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Submission/f1040--2016.pdf
Fo
rm 1040 Department of the Treasury—Internal Revenue Service (99)U.S. Individual Income Tax Return 2016 OMB No. 1545-0074 IRS Use Only—Do not write or staple in this space.
For the year Jan. 1–Dec. 31, 2016, or other tax year beginning , 2016, ending , 20 See separate instructions.
Your first name and initial Last name Your social security number
If a joint return, spouse’s first name and initial Last name Spouse’s social security number
▲ Make sure the SSN(s) above
and on line 6c are correct.
Home address (number and street). If you have a P.O. box, see instructions. Apt. no.
City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions).
Foreign country name Foreign province/state/county Foreign postal code
Presidential Election Campaign
Check here if you, or your spouse if filing
jointly, want $3 to go to this fund. Checking
a box below will not change your tax or
refund. You Spouse
Filing Status
Check only one
box.
1 Single
2 Married filing jointly (even if only one had income)
3 Married filing separately. Enter spouse’s SSN above
and full name here. ▶
4 Head of household (with qualifying person). (See instructions.) If
the qualifying person is a child but not your dependent, enter this
child’s name here. ▶
5 Qualifying widow(er) with dependent child
Exemptions 6a Yourself. If someone can claim you as a dependent, do not check box 6a . . . . .
b Spouse . . . . . . . . . . . . . . . . . . . . . . . . }
c Dependents:
(1) First name Last name
(2) Dependent’s
social security number
(3) Dependent’s
relationship to you
(4) ✓ if child under age 17
qualifying for child tax credit
(see instructions)
If more than four
dependents, see
instructions and
check here ▶
d Total number of exemptions claimed . . . . . . . . . . . . . . . . .
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)
Dependents on 6c
not entered above
Add numbers on
lines above ▶
Income
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 instructions.
7 Wages, salaries, tips, etc. Attach Form(s) W-2 . . . . . . . . . . . . 7
8a Taxable interest. Attach Schedule B if required . . . . . . . . . . . . 8a
b Tax-exempt interest. Do not include on line 8a . . . 8b
9 a Ordinary dividends. Attach Schedule B if required . . . . . . . . . . . 9a
b Qualified dividends . . . . . . . . . . . 9b
10 Taxable refunds, credits, or offsets of state and local income taxes . . . . . . 10
11 Alimony received . . . . . . . . . . . . . . . . . . . . . 11
12 Business income or (loss). Attach Schedule C or C-EZ . . . . . . . . . . 12
13 Capital gain or (loss). Attach Schedule D if required. If not required, check here ▶ 13
14 Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . . . 14
15 a IRA distributions . 15a b Taxable amount . . . 15b
16 a Pensions and annuities 16a b Taxable amount . . . 16b
17 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E 17
18 Farm income or (loss). Attach Schedule F . . . . . . . . . . . . . . 18
19 Unemployment compensation . . . . . . . . . . . . . . . . . 19
20 a Social security benefits 20a b Taxable amount . . . 20b
21 Other income. List type and amount 21
22 Combine the amounts in the far right column for lines 7 through 21. This is your total income ▶ 22
Adjusted
Gross
Income
23 Educator expenses . . . . . . . . . . . 23
24 Certain business expenses of reservists, performing artists, and
fee-basis government officials. Attach Form 2106 or 2106-EZ 24
25 Health savings account deduction. Attach Form 8889 . 25
26 Moving expenses. Attach Form 3903 . . . . . . 26
27 Deductible part of self-employment tax. Attach Schedule SE . 27
28 Self-employed SEP, SIMPLE, and qualified plans . . 28
29 Self-employed health insurance deduction . . . . 29
30 Penalty on early withdrawal of savings . . . . . . 30
31 a Alimony paid b Recipient’s SSN ▶ 31a
32 IRA deduction . . . . . . . . . . . . . 32
33 Student loan interest deduction . . . . . . . . 33
34 Tuition and fees. Attach Form 8917 . . . . . . . 34
35 Domestic production activities deduction. Attach Form 8903 35
36 Add lines 23 through 35 . . . . . . . . . . . . . . . . . . . 36
37 Subtract line 36 from line 22. This is your adjusted gross income . . . . . ▶ 37
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 11320B Form 1040 (2016)
Form 1040 (2016) Page 2
Tax and
Credits
38 Amount from line 37 (adjusted gross income) . . . . . . . . . . . . . . 38
39a Check
if:
{ You were born before January 2, 1952, Blind.
Spouse was born before January 2, 1952, Blind.
} Total boxes
checked ▶ 39a
b If your spouse itemizes on a separate return or you were a dual-status alien, check here ▶ 39b
Standard
Deduction
for—
• People who
check any
box on line
39a or 39b or
who can be
claimed as a
dependent,
see
instructions.
• All others:
Single or
Married filing
separately,
$6,300
Married filing
jointly or
Qualifying
widow(er),
$12,600
Head of
household,
$9,300
40 Itemized deductions (from Schedule A) or your standard deduction (see left margin) . . 40
41 Subtract line 40 from line 38 . . . . . . . . . . . . . . . . . . . 41
42 Exemptions. If line 38 is $155,650 or less, multiply $4,050 by the number on line 6d. Otherwise, see instructions 42
43 Taxable income. Subtract line 42 from line 41. If line 42 is more than line 41, enter -0- . . 43
44 Tax (see instructions). Check if any from: a Form(s) 8814 b Form 4972 c 44
45 Alternative minimum tax (see instructions). Attach Form 6251 . . . . . . . . . 45
46 Excess advance premium tax credit repayment. Attach Form 8962 . . . . . . . . 46
47 Add lines 44, 45, and 46 . . . . . . . . . . . . . . . . . . . ▶ 47
48 Foreign tax credit. Attach Form 1116 if required . . . . 48
49 Credit for child and dependent care expenses. Attach Form 2441 49
50 Education credits from Form 8863, line 19 . . . . . 50
51 Retirement savings contributions credit. Attach Form 8880 51
52 Child tax credit. Attach Schedule 8812, if required . . . 52
53 Residential energy credits. Attach Form 5695 . . . . 53
54 Other credits from Form: a 3800 b 8801 c 54
55 Add lines 48 through 54. These are your total credits . . . . . . . . . . . . 55
56 Subtract line 55 from line 47. If line 55 is more than line 47, enter -0- . . . . . . ▶ 56
Other
Taxes
57 Self-employment tax. Attach Schedule SE . . . . . . . . . . . . . . . 57
58 Unreported social security and Medicare tax from Form: a 4137 b 8919 . . 58
59 Additional tax on IRAs, other qualified retirement plans, etc. Attach Form 5329 if required . . 59
60 a Household employment taxes from Schedule H . . . . . . . . . . . . . . 60a
b First-time homebuyer credit repayment. Attach Form 5405 if required . . . . . . . . 60b
61 Health care: individual responsibility (see instructions) Full-year coverage . . . . . 61
62 Taxes from: a Form 8959 b Form 8960 c Instructions; enter code(s) 62
63 Add lines 56 through 62. This is your total tax . . . . . . . . . . . . . ▶ 63
Payments 64 Federal income tax withheld from Forms W-2 and 1099 . . 64
65 2016 estimated tax payments and amount applied from 2015 return 65
If you have a
qualifying
child, attach
Schedule EIC.
66a Earned income credit (EIC) . . . . . . . . . . 66a
b Nontaxable combat pay election 66b
67 Additional child tax credit. Attach Schedule 8812 . . . . . 67
68 American opportunity credit from Form 8863, line 8 . . . 68
69 Net premium tax credit. Attach Form 8962 . . . . . . 69
70 Amount paid with request for extension to file . . . . . 70
71 Excess social security and tier 1 RRTA tax withheld . . . . 71
72 Credit for federal tax on fuels. Attach Form 4136 . . . . 72
73 Credits from Form: a 2439 b Reserved c 8885 d 73
74 Add lines 64, 65, 66a, and 67 through 73. These are your total payments . . . . . ▶ 74
Refund
Direct deposit?
See
instructions.
75 If line 74 is more than line 63, subtract line 63 from line 74. This is the amount you overpaid 75
76a Amount of line 75 you want refunded to you. If Form 8888 is attached, check here . ▶ 76a
▶
▶
b Routing number ▶ c Type: Checking Savings
d Account number
77 Amount of line 75 you want applied to your 2017 estimated tax ▶ 77
Amount
You Owe
78 Amount you owe. Subtract line 74 from line 63. For details on how to pay, see instructions ▶ 78
79 Estimated tax penalty (see instructions) . . . . . . . 79
Third Party
Designee
Do you want to allow another person to discuss this return with the IRS (see instructions)? Yes. Complete below. No
Designee’s
name ▶
Phone
no. ▶
Personal identification
number (PIN) ▶
Sign
Here
Joint return? See
instructions.
Keep a copy for
your records.
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
accurately list all amounts and sources of income I received during the tax year. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Your signature Date Your occupation Daytime phone number
Spouse’s signature. If a joint return, both must sign. Date
▲
Spouse’s occupation If the IRS sent you an Identity Protection
PIN, enter it
here (see inst.)
Paid
Preparer
Use Only
Print/Type preparer’s name Preparer’s signature Date
Check if
self-employed
PTIN
Firm’s name ▶
Firm’s address ▶
Firm’s EIN ▶
Phone no.
www.irs.gov/form1040 Form 1040 (2016)
Version A, Cycle 3
Internal Use Only
DRAFT AS OF
September 13, 2016
Version A, Cycle 3
Internal Use Only
DRAFT AS OF
September 13, 2016
2016 Form 1040
SE:W:CAR:MP
U.S. Individual Income Tax Return
Form
1040 
Department of the Treasury—Internal Revenue Service 
(99)
U.S. Individual Income Tax Return
2016
2016. Catalog Number 11320B.
OMB No. 1545-0074
O M B Number 1545-0074. For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions.
IRS Use Only—Do not write or staple in this space.
See separate instructions.
▲
Make sure the SSN(s) above and on line 6c are correct.
Presidential Election Campaign
Check here if you, or your spouse if filing jointly, want $3 to go to this fund. Checking a box below will not change your tax or refund.
Filing Status
Check only one box. 
1
Single
2
Married filing jointly (even if only one had income)
3
Married filing separately. Enter spouse’s SSN above and full name here. ▶
4
Head of household (with qualifying person). (See instructions.) If the qualifying person is a child but not your dependent, enter this child’s name here.  ▶
5
Qualifying widow(er) with dependent child
Exemptions
6
a
Yourself. If someone can claim you as a dependent, do not check box 6a
b
Spouse
}
c
Dependents: 
(1)  First name                         Last name 
(2) Dependent’s
social security number 
(3) Dependent’s  relationship to  you 
(4)  ✓ if child under age 17 qualifying for child tax credit 
(see instructions) 
(4) Check if child under age 17 qualifying for child tax credit (see instructions).
If more than four  dependents, see  instructions and check here  ▶
d
Total number of exemptions claimed
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)
Dependents on 6c not entered above
Add numbers on  lines above  ▶
Income
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 instructions. 
7
Wages, salaries, tips, etc. Attach Form(s) W-2
7
8
a
Taxable interest. Attach Schedule B if required
8a
b
Tax-exempt interest. Do not include on line 8a
8b
9
a
Ordinary dividends. Attach Schedule B if required
9a
b
Qualified dividends
9b
10
Taxable refunds, credits, or offsets of state and local income taxes
10
11
Alimony received
11
12
Business income or (loss). Attach Schedule C or C-EZ
12
13
Capital gain or (loss). Attach Schedule D if required. If not required, check here  ▶
13
14
Other gains or (losses). Attach Form 4797
14
15
a
IRA distributions
15a
b  Taxable amount
15b
16
a
Pensions and annuities 
16a
b  Taxable amount
16b
17
Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E 
17
18
Farm income or (loss). Attach Schedule F
18
19
Unemployment compensation
19
20
a
Social security benefits 
20a
b  Taxable amount
20b
21
Other income. List type and amount
21
22
Combine the amounts in the far right column for lines 7 through 21. This is your total income  ▶
22
Adjusted Gross Income
23
Educator expenses
23
24
Certain business expenses of reservists, performing artists, and fee-basis government officials. Attach Form 2106 or 2106-EZ
24
25
Health savings account deduction. Attach Form 8889
25
26
Moving expenses. Attach Form 3903
26
27
Deductible part of self-employment tax. Attach Schedule SE
27
28
Self-employed SEP, SIMPLE, and qualified plans
28
29
Self-employed health insurance deduction
29
30
Penalty on early withdrawal of savings
30
31    
a
Alimony paid 
b  Recipient’s SSN  ▶
31a
32
IRA deduction
32
33
Student loan interest deduction
33
34
Tuition and fees. Attach Form 8917
34
35
Domestic production activities deduction. Attach Form 8903 
35
36
Add lines 23 through 35
36
37
Subtract line 36 from line 22. This is your adjusted gross income             ▶
37
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 11320B
Form  1040  (2016) 
Form 1040 (2016)
Page 2 
Tax and  Credits 
38
Amount from line 37 (adjusted gross income)
38
39
a
Check  if: 
{
}
Total boxes  checked  ▶
39a
b
If your spouse itemizes on a separate return or you were a dual-status alien,  check here ▶
Standard  Deduction  for—
• People who  check any  box on line  39a or 39b or who can be claimed as a  dependent,  see instructions.
• All others:
Single or  Married filing  separately,  $6,300
Married filing  jointly or  Qualifying  widow(er),  $12,600 
Head of  household,  $9,300 
40
Itemized deductions (from Schedule A) or your standard deduction (see left margin)
40
41
Subtract line 40 from line 38
41
42
Exemptions. If line 38 is $155,650 or less, multiply $4,050 by the number on line 6d. Otherwise, see instructions
42
43
Taxable income.  Subtract line 42 from line 41. If line 42 is more than line 41, enter -0-
43
44
Tax  (see instructions). Check if any from: 
a
b
c
44
45
Alternative minimum tax  (see instructions). Attach Form 6251
45
46
Excess advance premium tax credit repayment. Attach Form 8962
46
47
Add lines 44, 45, and 46           ▶
47
48
Foreign tax credit. Attach Form 1116 if required
48
49
Credit for child and dependent care expenses. Attach Form 2441
49
50
Education credits from Form 8863, line 19
50
51
Retirement savings contributions credit. Attach Form 8880
51
52
Child tax credit. Attach Schedule 8812, if required
52
53
Residential energy credits. Attach Form 5695
53
54
Other credits from Form: 
a
b
c
54
55
Add lines 48 through 54. These are your total credits
55
56
Subtract line 55 from line 47. If line 55 is more than line 47, enter -0-           ▶
56
Other Taxes
57
Self-employment tax. Attach Schedule SE
57
58
Unreported social security and Medicare tax from Form:
a
b
58
59
Additional tax on IRAs, other qualified retirement plans, etc. Attach Form 5329 if required
59
60
a
Household employment taxes from Schedule H
60a
b
First-time homebuyer credit repayment. Attach Form 5405 if required
60b
61
Health care: individual responsibility (see instructions)

61
62
Taxes from:
a
b
c
enter code(s)
62
63
Add lines 56 through 62. This is your total tax             ▶
63
Payments
64
Federal income tax withheld from Forms W-2 and 1099
64
65
2016 estimated tax payments and amount applied from 2015 return
65
If you have a qualifying child, attach Schedule EIC.
66
a
Earned income credit (EIC) 
66a
b
Nontaxable combat pay election 
66b
67
Additional child tax credit. Attach Schedule 8812            .
67
68
American opportunity credit from Form 8863, line 8
68
69
Net premium tax credit. Attach Form 8962 
69
70
Amount paid with request for extension to file
70
71
Excess social security and tier 1 RRTA tax withheld
71
72
Credit for federal tax on fuels. Attach Form 4136
72
73
Credits from Form:
a
b
c
d
73
74
Add lines 64, 65, 66a, and 67 through 73. These are your total payments             ▶
74
Refund
Direct deposit? See instructions.
75
If line 74 is more than line 63, subtract line 63 from line 74. This is the amount you overpaid 
75
76
a
Amount of line 75 you want refunded to you. If Form 8888 is attached, check here           ▶
76a
▶
▶
b
Routing number
▶ c Type: 
d
Account number
77
Amount of line 75 you want applied to your 2017 estimated tax ▶
77
Amount You Owe
78
Amount you owe. Subtract line 74 from line 63. For details on how to pay, see instructions    ▶
78
79
Estimated tax penalty (see instructions)
79
Third Party Designee
Do you want to allow another person to discuss this return with the IRS (see instructions)?
Designee’sname  ▶
Phoneno.  ▶
Personal identificationnumber (PIN)              ▶
Sign Here
Joint return? See instructions. Keep a copy for your records.
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 accurately list all amounts and sources of income I received during the tax year. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Your signature
Date
Spouse’s signature. If a joint return, both must sign. 
Date
▲
If the IRS sent you an Identity Protection PIN, enter it 
here (see inst.)
Paid Preparer Use Only
Preparer’s signature
Date
Check         if 
self-employed
www.irs.gov/form1040
Form 1040 (2016) 
    f1_01: Jan 1
    f1_02: Dec 31
    f1_03: 16
    f1_04: Bonnie R.
    f1_05: Jackson
    f1_06: 456789542
    f1_07:
    f1_08:
    f1_09:
    f1-10: 4193 Colorado Lane, Fort Collins
    f1-11:
    f1-12: CO 80505
    f1_13:
    f1_14:
    f1_15:
    c1_01: 1
    c1_02:
    c1_03: S
    f1-16:
    f1_17:
    c1_04: 1
    c1_05: 0
    f1_18:
    f1_19:
    f1_20:
    c1_06: 0
    f1_21:
    f1_22:
    f1_23:
    c1_07:
    f1_24:
    f1_25:
    f1_26:
    c1_08:
    f1_27:
    f1_28:
    f1_29:
    c1_09:
    c1_10:
    f1_30: 1
    f1_31:
    f1_32:
    f1_33:
    f1_34: 1
    f1_35: 65000
    f1_36: 00
    f1_37: 1700
    f1_38: 00
    f1_39:
    f1_40:
    f1_41:
    f1_42:
    f1_43: 2200
    f1_44: 00
    f1_45:
    f1_46:
    f1_47:
    f1_48:
    f1_49: -3850
    f1_50: 00
    c1_11:
    f1-_51: -1800
    f1_52: 00
    f1_53:
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    f1_55:
    f1_56:
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    f1_77: 00
    f1_78:
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    c2_01:
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    f2_10: 45534
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    c2_06:
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    f2_81: 00
    f2_82: 4347
    f2_83: 00
    c2_22:
    f2_84: 4347
    f2_85: 00
    c2_23:
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    f2_89:
    f2_90:
    f2_91:
    f2_92:
    f2_93:
    c2_24:
    f2_94:
    f2_95:
    f2_96:
    f2_97:
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    f2_105:
    f2_106:
Submission/f1040sa--2016.pdf
SCHEDULE A
(Form 1040)
Department of the Treasury
Internal Revenue Service (99)
Itemized Deductions
▶ Information about Schedule A and its separate instructions is at www.irs.gov/schedulea.
▶ Attach to Form 1040.
OMB No. 1545-0074
2016
Attachment
Sequence No. 07
Name(s) shown on Form 1040 Your social security number
Medical
and
Dental
Expenses
Caution: Do not include expenses reimbursed or paid by others.
1 Medical and dental expenses (see instructions) . . . . . 1
2 Enter amount from Form 1040, line 38 2
3 Multiply line 2 by 10% (0.10). But if either you or your spouse was
born before January 2, 1952, multiply line 2 by 7.5% (0.075) instead 3
4 Subtract line 3 from line 1. If line 3 is more than line 1, enter -0- . . . . . . . . 4
Taxes You
Paid
5 State and local (check only one box):
a Income taxes, or
b General sales taxes } . . . . . . . . . . . 5
6 Real estate taxes (see instructions) . . . . . . . . . 6
7 Personal property taxes . . . . . . . . . . . . . 7
8 Other taxes. List type and amount ▶
8
9 Add lines 5 through 8 . . . . . . . . . . . . . . . . . . . . . . 9
Interest
You Paid
Note:
Your mortgage
interest
deduction may
be limited (see
instructions).
10 Home mortgage interest and points reported to you on Form 1098 10
11


Home mortgage interest not reported to you on Form 1098. If paid
to the person from whom you bought the home, see instructions
and show that person’s name, identifying no., and address ▶
11
12

Points not reported to you on Form 1098. See instructions for
special rules . . . . . . . . . . . . . . . . . 12
13 Mortgage insurance premiums (see instructions) . . . . . 13
14 Investment interest. Attach Form 4952 if required. (See instructions.) 14
15 Add lines 10 through 14 . . . . . . . . . . . . . . . . . . . . . 15
Gifts to
Charity
If you made a
gift and got a
benefit for it,
see instructions.
16

Gifts by cash or check. If you made any gift of $250 or more,
see instructions . . . . . . . . . . . . . . . . 16
17

Other than by cash or check. If any gift of $250 or more, see
instructions. You must attach Form 8283 if over $500 . . . 17
18 Carryover from prior year . . . . . . . . . . . . 18
19 Add lines 16 through 18 . . . . . . . . . . . . . . . . . . . . . 19
Casualty and
Theft Losses 20 Casualty or theft loss(es). Attach Form 4684. (See instructions.) . . . . . . . . 20
Job Expenses
and Certain
Miscellaneous
Deductions
21


Unreimbursed employee expenses—job travel, union dues,
job education, etc. Attach Form 2106 or 2106-EZ if required.
(See instructions.) ▶ 21
22 Tax preparation fees . . . . . . . . . . . . . 22
23

Other expenses—investment, safe deposit box, etc. List type
and amount ▶
23
24 Add lines 21 through 23 . . . . . . . . . . . . 24
25 Enter amount from Form 1040, line 38 25
26 Multiply line 25 by 2% (0.02) . . . . . . . . . . 26
27 Subtract line 26 from line 24. If line 26 is more than line 24, enter -0- . . . . . . 27
Other
Miscellaneous
Deductions
28 Other—from list in instructions. List type and amount ▶
28
Total
Itemized
Deductions
29

Is Form 1040, line 38, over $155,650?
29
No. Your deduction is not limited. Add the amounts in the far right column
for lines 4 through 28. Also, enter this amount on Form 1040, line 40. } . .Yes. Your deduction may be limited. See the Itemized Deductions
Worksheet in the instructions to figure the amount to enter.
30

If you elect to itemize deductions even though they are less than your standard
deduction, check here . . . . . . . . . . . . . . . . . . . ▶
For Paperwork Reduction Act Notice, see Form 1040 instructions. Cat. No. 17145C Schedule A (Form 1040) 2016
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Submission/f1040sb--2016.pdf
SCHEDULE B
(Form 1040A or 1040)
Department of the Treasury
Internal Revenue Service (99)
Interest and Ordinary Dividends
▶ Attach to Form 1040A or 1040.
▶ Information about Schedule B and its instructions is at www.irs.gov/scheduleb.
OMB No. 1545-0074
2016
Attachment
Sequence No. 08
(Rev. January 2017)
Name(s) shown on return Your social security number
Part I
Interest
(See instructions
on back and the
instructions for
Form 1040A, or
Form 1040,
line 8a.)

Note: If you
received a Form
1099-INT, Form
1099-OID, or
substitute
statement from
a brokerage firm,
list the firm’s
name as the
payer and enter
the total interest
shown on that
form.
1


List name of payer. If any interest is from a seller-financed mortgage and the
buyer used the property as a personal residence, see instructions on back and list
this interest first. Also, show that buyer’s social security number and address ▶
1
Amount
2 Add the amounts on line 1 . . . . . . . . . . . . . . . . . . 2
3

Excludable interest on series EE and I U.S. savings bonds issued after 1989.
Attach Form 8815 . . . . . . . . . . . . . . . . . . . . . 3
4

Subtract line 3 from line 2. Enter the result here and on Form 1040A, or Form
1040, line 8a . . . . . . . . . . . . . . . . . . . . . . ▶ 4
Note: If line 4 is over $1,500, you must complete Part III. Amount
Part II
Ordinary
Dividends
(See instructions
on back and the
instructions for
Form 1040A, or
Form 1040,
line 9a.)
Note: If you
received a Form
1099-DIV or
substitute
statement from
a brokerage firm,
list the firm’s
name as the
payer and enter
the ordinary
dividends shown
on that form.
5 List name of payer ▶
5
6

Add the amounts on line 5. Enter the total here and on Form 1040A, or Form
1040, line 9a . . . . . . . . . . . . . . . . . . . . . . ▶ 6
Note: If line 6 is over $1,500, you must complete Part III.
Part III
Foreign
Accounts
and Trusts
(See
instructions on
back.)
You must complete this part if you (a) had over $1,500 of taxable interest or ordinary dividends; (b) had a
foreign account; or (c) received a distribution from, or were a grantor of, or a transferor to, a foreign trust. Yes No
7a At any time during 2016, did you have a financial interest in or signature authority over a financial
account (such as a bank account, securities account, or brokerage account) located in a foreign
country? See instructions . . . . . . . . . . . . . . . . . . . . . . . .
If “Yes,” are you required to file FinCEN Form 114, Report of Foreign Bank and Financial
Accounts (FBAR), to report that financial interest or signature authority? See FinCEN Form 114
and its instructions for filing requirements and exceptions to those requirements . . . . . .
b If you are required to file FinCEN Form 114, enter the name of the foreign country where the
financial account is located ▶
8 During 2016, did you receive a distribution from, or were you the grantor of, or transferor to, a
foreign trust? If “Yes,” you may have to file Form 3520. See instructions on back . . . . . .
For Paperwork Reduction Act Notice, see your tax return instructions. Cat. No. 17146N Schedule B (Form 1040A or 1040) 2016
Schedule B (Form 1040A or 1040) 2016 Page 2
General Instructions
Future Developments
For the latest information about developments
related to Schedule B (Form 1040A or 1040) and its
instructions, such as legislation enacted after they
were published, go to www.irs.gov/scheduleb.
What's New
The due date for filing FinCEN Form 114 has
changed. See below.
Purpose of Form
Use Schedule B if any of the following applies.
• You had over $1,500 of taxable interest or ordinary
dividends.
• You received interest from a seller-financed
mortgage and the buyer used the property as a
personal residence.
• You have accrued interest from a bond.
• You are reporting original issue discount (OID) of
less than the amount shown on Form 1099-OID.
• You are reducing your interest income on a bond
by the amount of amortizable bond premium.
• You are claiming the exclusion of interest from
series EE or I U.S. savings bonds issued after 1989.
• You received interest or ordinary dividends as a
nominee.
• You had a financial interest in, or signature
authority over, a financial account in a foreign
country or you received a distribution from, or were
a grantor of, or transferor to, a foreign trust.
Specific Instructions
TIP
You can list more than one payer on
each entry space for lines 1 and 5, but
be sure to clearly show the amount paid
next to the payer's name. Add the
separate amounts paid by the payers
listed on an entry space and enter the total in the
“Amount” column. If you still need more space, attach
separate statements using the same format as lines 1
and 5, but show your totals on Schedule B. Put your
name and social security number (SSN) on the
statements and attach them at the end of your return.
Part I. Interest
Line 1. Report on line 1 all of your taxable interest.
Taxable interest generally should be shown on your
Forms 1099-INT, Forms 1099-OID, or substitute
statements. Include interest from series EE, H, HH,
and I U.S. savings bonds. Also include any accrued
market discount that is includible in income. List each
payer’s name and show the amount. Don't report on
this line any tax-exempt interest from box 8 or box 9
of Form 1099-INT. Instead, report the amount from
box 8 on line 8b of Form 1040A or 1040. If an amount
is shown in box 9 of Form 1099-INT, you generally
must report it on line 12 of Form 6251. See the
Instructions for Form 6251 for more details. For more
information on market discount and other investment
income, see Pub. 550.
Seller-financed mortgages. If you sold your
home or other property and the buyer used the
property as a personal residence, list first any
interest the buyer paid you on a mortgage or other
form of seller financing. Be sure to show the buyer’s
name, address, and SSN. You must also let the
buyer know your SSN. If you don't show the buyer’s
name, address, and SSN, or let the buyer know your
SSN, you may have to pay a $50 penalty.
Nominees. If you received a Form 1099-INT that
includes interest you received as a nominee (that is, in
your name, but the interest actually belongs to
someone else), report the total on line 1. Do this even
if you later distributed some or all of this income to
others. Under your last entry on line 1, put a subtotal
of all interest listed on line 1. Below this subtotal, enter
“Nominee Distribution” and show the total interest you
received as a nominee. Subtract this amount from the
subtotal and enter the result on line 2.
TIP
If you received interest as a nominee,
you must give the actual owner a Form
1099-INT (unless the owner is your
spouse) and file Forms 1096 and
1099-INT with the IRS. For more details,
see the General Instructions for Certain Information
Returns and the Instructions for Forms 1099-INT and
1099-OID.
Accrued interest. When you buy bonds between
interest payment dates and pay accrued interest to
the seller, this interest is taxable to the seller. If you
received a Form 1099 for interest as a purchaser of a
bond with accrued interest, follow the rules earlier
under Nominees to see how to report the accrued
interest. But identify the amount to be subtracted as
“Accrued Interest.”
Original issue discount (OID). If you are reporting
OID in an amount less than the amount shown on
Form 1099-OID, follow the rules earlier under
Nominees to see how to report the OID. But identify
the amount to be subtracted as “OID Adjustment.”
Amortizable bond premium. If you are reducing your
interest income on a bond by the amount of amortizable
bond premium, follow the rules earlier under Nominees
to see how to report the interest. But identify the amount
to be subtracted as “ABP Adjustment.”
Line 3. If, during 2016, you cashed series EE or I
U.S. savings bonds issued after 1989 and you paid
qualified higher education expenses for yourself,
your spouse, or your dependents, you may be able
to exclude part or all of the interest on those bonds.
See Form 8815 for details.
Part II. Ordinary Dividends
TIP
You may have to file Form 5471 if, in
2016, you were an officer or director of
a foreign corporation. You may also
have to file Form 5471 if, in 2016, you
owned 10% or more of the total
(a) value of a foreign corporation’s stock, or (b)
combined voting power of all classes of a foreign
corporation’s stock with voting rights. For details,
see Form 5471 and its instructions.
Line 5. Report on line 5 all of your ordinary
dividends. This amount should be shown in box 1a
of your Forms 1099-DIV or substitute statements.
Nominees. If you received a Form 1099-DIV that
includes ordinary dividends you received as a
nominee (that is, in your name, but the ordinary
dividends actually belong to someone else), report
the total on line 5. Do this even if you later
distributed some or all of this income to others.
Under your last entry on line 5, put a subtotal of all
ordinary dividends listed on line 5. Below this
subtotal, enter “Nominee Distribution” and show the
total ordinary dividends you received as a nominee.
Subtract this amount from the subtotal and enter the
result on line 6.
TIP
If you received dividends as a nominee,
you must give the actual owner a Form
1099-DIV (unless the owner is your spouse)
and file Forms 1096 and 1099-DIV with the
IRS. For more details, see the General
Instructions for Certain Information Returns and the
Instructions for Form 1099-DIV.
Part III. Foreign Accounts and
Trusts
TIP
Regardless of whether you are required
to file FinCEN Form 114 (FBAR), you
may be required to file Form 8938,
Statement of Specified Foreign
Financial Assets, with your income tax
return. Failure to file Form 8938 may result in
penalties and extension of the statute of limitations.
See www.irs.gov/form8938 for more information.
Line 7a–Question 1. Check the “Yes” box if at any
time during 2016 you had a financial interest in or
signature authority over a financial account located
in a foreign country. See the definitions that follow.
Check the “Yes” box even if you aren't required to
file FinCEN Form 114.
Financial account. A financial account includes,
but isn't limited to, a securities, brokerage, savings,
demand, checking, deposit, time deposit, or other
account maintained with a financial institution (or
other person performing the services of a financial
institution). A financial account also includes a
commodity futures or options account, an insurance
policy with a cash value (such as a whole life
insurance policy), an annuity policy with a cash
value, and shares in a mutual fund or similar pooled
fund (that is, a fund that is available to the general
public with a regular net asset value determination
and regular redemptions).
Financial account located in a foreign country.
A financial account is located in a foreign country if
the account is physically located outside of the
United States. For example, an account maintained
with a branch of a United States bank that is
physically located outside of the United States is a
foreign financial account. An account maintained
with a branch of a foreign bank that is physically
located in the United States isn't a foreign financial
account.
Signature authority. Signature authority is the
authority of an individual (alone or in conjunction
with another individual) to control the disposition of
assets held in a foreign financial account by direct
communication (whether in writing or otherwise) to
the bank or other financial institution that maintains
the financial account. See the FinCEN Form 114
instructions for exceptions. Don't consider the
exceptions relating to signature authority in
answering Question 1 on line 7a.
Other definitions. For definitions of “financial
interest,” “United States,” and other relevant terms,
see the instructions for FinCEN Form 114.
Line 7a–Question 2. See FinCEN Form 114 and its
instructions at www.fincen.gov/fbar to determine
whether you must file the form. Check the “Yes” box
if you are required to file the form; check the “No”
box if you aren't required to file the form.
If you checked the “Yes” box to Question 2 on line
7a, you must electronically file FinCEN Form 114
with Treasury's Financial Crimes Enforcement
Network; go to www.fincen.gov/fbar for details. Do
not attach FinCEN Form 114 to your tax return.
FinCEN Form 114 for 2016 is now generally due
April 18, 2017, but FinCEN is providing an automatic
extension for all filers until October 16, 2017. See
www.fincen.gov for details.
▲!
CAUTION
If you are required to file FinCEN Form
114 but don't properly do so, you may
have to pay a civil penalty up to
$10,000. A person who willfully fails to
report an account or provide account
identifying information may be subject to a civil
penalty equal to the greater of $100,000 or 50% of
the balance in the account at the time of the
violation. Willful violations may also be subject to
criminal penalties.
Line 7b. If you are required to file FinCEN Form 114,
enter the name of the foreign country or countries in
the space provided on line 7b. Attach a separate
statement if you need more space.
Line 8. If you received a distribution from a foreign
trust, you must provide additional information. For
this purpose, a loan of cash or marketable securities
generally is considered to be a distribution. See
Form 3520 for details.
If you were the grantor of, or transferor to, a
foreign trust that existed during 2016, you may have
to file Form 3520.
Don't attach Form 3520 to Form 1040. Instead, file
it at the address shown in its instructions.
If you were treated as the owner of a foreign trust
under the grantor trust rules, you are also
responsible for ensuring that the foreign trust files
Form 3520-A. Form 3520-A is due on March 15,
2017, for a calendar year trust. See the instructions
for Form 3520-A for more details.
Version A, Cycle 11
INTERNAL USE ONLY
DRAFT AS OF
January 10, 2017
SCHEDULE B
(Form 1040A or 1040) 
Department of the Treasury Internal Revenue Service (99)
Interest and Ordinary Dividends
▶ Attach to Form 1040A or 1040.
 ▶ Information about Schedule B and its instructions is at www.irs.gov/scheduleb. 
Attach to Form 1040A or 1040. Information about Schedule B and its instructions is at ww.irs.gov/scheduleb.
OMB No. 1545-0074
2016
2016. Catalog Number 17146N.
Attachment
Sequence No. 08 
Attachment Sequence Number 08. For Paperwork Reduction Act Notice, see your tax return instructions.
(Rev. January 2017)
Revised January 2016. Catalog Number 17146N .
Part I 
Interest 
(See instructions on back and the  instructions for  Form 1040A, or Form 1040, 
line 8a.)  
 
Note:  If you  received a Form  1099-INT, Form  1099-OID, or  substitute  statement froma brokerage firm,  list the firm’s  name as thepayer and enter  the total interest  shown on that  form. 
1 
 
 
List name of payer. If any interest is from a seller-financed mortgage and the  buyer used the property as a personal residence, see instructions on back and list this interest first. Also, show that buyer’s social security number and address  ▶
1
Amount
2
Add the amounts on line 1
2
3 
 
Excludable interest on series EE and I U.S. savings bonds issued after 1989.  Attach Form 8815
3
4 
 
Subtract line 3 from line 2. Enter the result here and on Form 1040A, or Form 1040, line 8a         ▶
4
Note:  If line 4 is over $1,500, you must complete Part III. 
Amount
Part II 
Ordinary  Dividends 
(See instructions on back and theinstructions for Form 1040A, orForm 1040, 
line 9a.) 
Note:  If youreceived a Form1099-DIV orsubstitutestatement froma brokerage firm,list the firm’sname as thepayer and enterthe ordinarydividends shownon that form. 
5
5
6 
 
Add the amounts on line 5. Enter the total here and on Form 1040A, or Form 1040, line 9a          ▶
6
Note:  If line 6 is over $1,500, you must complete Part III. 
Part III  Foreign  Accounts  and Trusts  (Seeinstructions on back.) 
You must complete this part if you (a) had over $1,500 of taxable interest or ordinary dividends; (b) had a foreign account; or (c) received a distribution from, or were a grantor of, or a transferor to, a foreign trust. 
Yes
No
7
a
At any time during 2016, did you have a financial interest in or signature authority over a financial account (such as a bank account, securities account, or brokerage account) located in a foreign country? See instructions
If “Yes,” are you required to file FinCEN Form 114, Report of Foreign Bank and Financial Accounts (FBAR), to report that financial interest or signature authority? See FinCEN Form 114 and its instructions for filing requirements and exceptions to those requirements
b
If you are required to file FinCEN Form 114, enter the name of the foreign country where the financial account is located  ▶
8    
During 2016, did you receive a distribution from, or were you the grantor of, or transferor to, a foreign trust? If “Yes,” you may have to file Form 3520. See instructions on back
For Paperwork Reduction Act Notice, see your tax return instructions.
Cat. No. 17146N
Schedule B (Form 1040A or 1040) 2016
Schedule B (Form 1040A or 1040) 2016
Page 2 
General Instructions
Future Developments
For the latest information about developments related to Schedule B (Form 1040A or 1040) and its instructions, such as legislation enacted after they were published, go to www.irs.gov/scheduleb.
What's New
The due date for filing FinCEN Form 114 has changed. See below.
Purpose of Form
Use Schedule B if any of the following applies.
• You had over $1,500 of taxable interest or ordinary dividends.
• You received interest from a seller-financed mortgage and the buyer used the property as a personal residence.
• You have accrued interest from a bond.
• You are reporting original issue discount (OID) of less than the amount shown on Form 1099-OID.
• You are reducing your interest income on a bond by the amount of amortizable bond premium.
• You are claiming the exclusion of interest from series EE or I U.S. savings bonds issued after 1989. 
• You received interest or ordinary dividends as a nominee.
• You had a financial interest in, or signature authority over, a financial account in a foreign country or you received a distribution from, or were a grantor of, or transferor to, a foreign trust.
Specific Instructions
TIP
You can list more than one payer on each entry space for lines 1 and 5, but be sure to clearly show the amount paid next to the payer's name. Add the separate amounts paid by the payers
listed on an entry space and enter the total in the “Amount” column. If you still need more space, attach separate statements using the same format as lines 1 and 5, but show your totals on Schedule B. Put your name and social security number (SSN) on the statements and attach them at the end of your return.
Part I. Interest
Line 1. Report on line 1 all of your taxable interest. Taxable interest generally should be shown on your Forms 1099-INT, Forms 1099-OID, or substitute statements. Include interest from series EE, H, HH, and I U.S. savings bonds. Also include any accrued market discount that is includible in income. List each payer’s name and show the amount. Don't report on this line any tax-exempt interest from box 8 or box 9 of Form 1099-INT. Instead, report the amount from box 8 on line 8b of Form 1040A or 1040. If an amount is shown in box 9 of Form 1099-INT, you generally must report it on line 12 of Form 6251. See the Instructions for Form 6251 for more details. For more information on market discount and other investment income, see Pub. 550. 
Seller-financed mortgages. If you sold your home or other property and the buyer used the property as a personal residence, list first any interest the buyer paid you on a mortgage or other form of seller financing. Be sure to show the buyer’s name, address, and SSN. You must also let the buyer know your SSN. If you don't show the buyer’s name, address, and SSN, or let the buyer know your SSN, you may have to pay a $50 penalty.
Nominees. If you received a Form 1099-INT that includes interest you received as a nominee (that is, in your name, but the interest actually belongs to someone else), report the total on line 1. Do this even if you later distributed some or all of this income to others. Under your last entry on line 1, put a subtotal of all interest listed on line 1. Below this subtotal, enter “Nominee Distribution” and show the total interest you received as a nominee. Subtract this amount from the subtotal and enter the result on line 2.
TIP
If you received interest as a nominee, you must give the actual owner a Form 1099-INT (unless the owner is your spouse) and file Forms 1096 and   1099-INT with the IRS. For more details, 
see the General Instructions for Certain Information Returns and the Instructions for Forms 1099-INT and 
1099-OID.
Accrued interest. When you buy bonds between interest payment dates and pay accrued interest to the seller, this interest is taxable to the seller. If you received a Form 1099 for interest as a purchaser of a bond with accrued interest, follow the rules earlier under Nominees to see how to report the accrued interest. But identify the amount  to be subtracted as “Accrued Interest.”
Original issue discount (OID). If you are reporting OID in an amount less than the amount shown on Form 1099-OID, follow the rules earlier under Nominees to see how to report the OID. But identify the amount to be subtracted as “OID Adjustment.”
Amortizable bond premium. If you are reducing your interest income on a bond by the amount of amortizable bond premium, follow the rules earlier under Nominees to see how to report the interest. But identify the amount to be subtracted as “ABP Adjustment.”
Line 3. If, during 2016, you cashed series EE or I    U.S. savings bonds issued after 1989 and you paid qualified higher education expenses for yourself, your spouse, or your dependents, you may be able to exclude part or all of the interest on those bonds. See Form 8815 for details.
Part II. Ordinary Dividends
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You may have to file Form 5471 if, in 2016, you were an officer or director of a foreign corporation. You may also have to file Form 5471 if, in 2016, you owned 10% or more of the total 
(a) value of a foreign corporation’s stock, or (b) combined voting power of all classes of a foreign corporation’s stock with voting rights. For details, see Form 5471 and its instructions.
Line 5. Report on line 5 all of your ordinary dividends. This amount should be shown in box 1a of your Forms 1099-DIV or substitute statements. 
Nominees. If you received a Form 1099-DIV that includes ordinary dividends you received as a nominee (that is, in your name, but the ordinary dividends actually belong to someone else), report the total on line 5. Do this even if you later distributed some or all of this income to others. Under your last entry on line 5, put a subtotal of all ordinary dividends listed on line 5. Below this subtotal, enter “Nominee Distribution” and show the total ordinary dividends you received as a nominee. Subtract this amount from the subtotal and enter the result on line 6.
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If you received dividends as a nominee,   you must give the actual owner a Form 1099-DIV (unless the owner is your spouse) and file Forms 1096 and 1099-DIV with the IRS. For more details, see the General 
Instructions for Certain Information Returns and the Instructions for Form 1099-DIV.
Part III. Foreign Accounts and Trusts
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