERTY BUSINESS DEBT EXCLUDED 9148

INSOLVENCY

EXTENT OF INSOLVENCY (VALUE OF DEBTS IN EXCESS OF VALUE OF ASSETS) 9145AMOUNT OF INSOLVENCY EXCLUSION APPLIED TO DEBT 9146

QUALIFIED FARM DEBT EXCLUDED

[ # ] MAX CHARJVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW S0125S KEYFIELD

GAIN OR LOSS FROM FORECLOSURE

IF CANCELED DEBT WAS RECOURSE DEBT, FAIR MKT VALUE OF PROPERTY FORECLOSED 9150IF CANCELED DEBT WAS NONRECOURSE DEBT, BALANCE OF DEBT IMMEDIATELY BEFORE PROPERTY WAS TRANSFERRED 9151

ENTER MULTIPLE # OF FORM (IF CARRYING TO SCH C, E, F OR FM 4835) IF THERE IS ONLY ONE MULTIPLE, ENTER '1' 8737

OVERRIDE

ADJUSTED BASIS OF PROPERTY GIVEN UP 9152

101099C

LINES 17 THROUGH 20, OUTSIDE BASIS CALCULATION, AT RISK BASIS CALCULATION, PRIOR YEAR UNALLOWED LOSSES,

PASSIVE ACTIVITY CALCULATION AND UNREIMBURSED PARTNER EXPENSES WORKSHEET, ARE FOUND ON SIDE 2.

KEYFIELD

OHIO CITY

OHIO WORKING CITY 8605 [20]

FOREIGN PARTNERSHIP

B PARTNERSHIP ADDRESS

PARTNERSHIP ZIP CODE

42014743

12

15

AMOUNT

3

1237

7190

DATE TO: 8618 - -DATE FROM: 8619 - -

4769

YES

[40]

2

TOTAL FOREIGN TAXES PAID (FOR 1040 AND 1041 ONLY)

2

NOTE: INFORMATION FOR THE FOREIGN TAX CREDIT SHOULD BE ENTERED ON FORM 1116, UNLESS THE AMOUNT IS LESS THAN $300 ($600 IF FILING MFJ).

FOREIGN TRANSACTIONS

L

9

c UNRECAPTURED SECTION 1250 GAIN

CODE

13

4072

1DESCRIPTION

1

SECTION 179 EXPENSE DEDUCTION

D

INTEREST INCOME

INTEREST ON U.S. GOVERNMENT OBLIGATIONS5

YES

YES14051406

ORDINARY BUSINESS INCOME (LOSS) FROM TRADE OR BUSINESS ACTIVITIES

2

4056

4763

4728

LIMITED PARTNER OR OTHER LLC MEMBER

4739

76204755

GENERAL PARTNER OR LLC MEMBER-MANAGER

1

6ORDINARY DIVIDENDS 4057

b

4038a

QUALIFIED DIVIDENDS

4055

JVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW C0528D 10LPTK11

4071

1

16

4142

OTHER DEDUCTIONS

SECTION 179 CARRYOVER FROM PRIOR YEAR FORM 4562

14 4041

4073C GROSS NONFARM INCOME

A

B

NET EARNINGS (LOSS) FROM SELF-EMPLOYMENT - NONFARM

NET EARNINGS (LOSS) FROM SELF-EMPLOYMENT - FARM

4758

SELF-EMPLOYMENT EARNINGS (LOSS)

AMOUNT

10

11

FROM TRADE OR BUSINESS ACTIVITIES

FROM RENTAL REAL ESTATE ACTIVITIESNET SECTION 1231

GAIN OR (LOSS)(ENTIRE YEAR) FROM OTHER RENTAL ACTIVITIES

3

4095 YES

PUBLICLY TRADED PARTNERSHIP

4753

4080 4754

4133 47444060

2010

YESMATERIALLY PARTICIPATED IN TRADE OR BUSN ACTIVITY 4045

LAST NAME Multiple

REAL ESTATE PROFESSIONAL 1367

4752

YES4051

4044 YES

PARTNERSHIP IDENTIFICATION NUMBER [9]4052

8601

39 pg 1

PARTNERSHIP OWNERSHIP CODE: T = TP S = SP J = JT (Default)

PARTNERSHIP K-1 RECEIVED DATA SHEET 1

4054A

4751

INCOME OR LOSS

FEDERALCA / PA STATE

(IF DIFFERENT)

YESSOME IS NOT AT RISK 4047

PARTNERSHIP NAME

[40] YES4053

[30]

ACTIVE RENTAL REAL ESTATE8602

GUARANTEED PAYMENTS TO PARTNER

AMOUNT

NET SHORT-TERM CAPITAL GAIN (LOSS) (ENTIRE YEAR)

7619ROYALTY INCOME 4085

4134

b

4068

47574059

SECTION 179 DEDUCTION (FORM 1040 ONLY)

4144

COLLECTIBLES (28%) RATE GAIN OR (LOSS)

4745

CODE DESCRIPTION

3OTHER UNREIMBURSED EXPENSES

CREDITS

47754147

NET SHORT-TERM NONPORTFOLIO CAPITAL GAIN (LOSS) (ENTIRE YEAR)

NET LONG-TERM NONPORTFOLIO CAPITAL GAIN (LOSS) (ENTIRE YEAR)

2

G

1415

NET INCOME (LOSS) FROM RENTAL REAL ESTATE ACTIVITIES

FINAL DISPOSITION OR EXEMPT FROM LIMITATION

47594078

4058 4756

40814082

NET LONG-TERM CAPITAL GAIN (LOSS) (ENTIRE YEAR)

OTHERINCOME

OR(LOSS)

3

7

8

DESCRIPTIONCODE

NET INCOME (LOSS) FROM OTHER RENTAL ACTIVITIES

a

[ # ] MAX CHAR

DESCRIPTION / DISTRIBUTIVE SHARE ITEMS

GROSS FARMING OR FISHING INCOME

NOADJUST LIMITED PTR OR OTHER LLC MEMBER'S SELF EMPL INCOME BY ANY SEC 179, UNREIMBURSED PTSHP, AND DEPLETION EXPENSES

4

3970

CA (IF DIFFERENT)

OPTIONALJVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW C0528D KEYFIELD 10LPTK12

3972

OTHER DEDUCTIONS

ITEMS AFFECTING OUTSIDE BASIS CARRYOVER LOSSES AND AT-RISK CALCULATIONS ARE

LOCATED ON SIDES 3 AND 4.

OTHER PORTFOLIO INCOME (LOSS)

OTHER INCOME (LOSS)

BASIS

3977 39733976

39713975SECTION 59(e)(2) EXPENDITURES

3974

3

4791TWO-LETTER STATE CODE 4149

AMOUNTCODE DESCRIPTION

AMOUNT

8429

7187DISTRIBUTIONS OF PROPERTY OTHER THAN MONEY

47484148

AMOUNT

CA / PA STATE

3

4700TAX-EXEMPT DIVIDEND INCOME

39 pg 2

FEDERAL

PARTNERSHIP K-1 RECEIVED DATA SHEET 2LAST NAME

(IF DIFFERENT)

Multiple

ALTERNATIVE MINIMUM TAX (AMT) ITEMS

2010

DISTRIBUTIONS

2

18

7186

1

2

TAX-EXEMPT INTEREST INCOME

1

2

TAX-EXEMPT INCOME AND NONDEDUCTIBLE EXPENSES


CODE

TAX-EXEMPT INTEREST FROM PRIVATE ACTIVITY BONDS

EXCESS INTANGIBLE DRILLING COSTS

B

CASH AND MARKETABLE SECURITIES

1

A

A

OTHER INFORMATION

CODE DESCRIPTION

20

19

DESCRIPTION

NOTE: OTHER AMT ITEMS MUST BE ENTERED ON THE APPROPRIATE LINES OF FORM 6251.

3

FROM SUPPLEMENTAL LINE

17

NOTE:

CARRY TO THE TAX RETURN AND MUST BE MANUALLY ENTERED PER THE INSTRUCTIONS PROVIDED WITH THE SCH K-1. THE ALLOWED GAIN OR LOSS MAY ALSO BE SUBJECT TO THE AT-RISK BASIS LIMITATIONS AND SHOULD BE ENTERED IN THE CORRESPONDING AT-RISK FIELDS.

THE FOLLOWING ITEMS DO NOT CARRY AUTOMATICALLY TO THE OUTSIDE BASIS CALCULATION. THESE FIELDS HAVE BEEN PROVIDED TO ALLOW FOR MORE ACCURATE CALCULATION OF LOSSES ALLOWED ON OTHER LINES. ANY RELATED GAINS / LOSSES ALLOWED WILL NOT

OUTSIDE BASIS CALCULATION

OTHER CURRENT OUTSIDE BASIS INCOME (LOSS) ITEMS

DECREASES IN SHARE OF PARTNERSHIP LIABILITIES

OTHER BASIS INCREASES

OTHER BASIS DECREASES

427742787158

MONEY

PROPERTY (ADJUSTED BASIS)

4276END OF YEAR

7629

7155

7625

BASIS AT BEGINNING OF THE YEAR

OTHER

SHARE OF LIABILITIES

7626NONRECOURSE

BEGINNING OF YEAR ADJUSTMENTS

76237624 7627

SERVICES (FAIR MARKET VALUE - IF TAXED)

INCREASES IN SHARE OF PARTNERSHIP LIABILITIES

7634

76327633

76307628

7157

QUALIFIED NONRECOURSE FINANCING

76357636

PARTNERSCONTRIBUTIONS

7631

OTHER DEDUCTIONS 39623966

3969 396539683967

KEYFIELDOVERRIDE

INCREASES FOR YEAR (OTHER THAN INCOME ITEMS FROM ABOVE)

DECREASES FOR YEAR (OTHER THAN DEDUCTIONS FROM ABOVE)

AMOUNT AT RISK


OTHER INCOME (LOSS)

THE FOLLOWING ITEMS DO NOT CARRY AUTOMATICALLY TO THE AT-RISK BASIS CALCULATION. THESE FIELDS HAVE BEEN PROVIDED TO ALLOW FOR MORE ACCURATE CALCULATION OF LOSSES ALLOWED ON OTHER LINES. ANY GAINS / LOSSES ALLOWED RELATED TO THESE ENTIRES WILL NOT CARRY TO THE TAX RTN AND MUST BE MANUALLY ENTERED PER THE INSTRUCTIONS PROVIDED WITH THE SCH K-1.

PRIOR YEAR AT-RISK CARRYOVER LOSSES AND

PRIOR YEAR PASSIVE CARRYOVER LOSSES

ARE LOCATED ON SIDE 4.

3963

OTHER CURRENT AT-RISK BASIS INCOME (LOSS) ITEMS

CA (IF DIFFERENT)BASIS

NOTE:

SECTION 59(e)(2) EXPENDITURES

42457613

42447172

OTHER DEDUCTIONS

ROYALTY DEDUCTIONS

2997

47502996

4749

AT-RISK BASIS CALCULATION

1413 YESSUPPRESS PRINTING OF AT-RISK RECONCILIATION AND ALLOCATION WORKSHEETS

ADJUSTED AT-RISK BASIS AT BEGINNING OF YEAR (ENTER -1 FOR -0-)

DEDUCTIONS RELATED TO PORTFOLIO INCOME - OTHER

INVESTMENT INTEREST EXPENSE

4246NONDEDUCTIBLE EXPENSES

4266


7170UNREIMBURSED PARTNERSHIP EXPENSES

71714243

20% NONCASH CAPITAL GAIN PROPERTY

100% CASH

42423996

4241

7166

715971607161716271637165

39 pg 3 PARTNERSHIP K-1 RECEIVED DATA SHEET 3LAST NAME

4250

Number2010

NET LOSS FROM OTHER RENTAL ACTIVITIES

PRIOR YEAR OUTSIDE BASIS CARRYOVER LOSSES

BASIS CA (IF DIFFERENT)

4237

4240

71674238

7164

RENTAL REAL ESTATE ACTIVITIES

OTHER PORTFOLIO LOSS

OTHER LOSS

50% NONCASH

4236

ORDINARY LOSS

NET LOSS FROM RENTAL REAL ESTATE ACTIVITIES

SECTION 179 EXPENSE

30% NONCASHCHARITABLE

CONTRIBUTIONS 30% NONCASH CAPITAL GAIN PROPERTY

50% CASH

NET SHORT-TERM CAPITAL LOSS

OTHER RENTAL ACTIVITIES

NET LONG-TERM CAPITAL LOSS

NET SECTION 1231

LOSS

7169DEDUCTIONS RELATED TO PORTFOLIO INCOME - SUBJECT TO 2% FLOOR

FOREIGN TAXES


4239

7168

30% CASH

TRADE OR BUSINESS

4249

42644265

4260

4262

4267

42633995

42544255

4247

425142524253

4248

4261

4256425742584259


42724273

4268426942704271

7612

10LPTK13

3964

6OVERRIDE GROSS INCOME FROM BUSINESS

76403650

HOME OFFICE EXPENSE

7 OTHER EXPENSES

42047639AMORTIZATION

4

LEASE PAYMENTS (LESS INCLUSION AMOUNTS)d

INTEREST

VEHICLEEXPENSES

5

3PROPERTY TAX

TOTAL MEALS AND ENTERTAINMENTMEALS ANDENTERTAINMENT

a

b

b

c

DEPRECIATION

d

2 YES1407

a

b

c

TRAVEL EXPAWAY FROM

HOME(Not Meals

and Entertainment)

7390

7393

42024203

76377638

7389

73957396

7392

7397

4740

EXPENSES

UNREIMBURSED PARTNER EXPENSES

4228UNREIMBURSED PARTNERSHIP EXPENSES ARE: (1 - NONPASSIVE; 2 - ACTIVE RENTAL REAL ESTATE 3 - PASSIVE)

7391

SUBJECT TO D.O.T. LIMITATIONS

FEDERAL

1


LODGING

4233

4177

7388

4795

TRAVEL

OTHER

a

CAR RENTAL

NONDEDUCTIBLE EXPENSES

CALIFORNIA

4275

4222

SECTION 179 EXPENSE


NET SECTION1231 LOSS


41784179

4208


CHARITABLECONTRIBUTIONS

3994

3662

50% CASH

PRIOR YEAR PASSIVE ACTIVITY CARRYOVER LOSSES



ROYALTY DEDUCTIONS

CA (IF DIFFERENT)

4163

4206

42324211

42294230

761776184155NET SHORT-TERM CAPITAL LOSS



BASIS

2998


4156

Number2010

4205

CA PASSIVE

PRIOR YEAR AT-RISK BASIS CARRYOVER LOSSES

ORDINARY LOSS


39 pg 4 PARTNERSHIP K-1 RECEIVED DATA SHEET 4LAST NAME

30% CASH

41603659

4216

4225

4223

3661

42193988

3665

4157

4158

4161

NET SECTION 1231

LOSS

TRADE OR BUSINESS


OTHER LOSS

3660

7178

42264280

3666 4227

50% NONCASH

3664

4799



41894190

42174218


100% CASH

4162DEDUCTIONS RELATED TO PORTFOLIO INCOME - SUBJECT TO 2% FLOOR

3663

715041674168

30% NONCASH

4166

ENTER ALLLOSSES

ASPOSITIVENUMBERS

ORDINARY LOSS

47844234

41834083

4199

4235

4194

47414794


4165

4164

4224

4094

AMT PASSIVE

4159SECTION 179 EXPENSE


4207

42204221

4209

4231

4212421342144215

4210

4077

4188

ALL OTHER PASSIVE ACTIVITIES

FOREIGN TAXES


OTHER DEDUCTIONS

4172

PASSIVE

4050

UNREIMBURSED PARTNERSHIP EXPENSES

JVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW C0528D OPTIONAL OVERRIDE ASSET MGR 10LPTK14

1

AMOUNT OF SEC 179 DEDUCTION THAT IS QUALIFIED GULF OPPORTUNITY ZONE PROPERTY 396111

9

4a

6

1

INTEREST INCOME

INTEREST ON U.S. GOVERNMENT OBLIGATIONS

ORDINARY DIVIDENDS

OTHERINCOME

OR(LOSS)

3

OTHER DEDUCTIONS

EXCESS INTANGIBLE DRILLING COSTS 4748

2

TAX-EXEMPT INTEREST FROM PRIVATE ACTIVITY BONDS 4148

ALTERNATIVE MINIMUM TAX (AMT) ITEMS

AMOUNT

15

1

NOTE: OTHER ALTERNATIVE MINIMUM TAX ITEMS MUST BE ENTERED ON THE APPROPRIATE LINES OF FORM 6251.

32

CODE DESCRIPTION

3

12

CODE

3

SECTION 179 CARRYOVER FROM PRIOR YEAR FORM 4562

14 TOTAL FOREIGN TAXES PAID 7190

2

CREDITS

13

12

AMOUNT

4144

4068 4769

4133 47444134 4745

47594078

4142

4757

4763

AMOUNT

NET RENTAL REAL ESTATE INCOME OR (LOSS)

OTHER NET RENTAL INCOME OR (LOSS)

b

4147

NET SECTION 1231GAIN (LOSS)

(ENTIRE YEAR)

4755

4775

SECTION 179 DEDUCTION (1040 ONLY)


NET SHORT-TERM NONPORTFOLIO CAPITAL GAIN OR (LOSS)

JVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW C0528D [ # ] MAX CHAR 10LCSK11

AMOUNT

1

FOREIGN TRANSACTIONS

NOTE: INFORMATION ON THE FOREIGN TAX CREDIT SHOULD BE ENTERED ON FORM 1116.

47394038

7620

4060

40584085

4756

7619

(IF DIFFERENT)

4047

DISTRIBUTIVE SHARE ITEMS

[9]

4752

4057

4082 47534080 4754

4055 47514081

YES

[30]

A ENTITY IDENTIFICATION NUMBER 4052

FEDERALCA / PA STATE

1367

YES

YES

YES

SOME IS NOT AT RISK

YES

FINAL DISPOSITION OR EXEMPT FROM LIMITATION 4095

ACTIVE RENTAL REAL ESTATE

S CORPORATION K-1 RECEIVED DATA SHEET 1LAST NAME

1237 YES

MATERIALLY PARTICIPATED IN TRADE OR BUSN ACTIVITY

2010

FOREIGN ENTITY

40444045

Multiple

QUALIFIED DIVIDENDS

ROYALTIES

5a

40 pg 1

GENERAL INFORMATION

SHAREHOLDER OWNERSHIP CODE: T = TP S = SP J = JT (Default) 4054

4728

NET SHORT-TERM CAPITAL GAIN OR (LOSS)

b

c

COLLECTIBLES (28%) RATE GAIN (LOSS)


4059

DESCRIPTION

7

NET LONG-TERM CAPITAL GAIN OR (LOSS)a

FROM RENTAL REAL ESTATE ACTIVITIES

FROM OTHER RENTAL ACTIVITIES

10

8

FROM TRADE OR BUSINESS ACTIVITIES

B

NET LONG-TERM NONPORTFOLIO CAPITAL GAIN OR (LOSS)

[40]

2

3

ORDINARY BUSINESS INCOME OR (LOSS)

8605DATE FROM: DATE TO: 86188619

[20]

REAL ESTATE PROFESSIONAL

NOTE: UNREIMBURSED EXPENSES FROM AN S CORPORATION SHOULD BE REPORTED ON FORM 2106.

KEYFIELDOPTIONAL

ITEMS AFFECTING SHAREHOLDER BASIS, OTHER INFORMATION, OUTSIDE BASIS AND AT RISK BASIS CALCULATIONS,

PRIOR YEAR UNALLOWED LOSSES AND PASSIVE ACTIVITY CALCULATIONS ARE LOCATED ON SIDES 2 AND 3.

OHIO CITY[40]OHIO WORKING CITY

8601ENTITY ADDRESS

4051ENTITY NAME

8602ENTITY ZIP CODE

DESCRIPTIONCODE

CODE DESCRIPTION

KEYFIELD

THE FOLLOWING ITEMS DO NOT CARRY AUTOMATICALLY TO THE OUTSIDE BASIS CALCULATIONS. THESE FIELDS HAVE BEEN PROVIDED TO ALLOW FOR MORE ACCURATE CALCULATION OF LOSSES ALLOWED ON OTHER LINES. ANY RELATED GAINS / LOSSES ALLOWED WILL NOT CARRY TO THE TAX RETURN AND MUST BE MANUALLY ENTERED PER THE INSTRUCTIONS PROVIDED WITH THE SCH K-1. THE ALLOWED GAIN OR LOSS MAY ALSO BE SUBJECT TO THE AT-RISK BASIS LIMITATIONS AND SHOULD BE ENTERED IN THE CORRESPONDING AT-RISK FIELDS ON PG 3.

ITEMS AFFECTING SHAREHOLDER BASIS

CHARITABLE CONTRIBUTIONS

100% CASH

NEW LOANS

OTHER CURRENT YEAR OUTSIDE BASIS INCOME (LOSS) ITEMS

AT-RISK ENTRIES ARE LOCATED ON S-CORPORATION K-1 RECEIVED DATA SHEET 3.

3975

NOTE:

39723971

4246OTHER BASIS DECREASES

PRIOR YEAR OUTSIDE BASIS CARRYOVER LOSSES

4250

STOCK BASIS AT BEGINNING OF YEAR (ENTER -1 FOR -0-)

CAPITAL ADDITIONS

OTHER BASIS INCREASES

ORIGINAL LOAN BALANCE LESS CUMULATIVE PRINCIPAL PAYMENTS


3970

39773976

7155

4251

42727613

3996 3995


4240

42554256

4268

SPECIAL ORDERING ELECTION MADE (MUST HAVE OUTSIDE BASIS AMOUNTS ENTERED)

PRINT ELECTION STATEMENT (ONLY REQUIRED ONCE)

84314274

YES

CA (IF DIFFERENT)

71624249

LOAN BASIS AT BEGINNING OF YEAR (ENTER -1 FOR -0-)


TWO-LETTER STATE CODE 4149 470047914079

CA / PA STATE

7614

OTHER INFORMATION

84298430

7615SELF-EMPLOYED HEALTH INSURANCE PREMIUMS PAID

40 pg 2

FEDERAL

S CORPORATION K-1 RECEIVED DATA SHEET 2LAST NAME

(IF DIFFERENT)

Number2010

10LCSK12

4248

CA (IF DIFFERENT)

4247

4257

4269

4264

4270

4266

4252

4273


BASIS

7159ORDINARY LOSS

7166

7160

7164

7169

GROSS FARMING OR FISHING INCOME 4072

3

1

16

WAGES FROM THIS S-CORPORATION

CODE DESCRIPTION


TAX-EXEMPT DIVIDEND INCOME

DESCRIPTION

A

CODE

12

AMOUNT

AMOUNT

TRADE OR BUSINESS



1723

OTHER LOSS

71677168SECTION 179 EXPENSE DEDUCTION

4238





NET SECTION 1231 LOSS



ROYALTY DEDUCTIONS

7612

DEDUCTIONS RELATED TO PORTFOLIO INCOME - SUBJECT OT 2% FLOOR

7170

7171

7172

4243

4244

42604261

FOREIGN TAXES

30% NONCASH



42424241

4265

4267



42624263

50% CASH

423930% CASH

50% NONCASH

42584259

7163

7609715771587156 427976107611

4278

7161

7165

3974

3973

OTHER DEDUCTIONS

OTHER DEDUCTIONS

42364237

42534254


OTHER INCOME (LOSS)


OUTSIDE BASIS CALCULATION

YES

4276

4277



NET SECTION 1231 LOSS

42234224

42184219

3994

TRADE OR BUSINESS



3988

4275

4162

36633662

3665

42254226

4222

42204221

OTHER DEDUCTIONS


FOREIGN TAXES



ROYALTY DEDUCTIONS

DEDUCTIONS RELATED TO PORTFOLIO INCOME - SUBJECT OT 2% FLOOR

42054206

4231

4207420842094210

OTHER PORTFOLIO INCOME (LOSSES)

OTHER INCOME (LOSSES)


OTHER DEDUCTIONS

3965396439633962

39693968

YES

AMOUNT AT RISK

CA (IF DIFFERENT)AT-RISK

WILL NOT CARRY TO THE TAX RETURN AND MUST BE MANUALLY ENTERED PER THE INSTRUCTIONS PROVIDED WITH THE SCHEDULE K-1.

THE FOLLOWING ITEMS DO NOT CARRY AUTOMATICALLY TO THE AT-RISK BASIS CALCULATIONS. THESE FIELDS HAVE BEEN PROVIDED TO ALLOW FOR MORE ACCURATE CALCULATION OF LOSSES ALLOWED ON OTHER LINES. ANY GAINS / LOSSES ALLOWED RELATED TO THESE

NOTE:

47494750

2997

1413ADJUSTED AT-RISK BASIS AT BEGINNING OF YEAR (Enter -1 for -0-)

INCREASES FOR YEAR (OTHER THAN INCOME ITEMS FROM ABOVE)

DECREASES FOR YEAR (OTHER THAN DEDUCTIONS FROM ABOVE) 2996

SUPPRESS PRINTING OF AT-RISK RECONCILIATION AND ALLOCATION WORKSHEETS

AT-RISK BASIS CALCULATIONNOTE: ONLY THE SIMPLIFIED COMPUTATION OF AMOUNT AT RISK IS CALCULATED. TO USE THE DETAILED COMPUTATION, FILL OUT FORM 6198

AND OVERRIDE THE AMOUNT AT RISK BELOW.

4159

365936603661

OTHER LOSS

30% CASH

50% NONCASHCHARITABLE

CONTRIBUTIONS 30% NONCASH


JVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW C0528D OVERRIDE

ORDINARY LOSS

10LCSK13

76172998

4161

4166

AMT PASSIVE

50% CASH

Number

PRIOR YEAR AT-RISK BASIS CARRYOVER LOSSES

4155

CA PASSIVE

2010

4199

47404741

7618

4163




4229

40 pg 3 S CORPORATION K-1 RECEIVED DATA SHEET 3LAST NAME

39673966

OTHER CURRENT YEAR AT-RISK INCOME (LOSS) ITEMS


4160

42324211

4230

4214

4156

4157

4158



PASSIVE ACTIVITY CALCULATION PASSIVE

4050

42124213

4164

4165

3664

100% CASH

4183

715041674168

SECTION 59(e)(2) EXPENDITURES 41774172

42334083

4188

PRIOR YEARCARRYOVER

LOSSES

(ENTER ALL LOSSESAS POSITIVEAMOUNTS) NET SECTION 1231 LOSS: ALL OTHER PASSIVE ACTIVITIES

4194

4235

47954094


NET SECTION 1231 LOSS: RENTAL REAL ESTATE ACTIVITIES

7178

SECTION 179 EXPENSE

4794

42164217

4784

ORDINARY LOSS




42344077

KEYFIELD

4215

479941894190

41784179

4280

10FK1RECJVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW J0505T KEYFIELD [ # ] MAX CHAR

4178 4189NET LONG-TERM CAPITAL LOSS 4179 4190

PRIOR YEARCARRYOVER

LOSSES

ORDINARY LOSS



NET SHORT-TERM CAPITAL LOSS 41674168

4050 4740 47944094 4741 47957150 7178 4799

PASSIVE ACTIVITY CALCULATION

CA PASSIVEPASSIVE AMT PASSIVE

14 CODE DESCRIPTION AMOUNT

TW0-LETTER STATE CODE


123

TAX-EXEMPT INTEREST DIVIDENDS

OTHER INFORMATION

A 4079 47914149 4700

84298430

1


DESCRIPTION

3

DESCRIPTION

AMOUNT

DESCRIPTION

1

13

CODE

CODEDIRECTLY

APPORTIONEDDEDUCTIONS

CREDITS AND CREDIT RECAPTURE

47714066

4061

FIDUCIARY ADDRESS

FIDUCIARY ZIP CODE

a

ORDINARY DIVIDENDS

NET LONG-TERM CAPITAL GAIN OR (LOSS)

8601 [40]

[40]8602

OTHER RENTAL INCOME

8603ESTATE OR TRUST NAME

OTHER PORTFOLIO AND NONBUSINESS INCOME

7 NET RENTAL REAL ESTATE INCOME

[30]

INTEREST INCOME1

INTEREST ON U.S. GOVERNMENT OBLIGATIONS

4095

CA / PA STATE

FINAL DISPOSITION OR EXEMPT FROM LIMITATION

(IF DIFFERENT)

YES

DISTRIBUTIVE SHARE ITEMS

4751

4757

1237 YES

40784728

4739

7619 7620

* NOTE: ENTER 5, 6, 7, OR 8 IN EACH LINE OF THE GRID IN THE LINE # COLUMN TO ASSIGN THE DIRECTLY APPORTIONED DEDUCTIONS TO THE CORRECT ACTIVITY.

9

LINE # *

3

4752

4760c

AMOUNT

10


ORDINARY BUSINESS INCOME

2

40814055

FINAL YEAR DEDUCTIONS

2

AMOUNT

4082

ESTATE TAX DEDUCTION

4

QUALIFIED DIVIDENDS

3 NET SHORT-TERM CAPITAL GAIN OR (LOSS)

2a

5

6

8

C 4044FOREIGN ENTITY

CODE

b

28% RATE GAINb

MATERIALLY PARTICIPATED IN TRADE OR BUSN ACTIVITY 4045[30]

ACTIVE RENTAL REAL ESTATE

FIDUCIARY NAME

4057 4755

FEDERAL

1DESCRIPTION

BENEFICIARY OWNERSHIP CODE: T = TP S = SP J = JT (Default) 4054

YESREAL ESTATE PROFESSIONAL 1367A

4051B

[10]

[20]

41

GENERAL INFORMATION

FIDUCIARY K-1 RECEIVED DATA SHEETLAST NAME Multiple

2010

4080 47544038

ALTERNATIVE MINIMUM TAX ADJUSTMENT

4058

11

12

CODE AMOUNT

1

4052ENTITY IDENTIFICATION NUMBER

32

3

2

86058618 - -8619 - -

47564059

4753

YES

YES

OHIO CITY

OHIO WORKING CITY

DATE FROM: DATE TO:

0393ESTATE OR TRUST: 1 = Estate 2 = Trust

ENDED (ENTER 'C' FOR CONTINUE)DATE BONA FIDE RESIDENCE BEGAN

TOTAL AMOUNT OF ANY ITEMIZED DEDUCTIONS NOT CLAIMED BECAUSE THEY ARE RELATED TO EXCLUDED INCOME

U.S. STREET ADDRESS

U.S. ZIP CODE

FOREIGN STREET ADDRESS

FOREIGN CITY

0112

[20]

0113

FOREIGN STREET ADDRESS 0111

CITY

0208

IF HOME WAS MAINTAINED IN U.S. WHILE LIVING ABROAD, LIST U.S. ADDRESS

LIST ANY CONTRACTUAL TERMS OR OTHER CONDITIONS RELATING TO THE LENGTH OF EMPLOYMENT ABROAD

TYPE OF VISA UNDER WHICH TAXPAYER ENTERED FOREIGN COUNTRY

FOREIGN POSTAL CODE

NAME OF EMPLOYER

13STATEMENT SUBMITTED TO FOREIGN COUNTRY THAT TAXPAYER IS NOT RESIDENT OF THAT COUNTRY

1100

- -

YES

[22]

[11]

0213

8445

a[72]

e

[60]

0184

0120 - -

- -

c

YES

8450

FOREIGN STATE OR PROVINCE

NAME(S) OF OCCUPANT(S)

- -

FOREIGN COUNTRY

8449

1132 YES

b [38]

- -

NUMBER OF DAYS IN U.S. ON BUSINESS(3)

[2]

- - - -

YES

3214

Multiple

10

[20]0115d

LAST YEAR (AFTER 1981) FORM 2555 WAS FILED TO CLAIM EITHER EXCLUSION

2010

[35]

[20]

[22]

[22]

1311

102555IN

[35]

1227

[35]

[35]

[22]

[22]

[11]

0183


[30]

FOR WHAT PERIOD OF TIME?

0582

- -

TAXPAYER REQUIRED TO PAY INCOME TAX TO FOREIGN COUNTRY WHERE BONA FIDE RESIDENCE IS CLAIMED

FORM 2555 FOREIGN EARNED INCOME

[ # ] MAX CHAR

8356 YESHOME WAS RENTED WHILE LIVING ABROAD

YES

[22]

FOREIGN POSTAL CODE[2]

SPOUSE'S FORM 2555

4

[18]

[35]

a

1 = PURCHASED HOME 2 = RENTED HOUSE OR APARTMENT

FOREIGN AFFILIATE OF U.S. COMPANY

8447IF ANY FAMILY MEMBER LIVED ABROAD WITH TAXPAYER DURING YEAR, LIST FAMILY RELATIONSHIPb

0117

DATE ARRIVED IN U.S.(1)

DATE LEFT U.S.(2)

5

11

12

1232

KIND OF LIVING QUARTERS IN FOREIGN COUNTRY:

SELF

OTHER

PART II - TAXPAYERS QUALIFYING UNDER BONA FIDE RESIDENCE TEST

0177 - -

6a

d

[3]

[35]TAX HOME DURING YEAR

[27]

9

7

EMPLOYER IS: (CHECK ANY THAT APPLY)

8444

1131

A FOREIGN ENTITY

A U.S. COMPANY

8446 - -DATE TAX HOME WAS ESTABLISHED

a

0116

EMPLOYER'S U.S. ADDRESS:

8443

0114

STATE

8448

0211

1133

0209

02140215

PARTS III, IV, VI, VII, VIII AND IX ARE FOUND ON PAGE 2.

b8

15

NUMBER OF DAYS HOME WAS MAINTAINED

b

14 - -

INCOME EARNED IN U.S. ON BUSINESS(4)

LAST NAME

EMPLOYER'S FOREIGN ADDRESS:

e

YES

CITY

02070206

0212

FOREIGN STATE OR PROVINCE

b

YESDID VISA LIMIT LENGTH OF STAY OR EMPLOYMENT IN FOREIGN COUNTRY?

c

TYPE OF EXCLUSION AND TAX YEAR FOR WHICH REVOCATION WAS EFFECTIVE

0173CITIZEN OF WHAT COUNTRY (DEFAULT = U.S.)

[25]

3 = RENTED ROOM 4 = QUARTERS FURNISHED BY EMPLOYER

[35]

YES

42PAGE 1

1

3

8451RELATIONSHIP

IF SEPARATE HOME WAS MAINTAINED FOR FAMILY DUE TO ADVERSE LIVING CONDITIONS, LIST CITY AND COUNTRY

8442COUNTRY CODE

0210

1192

3042

DEDUCTIONS ALLOWED THAT ARE ALLOCABLE TO EXCLUDED INCOME

ADDITONAL LINES ARE AVAILABLE ON INPUT SCREEN

44

SPECIFY: 0190

3038NUMBER OF DAYS IN QUALIFYING PERIOD THAT FALL WITHIN 2010 TAX YEAR

3040

HOUSING DEDUCTION CARRYOVER FROM 2009

EXPLANATION OF DEDUCTIONS ALLOWED THAT ARE ALLOCABLE TO EXCLUDED INCOME

ALLOWABLE SHARE OF INCOME FOR PERSONAL SERVICES PERFORMED:

IN A PARTNERSHIP

IN A BUSINESS

b

HOUSING EXPENSE AND LIMITATION

20

PTSHP NAME, ADDRESS, NATURE OF INCOME 0189

0186 - - 0187 - -PHYSICAL PRESENCE TEST IS BASED ON 12-MONTH PERIOD

0188PRINCIPAL COUNTRY OF EMPLOYMENT DURING TAX YEAR


19

ALLOWANCES, REIMBURSEMENTS, OR EXPENSES PAID ON BEHALF OF TAXPAYER:

EF ONLY: NO TRAVEL STMT - EXPLAIN WHY TP DID NOT TRAVEL OUT OF COUNTRY DURING 12-MONTH PERIOD NAMED ABOVE

[25]COUNTRY

[54]

QUARTERS

SPECIFY: 0131

TOTAL EXCLUDABLE MEALS AND LODGING

YEARLY LIMITATION

DAILY LIMITATION

303230333034

COST OF LIVING AND OVERSEAS DIFFERENTIAL

b

c

e

302930303031

FORM 2555 FOREIGN EARNED INCOME

[ # ] MAX CHAR

d

1025552


d

a

a

EDUCATION

HOME LEAVE

INFORMATION CONCERNING TRAVEL ABROAD

FAMILY

a

b MEALS

CARc

[70]

[70]

PART IX - CLAIMING HOUSING DEDUCTION

[70]

49

f


[37]

PART VIII - CLAIMING HOUSING EXCLUSION, FOREIGN EARNED INCOME EXCLUSION, OR BOTH

3035OTHER FOREIGN EARNED INCOME

303934

23[54]

25 3036

QUALIFIED HOUSING EXPENSES FOR TAX YEAR

# DAYS IN QUALIFYING PERIOD WITHIN CURRENT TAX YEARLOCATION


PART VII - CLAIMING FOREIGN EARNED INCOME EXCLUSION

31,38

FOR ANY OTHER PURPOSE

3037

EMPLOYER PROVIDED AMOUNTS

[25]

PART VI - CLAIMING HOUSING EXCLUSION / DEDUCTION AND PART VII - CLAIMING FOREIGN EARNED INCOME EXCLUSION

28

SPECIFY: 0132

29

22

NONCASH INCOME:

3025302630273028

HOME (LODGING)

18

- - - - - -

21

30243023

17 [38]

NAME OF COUNTRY (INCLUDING U.S.)(a) [20]

DATE ARRIVED(b)

DATE LEFT(c)

[54]

INCOME EARNED INU.S. ON BUSINESS

OTHER PROPERTY OR FACILITIES

- - - -

[70]

- -

42PAGE 2

PART III - TAXPAYERS QUALIFYING UNDER PHYSICAL PRESENCE TEST

16 FROM THROUGH

NO. OF FULL DAYS PRESENT IN CNTRY

NO. OF DAYS IN U.S.

[70]

PART IV - ALL TAXPAYERS

3022


TOTAL WAGES, SALARIES, BONUSES, COMMISSIONS, ETC.

[70]

h

29

SM EMPLYR HEALTH INS PREM CR FORM 8941 9870EIN OF FLOW-THROUGH ENTITY 0581 -

b

8189

8186

[50]

8191 [65]

7 = Marginal Gas Production 8 = Transfer Oil 9 = Foreign Oil 10 = Geopressurized Brine 11 = Nonproducing

1 = Primary Oil (Default) 2 = Primary Gas 3 = Secondary Oil 4 = Secondary Gas 5 = Fixed Contract Gas 6 = Marginal Oil Production

DATE OF FIRST PRODUCTIONPROPERTY OR WELL LOCATION

8190 - -

PROPERTY OR WELL TYPE:

35813580

3582

4222

8318 YES

NO

OIL OIL AND GAS DEPLETION WORKSHEET

8185

2 PRODUCTION OR SEVERANCE TAXES

1 GROSS INCOME

INDEPENDENT PRODUCER

PRODUCE OVER 1000 BARRELS PER DAY

PART I - INCOME OR (LOSS)

8317

8319 YES

EXPENSED 35853586

35833584

AMORTIZED

7

DRY HOLE EXPENSES

3 LEASE OPERATING EXPENSES

4 ALLOCATED OVERHEAD

5 DEPRECIATION

6INTANGIBLE DRILLING COSTS

COST OR OTHER BASIS 3591

3588DELAY RENTALS 3589

3590OTHER EXPENSES

3587ROYALTIES PAID

12 ESTIMATED RESERVES AT END OF TAX YEAR 3593

PART II - COST DEPLETION

10 PRIOR YEARS' ACCUMULATED DEPLETION 35929

OVERRIDE DEPLETION ADJUSTMENT

13 CURRENT YEAR PRODUCTION 3594PART III - PERCENTAGE DEPLETION

17 OVERRIDE STATUTORY DEPLETION PERCENTAGE 8194

3596

28

25

27

3597

OVERRIDE EXCESS INTANGIBLE DRILLING COSTS 3599

IF RETURN IS NOT FOUND, PAYMENT IS TO BE REFUNDED TO THIRD PARTY LISTED ON LINE 5

4207

3598PART V - AMT ADJUSTMENTS

OVERRIDE INCOME LIMITATION (FIRST MULTIPLE ONLY)

PART IV - DEPLETION ALLOWED

23 DEPLETION CARRYOVER (PRIOR YR UNALLOWED DEPLETION) 359524

4226

4217 YES

[30]

8

6TAX FORM NUMBER

4208

FEE: THERE IS A $57 FEE FOR EACH PERIOD REQUESTED.

9

42284211

4209

REQUESTING CERTIFIED COPY OF TAX FORM FOR COURT OR ADMINISTRATIVE PROCEEDINGS YES

[34]

4205[14]

REQUEST FOR COPY OF TAX FORM

4204 [34]

THIRD PARTY TELEPHONE NUMBER

THIRD PARTY ZIP CODE

IF COPY IS TO BE MAILED TO SOMEONE ELSE, NAME OF THIRD PARTY

4203

4506

4201 [68]

THIRD PARTY STREET ADDRESS

4

STREET ADDRESS (INCLUDING APT, ROOM, SUITE) SHOWN ON LAST RETURN FILED

ZIP CODE SHOWN ON LAST RETURN FILED

4202 [68]

43UNIVERSAL DATA SHEET 43

(TO BE USED WITH SYSTEMS 1040, 1041, 1065, 1120, 1120S)2010

NAME

3603

2343bb

PASSIVE ACTIVITY CREDIT INCL ON LINES 1a THRU 1bb

r

i

3632

ALT MOTOR VEHICLE CREDIT

GENERAL CREDITS FROM ELECTING LARGE PTSHP

NEW MARKETS CREDIT

2640LOW-INCOME HOUSING CR FORM 8586

1

CURRENT YEAR CREDIT

EIN OF FLOW-THROUGH ENTITY


15PERCENT OF GROUP CREDIT THIS MEMBER RECEIVED

FORM 8882

3

3804

3673

EMPLOYER-PROVIDED CHILD CARE FACILITIES & SVCS CR

1120

ONLY

2620

2531

PASSIVE ACTIVITY CREDITS ALLOWED FOR 2009

4484CONTROLLED

GROUPS ONLY

CARRYFORWARD OF GENERAL BUSINESS CREDIT FROM PRIOR YEAR

CARRYBACK OF GENERAL BUSINESS CREDIT FROM 2010

SMALL CORP EXEMPT FROM AMT UNDER SECTION 55(e)

2689

16

2995

1314 YES

5

PART II - CREDIT LIMITATION BASED ON TAX AMOUNT

CARRYFORWARD OF FORM 8611 FROM 2007

7

6

19

24

18 BONUS DEPRECIATION AMOUNT ATTRIBUTABLE TO RESEARCH CREDIT 9797

97983449EMPOWEMENT ZONE EMPLOYMENT CREDIT

1120/1120S

ONLYb

WORK OPPORTUNITY CREDIT 2257c ALCOHOL FUEL CREDIT 2665

9781e RENEWABLE ELECTRICITY PRODUCTION CR (PART II) 3699

INVESTMENT CREDIT (PART III) 9752

f EMPLOYER FICA/MEDICARE PAID ON CERTAIN TIPS 3399g QUALIFIED RAILROAD TRACK MAINTENANCE CREDIT 3733

d LOW-INCOME HOUSING CREDIT (PART II)

8846

TIPS SUBJECT ONLY TO MEDICARE TAX

[33]5

7 CREDIT INCLUDED ON LINE 6 FROM PASSIVE ACT (SEE INSTR)

CREDIT FOR EMPLOYER SOC SEC AND MEDICARE TAXES PAID ON CERTAIN EMPLOYEE TIPS FROM PARTNERSHIPS AND S CORPORATIONS

CRYBACK FROM 2010 OF SS / MEDICARE TAX PAID ON TIPS 9716

T/S

2

EMPLOYEE TIPS ON WHICH EMPLOYER PAID SOCIAL SECURITY AND MEDICARE TAXES DURING TAX YEAR

1040 / 1041 ONLY - FORM 8846 PASSIVE CREDIT FOR FORM 8582CR

7976

9CREDIT CARRYFORWARD OF SS / MEDICARE TAXES PAID ON CERTAIN EMPL TIPS ORIGINATED IN TAX YR AFTER 2007

7459

CURRENT CR

9714

7457

35607458

ADD-TO

a

10UNIV9JVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW S0112S OPTIONAL OVERRIDE

9715

KEYFIELD ASSET MGR [ # ] MAX CHAR

10

11

4

OVERRIDE DEPLETION ALLOWED

EMPLOYER SS & MEDICARE TAXES PD CREDIT

1

PRIOR YR CRWK #

TIPS NOT SUBJECT TO CREDIT PROVISIONS

k

d

CREDIT ALLOWED FOR 2009 FROM PASSIVE ACTIVITIES

ACTIVITY NAME

a

CREDITS THAT REDUCE REGULAR TAX BEFORE GENERAL BUSINESS CREDIT:


FORM 8874

FORM 8910

FORM 1065-B

RESEARCH CREDIT LIMITATION

EIN OF FLOW-THROUGH ENTITY 4378 -

GENERAL BUSINESS CREDIT

CARRY DEPLETION TO FORM: 1 - Ordinary Income (Sch C) 3- Fiduciary K-1 Received 2- Royalty Income (Sch E) 4- Partnership K-1 Received

5- S Corporation K-1 Received

CARRY TO MULTIPLE FORM NUMBER:PROPERTY OR WELL DESCRIPTION

TELEPHONE NUMBER OF TAXPAYER

8192TAX PERIOD(S) (YEAR OR PERIOD ENDED DATE)

42274225

7

4210

4206

8193

[34]

5

0148 -

0345 -

0377 -

RETAILER OR REFINER

PERCENT OF OWNERSHIP (DEFAULT IS 100 PERCENT)

3800

4212

9 1041 ONLY 7781

7 WORKSHEET # CURRENT CREDIT PRIOR YR CREDIT

FORM 1040 / 1041 ONLY - FORM 8931 CREDITS FOR FORM 8582CR

8910

BUSINESS USEPERCENTAGE

[33]

8931

LINE 1G - SECURITYASSESSMENT

LINE 1H - SITE SECURITY PLAN

PART II - CREDIT FOR BUSINESS / INVESTMENT USE PART OF VEHICLE

14 PRIOR YR CREDITT / S / J WORKSHEET #

AGRICULTURAL CHEMICALS SECURITY CREDIT

CURRENT CREDIT

PART I - TENTATIVE CREDIT

VEHICLE YEAR

- -

VEHICLE MAKE AND MODEL (SEE GRID FOR ELIGIBLE VEHICLES) DATE PLACEDIN SERVICE[10]

- - - - - -

- - - -

LINE 1B - AGRI CHEMICALS

LINE 1C - THEFTPREVENTION

LINE 1D - PERIMETER

LINE 1A - SECURITYTRAINING

LINE 1C - SECURITY

MAXIMUM CREDIT

ACTIVITY NAME T / S

FOR USE WITH ALL SYSTEMS

FORM 1040 / 1041 ONLY - FORM 8908 CREDITS FOR FORM 8582CR

ACTIVITY NAME24 PRIOR YR CREDIT

7778

7777

- -

ENTER IN THE GRID BELOW THE QUALIFIED AGRICULTURAL CHEMICALS SECURITY EXPENSES FOR EACH FACILITY

ALTERNATIVE MOTOR VEHICLE CREDITS FROM PARTNERSHIPS AND S CORPORATIONS

26

ALTERNATIVE MOTOR VEHICLE CREDIT

AMOUNT ALLOCATED TO BENEFICIARIES OF THE ESTATE OR TRUST

1041 ONLY

CREDIT FROM PARTNERSHIPS, S CORPORATIONS, ESTATES AND TRUSTS

44 2010

CURRENT CREDIT

2

8582-CR

LINE LF - COMPUTER

JVA COPYRIGHT FORMS (SOFTWARE ONLY) - 2010 TW C0630D [ # ] MAX CHAR


NAMEUNIVERSAL DATA SHEET 44

FORM 1040 / 1041 ONLY - FORM 8910 PASSIVE CREDITS FOR FORM 8582CR

ACTIVITY NAME

ACTIVITY NAME

10UNIV6OVERRIDE

7780

[33]

3920

[33] WKSHT # FROM FORM PRIOR YR CREDIT

1

PASSIVE ACTIVITY CREDIT LIMITATIONS

4

T / S / J

[70]

[50]

38

3

1356

7772

7770 9790(b) TYPE B

39 DISPOSED ACTIVITY NAME 4730

40DESCRIPTION OF CREDIT PROPERTY FOR WHICH ELECTION IS BEING MADE:

4731

YESDISPOSED OF ENTIRE INTEREST (PASSIVE OR FORMER PASSIVE ACTIVITY) IN FULLY TAXABLE TRANSACTION, AND ELECT TO INCREASE BASIS OF THE CREDIT PROPERTY USED IN ACTIVITY BY UNALLOWED CREDIT THAT REDUCED PROPERTY'S BASIS

- -

2911

(a) TYPE A (b) TYPE B

9787

T / S / J[33]

97657768 9796

41

ENERGY EFFICIENT APPLIANCE CREDIT8909

19

777412

AMOUNT OF UNALLOWED CREDIT THAT REDUCED PROPERTY'S BASIS

1 7765

77717775

- -

97929793

AMOUNT FROM LINE 19 OF 2009 FOR M8909

AMOUNT FROM LINE 22a OF 2009 FORM 8909

- -

PURCHASEDATE

2

13

ENERGY EFFICIENT APPLIANCE CREDITS FROM PARTNERSHIPS, S CORPORATIONS, ESTATES, TRUSTS, AND COOPERATIVES

AMOUNT ALLOCATED TO BENEFICIARIES OF THE ESTATE OR TRUST OR PATRONS OF COOPERATIVE (SEE INSTRUCTIONS)

6 77677

(a) TYPE A

97949789

AMOUNT FROM LINE 22b OF 2009 FORM 8909

AMOUNT FROM LINE 20 OF 2009 FORM 8909

WORKSHEET # CURRENT CREDIT

2569

AVERAGE NUMBER OF ELIGIBLE DISHWASHERS PRODUCED IN THE 2 PRIOR CALENDAR YEARS

PART II - CLOTHES WASHERS

NUMBER OF ELIGIBLE CLOTHES WASHERS PRODUCED IN CURRENT CALENDAR YEAR

AVERAGE NUMBER OF ELIGIBLE CLOTHES WASHERS PRODUCED IN 2 CALENDAR YEARS

b

c

d

g

AVERAGE ANNUAL GROSS RECEIPTS

REFRIGERATORS

NUMBER OF ELIGIBLE REFRIGERATORS PRODUCED IN CURRENT CALENDAR YEAR

AVERAGE NUMBER OF ELIGIBLE REFRIGERATORS PRODUCED IN THE 2 PRIOR CALENDAR YEARS

PART I -DISHWASHERS

i AMOUNT FROM LINE 19 OF 2009 FOR M8909

20

9795

NUMBER OF ELIGIBLE DISHWASHERS PRODUCED IN CALENDAR YEAR 2010

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