41-001 (10/08/2021) 2021 IA 1040 Iowa Individual Income Tax Return For fiscal year beginning ________/________/________ and ending ________/________/_________ Step 1: Fill in all spaces. You must fill in your Social Security Number (SSN). Your last name: Your first name/middle initial: Spouse’s last name: Spouse’s first name/middle initial: Current mailing address (number and street, apartment, lot, or suite number) or PO Box: City, State, ZIP: Spouse SSN: Your SSN: Step 2 Filing Status: Mark one box only 1 Single: Were you claimed as a dependent on another person’s Iowa return? Yes No Email Address: 2 Married filing a joint return. (Two-income families may benefit by using status 3 or 4.) Check this box if you or your spouse were 65 or older as of 12/31/21. 3 Married filing separately on this combined return. Spouse use column B. Residence on 12/31/21: County No. School District No. 4 Married filing separate returns. Spouse's name: ▲SSN: Net Income: $ 5 Head of household with qualifying person. If qualifying person is not claimed as a dependent on this return, enter the person’s name and SSN below. 6 Qualifying widow(er) with dependent child. Name: SSN: Step 3 Exemptions B. Spouse (Filing Status 3 ONLY) A. You or Joint a. Personal Credit: Col. A: Enter 1 (enter 2 if filing status 2 or 5); Col. B: Enter 1 if filing status 3 . ....... ▲ X $ 40 = $ ▲ X $ 40 = $ b. Enter 1 for each taxpayer who is 65 or older and/or 1 for each taxpayer who is blind. ..................... ▲ X $ 20 = $ ▲ X $ 20 = $ c. Dependents: Enter 1 for each dependent. ......................................................................................... ▲ X $ 40 = $ ▲ X $ 40 = $ d. Enter first names of dependents here e. Total $ __________ e. Total $ __________ Step 4 Reportable Social Security benefits as calculated on line 13 of Iowa Social Security Worksheet B. Spouse/Status 3 ▲ A. You or Joint ▲ B. Spouse/Status 3 A. You or Joint B. Spouse/Status 3 A. You or Joint Step 5 Gross Income 1. Wages, salaries, tips, etc ................................................................. 1. .00 .00 2. Taxable interest income. If more than $1,500, complete Sch. B ....... 2. .00 .00 3. Ordinary dividend income. If more than $1,500, complete Sch. B .... 3. .00 .00 4. Taxable alimony received................................................................. 4. .00 .00 5. Business income/(loss). See instructions ......................................... 5. .00 .00 NOTE: Use only blue or black ink, no pencils or red ink. 6. Capital gain/(loss). See instructions ................................................. 6. .00 .00 7. Other gains/(losses). See instructions .............................................. 7. .00 .00 8. Taxable IRA distributions ................................................................. 8. .00 .00 9. Taxable pensions and annuities ....................................................... 9. .00 .00 10. Rents, royalties, partnerships, estates, etc. See instructions ............ 10. .00 .00 11. Farm income/(loss). See instructions ............................................... 11. .00 .00 12. Unemployment compensation. See instructions ............................... 12. .00 .00 13. Gambling winnings ........................................................................... 13. .00 .00 14. Other income, bonus depreciation, and section 179 adjustment ..... 14. .00 .00 15. Gross Income. Add lines 1-14 ............................................................................................................................... 15. _________________ .00 ▲ ______________ .00 Step 6 Adjust- ments to Income 16. Payments to an IRA, Keogh, or SEP ................................................ 16. .00 .00 17. Deductible part of self-employment tax. ........................................... 17. .00 .00 18. Health insurance premium ............................................................... 18. .00 .00 19. Penalty on early withdrawal of savings ............................................. 19. .00 .00 20. Alimony paid .................................................................................... 20. .00 .00 21. Pension/retirement income exclusion ............................................... 21. .00 ▲ .00 22. Moving expense deduction from federal form 3903 .......................... 22. .00 .00 23. Iowa capital gain deduction. Must include corresponding IA 100 schedule .......................................................................................... 23. .00 ▲ .00 24. Other adjustments ............................................................................ 24. .00 .00 25. Total adjustments. Add lines 16-24 ...................................................................................................................... 25. .00 ▲ .00 26. Net Income. Subtract line 25 from line 15 ............................................................................................................. 26. __________________ .00 ▲ ______________ .00 Step 7 Federal Taxes and Qualified Deduc- tions 27. Federal income tax refund/overpayment received in 2021 ............... 27. .00 ▲ .00 28. Self-employment/household employment/other federal taxes .......... 28. .00 ▲ .00 29. Addition for federal taxes. Add lines 27 and 28 .................................................................................................... 29. .00 .00 30. Total. Add lines 26 and 29.................................................................................................................................... 30. .00 .00 31. Federal tax withheld in 2021, federal estimated tax payments made in 2021, and federal taxes paid in 2021 for 2020 and prior years ...... 31. .00 ▲ .00 32. Qualified business income deduction. 50.0% (.50) of federal amount. See instructions ................................................................... 32. .00 ▲ .00 33. DPAD 199A(g) deduction. 50.0% (.5) of federal amount ................... 33. .00 ▲ .00 34. Total federal tax and other qualified deductions. Add lines 31, 32, and 33 ............................................................ 34. .00 .00 35. Balance. Subtract line 34 from line 30. Enter here and on line 36, page 2 ............................................................ 35. .00 ▲ .00

41-001 (09/08/2021) 2021 IA 1040, page 2 B. Spouse/Status 3 A. You or Joint B. Spouse/Status 3 A. You or Joint Step 8 Taxable Income 36. BALANCE. From side 1, line 35 ............................................................................................................................ 36. .00 .00 37. Deduction. Check one box ▲ Itemized.(Include IA Schedule A) Standard ........................................... 37. .00 ▲ .00 38. TAXABLE INCOME. SUBTRACT line 37 from line 36 .......................................................................................... 38. ______________ .00 ________________ .00 Step 9 Tax, Credits, and Check- off Contri- butions 39. Tax from tables or alternate tax ....................................................... 39. .00 ▲ .00 40. Iowa lump-sum tax. See instructions ............................................... 40. .00 ▲ .00 41. Iowa alternative minimum tax. Must include IA 6251. ...................... 41. .00 ▲ .00 42. Total tax. ADD lines 39, 40, and 41. ................................................................................................................... 42. .00 .00 43. Total exemption credit amount(s) from Step 3, side 1. ..................... 43. .00 .00 44. Tuition and textbook credit for dependents K-12. ............................. 44. .00 ▲ .00 45. Volunteer firefighter/EMS/reserve peace officer credit. .................... 45. .00 ▲ .00 46. Total credits. ADD lines 43, 44, and 45. ................................................................................................................ 46. .00 .00 47. BALANCE. SUBTRACT line 46 from line 42. If less than zero, enter zero. ........................................................... 47. .00 ▲ .00 48. Credit for nonresident or part-year resident. Must include IA 126 and federal return. ............................................ 48. .00 ▲ .00 49. BALANCE. SUBTRACT line 48 from 47. If less than zero, enter zero. .................................................................. 49. .00 ▲ .00 50. Out-of-state tax credit. Must include IA 130. ......................................................................................................... 50. .00 ▲ .00 51. BALANCE. SUBTRACT line 50 from 49. If less than zero, enter zero. .................................................................. 51. .00 ▲ .00 52. Other nonrefundable Iowa credits. Must include IA 148 Tax Credits Schedule. .................................................... 52. .00 ▲ .00 53. BALANCE. SUBTRACT line 52 from line 51. If less than zero, enter zero. ........................................................... 53. .00 ▲ .00 54. School district surtax or EMS surtax. Take percentage from table; multiply by line 53. ......................................... 54. .00 ▲ .00 55. Total state and local tax. ADD lines 53 and 54. ..................................................................................................... 55. .00 ▲ .00 56. TOTAL state and local tax before contributions. Combine columns A and B on line 55 and enter here. .................................................. 56. .00 57. Contributions will reduce your refund or add to the amount you owe. Amounts must be in whole dollars. Fish/Wildlife 57a: ▲ State Fair 57b: ▲ Firefighters/Veterans 57c: ▲ Child Abuse Prevention 57d: ▲ Enter here.... 57. .00 58. TOTAL STATE AND LOCAL TAX, AND CONTRIBUTIONS. Add line 56 and line 57 and enter here. ...................................................... 58. ▲ ________________ .00 Step 10 Credits 59. Iowa Fuel Tax Credit. Must include IA 4136 ..................................... 59. .00 ▲ .00 60. Check One: Child and Dependent Care Credit OR ▲ Early Childhood Development Credit 60. .00 ▲ .00 61. Iowa earned income tax credit. 15.0% (.15) of federal credit ............ 61. .00 ▲ .00 62. Other refundable credits. Include IA 148 Tax Credits Schedule. ....... 62. .00 ▲ .00 63. Iowa income tax withheld. ................................................................. 63. .00 ▲ .00 64. Estimated and voucher payments made for tax year 2021. .............. 64. .00 ▲ .00 65. TOTAL. ADD lines 59 through 64 and enter here ............................. 65. .00 ▲ .00 66. TOTAL CREDITS. ADD columns A and B on line 65 and enter here ...................................................................................................... 66. ________________ .00 Step 11 Refund 67. If line 66 is more than line 58, subtract line 58 from line 66. This is the amount you overpaid. ............................................................... 67. ▲ .00 68. Amount of line 67 to be REFUNDED. .................................................................................................................................... REFUND 68. ▲ .00 68a. Routing number: 68b. Type Checking Savings 68c. Account number: 69. Amount of line 67 to be applied to your 2022 estimated tax. ............. 69. .00 ▲ .00 Step 12 Pay 70. If line 66 is less than line 58, subtract line 66 from line 58. This is the AMOUNT OF TAX YOU OWE .................................................... 70. ▲ .00 71. Penalty for underpayment of estimated tax from IA 2210, IA 2210S, or IA 2210F. Check if annualized income method is used. ▲ 71. ▲ .00 72. Penalty and interest ▲ 72a. Penalty .00 ▲ 72b. Interest .00 ADD. Enter total. ...... 72. .00 73. TOTAL AMOUNT DUE. ADD lines 70, 71, and 72. Enter here. ............................................................................ PAY THIS AMOUNT 73. ▲ .00 Step 13 I, the undersigned, declare under penalties of perjury or false certificate, that I have examined this return, and, to the best of my knowledge and belief, it is true, correct, and complete. SIGN HERE ▲ Your signature Date Check if deceased Date of death Preparer's signature Date SIGN HERE ▲ Spouse's signature Date Check if deceased Date of death Preparer's PTIN Firm's FEIN Daytime telephone number Daytime telephone number This return is due May 2nd, 2022. Sign, enclose W-2s, and verify SSNs. MAILING ADDRESS: Iowa Income Tax Document Processing, PO BOX 9187, Des Moines IA 50306-9187 Make check payable to Iowa Department of Revenue