Form 1040A United States Individual Income Tax Return 2005. Summary: This is an example of Form 1040A (2005) with these line items completed as would pertain to the text.

Under “Label”:

“Your first name and initial” field contains Sara L

“Last name” field contains Brown

“Your social security number” field contains 111-00-1111

“Home address (number and street). If you have a Post Office box, see page 18.” field contains 1040A Main Street

“City, town or post office, state, and ZIP code. If you have a foreign address, see page 18.” field contains Hometown Arizona 85240

“Presidential Election Campaign ”

“Do you, or your spouse if filing a joint return, want $3 to go to this fund? You: Yes Note. Checking Yes will not change your tax or reduce your refund. Do you, or your spouse if filing a joint return, want $3 to go to this fund? You: Yes” checkbox checked

Under “Filing Status”:

“1. Single” checkbox checked

Under “Exemptions”:

“6d. Total number of exemptions claimed. Add numbers on line above” field contains 0

Under “Income”:

“7. Wages, salaries, tips, etc. Attach Form(s) W-2.” field contains 1,550

“8a. Taxable interest. Attach Schedule 1 if required.” field contains 1,050

“9. Ordinary dividends. Attach Schedule 1 if required.” field contains 1,050

“10. Capital gain distributions (see page 27).” field contains 700

“15. Add lines 7 through 14b (far right column). This is your total income” field contains 4,350

Under “Adjusted gross income”:

“21. Subtract line 20 from line 15. This is your adjusted gross income.” field contains 4,350