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1040
L A B E L H E R E

Form

Department of the Treasury—Internal Revenue Service

U.S. Individual Income Tax Return
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If a joint return, spouse’s first name and initial

2009

(99)

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

Label
(See instructions on page 14.)

For the year Jan. 1–Dec. 31, 2009, or other tax year beginning Last name Your first name and initial, 2009, ending

, 20

OMB No. 1545-0074 Your social security number

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Last name Apt. no.

452 65

2354

Spouse’s social security number

Use the IRS label. Otherwise, please print or type.

Home address (number and street). If you have a P.O. box, see page 14.

4560 w. 55
City, town or post office, state, and ZIP code. If you have a foreign address, see page 14.

Youmust enter your SSN(s) above.
Checking a box below will not change your tax or refund.
You Spouse

Presidential Election Campaign

Chicago IL 60623
Check here if you, or your spouse if filing jointly, want $3 to go to this fund (see page 14) 1 2 3 6a b c Single Married filing jointly (even if only one had income) Married filing separately. Enter spouse’s SSN above and full name here. Spouse .Dependents:
(1) First name

Filing Status
Check only one box.

4

Head of household (with qualifying person). (See page 15.) If the qualifying person is a child but not your dependent, enter this child’s name here.

5 . . . .

Qualifying widow(er) with dependent child (see page 16)

Exemptions

Yourself. If someone can claim you as a dependent, do not check box 6a . . . . . . . .. . . . . . . .
(2) Dependent’s social security number

. .

. .

. .

. .

Last name

(3) Dependent’s (4)  if qualifying relationship to you child for child tax credit (see page 17)

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 page 18) Dependents on 6c not entered above

1 0 0 0 1

If morethan four dependents, see page 17 and check here d Total number of exemptions claimed . . . . . . . . . . . . . . . . . . . . . 8b . 9b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 8a 9a 10 11 12 13 14 15b 16b 17 18 19 20b 21 22

Add numbers on lines above

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

7 8a b 9a b 10 11 12 13 14 15a 16a17 18 19 20a 21 22 23 24 25 26 27 28 29 30 31a 32 33 34 35 36 37

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

0 0 0 0 0 23568 0 0 0 0 0 0 0 0 0 23568

0
.

Qualified dividends (see page 22) . . . . . . . 0 Taxable refunds, credits, oroffsets of state and local income taxes (see page 23) . . Alimony received . . . . . . . . . . . . . . . . . . . . . Business income or (loss). Attach Schedule C or C-EZ . . . . . . . . . . Capital gain or (loss). Attach Schedule D if required. If not required, check here Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . . . 15a b Taxable amount (see page 24) IRA distributions . 00 b Taxable amount (see page 25) Pensions and annuities 16a Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E Farm income or (loss). Attach Schedule F . . . . . . . . . . . . . . Unemployment compensation in excess of $2,400 per recipient (see page 27) . . . 0 b Taxable amount (see page 27) Social security benefits 20a Other income. List type and amount(see page 29) Add the amounts in the far right column for lines 7 through 21. This is your total income Educator expenses (see page 29) . . . . . . . 23 24 25 26 27 28 29 30 31a 32 33 34 . . . . . .

If you did not get a W-2, see page 22. Enclose, but do not attach, any payment. Also, please use Form 1040-V.

Adjusted Gross Income

0 0 0 0 1665 0 0 0 0 0 0 0 0
. . . . . 36 37

Certain...
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