Form

1040

Name, Address, and SSN See separate instructions.

P R I N T C L E A R L Y

Presidential Election Campaign

Filing Status Check only one box.

Exemptions

Department of the Treasury—Internal Revenue Service

For the year Jan. 1–Dec. 31, 2010, or other tax year beginning Last name Your first name and initial

Jeremy W

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

If you did not get a W-2, see page 20.

Enclose, but do not attach, any payment. Also, please use Form 1040-V.

Adjusted Gross Income

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

, 2010, ending

, 20

OMB No. 1545-0074 Your social security number

Martens

870-91-1234

Cathrine F

Spouse’s social security number

Martens

839-09-1101 Apt. no.

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

c

4821 N. Anderson Ave City, town or post office, state, and ZIP code. If you have a foreign address, see instructions.

a

Check here if you, or your spouse if filing jointly, want $3 to go to this fund 1 2 3

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

4

.

Spouse . Dependents:

Kenneth Kendra

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(2) Dependent’s social security number

Last name

Martens Martens

Total number of exemptions claimed

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You

a

Qualifying widow(er) with dependent child

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}

(4)  if child under age 17 qualifying for child tax credit (see page 15)

Son Daughter

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Wages, salaries, tips, etc. Attach Form(s) W-2 . Taxable interest. Attach Schedule B if required . Tax-exempt interest. Do not include on line 8a . Ordinary dividends. Attach Schedule B if required

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8a

28,765. 1,180.

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9a

469.

7

10 11

12 13 14

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

.

12 13 14

15a 16a 17

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

15b 16b 17

18 19 20a

Farm income or (loss). Attach Schedule F . Unemployment compensation . . . . Social security benefits 20a

18 19 20b

21 22

Other income. List type and amount FORM W-2G Combine the amounts in the far right column for lines 7 through 21. This is your total income

23

Educator expenses

24

Certain business expenses of reservists, performing artists, and fee-basis government officials. Attach Form 2106 or 2106-EZ

25

Health savings account deduction. Attach Form 8889

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24 25

26 27 28

Moving expenses. Attach Form 3903 . . . . . One-half of self-employment tax. Attach Schedule SE Self-employed SEP, SIMPLE, and qualified plans .

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26 27 28

29 30 31a

Self-employed health insurance deduction Penalty on early withdrawal of savings . .

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32 33 34

Alimony paid b Recipient’s SSN a IRA deduction . . . . . . . Student loan interest deduction . . Tuition and fees. Attach Form 8917 .

29 30 31a

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. . .

. . .

. . .

32 33 34

35 36 37

Domestic production activities deduction. Attach Form 8903 35 Add lines 23 through 31a and 32 through 35 . . . . . . . Subtract line 36 from line 22. This is your adjusted gross income

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2

4

289. . .

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Add numbers on lines above a

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2

Dependents on 6c not entered above

10 11

. .

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

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

b

Spouse

child’s name here. a

5

(3) Dependent’s relationship to you

839-09-2022 839-09-2032

.

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

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

6a

7 8a b 9a

.

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

Married filing separately. Enter spouse’s SSN above and full name here. a b c

.

Make sure the SSN(s) above and on line 6c are correct.

Checking a box below will not change your tax or refund.

Riverbank CA 95367

d

Income

(99)

Last name

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

(1) First name

If more than four dependents, see instructions and check here a

2010

U.S. Individual Income Tax Return

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

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21 22

6,474. 250. 37,138.

23

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

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. a

36 37

REV 06/22/11 TTW

37,138. Form 1040

(2010)

Form 1040 (2010)

Tax and Credits

38

Amount from line 37 (adjusted gross income)

39a

Check if:

b 40

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

39b Itemized deductions (from Schedule A) or your standard deduction (see instructions) . .

41

Subtract line 40 from line 38

.

.

42 43

Exemptions. Multiply $3,650 by the number on line 6d . . . . . . . . . . . Taxable income. Subtract line 42 from line 41. If line 42 is more than line 41, enter -0- .

. .

44 45 46

Tax (see instructions). Check if any tax is from: a Form(s) 8814 Alternative minimum tax (see instructions). Attach Form 6251 . . Add lines 44 and 45 . . . . . . . . . . . . . . .

47 48

Foreign tax credit. Attach Form 1116 if required .

Credit for child and dependent care expenses. Attach Form 2441

47 48

49 50 51

Education credits from Form 8863, line 23 . . . . . Retirement savings contributions credit. Attach Form 8880 Child tax credit (see instructions) . . . . . . . .

49 50 51

52 53 54 55

Residential energy credits. Attach Form 5695 . . . . 52 3800 b 8801 c Other credits from Form: a 53 Add lines 47 through 53. These are your total credits . . . . . Subtract line 54 from line 46. If line 54 is more than line 46, enter -0-

56 57

Self-employment tax. Attach Schedule SE . . . . Unreported social security and Medicare tax from Form:

{

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You were born before January 2, 1946, Spouse was born before January 2, 1946,

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Blind. Blind.

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870-91-1234 Page 2 37,138. . 38

Total boxes checked a 39a

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b . . . .

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58 59 60

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

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.

a Form(s) W-2, box 9 b Schedule H Add lines 55 through 59. This is your total tax .

. .

.

Payments

61 62 63

Federal income tax withheld from Forms W-2 and 1099 . . 2010 estimated tax payments and amount applied from 2009 return Making work pay credit. Attach Schedule M . . . . . . .

61 62

2,998.

63

If you have a qualifying child, attach Schedule EIC.

64a b

Earned income credit (EIC) . . . . Nontaxable combat pay election 64b Additional child tax credit. Attach Form 8812

800. 1,737.

65 66 67 68 69 70 71 72

Refund

Sign Here

Paid Preparer Use Only

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64a

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American opportunity credit from Form 8863, line 14 . First-time homebuyer credit from Form 5405, line 10 . Amount paid with request for extension to file . . .

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65 66

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.

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1,083. 0.

54 a

a

55 56 57 58 59 60

0.

917.

67 68

. . . . 69 Credit for federal tax on fuels. Attach Form 4136 . . . . 70 Credits from Form: a 2439 b 8839 c 8801 d 8885 71 Add lines 61, 62, 63, 64a, and 65 through 71. These are your total payments .

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.

a

74a b d

Amount of line 73 you want refunded to you. If Form 8888 is attached, check here . a Routing number Checking Savings X X X X X X X X X a c Type: Account number X X X X X X X X X X X X X X X X X Amount of line 73 you want applied to your 2011 estimated tax a 75 Amount you owe. Subtract line 72 from line 60. For details on how to pay, see instructions ▶

75 76

1,083.

Excess social security and tier 1 RRTA tax withheld

77 77 Estimated tax penalty (see instructions) . . . . . . . Do you want to allow another person to discuss this return with the IRS (see instructions)? Designee’s name a

Phone no. a

6,452. 6,452. 6,452.

72 73 74a

76

a

Yes. Complete below.

No

Personal identification a number (PIN)

Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Your signature

F

Joint return? See page 12. Keep a copy for your records.

.

. .

If line 72 is more than line 60, subtract line 60 from line 72. This is the amount you overpaid

a


Third Party Designee

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. .

73

Direct deposit? See a instructions.

Amount You Owe

.

. .

Form 5405, line 16 . . . . . .

c

44 45 46

1,083.

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. . . . a 4137

43

Form 4972 . . . . . . a . . . .

. .

Other Taxes

11,400. 25,738. 14,600. 11,138. 1,083.

40 41 42

Your occupation

Date

Spouse’s occupation

Daytime phone number

Insurance Claim Adjuster

Spouse’s signature. If a joint return, both must sign.

Unemployed

Print/Type preparer’s name

Firm’s name

Date

a

Preparer’s signature

Date

Check if self-employed

PTIN

Firm's EIN a

SELF PREPARED

Phone no.

Firm’s address a REV 06/22/11 TTW

Form 1040 (2010)

SCHEDULE EIC

Earned Income Credit 1040A

(Form 1040A or 1040)

..........

Qualifying Child Information

2010

1040

EIC

Complete and attach to Form 1040A or 1040 only if you have a qualifying child.

Department of the Treasury Internal Revenue Service (99)

OMB No. 1545-0074

`

Attachment Sequence No. 43 Your social security number

Name(s) shown on return

Jeremy W & Cathrine F Martens

Before you begin:

! F CAUTION

870-91-1234

• See the instructions for Form 1040A, lines 41a and 41b, or Form 1040, lines 64a and 64b, to make sure that (a) you can take the EIC, and (b) you have a qualifying child. • Be sure the child’s name on line 1 and social security number (SSN) on line 2 agree with the child’s social security card. Otherwise, at the time we process your return, we may reduce or disallow your EIC. If the name or SSN on the child’s social security card is not correct, call the Social Security Administration at 1-800-772-1213.

• If you take the EIC even though you are not eligible, you may not be allowed to take the credit for up to 10 years. See page 2 of schedule for details. • It will take us longer to process your return and issue your refund if you do not fill in all lines that apply for each qualifying child.

Child 1

Qualifying Child Information 1 Child’s name If you have more than three qualifying children, you only have to list three to get the maximum credit.

First name

Last name

Kenneth

Child 3

Child 2 First name

Kendra

Martens

First name

Last name

Last name

Martens

2 Child’s SSN The child must have an SSN as defined in the instructions for Form 1040A, lines 41a and 41b, or Form 1040, lines 64a and 64b, unless the child was born and died in 2010. If your child was born and died in 2010 and did not have an SSN, enter “Died” on this line and attach a copy of the child’s birth certificate, death certificate, or hospital medical records.

839-09-2032

839-09-2022

3 Child’s year of birth Year

2

0

0

3

If born after 1991 and the child was younger than you (or your spouse, if filing jointly), skip lines 4a and 4b; go to line 5.

Year

2

0

0

5

Year

If born after 1991 and the child was younger than you (or your spouse, if filing jointly), skip lines 4a and 4b; go to line 5.

If born after 1991 and the child was younger than you (or your spouse, if filing jointly), skip lines 4a and 4b; go to line 5.

4 a Was the child under age 24 at the end of 2010, a student, and younger than you (or your spouse, if filing jointly)?

Yes.

No.

Go to line 5.

Continue.

Yes.

No.

Go to line 5.

Yes.

Continue.

No.

Go to line 5.

Continue.

b Was the child permanently and totally disabled during any part of 2010?

Yes. Continue.

No. The child is not a qualifying child.

Yes. Continue.

No. The child is not a qualifying child.

Yes. Continue.

No. The child is not a qualifying child.

5 Child’s relationship to you (for example, son, daughter, grandchild, niece, nephew, foster child, etc.)

Son

Daughter

12 months Do not enter more than 12 months.

12 months Do not enter more than 12 months.

6 Number of months child lived with you in the United States during 2010 • If the child lived with you for more than half of 2010 but less than 7 months, enter “7.” • If the child was born or died in 2010 and your home was the child’s home for the entire time he or she was alive during 2010, enter “12.”

For Paperwork Reduction Act Notice, see your tax return instructions.

BAA

REV 06/22/11 TTW

months Do not enter more than 12 months. Schedule EIC (Form 1040A or 1040) 2010

Form

8812

Department of the Treasury Internal Revenue Service (99) Name(s) shown on return

1040 . .1040A ........ 1040NR

Additional Child Tax Credit

..........

OMB No. 1545-0074

`

2010

8812 Complete and attach to Form 1040, Form 1040A, or Form 1040NR.

Your social security number

Jeremy W & Cathrine F Martens Part I All Filers 1

1040 filers: 1040A filers: 1040NR filers:

870-91-1234

}

Enter the amount from line 6 of your Child Tax Credit Worksheet (see the Instructions for Form 1040, line 51). Enter the amount from line 6 of your Child Tax Credit Worksheet (see the Instructions for Form 1040A, line 33). Enter the amount from line 6 of your Child Tax Credit Worksheet (see the Instructions for Form 1040NR, line 48).

If you used Pub. 972, enter the amount from line 8 of the worksheet on page 4 of the publication. 2 3 4a b 5

6

Enter the amount from Form 1040, line 51, Form 1040A, line 33, or Form 1040NR, line 48 . . . . . . Subtract line 2 from line 1. If zero, stop; you cannot take this credit . . . . . . . . . . . . . Earned income (see instructions on back) . . . . . . . . . . . . 4a 28,765. Nontaxable combat pay (see instructions on 4b back) . . . . . . . . . . . . . Is the amount on line 4a more than $3,000? No. Leave line 5 blank and enter -0- on line 6. Yes. Subtract $3,000 from the amount on line 4a. Enter the result . . . 5 25,765. Multiply the amount on line 5 by 15% (.15) and enter the result . . . . . . . . . . . . . . Next. Do you have three or more qualifying children? No. If line 6 is zero, stop; you cannot take this credit. Otherwise, skip Part II and enter the smaller of line 3 or line 6 on line 13. Yes. If line 6 is equal to or more than line 3, skip Part II and enter the amount from line 3 on line 13. Otherwise, go to line 7.

Part II

Withheld social security and Medicare taxes from Form(s) W-2, boxes 4 and 6. If married filing jointly, include your spouse’s amounts with yours. If you worked for a railroad, see instructions on back . . . . . . . . . .

8

1040 filers:

1040A filers: 1040NR filers:

Enter the total of the amounts from Form 1040, lines 27 and 57, plus any taxes that you identified using code “UT” and entered on the dotted line next to line 60. Enter -0-.

Enter the total of the amounts from Form 1040NR, lines 27 and 55, plus any taxes that you identified using code "UT" and entered on the dotted line next to line 59. Add lines 7 and 8 . . . . . . . . . . . . . . . . . . Enter the total of the amounts from Form 1040, lines 1040 filers: 64a and 69.

1040A filers:

11 12

1

2,000.

2 3

1,083. 917.

6

3,865.

Certain Filers Who Have Three or More Qualifying Children

7

9 10

Attachment Sequence No. 47

Enter the total of the amount from Form 1040A, line 41a, plus any excess social security and tier 1 RRTA taxes withheld that you entered to the left of line 44 (see instructions on back). 1040NR filers: Enter the amount from Form 1040NR, line 64. Subtract line 10 from line 9. If zero or less, enter -0- . . . . . . . Enter the larger of line 6 or line 11 . . . . . . . . . . . . Next, enter the smaller of line 3 or line 12 on line 13.

Part III Additional Child Tax Credit 13 This is your additional child tax credit

} }

7

8

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9

10

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11 12

. . . . . . . . . . . . . . . . . . .

13

1040 . .1040A ........ 1040NR `

..........

For Paperwork Reduction Act Notice, see your tax return instructions.

BAA

REV 06/22/11 TTW

917. Enter this amount on Form 1040, line 65, Form 1040A, line 42, or Form 1040NR, line 62.

Form 8812 (2010)

SCHEDULE M (Form 1040A or 1040) Department of the Treasury Internal Revenue Service (99)

OMB No. 1545-0074

Making Work Pay Credit a Attach

a

to Form 1040A or 1040.

2010 Attachment Sequence No.

See separate instructions.

Name(s) shown on return

Jeremy W & Cathrine F Martens

▲ ! CAUTION

▲ ! CAUTION

166

Your social security number

870-91-1234

To take the making work pay credit, you must include your social security number (if filing a joint return, the number of either you or your spouse) on your tax return. A social security number does not include an identification number issued by the IRS. Only the Social Security Administration issues social security numbers.

You cannot take the making work pay credit if you can be claimed as someone else's dependent or if you are a nonresident alien.

Important: Check the “No” box on line 1a and see the instructions if: (a) You have a net loss from a business, (b) You received a taxable scholarship or fellowship grant not reported on a Form W-2, (c) Your wages include pay for work performed while an inmate in a penal institution, (d) You received a pension or annuity from a nonqualified deferred compensation plan or a nongovernmental section 457 plan, or (e) You are filing Form 2555 or 2555-EZ. 1a

Do you (and your spouse if filing jointly) have 2010 wages of more than $6,451 ($12,903 if married filing jointly)? Yes. Skip lines 1a through 3. Enter $400 ($800 if married filing jointly) on line 4 and go to line 5. No. Enter your earned income (see instructions) . . . . . . . 1a

b Nontaxable combat pay included on line 1a (see instructions) . . . . . . . . . 2

Multiply line 1a by 6.2% (.062) .

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2

3

Enter $400 ($800 if married filing jointly) .

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3

4

Enter the smaller of line 2 or line 3 (unless you checked “Yes” on line 1a) .

5

Enter the amount from Form 1040, line 38*, or Form 1040A, line 22 .

.

5

37,138.

6

Enter $75,000 ($150,000 if married filing jointly)

.

.

6

150,000.

7

Is the amount on line 5 more than the amount on line 6? No. Skip line 8. Enter the amount from line 4 on line 9 below. Yes. Subtract line 6 from line 5 . . . . . . . . . . .

.

7

8

Multiply line 7 by 2% (.02)

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8

9

Subtract line 8 from line 4. If zero or less, enter -0-

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9

800.

No. Enter -0- on line 10 and go to line 11. Yes. Enter the total of the payments you (and your spouse, if filing jointly) received in 2010. Do not enter more than $250 ($500 if married filing jointly) . . . . . . . . . . . .

10

0.

Making work pay credit. Subtract line 10 from line 9. If zero or less, enter -0-. Enter the result here and on Form 1040, line 63; or Form 1040A, line 40 . . . . . . . . . . . . . .

11

800.

10

11

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1b

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4

800.

Did you (or your spouse, if filing jointly) receive an economic recovery payment in 2010? You may have received this payment in 2010 if you did not receive an economic recovery payment in 2009 but you received social security benefits, supplemental security income, railroad retirement benefits, or veterans disability compensation or pension benefits in November 2008, December 2008, or January 2009 (see instructions).

*If you are filing Form 2555, 2555-EZ, or 4563 or you are excluding income from Puerto Rico, see instructions. For Paperwork Reduction Act Notice, see your tax return instructions.

BAA

REV 06/22/11 TTW

Schedule M (Form 1040A or 1040) 2010

Form

W-2G

Certain Gambling Winnings

2010

G Keep for your records Name as Shown on Return

Social Security Number

Cathrine F Martens

839-09-1101

Certain Gambling Winnings

X Spouse’s W-2G Non-standard W-2G (handwritten, typewritten, or altered in any way) Corrected W-2G 1

Payer’s Name

Casino Winnings

Gross winnings

3

Type of wager

5

Transaction

7

Winnings from identical wagers

Street Address City

State

Federal ID Number

2

Federal income tax withheld

4

Date won

6

Race

8

Cashier

10

Window

250.00

ZIP Code

Telephone Number

9 Payer has a foreign address (see Tax Help)

Winner’s taxpayer identification no.

839-09-1101 Transfer winner information from the Federal Information Worksheet

11

First identification

12

Second identification

13

State/Payer’s state identification no.

14

State income tax withheld

15

Locality name

16

Local income tax withheld

Winner’s Name

Cathrine F Martens Street Address

4821 N. Anderson Ave City

State

ZIP Code

Riverbank

CA

95367

Winner has a foreign address (see Tax Help)

Form 1040 Line 44

Qualified Dividends and Capital Gain Tax Worksheet

2010

G Keep for your records

Name(s) Shown on Return

Social Security Number

Jeremy W & Cathrine F Martens

870-91-1234

1 2 3

4 5

6 7 8

9 10 11 12 13 14 15 16

17 18

19

Enter the amount from Form 1040, line 43 1 11,138. Enter the amount from Form 1040, line 9b 2 289. Are you filing Schedule D? Yes. Enter the smaller of line 15 or 16 of Schedule D. If either line 15 or 16 is blank or loss, enter -03 X No. Enter the amount from Form 1040, line 13. Add lines 2 and 3 4 289. If filing Form 4952 (used to figure investment interest expense deduction), enter any amount from line 4g of that form. Otherwise enter -05 0. Subtract line 5 from line 4. If zero or less, enter -06 289. Subtract line 6 from line 1. If zero or less, enter -07 10,849. Enter: $34,000 if single or married filing separately, $68,000 if married filing jointly or 8 68,000. qualifying widow(er), or $45,550 if head of household. Enter the smaller of line 1 or line 8 9 11,138. Enter the smaller of line 7 or line 9 10 10,849. Subtract line 10 from line 9 (this amount taxed at 0%) 11 289. Enter the smaller of line 1 or line 6 12 289. Enter the amount from line 11 13 289. Subtract line 13 from line 12. 14 0. Multiply line 14 by 15% (.15) 15 Figure the tax on the amount on line 7. If the amount on line 7 is less than $100,000, use the Tax Table to figure this tax. If the amount on line 7 is $100,000 or more, use the Tax Computation Worksheet 16 Add lines 15 and 16 17 Figure the tax on the amount on line 1. If the amount on line 1 is less than $100,000, use the Tax Table to figure this tax. If the amount on line 1 is $100,000 or more, use the Tax Computation Worksheet 18 Tax on all taxable income. Enter the smaller of line 17 or line 18 here and on Form 1040, line 44 19

0.

1,083. 1,083.

1,113. 1,083.

Tax Payments Worksheet

2010

G Keep for your records Name(s) Shown on Return

Social Security Number

Jeremy W & Cathrine F Martens

870-91-1234

Estimated Tax Payments for 2010 (If more than 4 payments for any state or locality, see Tax Help) Federal Date

Amount

State Date

Amount

Local ID

Date

Amount

1

04/15/10

04/15/10

04/15/10

2

06/15/10

06/15/10

06/15/10

3

09/15/10

09/15/10

09/15/10

4

01/18/11

01/18/11

01/18/11

ID

5

Tot Estimated Payments Tax Payments Other Than Withholding (If multiple states, see Tax Help) 6 7 8 9

Federal

Forms W-2 Forms W-2G Forms 1099-R Forms 1099-MISC and 1099-G Schedules K-1 Forms 1099-INT, DIV and OID Social Security and Railroad Benefits Form 1099-B St Loc Other withholding St Loc Other withholding St Loc Other withholding St Loc Total Withholding Lines 10 through 18c Total Tax Payments for 2010

Prior Year Taxes Paid In 2010 (If multiple states or localities, see Tax Help) 21 22 23 24

ID

Local

ID

Overpayments applied to 2010 Credited by estates and trusts Totals Lines 1 through 7 2010 extensions

Taxes Withheld From: 10 11 12 13 14 15 16 17 18 a b c 19 20

State

Tax paid with 2009 extensions 2009 estimated tax paid after 12/31/09 Balance due paid with 2009 return Other (amended returns, installment payments, etc)

Federal

State

2,297.

Local

518.

316.

518. 518.

316. 316.

647. 54.

2,998. 2,998. State

ID

Local

ID

Federal Carryover Worksheet

2010

G Keep for your records Name(s) Shown on Return

Social Security Number

Jeremy W & Cathrine F Martens

870-91-1234

2009 State and Local Income Tax Information (See Tax Help) (a) State or Local ID

(b) Paid With Extension

(c) Estimates Pd After 12/31

(d) Total Withheld/Pmts

(e) Paid With Return

(f) Total Overpayment

(g) Applied Amount

Totals Other Tax and Income Information 1 2 3 4 5 6 7 8

2009

Filing status Number of exemptions for blind or over 65 (0 - 4) Itemized deductions after limitation Check box if required to itemize deductions Adjusted gross income Tax liability for Form 2210 or Form 2210-F Alternative minimum tax Federal overpayment applied to next year estimated tax

2010

2 MFJ

1 2 3 4 5 6 7 8

834. 37,138. 0.

QuickZoom to the IRA Information Worksheet for IRA information

Excess Contributions 9a b 10 a b 11 a b

Taxpayer’s excess Archer MSA contributions as of 12/31 Spouse’s excess Archer MSA contributions as of 12/31 Taxpayer’s excess Coverdell ESA contributions as of 12/31 Spouse’s excess Coverdell ESA contributions as of 12/31 Taxpayer’s excess HSA contributions as of 12/31 Spouse’s excess HSA contributions as of 12/31

2010 2009 2008 2007 2006 2005

2010

2009

2010

9a b 10 a b 11 a b

Loss and Expense Carryovers 12 a Short-term capital loss b AMT Short-term capital loss 13 a Long-term capital loss b AMT Long-term capital loss 14 a Net operating loss available to carry forward b AMT Net operating loss available to carry forward 15 a Investment interest expense disallowed b AMT Investment interest expense disallowed 16 Nonrecaptured net Section 1231 losses from: a b c d e f

2009

12 a b 13 a b 14 a b 15 a b 16 a b c d e f

2010

Federal Carryover Worksheet page 2

Jeremy W & Cathrine F Martens

870-91-1234

Loss and Expense Carryovers (cont’d) 17

AMT Nonrecap’d net Sec 1231 losses from:

a b c d e f

2010 2009 2008 2007 2006 2005

20

21 22 23

General business credit Adoption credit from: a 2010 b 2009 c 2008 d 2007 e 2006 f 2005 Mortgage interest credit from: a 2010 b 2009 c 2008 d 2007 Credit for prior year minimum tax District of Columbia first-time homebuyer credit Residential energy efficient property credit

Section 179 expense deduction disallowed Excess a Taxpayer (Form 2555, line 46) foreign b Taxpayer (Form 2555, line 48) housing c Spouse (Form 2555, line 46) deduction: d Spouse (Form 2555, line 48)

2009

2010

2009

2010

18 19 a b c d e f 20 a b c d 21 22 23

Other Carryovers 24 25

2010

17 a b c d e f

Credit Carryovers 18 19

2009

24 25 a b c d

File by Mail Instructions for your 2010 California Tax Return Important: Your taxes are not finished until all required steps are completed. (If you prefer, you can still e-file. Go to the end of these instructions for more information.) Jeremy W & Cathrine F Martens 4821 N. Anderson Ave Riverbank, CA 95367 |

Balance | Your California state tax return (Form 540) shows you are due a Due/ | refund of $518.00. Refund | ______________________________________________________________________________________ | | | Your tax return - The official return for mailing is included in | this printout. Remember to sign and date the return. | | Attach the following to your California tax return: | - a copy of your federal return | - any Form(s) W-2G, 592-B, 593, and 1099s that have | California withholding you may have received | to the front of your return. Do not attach any Form(s) W-2. | | Mail your return and attachments to: | Franchise Tax Board | PO Box 942840 | Sacramento, CA 94240-0009 | | Deadline: Postmarked by April 18, 2011 | | Don't forget correct postage on the envelope. ______________________________________________________________________________________ | | What You | Keep these instructions and a copy of your return for your records. Need to | If you did not print one before closing TurboTax, go back to the Keep | program and select Print & File tab, then select the Print for Your | Records category. ______________________________________________________________________________________ | | 2010 | Taxable Income $ 23,324.00 California | Total Tax $ 0.00 Tax | Total Payments/Credits $ 518.00 Return | Amount to be Refunded $ 518.00 Summary | Effective Tax Rate 2.3% ______________________________________________________________________________________ | | Special | Your printed state tax forms may have special formatting on them, Formatting | such as bar codes or other symbols. This is to enable fast | processing. Don't worry, these forms have been approved by your | taxing authority and are acceptable for printing and mailing. ______________________________________________________________________________________ | | Changed | You can still file electronically. Just go back to TurboTax, select Your Mind | the Print & File tab, then select the E-file category. We'll walk | you through the process. Once you file, we will let you know if your About e-filing? | return is accepted (or rejected) by the state taxing agency. ______________________________________________________________________________________ |

What You Need to Mail

Page 1 of 1

For Privacy Notice, get form FTB 1131.

FORM

California Resident Income Tax Return 2010

540 C1 Side 1

APE

ATTACH FEDERAL RETURN

870-91-1234 JEREMY CATHRINE

MART ** 839-09-1101 W MARTENS F MARTENS

4821 N ANDERSON AVE RIVERBANK CA 01 06 09 10 12 14 16 17 18 31 34 41 42 43 44 45 46 61 62 63 64 71

REV 06/22/11 TTW

2 0 0 2 28765 6474 0 30664 7340 382 0 0 0 0 0 0 120 0 0 0 0 518

95367

05-22-1970 0 0 0 0 0 0 0 518 0 518 0 0 0 0 0 0 0 0 0 0

72 73 74 75 76 77 78 91 92 93 94 95 400 401 402 403 404 405 406 407

P AC A R RP

10

408 410 413 415 416 417 418 110 111 112 113 115 116 117

0 0 0 0 0 0 0 0 0 0 0 518 0 0

03-08-1969 APE FS 3800 3803 SCHG1 5870A 5805 5805F DESIGNEE TPID FN

0 0 0 0 0 0 0 0

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete.

Sign Here It is unlawful to forge a spouse’s/ RDP’s signature. Joint tax return? (see page 17)

Your signature_____________________________________Spouse’s/RDP’s signature (if a joint return, both must sign) _____________________________________ Daytime phone number (optional) ____________________________________ Date ____________________________________ Your email address (optional). Enter only one. __________________________________________________________________________________________________________ Paid preparer’s signature (declaration of preparer is based on all information of which preparer has any knowledge) Paid preparer’s PTIN/SSN

฀ ฀

SELF-PREPARED Firm’s name (or yours, if self-employed)

Firm’s address

฀ ฀FEIN

Do you want to allow another person to discuss this return with us (see page 17)? . . . . . . . . . . . . . . . . . . __________________________________________________________________ Print Third Party Designee’s Name

175

3101106

฀

Yes

No

__________________________________ Telephone Number

Filing Status

870-91-1234 W & CATHRINE F MARTENS Your name: JEREMY ______________________________________Your SSN or ITIN: ______________________________ 1 2 3 4 5

Single Married/RDP filing jointly. (see page 3) Married/RDP filing separately. Enter spouse’s/RDP’s SSN or ITIN above and full name here _____________________________________ Head of household (with qualifying person). (see page 3) Qualifying widow(er) with dependent child. Enter year spouse/RDP died. __________ If your California filing status is different from your federal filing status, check the box here . . . . . . . . . . . . . . . . . . . . . . . . . . . .

฀฀

6 If someone can claim you (or your spouse/RDP) as a dependent, check the box here (see page 7) . . . . . . . . . . . . . . . . . . . . . . .

Exemptions

7 Personal: If you checked 1, 3, or 4 above, enter 1 in the box. If you checked 2 or 5, enter 2 in the box. Whole dollars only 198. If you checked the box on line 6, see page 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 2 X $99 = $___________________ 8 Blind: If you (or your spouse/RDP) are visually impaired, enter 1; if both are visually impaired, enter 2. . 8 X $99 = $___________________ X $99 = $___________________ 9 Senior: If you (or your spouse/RDP) are 65 or older, enter 1; if both are 65 or older, enter 2 . . . . . . . . . 9 10 Dependents: Enter name and relationship. Do not include yourself or your spouse/RDP. _____________________________ KENNETH MARTENS SON 198. ฀10 2 X $99 = $___________________ _________________________ __________________________ Total dependent exemptions. . 396. $ ___________________ 11 Exemption amount: Add line 7 through line 10. Transfer this amount to line 32 . . . . . . . . . . . . . . . . . . . 11

Taxable Income

12 13 14 15 16 17 18 19

28,765. State wages from your Form(s) W-2, box 16 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Enter federal adjusted gross income from Form 1040, line 37; Form 1040A, line 21; Form 1040EZ, line 4 . . . . . . . . . . . . . . . . . . California adjustments – subtractions. Enter the amount from Schedule CA (540), line 37, column B . . . . . . . . . . . . . . . . . . . Subtract line 14 from line 13. If less than zero, enter the result in parentheses (see page 9) . . . . . . . . . . . . . . . . . . . . . . . . . . . . California adjustments – additions. Enter the amount from Schedule CA (540), line 37, column C . . . . . . . . . . . . . . . . . . . . . . California adjusted gross income. Combine line 15 and line 16 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Enter the larger of your CA standard deduction OR your CA itemized deductions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subtract line 18 from line 17. This is your taxable income. If less than zero, enter -0-. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13 14 15 16 17 18 19

Tax

6

31 32 33 34 35

Tax. Check box if from: Tax Table Tax Rate Schedule FTB 3800 FTB 3803 . . . . . . . . . . . . . . . . . . . . . . . . Exemption credits. Enter the amount from line 11. If your federal AGI is more than $162,186 (see page 10) . . . . . . . . . . . . . . . . Subtract line 32 from line 31. If less than zero, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tax. (see page 11) Check box if from:฀ Schedule G-1 Form FTB 5870A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Add line 33 and line 34. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

31 32 33 34 35

New jobs credit, amount generated (see page 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 New jobs credit, amount claimed (see page 11). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ฀ 42 43 Credit _________________________________________ Code ____________ amount . . . . . . . . . . . . . . . . . . . . . . . . . . . Credit _________________________________________ Code ____________ amount . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 To claim more than two credits (see page 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Nonrefundable renter’s credit (see page 12) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Add line 42 through line 46. These are your total credits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Subtract line 47 from line 35. If less than zero, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Alternative minimum tax. Attach Schedule P (540) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mental Health Services Tax (see page 12) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other taxes and credit recapture (see page 13) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Add line 48, line 61, line 62, and line 63. This is your total tax. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

37,138. 6,474. 30,664. 30,664. 7,340. 23,324. 382. 396. 0.

Special Credits Other Taxes

61 62 63 64

71 California income tax withheld (see page 13). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 72 2010 CA estimated tax and other payments (see page 13) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ฀ 72 73 Real estate and other withholding (see page 13) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ฀ 73 74 74 Excess SDI (or VPDI) withheld (see page 13) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child and Dependent Care Expenses Credit (see page 13). Attach form FTB 3506. 75 Qualifying person’s social security number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 _______ _____________ 76 Qualifying person’s social security number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 _______ _____________ 77 Enter the amount from form FTB 3506, Part III, line 8. . . . . . . . . . . . . . . . . . . . . . . . 77 78 78 Child and Dependent Care Expenses Credit from form FTB 3506, Part III, line 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Add line 71, line 72, line 73, line 74, and line 78. These are your total payments (see page 14) . . . . . . . . . . . . . . . . . . . . . . . . 79

518.

Overpaid tax. If line 79 is more than line 64, subtract line 64 from line 79 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Amount of line 91 you want applied to your 2011 estimated tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Overpaid tax available this year. Subtract line 92 from line 91 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tax due. If line 79 is less than line 64, subtract line 79 from line 64 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

518.

Use Overpaid Tax/ Tax Due Tax

41 42 43 44 45 46 47 48

Payments

0.

91 92 93 94 95

Use Tax. This is not a total line (see page 14) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Side 2 Form 540

C1

2010

175

3102106

61 62 63 64

91 92 93 94

120. 120. 0. 0.

0.

518.

518.

95

REV 06/22/11 TTW

Code 400 401 402 403 404 405 406 407 408 410 413 415 416 417 418

110 Add code 400 through code 418. This is your total contribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

110

111 AMOUNT YOU OWE. Add line 94, line 95, and line 110 (see page 15). Mail to: FRANCHISE TAX BOARD, PO BOX 942867, SACRAMENTO CA 94267-0009 . . . . . . . . . . . . . . . Pay online – Go to ftb.ca.gov and search for web pay.

112 Interest, late return penalties, and late payment penalties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 113 Underpayment of estimated tax. Check box: FTB 5805 attached ฀ FTB 5805F attached . . . . . . . . . . . . . . . . . . . 113 114 Total amount due (see page 16). Enclose, but do not staple, any payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114

Refund and Direct Deposit

Amount You Owe

California Seniors Special Fund (see page 22) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alzheimer’s Disease/Related Disorders Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . California Fund for Senior Citizens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rare and Endangered Species Preservation Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . State Children’s Trust Fund for the Prevention of Child Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . California Breast Cancer Research Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . California Firefighters’ Memorial Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Emergency Food for Families Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . California Peace Officer Memorial Foundation Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . California Sea Otter Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . California Cancer Research Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Arts Council Fund. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . California Police Activities League (CALPAL) Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . California Veterans Homes Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Safely Surrendered Baby Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Interest and Penalties

Contributions

JEREMY W & CATHRINE F MARTENS 870-91-1234 Your name: ______________________________________Your SSN or ITIN: ______________________________

115 REFUND OR NO AMOUNT DUE. Subtract line 95 and line 110 from line 93 (see page 16). Mail to: FRANCHISE TAX BOARD, PO BOX 942840, SACRAMENTO CA 94240-0009 . . . . . . . . . . . . . . . . . .

Amount

111

518.

115

Fill in the information to authorize direct deposit of your refund into one or two accounts. Do not attach a voided check or a deposit slip (see page 16). Have you verified the routing and account numbers? Use whole dollars only. All or the following amount of my refund (line 115) is authorized for direct deposit into the account shown below: Checking Savings ฀Type ฀Account number

116 Direct deposit amount

The remaining amount of my refund (line 115) is authorized for direct deposit into the account shown below: Checking Savings ฀ ฀Routing number ฀Type ฀Account number

117 Direct deposit amount

175

Form 540

฀Routing number

REV 06/22/11 TTW

3103106

C1

2010 Side 3

TAXABLE YEAR

DO NOT ATTACH PAYMENT TO THIS SCHEDULE

CALIFORNIA SCHEDULE

2010

Wage and Tax Statement

W-2

Important: Attach this form to the back of your Forms 540/540A, 540 2EZ, or Form 540NR (Long or Short). Name(s) as shown on return

SSN or ITIN

JEREMY W & CATHRINE F MARTENS

8

7

0

-9

1

-1

2

3

4

Caution: If this form is filled out do not send your Form(s) W-2 to the Franchise Tax Board. If your Form(s) W-2 are from multiple states, attach copies showing California tax withheld to this schedule. Also attach Form(s) 592-B, 593, and 1099. If this schedule is blank, attach your Form(s) W-2 to the lower front of your tax return.

Taxpayer W-2 information. 1st W-2

2nd W-2

870-91-1234 39-0902999 State & Employer’s State ID Number (box 15) CA 39-0902999 Employer Name (box c) RAINY DAY INSURANCE State Wages, Tips, etc. (box 16) 28,765. CA State Income Tax (box 17) 518. Social Security Wages (box 3) 28,765. SDI/VPDI (Local Income Tax) (box 14 or 19) 316.

Social Security Wages (box 3) SDI/VPDI (Local Income Tax) (box 14 or 19)

3rd W-2 Social Security Number (box a) Employer ID Number (EIN) (box b) State & Employer’s State ID Number (box 15) Employer Name (box c) State Wages, Tips, etc. (box 16) CA State Income Tax (box 17) Social Security Wages (box 3) SDI/VPDI (Local Income Tax) (box 14 or 19)

4th W-2 Social Security Number (box a) Employer ID Number (EIN) (box b) State & Employer’s State ID Number (box 15) Employer Name (box c) State Wages, Tips, etc. (box 16) CA State Income Tax (box 17) Social Security Wages (box 3) SDI/VPDI (Local Income Tax) (box 14 or 19)

Social Security Number (box a) Employer ID Number (EIN) (box b)

Social Security Number (box a) Employer ID Number (EIN) (box b) State & Employer’s State ID Number (box 15) Employer Name (box c) State Wages, Tips, etc. (box 16) CA State Income Tax (box 17)

Spouse/RDP W-2 information. 1st W-2 Social Security Number (box a) Employer ID Number (EIN) (box b) State & Employer’s State ID Number (box 15) Employer Name (box c) State Wages, Tips, etc. (box 16) CA State Income Tax (box 17) Social Security Wages (box 3) SDI/VPDI (Local Income Tax) (box 14 or 19)

2nd W-2 Social Security Number (box a) Employer ID Number (EIN) (box b) State & Employer’s State ID Number (box 15) Employer Name (box c) State Wages, Tips, etc. (box 16) CA State Income Tax (box 17) Social Security Wages (box 3) SDI/VPDI(Local Income Tax) (box 14 or 19)

3rd W-2 Social Security Number (box a) Employer ID Number (EIN) (box b)

4th W-2 Social Security Number (box a) Employer ID Number (EIN) (box b)

State & Employer’s State ID Number (box 15) Employer Name (box c) State Wages, Tips, etc. (box 16) CA State Income Tax (box 17)

State & Employer’s State ID Number (box 15) Employer Name (box c) State Wages, Tips, etc. (box 16) CA State Income Tax (box 17)

Social Security Wages (box 3) SDI/VPDI (Local Income Tax) (box 14 or 19)

Social Security Wages (box 3) SDI/VPDI (Local Income Tax) (box 14 or 19)

1. Total state wages from the Form(s) W-2 for taxpayer (Add box 16 from all Form(s) W-2 for taxpayer) For nonresidents or part-year residents, enter your total California wages from all your Form(s) W-2 for taxpayer (Add box 16 from all Form(s) W-2 for taxpayer) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

28,765. . . . . . . . . . . . $__________________ 2. Total state wages from the Form(s) W-2 for spouse/RDP (Add box 16 from all Form(s) W-2 for spouse/RDP) For nonresidents or part-year residents, enter the total California wages from all Form(s) W-2 for spouse/RDP (Add box 16 from all Form(s) W-2 for spouse/RDP). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . $__________________ 3. Total California Wages from all Form(s) W-2 (Add line 1 and line 2, and enter here and on Form 540 2EZ, line 9; Form 540 or Form 540NR (Long or Short), line 12. If completing Form 540X, 28,765. report any W-2 income on line 1a, column B, that was not reported on your original tax return.) . . . . . . . $__________________

For Privacy Notice, get form FTB 1131.

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Schedule W-2 2010

SCHEDULE

TAXABLE YEAR

2010

CA (540)

California Adjustments — Residents

Important: Attach this schedule behind Form 540, Side 3 as a supporting California schedule. Name(s) as shown on return

J E R E M Y

SSN or ITIN

W

&

C A T H R I N E

F

M A R T E N S

Part I Income Adjustment Schedule Section A – Income 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

22

A

8

7

Federal Amounts (taxable amounts from your federal return)

0 B

Wages, salaries, tips, etc. See instructions before making an entry in column B or C . . . . 7 28,765. Taxable interest (b)________________________. . . . . . . . . . . . . . . . . . . . . . . . . . . . .8(a) 1,180. 289. . . . . . . . . . . .9(a) Ordinary dividends. See instructions. (b) ________________________ 469. Taxable refunds, credits, offsets of state and local income taxes . . . . . . . . . . . . . . . . . . . 10 Alimony received . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Business income or (loss) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Capital gain or (loss). See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Other gains or (losses) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 IRA distributions. See instructions. (a) ____________________ . . . . . . . . . . . . . . . .15(b) Pensions and annuities. See instructions. (a) ____________________ . . . . . . . . . . .16(b) Rental real estate, royalties, partnerships, S corporations, trusts, etc.. . . . . . . . . . . . . . . 17 Farm income or (loss) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Unemployment compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 6,474. Social security benefits (a) ____________________ . . . . . . . . . . . . . . . . . . . . . . . . .20(b) Other income. a California lottery winnings e NOL from FTB 3805D, 3805Z, 250. b Disaster loss carryover from FTB 3805V 3806, 3807, or 3809 21 _______________ c Federal NOL (Form 1040, line 21) f Other (describe): d NOL carryover from FTB 3805V ________________________ ________________________ Total. Combine line 7 through line 21 in column A. Add line 7 through line 21f in 37,138. column B and column C. Go to Section B. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 _______________

{

-9

1

-1

Subtractions See instructions

2 C

3

4

Additions See instructions

6,474. a _____________ b _____________ c _____________ d _____________ e _____________ f _____________

a _____________ b _____________ c _____________ d _____________ e _____________ f _____________

6,474.

Section B – Adjustments to Income 23 24

Educator expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Certain business expenses of reservists, performing artists, and fee-basis government officials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Health savings account deduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Moving expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 One-half of self-employment tax. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Self-employed SEP, SIMPLE, and qualified plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Self-employed health insurance deduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Penalty on early withdrawal of savings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31a Alimony paid. (b) Recipient’s: SSN ___ ___

32 33 34 35

Last name ______________________________ . . . . IRA deduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Student loan interest deduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tuition and fees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Domestic production activities deduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

23 24 25 26 27 28 29 30

31a 32 33 34 35

36

Add line 23 through line 31a and line 32 through line 35 in columns A, B, and C. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

37

Total. Subtract line 36 from line 22 in columns A, B, and C. See instructions . . . . . . . . 37

37,138.

6,474. REV 06/22/11 TTW

For Privacy Notice, get form FTB 1131.

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Schedule CA (540) 2010 Side 1

Part II Adjustments to Federal Itemized Deductions 38

834. Federal itemized deductions. Add the amounts on federal Schedule A (Form 1040), lines 4, 9, 15, 19, 20, 27, and 28 . . . . . . . . . . 38 _________________

39

Enter total of federal Schedule A (Form 1040), line 5 (State Disability Insurance, and state and local income tax, or 834. General Sales Tax), line 7 (new motor vehicle tax), and line 8 (foreign income taxes only). See instructions . . . . . . . . . . . . . . . . . 39 _________________

40

0. Subtract line 39 from line 38 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 _________________

41

Other adjustments including California lottery losses. See instructions. Specify _________________________________. . . . . . 41 _________________

42

0. Combine line 40 and line 41 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 _________________

43

Is your federal AGI (Form 540, line 13) more than the amount shown below for your filing status? Single or married/RDP filing separately . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$162,186 Head of household . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$243,283 Married/RDP filing jointly or qualifying widow(er) . . . . . . . . . . . . . . . . . . . . .$324,376 No. Transfer the amount on line 42 to line 43. Yes. Complete the Itemized Deductions Worksheet in the instructions for Schedule CA (540), line 43 . . . . . . . . . . . . . . . . . . . . . . 43

0.

Enter the larger of the amount on line 43 or your standard deduction listed below Single or married/RDP filing separately . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$3,670 Married/RDP filing jointly, head of household, or qualifying widow(er) . . . . . . .$7,340 Transfer the amount on line 44 to Form 540, line 18 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

7,340.

44

Side 2

Schedule CA (540) 2010

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Nonrefundable Renter’s Credit Qualification Record ฀Tip

175

e-file and skip this page! The tax software product you use to e-file will help you find out if you qualify for this credit and will figure the correct amount of the credit automatically. Go to ftb.ca.gov to check your e-file options. You can claim the nonrefundable renter’s credit using CalFile and ReadyReturn.

If you were a resident of California and paid rent on property in California, which was your principal residence, you may qualify for a credit that you can use to reduce your tax. Answer the questions below to see if you qualify. For purposes of California income tax, references to a spouse, husband, or wife also refer to a California Registered Domestic Partner (RDP), unless otherwise specified. When we use the initials RDP they refer to both a California registered domestic “partner” and a California registered domestic “partnership,” as applicable. For more information on RDPs, get FTB Pub. 737. Do not mail this record. Keep with your tax records.

1. Were you a resident of California for the entire year in 2010? Military personnel. If you are not a legal resident of California, you do not qualify for this credit. However, your spouse/RDP may claim this credit if he or she was a resident, did not live in military housing during 2010, and is otherwise qualified. YES. Go to question 2. NO. Stop. File the Long or Short Form 540NR, California Nonresident or Part-Year Resident Income Tax Return. See “Order Forms and Publications” on page 63.

2. Is your California adjusted gross income the amount on Form 540/540A, line 17: • $34,722 or less if single or married/RDP filing separately; or • $69,444 or less if married/RDP filing jointly, head of household, or qualifying widow(er)? YES. Go to question 3. NO. Stop here. You do not qualify for this credit.

3. Did you pay rent, for at least half of 2010, on property (including a mobile home that you owned on rented land) in California, which was your principal residence? YES. Go to question 4.

NO. Stop here. You do not qualify for this credit.

4. Can you be claimed as a dependent by a parent, foster parent, legal guardian, or any other person in 2010? NO. Go to question 6.

YES. Go to question 5.

5. For more than half the year in 2010, did you live in the home of the person who can claim you as a dependent? NO. Go to question 6.

YES. Stop here. You do not qualify for this credit.

6. Was the property you rented exempt from property tax in 2010? You do not qualify for this credit if, for more than half of the year, you rented property that was exempt from property taxes. Exempt property includes most government-owned buildings, church-owned parsonages, college dormitories, and military barracks. However, if you or your landlord paid possessory interest taxes for the property you rented, then you may claim this credit. NO. Go to question 7. YES. Stop here. You do not qualify for this credit.

7. Did you claim the homeowner’s property tax exemption anytime during 2010? You do not qualify for this credit if you or your spouse/RDP received a homeowner’s property tax exemption at any time during the year. However, if you lived apart from your spouse/RDP for the entire year and your spouse/RDP received a homeowner’s property tax exemption for a separate residence, then you may claim this credit if you are otherwise qualified. NO. Go to question 8. YES. If your filing status is single or married/RDP filing separately, stop here, you do not qualify for this credit. If your filing status is married/RDP filing jointly, go to question 9.

8. Were you single in 2010? YES. Go to question 11.

NO. Go to question 9.

9. Did your spouse/RDP claim the homeowner’s property tax exemption anytime during 2010? You do not qualify for this credit if you or your spouse/RDP received a homeowner’s property tax exemption at any time during the year. However, if you lived apart from your spouse/RDP for the entire year and your spouse/RDP received a homeowner’s property tax exemption for a separate residence, then you may claim this credit if you are otherwise qualified. NO. Go to question 11. YES. If both you and your spouse/RDP claimed the homeowner’s property tax exemption, stop here, you do not qualify for this credit. Otherwise, go to question 10.

10. Did you and your spouse/RDP maintain separate residences for the entire year in 2010? YES. Go to question 11.

NO. Stop here. You do not qualify for this credit.

11. If you are: • Single, enter $60 on Form 540/540A, line 46. • Head of household or qualifying widow(er), enter $120 on Form 540/540A, line 46. • Married/RDP filing separately: if you and your spouse/RDP lived in the same rental property and both qualify for this credit, one spouse/RDP may claim the full amount of the credit ($120), or each spouse/RDP may claim half the amount ($60 each). If you and your spouse/RDP lived apart for the entire year and you qualify for this credit, you may claim half the amount of the credit ($60). Enter your credit amount on Form 540/540A, line 46. • Married/RDP filing jointly, enter $120 on Form 540/540A, line 46. (Exception: If one spouse/RDP claimed the homeowner’s tax exemption and you lived apart from your spouse/RDP for the entire year, enter $60 on Form 540/540A, line 46.) Fill in the street address(es) and landlord information below for the residence(s) you rented in California during 2010, which qualified you for this credit.

Street Address

City, State, and ZIP Code

120.

Dates Rented in 2010 (From______to______)

to a_________________________________________________________________________________________________________ to b_________________________________________________________________________________________________________ Enter the name, address, and telephone number of your landlord(s) or the person(s) to whom you paid rent for the residence(s) listed above. Name Street Address City, State, ZIP Code, and Telephone Number

a_________________________________________________________________________________________________________ b_________________________________________________________________________________________________________ Page 18 Personal Income Tax Booklet 2010 (REV 01-11)

REV 06/22/11 TTW

Jeremy W & Cathrine F Martens

870-91-1234

1

Additional information from your 2010 California Tax Return Some forms were not able to fit all of the information you entered. We've included this information below.

Form 540: California Resident Income Tax Return Additional Dependents Statement

Continuation Statement

Dependent(s) KENDRA MARTENS

Relationship DAUGHTER