VIEW ONLY

Head of household (with qualifying person). (See instr.)

If the qualifying person is a child but not your dependent,
enter this child's name here.
Married filing separately. Enter spouse's SSN above and
full name here.
Form
U.S. Indi vidual Income Tax Return 1040A 2011
OMB No. 1545-0074
Your social security number
Spouse's social securi ty number
Filing
status
Boxes
checked on
6a and 6b
Yourself. If someone can claim you as a dependent, 6a
Exemptions
Spouse b
No. of children
on 6c who:
lived with
did not live
with you due
to divorce or
separation
Dependents
on 6c not
entered above
d
Add numbers
on lines
above
Total number of exemptions claimed.
Wages, salaries, tips, etc. Attach Form(s) W-2. 7 7
Taxable interest. Attach Schedule B if required. 8a 8a
8b Tax-exempt interest. Do not include on line 8a. b
Attach
Form(s) W-2
here. Also
attach
Form(s)
1099-R if tax
was withheld.
Ordinary dividends. Attach Schedule B if required. 9a 9a
IRA
distributions.
11a Taxable amount 11b
11a 11b
Taxable amount 12b 12a Pensions and
annuities. 12b 12a
13
13
14a Taxable amount Social security
benefits.
14b
14b 14a
Add lines 7 through 14b (far right column). This is your total i ncome. 15 15
17 17
Income
18
Add lines 16 through 19. These are your total adjustments. 20
Subtract line 20 from line 15. This is your adjusted gross i ncome.
18
21
Dependents:
Check only
one box.
Form 1040A (2011)
(1) First name Last name
20
21
Adjusted
gross
income
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions.
10 10
You Spouse
19 19
1
Single
Married filing jointly (even if only one had income)
2
3
Qualifying widow(er) with dependent child (see instructions)
4
5
16 16
9b b
}
security number
Dependent's social (2) (3) Dependent's
(4) X if child under
for child taxcredit
(see instructions)
you
age 17 qualifying
If more than six
dependents,
see Instructions.
UYA
If you did not
get a W-2, see
instructions.
Enclose, but do
not attach, any
payment. Also,
Department of the Treasury - Internal Revenue Service
IRS Use Only - Do not write or staple in this space.
do not check
(see instructions).
(see instructions).
(see instructions).
Capital gain distributions (see instructions).
Qualified dividends (see instructions).
IRA deduction (see instructions).
Student loan interest deduction (see instructions).
(see instructions)
Check here if you, or your spouse if filing
jointly, want $3 to go to this fund. Checking
box 6a.
Make sure the SSN(s) above
and on line 6c are correct.
c
Educator expenses (see instructions).
Tuition and fees. Attach Form 8917.
(99)
please use Form
1040-V.
relationship to you
Unemployment compensation and Alaska Permanent Fund dividends.
Your first name and initial
If a joint return, spouse's first name and initial
Home address (number and street). If you have a P.O. box, see instructions.
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/county Foreign postal code
Last name
Last name
Apt. no.
Presidential Election Campaign
a box below will not change your tax or
refund.
511-33-4238 Swati M Falak
5401W, 110 ST, OVERLAND PARK
Kansas, KS 66211
X
NRA
X
1
0
0
0
1
14,242.
14,242.
0.
14,242.
VIEW ONLY
30
22 Enter the amount from line 21 (adjusted gross income). 22
Total boxes
checked
Blind You were born before J anuary 2, 1947, Check
if:
23a
23a Blind Spouse was born before J anuary 2, 1947,
b
23b deductions, check here
and
payments
24
Subtract line 24 from line 22. If line 24 is more than line 22, enter -0-. 25 25
26 26
Subtract line 26 from line 25. If line 26 is more than line 25, enter -0-. 27
27
Tax, including any alternative minimum tax (see instructions). 28 28
31 31
35
36
Subtract line 34 from line 28. If line 34 is more than line 28, enter -0-. This is your
36 Federal income tax withheld from Forms W-2 and 1099.
37
37
2011 estimated tax payments and amount
applied from 2010 return.
Add lines 36, 37, 38a, 39, and 40. These are your total payments. 41
If line 41 is more than line 35, subtract line 35 from line 41.
This is the amount you overpaid.
41
43a
Refund
Amount of line 42 you want appl i ed to your
2012 esti mated tax.
44
44
Amount you owe. 45
45
46 46 Estimated tax penalty (see instructions).
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 taxyear. Declaration
of preparer (other than the taxpayer) is based on all information of which the preparer has any knowledge.
Enter your standard deducti on
Form 1040A (2011)
42
Amount of line 42 you want refunded to you. 43a
Credit for child and dependent care expenses. Attach 29
29
33 33
32 32
Credit for the elderly or the disabled. Attach
Schedule R.
30
35
Add lines 29 through 33. These are your total credits.
Additional child tax credit. Attach Form 8812. 39
Routing
number
Account
number
Checking Savings
b
c
d
Amount
you owe
Earned i ncome credit (EIC). 38a
Page 2
Form 1040A (2011)
Sign
here
Date Your signature
Keep a copy
for your
records.
Date Spouse's signature. If a joint return, both must sign.
PTIN Date Print/type preparer's name Check
self-employed
Paid
preparer
use only
Firm's name Firm's EIN
Phone no.
Your occupation Daytime phone number
Spouse's occupation
Designee's
name
Do you want to allow another person to discuss this return with the IRS (see instructions)?
Thi rd party
designee
Phone
no.
Yes. Complete the following. No
Personal identification
number (PIN)
34 34
Type:
This is your
Direct Deposit?
UYA
}
qualifying
child, attach
Schedule EIC.
See instructions
J oint return?
See instructions.
If you are married filing separately and your spouse itemizes
Exempti ons. Multiply $3,700 by the number on line 6d.
{
taxable i ncome.
Education credits from Form 8863, line 23.
b Nontaxable combat pay election. 38b
and fill in 43b,
43c, and 43d
24
If you have a
38a
39
If Form 8888 is attached, check here
or Form 8888.
40 American opportunity credit from Form 8863, line 14.
40
Subtract line 41 from line 35. For details on how to pay, see
Retirement savings contributions credit. Attach Form 8880.
Child tax credit (see instructions).
42
Firm's address
if Preparer's signature
total tax.
instructions.
Deduction
for-
People who
Standard
check any
boxon line
23a or 23b
or
who can be
claimed as a
dependent,
see
instructions.
All others:
Single or
Married filing
separately,
$5,800
Married filing
jointly or
Qualifying
widow(er),
$11,600
Head of
household,
$8,500
Tax, credits,
.
Form 2441.
If the IRS sent you an Identity Protection
PIN, enter it
here (see inst.)
Swati M Falak 511-33-4238
14,242.
0
5,800.
8,442.
3,700.
4,742.
473.
0.
473.
1,366.
1,366.
2,732.
2,259.
2,259.
101000035 X
355002664623
Service
Service