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Form 1040 Department of the Treasury—Internal Revenue Service U.S. Individual Income Tax Return 2009 (99) IRS Use Only—Do not write or staple in this space. Label (See instructions on page 14.) Use the IRS label. Otherwise, please print or type. L A B E L

H E R E For the year Jan. 1–Dec. 31, 2009, or other tax year beginning , 2009, ending , 20 OMB No. 1545-0074 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 Home address (number and street). If you have a P.O. box, see page 14. Apt. no.  You must enter your SSN(s) above.  City, town or post office, state, and ZIP code. If you have a foreign address, see page 14. Checking a box below will not change your tax or refund. Presidential Election Campaign  Check here if you, or your spouse if filing jointly, want $3 to go to this fund (see page 14)  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 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 If more than four dependents, see page 17 and check here  6a Yourself. If someone can claim you as a dependent, do not check box 6a . . . . . b Spouse . . . . . . . . . . . . . . . . . . . . . . . .  Boxes checked on 6a and 6b c Dependents: (1) First name Last name (2) Dependent’s social security number (3) Dependent’s relationship to you (4) if qualifying child for child tax credit (see page 17) ✓ 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 d Total number of exemptions claimed . . . . . . . . . . . . . . . . . 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 page 22. Enclose, but do not attach, any payment. Also, please use Form 1040-V. 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 (see page 22) . . . . . . . 9b 10 Taxable refunds, credits, or offsets of state and local income taxes (see page 23) . . 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 (see page 24) 15b 16 a Pensions and annuities 16a b Taxable amount (see page 25) 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 in excess of $2,400 per recipient (see page 27) . . . 19 20 a Social security benefits 20a b Taxable amount (see page 27) 20b 21 Other income. List type and amount (see page 29) 21 22 Add the amounts in the far right column for lines 7 through 21. This is your total income  22 Adjusted Gross Income 23 Educator expenses (see page 29) . . . . . . . 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 One-half of self-employment tax. Attach Schedule SE . 27 28 Self-employed SEP, SIMPLE, and qualified plans . . 28 29 Self-employed health insurance deduction (see page 30) 29 30 Penalty on early withdrawal of savings . . . . . . 30 31 a Alimony paid b Recipient’s SSN  31a 32 IRA deduction (see page 31) . . . . . . . . 32 33 Student loan interest deduction (see page 34) . . . 33 34 Tuition and fees deduction. Attach Form 8917 . . . 34 35 Domestic production activities deduction. Attach Form 8903 35 36 Add lines 23 through 31a and 32 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 page 97. Cat. No. 11320B Form 1040 (2009) Tax Return Page Reference Questions about what to put on a line? Help is on the page number in the circle. 14 14 FOR REFERENCE ONLY—DO NOT FILE 14 14 15 16 17 19 18 17 76 21 22 22 24 23 24 24 74 25 24 25 27 27 30 29 30 30 22 16 14 22 27 24 30 31 31 30 31 34 35 35 30 24 22 29 35 35 - 12 -