Scan 0001

OMS No. 1545·0074

8879

Form

IRS e-fi/e Signature Authorization

Declaration

2010

~ Do not send to the IRS. This is not a tax return. ~ Keep this form for your records. See instructions.

Department of the Treasury Internal Revenue Service

Control Number (DCN)

00-871154-18103-1

Taxpayer's name

JEREMIAH

Social security number

GRIFFITH

474-04-3631

Spouse's name

Spouse's

KIM SESSIONS lea.•tl~i#1Tax Return Information

528-97-6647 - Tax Year Ending December

social

gross income (Form 1040, line 38; Form 1040A, line 22; Form 1040EZ, line 4). .................... 2 Total tax (Form 1040, line 60; Form 1040A, line 37; Form 1040EZ, line 11). ..... ... ... .. ,.,., . ... ,.,

,

and Signature

. .. . . . . "

32,432.

1

.. .

2

..... .. .

3 4

,

3 Federal income tax withheld (Form 1040, line 61; Form 1040A, line 38; Form 1040EZ, line 7). 4 Refund(Form 1040,line 74a; Form 1040A,line 46a; Form 1040EZ,line 12a;Form 1040·SS,Part I, line 12a) ....... . 5 Amount you owe (Form 1040, line 76; Form 1040A, line 48; Form 1040EZ, line 13). .......

Declaration

number

31, 2010 (Whole Dollars Only)

1 Adjusted

11.11Iii1 Taxpayer

security

.

,

. .. .

1,060. 4,899.

5 (Be sure you get and keep a copy of your return)

Authorization

Underpenaltiesof perjury, I declarethat I haveexamineda copy of my electronic individual incometax return and accompanyingschedulesand statementsfor the tax year ending December31, 2010,and to the best of my knowledgeand belief, it is true, correct, and complete.I further declarethat the amounts in Part I aboveare the amountsfrom my electronic incometax return, I consentto allow my intermediateservice provider, transmitter, or electronic return originator (ERO)to send my return to the IRSand to receivefrom the IRS(a) an acknowledgementof receipt or reasonfor rejection of the transmission, (b) the reasonfor any delay in processingthe return or refund, and (c) the date of any refund. If applicable, I authorizethe U.S.Treasury and its designatedFinancialAgentto initiate an ACHelectronicfunds withdrawal (direct debit) entry to the financial institution accountindicated in the tax preparationsoftware for paymentof my Federaltaxes owed on this return and/or a paymentof estimatedtax, and the financial institution to debit the entry to this account.I further understandthat this authorizationmay apply to future Federaltax paymentsthat I direct to be debitedthroughthe ElectronicFederalTax PaymentSystem(EFTPS).In order for me to initiate future payments,I requestthat the IRSsend me a personalidentification number(PIN) to accessEFTPS.This authorizationis to remain in full force and effect until I notify the U.S.Treasury FinancialAgentto terminate the authorization.To revokea payment,I must contactthe U.S.Treasury FinancialAgentat 1-888-353-4537no later than 2 businessdays prior to the payment(settlement) date. I also authorizethe financial institutions involvedin the processingof the electronic paymentof taxesto receiveconfidential information necessaryto answer inquiries and resolve issues related to the payment.I further acknowledgethat the personalidentification number(PIN) below is my signaturefor my electronic incometax return and, if applicable,my ElectronicFundsWithdrawalConsent.

Taxpayer's

PIN: check one box only

[K] I authorize

HAYNIE AND COMPANY CPA'S

to enter or generate

78905

my PIN

ERO finn name

Enter five numbers,

but

do not enter all zeros

as my signature on my tax year 2010 electronically filed income tax return. enter my PIN as my signature on my tax year 2010 electronically filed income tax return. Check this box only if you are entering own PIN and your return is filed using the Practitioner PIN method. The ERO must complete Part III below.

D I will

Date ~

Your signature

Spouse's

your

PIN: check one box only

[K] I authorize

HAYNIE AND COMPANY CPA'S

to enter or generate

my PIN

ERO firm name

as my signature

on my tax year 2010 electronically

filed income tax return.

D own I will enter my PIN as my signature on my tax year 2010 electronically filed income tax return. Check this box only PIN and your return is filed using the Practitioner PIN method. The ERO must complete Part III below. Spouse's signature

if you are entering

your

Date ~

~

Practitioner

(pitt. frO Certification ERO's EFIN/PIN.

80240 Enter five numbers, but do not enter all zeros

and Authentication

Enter your six-digit

EFIN followed

PIN Method Returns Only - Practitioner by your five-digit

continue

below

PIN Method Only self-selected

87115412345

PIN ...

do not enter all zeros

I certify that the above numeric entry is my PIN, which is my signature for the tax year 2010 electronically filed income tax return for the taxpayer(s) indicated above. I confirm that I am submitting this return in accordance with the requirements of the Practitioner PIN method and Publication 1345, Handbook for Authorized IRS e-tite Providers of Individual Income Tax Returns. ERa's signature

~

LARRY R.

BERGHOUT, CPA

Date ~

ERO Must Retain This Form - See Instructions . Do Not Submit This Form to the IRS Unless Requested BAA

For Paperwork

Reduction

Act Notice, see your tax return instructions. FDIA1701L

11119110

To Do So Form 8879 (2010)

Form

Department of the Treasury -

1040A

Name, Address, and SSN

Internal Revenue Service

U.S. Individual Income Tax Return -

Your first name and initial

IRS Use Only -

Do not write or staple in this space OMS No. 1545·0074 Your social security number

JEREMIAH GRIFFITH

474-04-3631

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

See separate instructions

2010

(99)

Last name

Last name

Spouse's social security number

KIM SESSIONS

528-97-6647

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

•.

1300 E 6125 S City. town or post office.

If you have a foreign

address,

State

see instructions.

ZIP code

Checking a box belowwill not change your tax or refund

SOUTH OGDEN, UT 84405-7116 Presi denti al Election Campaign

Filing status

~

Check here if you, or your spouse if filin 1 2 3

~

X

Check only one box.

Exemptions

6a

[Xl

b Spouse . c Dependents: (1)

If more than six dependents, see instructions.

jointl

,want $3 to go to this fund (see instructions).,

Single Marriedfilingjointly(evenif onlyonehadincome) Marriedfilingseparately. Enterspouse'sSSN aboveand full namehere~

[R] Yourself.

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

Apartment no.

4

0

5

First name

0

....

•••••

.....

····.0'

. ... . .....

.

..

.

. ...

ZACHARY GRIFFITH

646-90-8270

Spouse

" ""

}

Boxes checked on 6aand6b, ,

2 ------

. .......

(2) Dependent's social security number

Last name

You

Headof household (withqualifyingperson).(Seeinstructions.) If thequalifyingpersonis a childbutnotyourdependent, enterthischild'snamehere ~ ----------------------Qualifying widow(er) with dependent child (see instructions)

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

••••••

~

(3) Dependent's relationship to you

(4) t/ IT child under age 17 qual for child tax cr (see instrs)

Ix

SON

No. of children on 6c who: lived with you. ..

•

•

.. ------1

,

did not live with you due to divorce or separation (see instructions) ... Dependents on 6c not entered above ...

d Total number of exemptions claimed .... , ..........

. ......

.....

... ...

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

. .

-----------

Add numbers .\ on lines above ~

....

31

Income AttachForm(s) W-2 here.Also attachForm(s) 1099-Rif tax waswithheld.

If you did not get a W-2, see

7 Wages, 'salaries, tips, etc. Attach Form(s) W-2 .. 8a Taxable interest. Attach Schedule B if required. b Tax-exemptinterest.Donot includeonline8a..... , .

Adjusted gross income

32,432. _

8b

9a Ordinary dividends. Attach Schedule B if required ... , .. , .... b Qualified dividends (see instructions), .. , 10 Capital gain distributions (see instructions) ... 11 a IRA distributions. ' 11 a

11 b Taxable amount,

12a Pensions and annuities

12bTaxabie amount.

12a

9a 9b 10 11 b 12b

13 Unemployment compensation and Alaska Permanent Fund dividends (see instructions). . . . .

irrstructiona.

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

7 __:=.8.::a

.........

.

13

, ., .

14a Social security benefits. . . . ... , .... , ... , 14a 14b Taxable amount. 15 Add lines 7 through 14b (far right column). This is your total income, , . 16 Educator expenses (see instructions) ,. 17 IRA deduction (see instructions) .. , ,... 18 Student loan interest deduction (see instructions) .... , .... , 19 Tuition and fees. Attach Form 8917. 20

Add lines 16 through 19. These are your total adjustments.

--'-16-=----'-17'---.:.18=---'-1.:..9 , . , .. ,

21 Subtract line 20 from line 15. This is your adjusted gross income, BAA For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions.

FDIA1312L

01108111

~

-'-

14b 15

32,432.

_ _ _ _

.

20 ~ 21

O. 32,432. Form 1040A (2010)

Form 1040A (2010)

JEREMIAH 22

Tax, credits, and payments

GRIFFITH

Enter the amount

{D

23a Check

AND

KIM

SESSIONS

from line 21 (adjusted

474-04-3631

gross income).

0

You were born beforeJanuary2,1946,

................. Blind

}

0 Spousewas born beforeJanuary2, 1946, 0 Blind

If:

b If you are married filing separately and your spouse see instructions and check here. . deduction

(see instructions).

itemizes

..

deductions, . . . . . . . . ..

•.

23 b

26

Exemptions.

27

Subtract line 26 from line 25. If line 26 is more than line 25, enter -0-. This is your taxable income. . . . . .

28

Tax, including

.

Multiply

$3,650 by the number

any alternative

minimum

~

..

Attach Schedule

_29 R.

31

Education Retirement

credits from Form 8863, line 23 . . . . . . .

33

Child tax credit (see instructions).

34

Add lines 29 through

35

Subtract

line 34 from line 28. If line 34 is more than line 28, enter -0-

36

Advance

earned

37

Add lines 35 and 36. This is your total tax

38

Federal

39

2010 estimated

savings contributions

credit. Attach

31

10,082.

income credit payments

income tax withheld

8~1_=6~. 34

.

s

W-2, box 9

.

and amount

applied

M. . .

credit (EIC).

.

-::-.-:8:,-0'-:0'-'--.

--.:41=-=.a

--=2:::..,<-7-=-=2...:.7-=-.

_

42 43

Additional American

child tax credit. Attach Form 8812... opportunity credit from Form 8863, line 14.

44

Add lines 38, 39, 40, 41a,42, and 43. Theseare your total payments..

45

If line 44 is more than line 37, subtract This is the amount you overpaid.

--"42=_4_3"--

-='1..;:,8-,:4;...:..-. 1_2 __8_. ~44

line 37 from line 44. .

190001383024

47

Amount of line 45 you want applied estimated tax .

48

Amount you owe. Subtract see instructions. .

49

Estimated

R.

4,899. 45

.

4,899.

~0 _46=.=a

to

o

324377613

~ dAccount number ..

tax penalty

_

_4...:.;0=--

.

~ bRouting number ...

0.

37

from

pay election._4...:.1'-b"--

of line 45 you want refunded

_

-=1:..!.,....:0=-6~0-=-.

--=-39~ Schedule

0.

-=..:36=-~

--=.38::.......

1,008.

35

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

.

from Forms W-2 and 1099.

tax payments

_

--=-33-=--

from Form(s)

1,008.

192.

__32

.

33. These are your total credits

Making work pay credit. Attach

4::...<,-=8c.::.9-.::..9...:-.

Savings

to your 2011 47

line 44 from line 37. For details on how to pay, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . •. __48

(see instructions}

....

49

lID

Yes.

Complete

BERGHOUT,

CPA

_

the following.

~

Personal identification •. 12345 number(PIN)

~~~ne~ 801-972-4800

Underpenaltiesof perjury.I declarethat I haveexaminedthis returnand accompanyingSChedules andstatements,and to the bestof my knowledgeand belief,they are true,correct.andaccuratelylist all amountsandsourcesof incomeI receivedcunnq the tax year. Declarationof preparer(otherthanthe taxpayer)IS basedon all informationof whichthe preparerhasany knowledge. Yoursignature Date Youroccupation OPERATOR

~ Spouse'ssignature.If a joint return.both mustsign.

PrintIType

Paid preparer use only

27

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

Form 8880.

Doyou want to allow anotherpersonto discussthis rsturn with the IRS (soo instructions)?

Sign here

Keepa copy for your records.

10,950.

_

designee

Joint return? Seeinstructions.

21,032_

26

_

--=-30~

32

~:~~nee's ~ LARRY

11,400.

25

28

Creditfor child and dependentcare expenses.Attach Form 2441.. . .

combat

24

tax

Credit for the elderly or the disabled.

income

Page 2 --=3-=2'-',_4.::..3=-=.2-=-.

D

.

on line 6d. ..

29

bNontaxable

party

,....:22==-

line 24 from line 22. If line 24 is more than line 22, enter ·0-..

30

46a Amount

Third

23a

Subtract

41 a Earned

Amount you owe

~

25

40

Direct deposit? See instructions and fill in 46b, 46c, and 46d or Form 8888.

checked.

Enter your standard

2009 return .

Refund

Total boxes

24

(see instructions)

If you have a qualifying child, attach Schedule EIC.

D

. . . . . . ..

LARRY

preparer"s

R.

Preparer's

name

BERGHOUT,

Firm'sname •. HAYNIE Firm'saddress~ 1785

AND

WEST

CPA

R. CPA

BERGHOUT, 1

occupation

Check~ P00439981

2/07/11

S

SOUTH

SALT LAKE CITY, DT

Spouse's

HOMEMAKER Date

signature

LARRY

COMPANY 2300

Date

84119-2065

Firm'sEIN ~

87-0325228

Phoneno.

8

°

1- 97 2 - 4 8 0 0 Form 1040A (2010)

FDIA1312L

01/08/11

SCHEDULE EIC

Earned Income Credit

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

OMB No. 1545·0074

Qualifying Child Information

201043

Complete and attach to Form 7040A or 7040 only if you have a qualifying child.

(99)

Attachment Sequence No.

Name(s) shown on return

JEREMIAH

GRIFFITH

Before you begin:

Your social security

AND KIM

number

474-04-3631

SESSIONS

• 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.

CAUTION!

• 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 the instructions for details.

•

It will take us longer to process your return and issue your refund if vou do not fill in all lines that apply for each qualifying child .

Qualifying Child Information 1

Child 1

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

2

Last name

First name

. ZACHARY

GRIFFITH

646-90-8270

3 Child's year of birth

2006

Year

If born after 7997 AND the child was

*~~g%'i~P,:f to Ime5.

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

~~Yp~?Mt!{a Sf~)N6; ~o

DYes. DNo. Go to line 5. Continue.

bWas the child permanently and totally d;sabl",d dur:na !Ony D""{ 01 ~~1M ...

D ..~·

Dv--. Continuo.

Last name

BRYSON

First name

Last name

SESSIONS

The child is not a qualifying child.

647-36-4901 1997

Year

If born after 7997 AND the child was

*~~g~~ntp,:f to Ime 5.

~~!f, ~?~ls°'l!a sf,fJs,{f;;~o

DYes. DNo. Continue. Go to line 5.

n-.

ONQ. The

Continue.

child

is not :l qualifying child.

Year If born after 7997 AND the child was

*~~g~~'i~p,~~ ~~Ih ~?~ls°~~ Sf~Js,{f;;ibo to Ime 5.

DYes. DNo. Continue. Go to line 5.

O'G~' Continue.

Orto. The

child

is not a

qualifying child.

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

6

First name

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 201O. 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 ...

S

Child 3

Child 2

.

SON

SON

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 'T.

•

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:. . . . . . . . . . . . . . . ... .. .... ,

,

1-2

--

months

Do not enter more than 72 months. BAA For Paperwork Reduction Act Notice, see your tax return instructions.

FDIA7401L11/04110

12

--

months

Do not enter more than 72 months.

--

months

Do not enter more than 72 months.

Schedule EIC (Form 1040A or 1040) 2010

881 2

Form

Department of the Treasury Internal Revenue Service

OMS No. 1545-0074

Additional Child Tax Credit Complete

(99)

and attach to Form

7040, Form

7040A, or Form

2010 7040NR.

Name(s) shown on return

~~g~~~c~n~o.

47

Your social security number

KIM SESSIONS

474-04-3631

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

1040 filers:

1,000.

If you used Pub 972, enter the amount from line 8 of the worksheet on page 4 of the publication. 2 Enter the amount from Form 1040, line 51, Form 1040A, line 33, or Form 1040NR, line 48 . 3 Subtract line 2 from line 1. If zero, stop; you cannot take this credit ... 4a Earned income (see instructions) ... b Nontaxable combat pay (see instructions) ..... 5 Is the amount on line 4a more than $3,000? No. Leave line 5 blank and enter -0- on line 6.

2 3

816. 184.

32,432.

4b

o

6

29,432. ~ Yes. Subtract $3,000 from the amount on line 4a. Enter the result. 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.

[R]

o

Yes. If line 6 is equal to or more than line 3, skip Part II and enter the amount from line

Otherwise, go to line 7.

3 on line 13.

Certain Filers Who Have Three or More Qualif in Children 7 Withheld social security and Medicare taxes from Form(s) W-2, boxes 4 and 6.

S

If married filing jointly, include your spouse's amounts with yours. If you worked for a railroad, see the instructions. . .......... .............. 8

9 10

1040 filers:

Enter the total of the amounts from Form 1040, lines 27 and 57, plus any taxes that you Identified usinq code 'UT' and entered on the dotted line next to line 60. 1040A filers: Enter -0-. 1040NR filers: Enter the total of the amounts from Form 1040NR, lines 27 and 55, plus any taxes that you Identified usmq code 'UT' and entered on the dotted line next to line 59. Add lines 7 and 8. . 1040 filers:

1--7_1--

_

8

9

Enter the total of the amounts from Form 1040, lines 64a and 69.

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). l040NR filers: Enter the amount from Form 1040NR, line 64.

1040A filers:

11

L....:..10-'--'--

_

Subtract line 10 from line 9. If zero or less, enter -0-.

11

12

12 Enter the larger of line 6 or line 11 ..... Next, enter the smaller of line 3 or line 12 on line 13.

13

This is your additional

child tax credit.

184.

13

.

Enter this amount on Form 7040, line 65,

Form 1040A, line 42, or Form

BAA

For Paperwork

Reduction

Act Notice, see your tax return instructions.

FDIA300lL

07/08/10

7040NR, line 62.

Form 8812 (2010)

Form

8863

Department of the Treasury Internal Revenue Service

2010

~ See separate instructions to find out if you are eligible to take the credits. ~ Attach to Form 1040 or Form 1040A. .

(99)

Attachment Sequence No.

Your social security

Name(s) shown on return

JEREMIAH GRIFFITH AND KIM SESSIONS CAUTION!

OMB No. 1545-0074

Education Credits (American Opportunity and Lifetime Learning Credits)

50

number

474-04-3631

You cannot take both an education credit and the tuition and fees deduction (see Form 8977) for the same student for the

same year.

W.lII.'. American

Opportunity Credit

You cannot take the American opportunity credit for more than 4 tax years for the same student (e) Multiply the 1 (a) Student's name (b) Student's (c) Qualified (d) Subtract $2,000 (as shown on page 1 social security expenses (see from the amount in amount in column (d) by 25% (.25) of your tax return) number (as shown instructions). Do column (c). If zero on page 1 of not enter more or less, enter -0your tax return) than $4,000 for First name each student. --------------Last name Caution'

JEREMIAH GRIFFITH

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

474-04-3631

(t) If column (d) is

zero, enter the amount from column (c). Otherwise, add $2,000 to the amount in column (e).

320.

320.

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

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

2

opportunity credit. Add the amounts on line 1, column (t). .If .you.are t~klng t.helifetime learning credit for a different student, go to Part II; otherwise, go to Part III ....

Tentative American

~arari:l.lLifetime Caution:

3 First name

_.... ,

..

,

...

. . . ....... "

....

'

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

.....

...

,

.. . ..

"

,

.....

..... ...

lifetime learning credit. Multiply line 5 by 20% (.20). If you have an entry on line 2, go to Part III; . .. , .. , ........ .......... . . . ... . .. . ... . .. . .. . ........ . . . ..... , . . .............

otherwise go to Part IV .

BAA For Paperwork

320.

You cannot take the Amencan opportunity credit and the lifetime learning credit for the same student In the same year. (c) Qualified (b) Student's social (a) Student's name (as shown on page 1 of your tax return) expenses security number (as (see instructions) shown on page 1 of your tax return) Last name

Add the amounts on line 3, column (c), and enter the total ........... .... . .. . ....... 5 Enter the smaller of line 4 or $10,000. .......... Tentative

2

Learning Credit.

4

6

~I

'

Reduction Act Notice, see your tax return instructions.

FDIA3601L

12131110

4

5 6 Form 8863 (2010)

474-04-3631

Page 2

320. Enter: $180,000 if married filing jointly; $90,000 if single, head of household, or qualifying widow(er). . . . . . . . . 9 Enter the amount from Form 1040, line 38,* or Form 1040A, line 22

8

10 11 12

8 9

180,000. 32,432.

Subtract line 9 from line 8. If zero or less, stop; you cannot take any education credit. . . . . . . . . . . .

10

147,568.

Enter: $20,000 if married filing jointly; $10,000 if single, head of household, or qualifying widow(er).

11

20,000.

If line 10 is: • Equal to or more than line 11, enter 1.000 on line 12. . . . . •.. Less than line 11, divide line 10 by line 11. Enter the result as a decimal (rounded to at least three places). . . . . . . . . . . ..

13

14

} ..

1. 000

..

Multiply line 7 by line 12. Caution: If you were under age 24 at the end of the year and meet the conditions in the instructions, you cannot take the refundable American opportunity credit. Skip line 14, enter the amount from line 13 on line 15, and check this box..

. ... • Df-'-13=--1--

Refundable American opportunity credit. Multiply line 13 by 40% (.40). Enter the amount here and on Form 1040, line 66, or Form 1040A, line 43. Then go to line 15 below

tRait .l~

Nonrefundable

14

128. 192.

Education Credits

15

Subtract line 14 from line 13.

15

16

Enter the amount from line 6, if any. If you have no entry on line 6, skip lines 17 through 22, and enter the amount from line 15 on line 6 of the Credit Limit Worksheet (see instructions).

16

17 18 19

Enter: $120,000 if married filing jointly; $60,000 if single, head of household, or qualifying widow(er). Enter the amount from Form 1040, line 38,* or Form 1040A, line 22. Subtract line 18 from line 17. If zero or less, skip lines 20 and 21, and enter zero on line 22.

f-'-'7=-----1--

_

f-=-18::......f-

_

19 r--~-------

20

Enter: $20,000 if married filing jointly; $10,000 if single, head of household, or qualifying widow(er). . . . . . . . . . . . . . ..............

21

If line 19 is: • Equal to or more than line 20, enter 1.000 on line 21 and go to line 22 • Less than line 20, divide line 19 by line 20. Enter the result as a decimal (rounded to at least three places). . . . .......... ......... Multiply line 16 by line 21. Enter here and on line 1 of the Credit limit Worksheet (see instructions).

22

23

3.:....:;.2...:.0--'-.

<-=-20=--'--

Nonrefundable education credits. Enter the amount from line 11 of the Credit Limit Worksheet (see instructions) here and on Form 1040, line 49, or Form 1040A, line 31 . . .

_

r=2'=--f-------·f--=22=-t--------

23

192.

• If you are filing Form 2555, 2555-EZ, or 4563. or you are excluding income from Puerto Rico, see Pub 970 for the amount to-enter.

Form 8863 (2010)

FDIA3601L12131110

OM8 No. 1545-0074

SCHEDULE M

Making Work Pay Credit

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

(99)

• Attach to Form 1040A or 1040.

2010

• See separate instructions.

Name(s) shown on return

Attachment Sequence No. Your social security

JEREMIAH GRIFFITH AND KIM SESSIONS

166

number

474-04-3631

Caution:

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.

Caution:

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. 1 a Doyou(andyourspouseif filing jointly) have2010 wagesof morethan$6,451 ($12,903 if marriedfilingjointly)?

!Kl Yes. Skip lines 1a through 3. Enter $400 ($800 if married filing jointly)

o

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). .

1b 2

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

3 800.

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

32,432.

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?

o!Kl

.

.

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

8

Multiply line 7 by 2% (,02).

9

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

10

_

.

.

I-~+---------

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).

!Kl No. Ent~r -0- on line 10 and go to line 11.

o

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)

f---'-10"--f-

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-'---'--

...:..O-'-,

8-'--'-0...:..0-'

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

FDIA8501 L

09/2011 0

Schedule M (Form 1040A or 1040) 2010

r

40001

2010 TC-40

Utah Individual Income Tax Return All State Income Tax Dollars Fund Education

Intuit

1032

Fiscal year end month/year (mm/yy) Amended Return - enter code

Form 8886 filed

Your Social Security No.

474043631

X if deceased

JEREMIAH

GRIFFITH

KIM

SESSIONS

Spouse's SSN

528976647

1300 E 6125 S

SOUTH OGDEN

UT

844057116 UTIA0112L

Filing Status - enter code

- 2

- 2 Exemptions - enter number

1 = Single 2= Married filing jointly 3= Marriedfilingseparately

a b

1 1

c

1

Yourself } Spouse Dependents

4= Head of Household 5= Qualifying widow(er)

d

3

Total exemptions (add a throughc)

fromfederalreturn

-

R = Republican N = No contribution

Does not increase tax or reduce refund.

5

Additions to income from TC-40A, Part 1 (attach TC-40A, page 1)

6

Total income (add lines 4 and 5)

7

State tax refund included on federal Form 1040, line 10

-7

8

Subtractions from income from TC-40A, Part 2 (attach TC-40A, page 1)

-8

9

Utah taxable income (subtract the total of lines 7 and 8 from line 6 (not less than zero»

- 9

- 4

6

-10 - 11

13 Add lines 11 and 12

15 Subtract line 14 from line 13

Enter amount based on filing status: if line 1 equals 1 or 3, enter $12,535; if line 1 equals 4, enter $18,802; if line 1 equals 2 or 5, enter $25,070

18

Subtract line 17 from line 9 (not less than zero)

19

Multiply line 18 by 1.3% (.013)

13

19614

15

19614

1622

Filing electronically is quick, easy and free, and will speed up your refund.

f---------To learn more, go to

taxexpress. utah.gov

25070 18

7362

20 Taxpayer tax credit (subtract line 19 from line 16 (not less than zero» 21 If you are a qualified exempt taxpayer, enter 'X' (see worksheet in instructions) 22

32432

11400

1177

17

32432

8214

14 State income tax deducted on federal Schedule A, line 5 (see instructions)

Multiply line 15 by 6% (.06)

32432

- 5

Enter your federal standard or itemized deductions

16

- N

Democratic L = Libertarian

Federal adjusted gross income from federal return

12

N

o =

4

10 Utah tax calculation - multiply line 9 by 5% (.05) 11 Exemption amount - multiply $2,738 by line 2d above

11/10110

3 Election Campaign Fund - enter code C = Constitution Yourself Spouse

96 - 20

1081 541

Utah income tax (subtract line 20 from line 10 (not less than zero»

23 Apportionable nonrefundable credits from TC-40A, Part 3 (attach TC-40A, page 1) 24

L

Subtract line 23 from line 22 (not less than zero) Non or Part-Year Residents, complete TC-408 before continuing on page 2

24

541

--.J

r

40002

Utah Individual Income Tax Return - 2010

TC-40

I SSN

_L_as_t _na_m_e----'G_R_I_F_F_I_T_H-'--

25

Entertax (full-year resident,entertax from line 24; non or part-yearresident,entertax from TC-40B,line 37)

26

Nonapportionable

27

Subtract

28

Contributions

nonrefundable

credits from form TC-40A,

Part 4 (attach TC-40A,

Code

page 1)

on line 28 Code

Utah Nongame

02 03

Pamela

05 09

School

10

Methamphetamine

Wildlife

Atkinson

Kurt Oscarson

Children's

Account

School District Foundation

Housing

Reconstruction

& Rehabilitation

AMENDED

RETURN ONLY - previous

30

Recapture

of low-income

31

Utah use tax

32

Total tax, use tax and additions to tax (add lines 27 through

33

Utah income tax withheld

34

Credit for Utah income taxes prepaid

35

Pass-through

36

Mineral

37

AMENDED

38

Refundable

39

Total withholding

40

TAX DUE - Subtrad

41

Penalty

42

PAY THIS AMOUNT

(add lines 40 and 41) line 32 from line 39 (not less than zero)

housing

28

entity withholding

Fund

refund

credit

shown on TC-40W,

withholding

.28d

Spay and Neuter Program

29

production

.28b .28c

Account

Organ Transplant

District & Nonprofit

Cat & Dog Community

RETURN ONLY - previous

Part 3 (attach TC-40W, Part 2 (attach TC-40W,

to 2010

page 2) page 2)

payments

Part 5 (attach TC-40A,

and refundable

888

page 1)

from TC-546 and 2009 refund applied

tax from TC-40W,

541

32

Part 1 (attach TC-40W,

tax from TC-40W,

credits from TC-40A,

31)

page 2)

credits (add lines 33 through

38)

888

39

line 39 from line 32 (not less than zero)

41

and interest

43

REFUND

44

Enter the amount

45

DIRECT DEPOSIT YOUR REFUND • Routing

Sch Dist Code

Amount

.28a

Account

Homeless

541

27

28d and enter total contributions

Description

01

474043631 541

line 26 from line 25 (not less than zero) - add lines 28a through

Page 2

Intuit

- Subtract

of refund you want applied

number

- provide

324377613

Check box if refund will go to an account

347

to your 2011 taxes account

information

• Account

number

.44 checking

190001383024

outside the United States

(see instructions)

Account

type:

•

savings

•

X

•

46 To deposit total refund to your Utah Educational Savings Plan account(s), enter 'X' (see instructions) Under penalties of perjury, I declare to the best of my knowledge and belief, this return and accompanying schedules reflect my true tax status,

SIGN

Your signature

I Spouse's signature

Date

Date

HERE Third Party Name of designee (if any) you authorize to discuss this return Designee Paid Preparer's Section

L

Desiqnee's telephone number

Designee.

Preparer's telephone number

Preparer's •

PREPARER Preparer's signature

PIN Date

2/07/11 LARRY R_ BERGHOUT, CPA Firm's name and address HAYNIE AND COMPANY CPA'S 1785 WEST 2300 SOUTH SALT LAKE CITY UTIAOl12L

11110110

801-972-4800

PTIN

P0043998 1

Preparer's • EIN

UT 841192065

87032522 8

r

40008

Part 1 - Utah Withholding Tax Schedule

Intuit

G=R~I=F~F~IT==H

TC-40W

Page 1

I~s=sN~~4~7~4~-~0~4~-~3

=La=s~tn=a~m=e __

IMPORTANT

Line Explanations:

1 2

Employer/payer 10 number from W-2 box 'b' or 1099 Utah withholding 10 number from W-2 box '15' or 1099

3 4 5 6 7

Employer/payer name and address from W-2 box 'c' or 1099 Enter 'X' if reporting Utah withholding from form 1099 Employee's Social Security number from W-2 box 'a' or 1099 Utah wages/income fromW-2 box '16' or 1099 Utah withholding tax from W-2 box '17' or 1099

Do not send your W-2s or 1099s with your return. Instead, enter W-2 or 1099 information below, but only if there is Utah withholding on the form.

Use additional forms TC·40W if you have more than four W-2s and/or 1099s with Utah withholding tax. Enter mineral production withholding from TC-675R in Part 2 of TC-40W; enter pass-through entity withholding in Part 3 of TC-40W.

1

410215170

2

Z88464

2

12251777-003-W

3

TARGET CORPORATION MAILSTOP NCD-0280, PO BOX 9401

3

URS FEDERAL TECHNICAL SERVICES 20501 SENECA MEADOWS PKW

510391628

MINNEAPOLIS, 4

MN 55440-9401

GERMANTOWN,

MD 20876

4

5

474043631

5

474043631

6

9957

6

22475

7

123

7

765

1 2

2

3

3

4

4

5

5

6

6

7

7

888

Enter total Utah withholding lax from all lines 7 here and on TC-40, page 2, line 33

Submit this page ONLY if data entered.

L

UTIA0212L

Attach this form to your 2010 Utah Income Tax Return. Do not attach W-2s or 1099s to your Utah return.

11/1 1/10