1040 U.S.

Individual Income Tax Return 2022

Form
Department of the Treasury—Internal Revenue Service

OMB No. 1545-0074 IRS Use Only—Do not write or staple in this space.

Filing Status x Single Married filing jointly Married filing separately (MFS) Head of household (HOH)
Qualifying surviving
Check only spouse (QSS)
one box. If you checked the MFS box, enter the name of your spouse. If you checked the HOH or QSS box, enter the child’s name if the qualifying
person is a child but not your dependent:
Your first name and middle initial Last name Your social security number
MARY H VANHAM 344 46 1282
If joint return, spouse’s first name and middle initial Last name Spouse’s social security number

Home address (number and street). If you have a P.O. box, see instructions. Apt. no. Presidential Election Campaign
3857 TERRITORY ST 3857 Check here if you, or your
spouse if filing jointly, want $3
City, town, or post office. If you have a foreign address, also complete spaces below. State ZIP code
to go to this fund. Checking a
LAS VEGAS NV 89121 box below will not change
Foreign country name Foreign province/state/county Foreign postal code your tax or refund.
You Spouse

Digital At any time during 2022, did you: (a) receive (as a reward, award, or payment for property or services); or (b) sell,
Assets exchange, gift, or otherwise dispose of a digital asset (or a financial interest in a digital asset)? (See instructions.) Yes X No
Standard Someone can claim: You as a dependent Your spouse as a dependent
Deduction Spouse itemizes on a separate return or you were a dual-status alien

Age/Blindness You: x Were born before January 2, 1958 Are blind Spouse: Was born before January 2, 1958 Is blind
Dependents (see instructions): (2) Social security (3) Relationship (4) Check the box if qualifies for (see instructions):
(1) First name Last name number to you Child tax credit Credit for other dependents
If more
than four
dependents,
see instructions
and check
here . .
1a Total amount from Form(s) W-2, box 1 (see instructions) . . . . . . . . . . . . . 1a 72000
Income
b Household employee wages not reported on Form(s) W-2 . . . . . . . . . . . . . 1b 0
Attach Form(s) c Tip income not reported on line 1a (see instructions) . . . . . . . . . . . . . . 1c 0
W-2 here. Also
attach Forms d Medicaid waiver payments not reported on Form(s) W-2 (see instructions) . . . . . . . . 1d 0
W-2G and e Taxable dependent care benefits from Form 2441, line 26 . . . . . . . . . . . . 1e 0
1099-R if tax
was withheld. f Employer-provided adoption benefits from Form 8839, line 29 . . . . . . . . . . . 1f 0
If you did not g Wages from Form 8919, line 6 . . . . . . . . . . . . . . . . . . . . . 1g 0
get a Form h Other earned income (see instructions) . . . . . . . . . . . . . . . . . . 1h 0
W-2, see
instructions.
i Nontaxable combat pay election (see instructions) . . . . . . . 1i
z Add lines 1a through 1h . . . . . . . . . . . . . . . . . . . . . . 1z 72000
Attach Sch. B 2a Tax-exempt interest . . . 2a 0 b Taxable interest . . . . . 2b 0
if required. 3a Qualified dividends . . . 3a 0 b Ordinary dividends . . . . . 3b 0
4a IRA distributions . . . . 4a b Taxable amount . . . . . . 4b 0
Standard 5a Pensions and annuities . . 5a b Taxable amount . . . . . . 5b 0
Deduction for—
6a Social security benefits . . 6a 0 b Taxable amount . . . . . . 6b 0
• Single or
Married filing c If you elect to use the lump-sum election method, check here (see instructions) . . . . .
separately,
$12,950 7 Capital gain or (loss). Attach Schedule D if required. If not required, check here . . . . . 7 0
• Married filing 8 Other income from Schedule 1, line 10 . . . . . . . . . . . . . . . . . . 8 0
jointly or
Qualifying 9 Add lines 1z, 2b, 3b, 4b, 5b, 6b, 7, and 8. This is your total income . . . . . . . . . . 9 72000
surviving spouse,
$25,900
10 Adjustments to income from Schedule 1, line 26 . . . . . . . . . . . . . . . 10 8650
• Head of 11 Subtract line 10 from line 9. This is your adjusted gross income . . . . . . . . . . 11 63350
household,
$19,400 12 Standard deduction or itemized deductions (from Schedule A) . . . . . . . . . . 12 58460
• If you checked 13 Qualified business income deduction from Form 8995 or Form 8995-A . . . . . . . . . 13 0
any box under
Standard 14 Add lines 12 and 13 . . . . . . . . . . . . . . . . . . . . . . . . 14 58460
Deduction,
see instructions.
15 Subtract line 14 from line 11. If zero or less, enter -0-. This is your taxable income . . . . . 15 4890

For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Form 1040 (2022)

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Form 1040 (2022) Page 2

Tax and 16 Tax (see instructions). Check if any from Form(s): 1 8814 2 4972 3 . . 16 488
Credits 17 Amount from Schedule 2, line 3 . . . . . . . . . . . . . . . . . . . . 17 0
18 Add lines 16 and 17 . . . . . . . . . . . . . . . . . . . . . . . . 18 488
19 Child tax credit or credit for other dependents from Schedule 8812 . . . . . . . . . . 19 0
20 Amount from Schedule 3, line 8 . . . . . . . . . . . . . . . . . . . . 20 0
21 Add lines 19 and 20 . . . . . . . . . . . . . . . . . . . . . . . . 21 0
22 Subtract line 21 from line 18. If zero or less, enter -0- . . . . . . . . . . . . . . 22 488
23 Other taxes, including self-employment tax, from Schedule 2, line 21 . . . . . . . . . 23 0
24 Add lines 22 and 23. This is your total tax . . . . . . . . . . . . . . . . . 24 488
Payments 25 Federal income tax withheld from:
a Form(s) W-2 . . . . . . . . . . . . . . . . . . 25a 11457
b Form(s) 1099 . . . . . . . . . . . . . . . . . . 25b 0
c Other forms (see instructions) . . . . . . . . . . . . . 25c 0
d Add lines 25a through 25c . . . . . . . . . . . . . . . . . . . . . . 25d 11457
If you have a
26 2022 estimated tax payments and amount applied from 2021 return . . . . . . . . . . 26 0
qualifying child, 27 Earned income credit (EIC) . . . . . . . . . . . . . . 27 0
attach Sch. EIC.
28 Additional child tax credit from Schedule 8812 . . . . . . . . 28 0
29 American opportunity credit from Form 8863, line 8 . . . . . . . 29 0
30 Reserved for future use . . . . . . . . . . . . . . . 30
31 Amount from Schedule 3, line 15 . . . . . . . . . . . . 31 0
32 Add lines 27, 28, 29, and 31. These are your total other payments and refundable credits . . 32 0
33 Add lines 25d, 26, and 32. These are your total payments . . . . . . . . . . . . 33 11457
Refund 34 If line 33 is more than line 24, subtract line 24 from line 33. This is the amount you overpaid . . 34 10969
35a Amount of line 34 you want refunded to you. If Form 8888 is attached, check here . . . . 35a 10969
Direct deposit? b Routing number 3 2 2 4 8 4 4 0 1 c Type: X Checking Savings
See instructions.
d Account number 1 0 2 1 8 8 3 9 5 2
36 Amount of line 34 you want applied to your 2023 estimated tax . . . 36 0
Amount 37 Subtract line 33 from line 24. This is the amount you owe.
You Owe For details on how to pay, go to www.irs.gov/Payments or see instructions . . . . . . . . 37 0
38 Estimated tax penalty (see instructions) . . . . . . . . . . 38 0
Third Party Do you want to allow another person to discuss this return with the IRS? See
Designee instructions . . . . . . . . . . . . . . . . . . . . . Yes. Complete below. X No
Designee’s Phone Personal identification
name no. number (PIN)
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
Sign belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Here Your signature Date Your occupation If the IRS sent you an Identity
Protection PIN, enter it here
(see inst.) 2 4 4 1 9 4
Joint return? STAFF
See instructions. Spouse’s signature. If a joint return, both must sign. Date Spouse’s occupation If the IRS sent your spouse an
Keep a copy for Identity Protection PIN, enter it here
your records. (see inst.)

Phone no. 702-580-9477 Email address Maryvanham9@gmail.com

Preparer’s name Preparer’s signature Date PTIN Check if:
Paid Self-employed
Preparer
Firm’s name Phone no.
Use Only
Firm’s address Firm’s EIN
Go to www.irs.gov/Form1040 for instructions and the latest information. Form 1040 (2022)
 SCHEDULE 1 OMB No. 1545-0074
Additional Income and Adjustments to Income
(Form 1040)
Department of the Treasury
Attach to Form 1040, 1040-SR, or 1040-NR. 2022
Attachment
Go to www.irs.gov/Form1040 for instructions and the latest information.
Internal Revenue Service Sequence No. 01
Name(s) shown on Form 1040, 1040-SR, or 1040-NR Your social security number
MARY H VANHAM 344 - 46 - 1282
Part I Additional Income
1 Taxable refunds, credits, or offsets of state and local income taxes . . . . . . . . . 1 0
2a Alimony received . . . . . . . . . . . . . . . . . . . . . . . . . . . 2a 0
b Date of original divorce or separation agreement (see instructions):
3 Business income or (loss). Attach Schedule C . . . . . . . . . . . . . . . . . 3 0
4 Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . . . . . . . 4 0
5 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E . 5 0
6 Farm income or (loss). Attach Schedule F . . . . . . . . . . . . . . . . . . . 6 0
7 Unemployment compensation . . . . . . . . . . . . . . . . . . . . . . . 7 0
8 Other income:
a Net operating loss . . . . . . . . . . . . . . . . . . . 8a ( 0)
b Gambling . . . . . . . . . . . . . . . . . . . . . . 8b 0
c Cancellation of debt . . . . . . . . . . . . . . . . . . 8c 0
d Foreign earned income exclusion from Form 2555 . . . . . . . 8d ( 0)
e Income from Form 8853 . . . . . . . . . . . . . . . . . 8e 0
f Income from Form 8889 . . . . . . . . . . . . . . . . . 8f 0
g Alaska Permanent Fund dividends . . . . . . . . . . . . . 8g 0
h Jury duty pay . . . . . . . . . . . . . . . . . . . . . 8h 0
i Prizes and awards . . . . . . . . . . . . . . . . . . . 8i 0
j Activity not engaged in for profit income . . . . . . . . . . . 8j 0
k Stock options . . . . . . . . . . . . . . . . . . . . . 8k 0
l Income from the rental of personal property if you engaged in the rental
for profit but were not in the business of renting such property . . . 8l 0
m Olympic and Paralympic medals and USOC prize money (see
instructions) . . . . . . . . . . . . . . . . . . . . . 8m 0
n Section 951(a) inclusion (see instructions) . . . . . . . . . . 8n 0
o Section 951A(a) inclusion (see instructions) . . . . . . . . . . 8o 0
p Section 461(l) excess business loss adjustment . . . . . . . . 8p 0
q Taxable distributions from an ABLE account (see instructions) . . . 8q 0
r Scholarship and fellowship grants not reported on Form W-2 . . . 8r 0
s Nontaxable amount of Medicaid waiver payments included on Form
1040, line 1a or 1d . . . . . . . . . . . . . . . . . . . 8s ( 0)
t Pension or annuity from a nonqualifed deferred compensation plan or
a nongovernmental section 457 plan . . . . . . . . . . . . 8t 0
u Wages earned while incarcerated . . . . . . . . . . . . . 8u 0
z Other income. List type and amount:
8z 0
9 Total other income. Add lines 8a through 8z . . . . . . . . . . . . . . . . . . 9 0
10 Combine lines 1 through 7 and 9. Enter here and on Form 1040, 1040-SR, or 1040-NR, line 8 10 0
For Paperwork Reduction Act Notice, see your tax return instructions. Schedule 1 (Form 1040) 2022

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Schedule 1 (Form 1040) 2022 Page 2

Part II Adjustments to Income

11 Educator expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 0
12 Certain business expenses of reservists, performing artists, and fee-basis government
officials. Attach Form 2106 . . . . . . . . . . . . . . . . . . . . . . . . 12 0
13 Health savings account deduction. Attach Form 8889 . . . . . . . . . . . . . . 13 4650
14 Moving expenses for members of the Armed Forces. Attach Form 3903 . . . . . . . 14 0
15 Deductible part of self-employment tax. Attach Schedule SE . . . . . . . . . . . 15 0
16 Self-employed SEP, SIMPLE, and qualified plans . . . . . . . . . . . . . . . . 16 0
17 Self-employed health insurance deduction . . . . . . . . . . . . . . . . . . 17 0
18 Penalty on early withdrawal of savings . . . . . . . . . . . . . . . . . . . . 18 0
19a Alimony paid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19a
b Recipient’s SSN . . . . . . . . . . . . . . . . . . . . . .
c Date of original divorce or separation agreement (see instructions):
20 IRA deduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 4000
21 Student loan interest deduction . . . . . . . . . . . . . . . . . . . . . . 21 0
22 Reserved for future use . . . . . . . . . . . . . . . . . . . . . . . . . 22
23 Archer MSA deduction . . . . . . . . . . . . . . . . . . . . . . . . . 23 0
24 Other adjustments:
a Jury duty pay (see instructions) . . . . . . . . . . . . . . 24a 0
b Deductible expenses related to income reported on line 8l from the
rental of personal property engaged in for profit . . . . . . . . 24b 0
c Nontaxable amount of the value of Olympic and Paralympic medals
and USOC prize money reported on line 8m . . . . . . . . . . 24c 0
d Reforestation amortization and expenses . . . . . . . . . . . 24d 0
e Repayment of supplemental unemployment benefits under the Trade
Act of 1974 . . . . . . . . . . . . . . . . . . . . . . 24e 0
f Contributions to section 501(c)(18)(D) pension plans . . . . . . . 24f 0
g Contributions by certain chaplains to section 403(b) plans . . . . 24g 0
h Attorney fees and court costs for actions involving certain unlawful
discrimination claims (see instructions) . . . . . . . . . . . . 24h 0
i Attorney fees and court costs you paid in connection with an award
from the IRS for information you provided that helped the IRS detect
tax law violations . . . . . . . . . . . . . . . . . . . 24i 0
j Housing deduction from Form 2555 . . . . . . . . . . . . . 24j 0
k Excess deductions of section 67(e) expenses from Schedule K-1 (Form
1041) . . . . . . . . . . . . . . . . . . . . . . . . 24k 0
z Other adjustments. List type and amount:
24z 0
25 Total other adjustments. Add lines 24a through 24z . . . . . . . . . . . . . . . 25 0
26 Add lines 11 through 23 and 25. These are your adjustments to income. Enter here and on
Form 1040 or 1040-SR, line 10, or Form 1040-NR, line 10a . . . . . . . . . . . . 26 8650
Schedule 1 (Form 1040) 2022
 SCHEDULE A Itemized Deductions OMB No. 1545-0074
(Form 1040)
Department of the Treasury
Go to www.irs.gov/ScheduleA for instructions and the latest information.
Attach to Form 1040 or 1040-SR. 2022
Attachment
Internal Revenue Service Caution: If you are claiming a net qualified disaster loss on Form 4684, see the instructions for line 16. Sequence No. 07
Name(s) shown on Form 1040 or 1040-SR Your social security number
MARY H VANHAM 344 46 1282
Medical Caution: Do not include expenses reimbursed or paid by others.
and 1 Medical and dental expenses (see instructions) STATEMENT#1
. . . . . . . 1 18644
Dental 2 Enter amount from Form 1040 or 1040-SR, line 11 2 63350
Expenses 3 Multiply line 2 by 7.5% (0.075) . . . . . . . . . . . . . 3 4751
4 Subtract line 3 from line 1. If line 3 is more than line 1, enter -0- . . . . . . . . . . 4 13893
Taxes You 5 State and local taxes.
Paid a State and local income taxes or general sales taxes. You may include
either income taxes or general sales taxes on line 5a, but not both. If
you elect to include general sales taxes instead of income taxes,
check this box . . . . . . . . . . . . . . . . . 5a 6987
b State and local real estate taxes (see instructions) . . . . . . . 5b 0
c State and local personal property taxes . . . . . . . . . . 5c 0
d Add lines 5a through 5c . . . . . . . . . . . . . . . 5d 6987
e Enter the smaller of line 5d or $10,000 ($5,000 if married filing
separately) . . . . . . . . . . . . . . . . . . . 5e 6987
6 Other taxes. List type and amount:
PROPERTY TAX-4000 6 4000
7 Add lines 5e and 6 . . . . . . . . . . . . . . . . . . . . . . . . . 7 10987
Interest 8 Home mortgage interest and points. If you didn’t use all of your home
You Paid mortgage loan(s) to buy, build, or improve your home, see
Caution: Your instructions and check this box . . . . . . . . . . . X
mortgage interest
deduction may be a Home mortgage interest and points reported to you on Form 1098.
limited. See See instructions if limited . . . . . . . . . . . . . . 8a 0
instructions.
b Home mortgage interest not reported to you on Form 1098. See
instructions if limited. If paid to the person from whom you bought the
home, see instructions and show that person’s name, identifying no.,
and address . . . . . . . . . . . . . . . . . . . 8b 0

c Points not reported to you on Form 1098. See instructions for special
rules . . . . . . . . . . . . . . . . . . . . . 8c 0
d Reserved for future use . . . . . . . . . . . . . . . 8d
e Add lines 8a through 8c . . . . . . . . . . . . . . . 8e 0
9 Investment interest. Attach Form 4952 if required. See instructions . 9 0
10 Add lines 8e and 9 . . . . . . . . . . . . . . . . . . . . . . . . . 10 0
Gifts to 11 Gifts by cash or check. If you made any gift of $250 or more, see
Charity instructions . . STMT
. . #2
. . . . . . . . . . . . . . . 11 23080
Caution: If you 12 Other than by cash or check. If you made any gift of $250 or more,
made a gift and
got a benefit for it, see instructions. You must attach Form 8283 if over $500 . . . . 12 0
see instructions. 13 Carryover from prior year . . . . . . . . . . . . . . 13 10500
14 Add lines 11 through 13 . . . . . . . . . . . . . . . . . . . . . . . 14 33580
Casualty and 15 Casualty and theft loss(es) from a federally declared disaster (other than net qualified
Theft Losses disaster losses). Attach Form 4684 and enter the amount from line 18 of that form. See
instructions . . . . . . . . . . . . . . . . . . . . . . . . . . 15 0
Other 16 Other—from list in instructions. List type and amount:
Itemized
Deductions 16 0
Total 17 Add the amounts in the far right column for lines 4 through 16. Also, enter this amount on
Itemized Form 1040 or 1040-SR, line 12 . . . . . . . . . . . . . . . . . . . . 17 58460
Deductions 18 If you elect to itemize deductions even though they are less than your standard deduction,
check this box . . . . . . . . . . . . . . . . . . . . . . . .
For Paperwork Reduction Act Notice, see the Instructions for Form 1040. Schedule A (Form 1040) 2022

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 8889 Health Savings Accounts (HSAs) OMB No. 1545-0074

2022
Form
Attach to Form 1040, 1040-SR, or 1040-NR.
Department of the Treasury Attachment
Internal Revenue Service Go to www.irs.gov/Form8889 for instructions and the latest information. Sequence No. 52
Name(s) shown on Form 1040, 1040-SR, or 1040-NR Social security number of HSA beneficiary.
If both spouses have HSAs, see instructions.
MARY H VANHAM 344 46 1282
Before you begin: Complete Form 8853, Archer MSAs and Long-Term Care Insurance Contracts, if required.
Part I HSA Contributions and Deduction. See the instructions before completing this part. If you are filing jointly
and both you and your spouse each have separate HSAs, complete a separate Part I for each spouse.
1 Check the box to indicate your coverage under a high-deductible health plan (HDHP) during 2022.
See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X Self-only Family
2 HSA contributions you made for 2022 (or those made on your behalf), including those made by the
unextended due date of your tax return that were for 2022. Do not include employer contributions,
contributions through a cafeteria plan, or rollovers. See instructions . . . . . . . . . . . 2 7000
3 If you were under age 55 at the end of 2022 and, on the first day of every month during 2022, you
were, or were considered, an eligible individual with the same coverage, enter $3,650 ($7,300 for
family coverage). All others, see the instructions for the amount to enter . . . . . . . . . . 3 4650
4 Enter the amount you and your employer contributed to your Archer MSAs for 2022 from Form 8853,
lines 1 and 2. If you or your spouse had family coverage under an HDHP at any time during 2022, also
include any amount contributed to your spouse’s Archer MSAs . . . . . . . . . . . . . 4 0
5 Subtract line 4 from line 3. If zero or less, enter -0- . . . . . . . . . . . . . . . . . 5 4650
6 Enter the amount from line 5. But if you and your spouse each have separate HSAs and had family
coverage under an HDHP at any time during 2022, see the instructions for the amount to enter . . 6 4650
7 If you were age 55 or older at the end of 2022, married, and you or your spouse had family coverage
under an HDHP at any time during 2022, enter your additional contribution amount. See instructions . 7 0
8 Add lines 6 and 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 4650
9 Employer contributions made to your HSAs for 2022 . . . . . . . . 9 0
10 Qualified HSA funding distributions . . . . . . . . . . . . . . 10 0
11 Add lines 9 and 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 0
12 Subtract line 11 from line 8. If zero or less, enter -0- . . . . . . . . . . . . . . . . . 12 4650
13 HSA deduction. Enter the smaller of line 2 or line 12 here and on Schedule 1 (Form 1040), Part II, line 13 13 4650
Caution: If line 2 is more than line 13, you may have to pay an additional tax. See instructions. STMT #3
Part II HSA Distributions. If you are filing jointly and both you and your spouse each have separate HSAs, complete
a separate Part II for each spouse.
14a Total distributions you received in 2022 from all HSAs (see instructions) . . . . . . . . . . 14a
b Distributions included on line 14a that you rolled over to another HSA. Also include any excess
contributions (and the earnings on those excess contributions) included on line 14a that were
withdrawn by the due date of your return. See instructions . . . . . . . . . . . . . . 14b
c Subtract line 14b from line 14a . . . . . . . . . . . . . . . . . . . . . . . . 14c
15 Qualified medical expenses paid using HSA distributions (see instructions) . . . . . . . . . 15
16 Taxable HSA distributions. Subtract line 15 from line 14c. If zero or less, enter -0-. Also, include this
amount in the total on Schedule 1 (Form 1040), Part I, line 8f . . . . . . . . . . . . . . 16
17a If any of the distributions included on line 16 meet any of the Exceptions to the Additional 20%
Tax (see instructions), check here . . . . . . . . . . . . . . . . . . . . . .
b Additional 20% tax (see instructions). Enter 20% (0.20) of the distributions included on line 16 that
are subject to the additional 20% tax. Also, include this amount in the total on Schedule 2 (Form
1040), Part II, line 17c . . . . . . . . . . . . . . . . . . . . . . . . . . 17b
Part III Income and Additional Tax for Failure To Maintain HDHP Coverage. See the instructions before
completing this part. If you are filing jointly and both you and your spouse each have separate HSAs,
complete a separate Part III for each spouse.
18 Last-month rule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 0
19 Qualified HSA funding distribution . . . . . . . . . . . . . . . . . . . . . . . 19 0
20 Total income. Add lines 18 and 19. Include this amount on Schedule 1 (Form 1040), Part I, line 8f . 20 0
21 Additional tax. Multiply line 20 by 10% (0.10). Include this amount in the total on Schedule 2 (Form
1040), Part II, line 17d . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 0
For Paperwork Reduction Act Notice, see your tax return instructions. Form 8889 (2022)

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Enter any qualified conservation contributions (QCCs) made during the year.

1 If you are a qualified farmer or rancher, enter any QCCs subject to the limit based on 100%
of adjusted gross income (AGI) 0
2 Enter any QCCs not entered on line 1 0
Enter your other charitable contributions made during the year.

3 Enter cash contributions that you elect to treat as qualified contributions plus cash
contributions payable for relief efforts in 2018 or 2019 qualified disaster areas that you
elected to treat as qualified contributions 0
4 Enter your contributions of capital gain property "for the use of" any qualified organization 0
5 Enter your other contributions "for the use of" any qualified organization. Don't include
any contributions you entered on a previous line 0
6 Enter your contributions of capital gain property to qualified organizations that aren't 50%
limit organizations. Don't include any contributions you entered on a previous line 0
7 Enter your other contributions to qualified organizations that aren't 50% limit
organizations. Don't include any contributions you entered on a previous line 0
8 Enter your contributions of capital gain property to 50% limit organizations deducted at fair
market value. Don't include any contributions you entered on a previous line 0
9 Enter your noncash contributions to 50% limit organizations other than capital gain
property you deducted at fair market value. Be sure to include contributions of capital gain
property to 50% limit organizations if you reduced the property's fair market value. Don't
include any contributions you entered on a previous line 0
10 Enter your cash contributions to 50% limit organizations. Don't include any contributions
you entered on a previous line 23080
Figure your deduction for the current year and prior year (if any result is zero or less, enter -0-)

11 Enter your adjusted gross income (AGI) 63350

Cash contributions subject to the limit based on 60% of AGI

12 Multiply line 11 by 0.6 38010

13 Deductible amount. Enter the smaller of line 10 or line 12 23080
14 Carryover. Subtract line 13 from line 10 0
15. Prior year cash contributions subject to the limit based on 60% of AGI

Year Contributions subject to 60% Subtract (until allowed Deductible amount Carryover. Subtract
deduction) from line 12 column (d) from
(a) (b) smallest of 60% of column (b)
(c) AGI, column b or
column c (e)

(d)

2019 3500 14930 3500 0

2020 3000 11430 3000 0
2021 4000 8430 4000 0

Current year Noncash contributions subject to the limit based on 50% of AGI

16 Multiply line 11 by 0.5 31675

17 Add line 13 and line15d 33580
18 Subtract line 17 from line 16 0
19 Deductible amount. Enter the smaller of line 9 or line 18 0
20 Carryover. Subtract line 19 from line 9 0
21.Prior year Noncash contributions subject to the limit based on 50% of AGI

Year Contributions subject to 50% Subtract (until allowed Deductible amount Carryover. Subtract
deduction )from line 50% of column (d) from
(a) (b) AGI smallest of 50% of AGI column (b)
or column c
(c) (e)
(d)

Contributions (other than capital gain property) subject to limit based on 30% of AGI

22 Multiply line 11 by 0.5 31675

23 Add line 17,line 19 and line 21d 33580
24 Subtract line 23 from line 22 0
25 Multiply line 11 by 0.3 19005
26 Add lines 5 and 7 0
27 Deductible amount. Enter the smallest of line 24, 25, or 26 0
28 Carryover. Subtract line 27 from line 26 0
29.PRIOR YEAR : Contributions (other than capital gain property) subject to limit based on 30% of AGI

Year Contributions subject to 30% Subtract (until allowed Deductible amount Carryover. Subtract
deduction) from line 22 column (d) from
(a) (b) smallest of column b, column (b)
(c) column c or line 11*.3
(e)
(d)

Contributions of capital gain property subject to limit based on 30% of AGI

30 Multiply line 11 by 0.5 31675

31 Add line 23,line27 and line 29d 33580
32 Subtract line 31 from line 30 0
33 Multiply line 11 by 0.3 19005
34 Deductible amount. Enter the smallest of line 8, 32, or 33 0
35 Carryover. Subtract line 34 from line 8 0
36.PRIOR YEAR: Contributions of capital gain property subject to limit based on 30% of AGI

Year Contributions subject to 30% Subtract (until allowed Deductible amount Carryover. Subtract
(a) (b) deduction )from line 30 smallest of column b, column (d) from
(c) column c or line 11*.3 column (b)
(d) (e)
Contributions subject to the limit based on 20% of AGI

37 Multiply line 11 by 0.5 31675

38 Add line 31, line 34 and line 36d 33580
39 Subtract line 38 from line 37 0
40 Subtract line 27, line29d,line 34,line 36d from line 33 19005
41 Multiply line 11 by 0.2 12670
42 Add lines 4 and 6 0
43 Deductible amount. Enter the smallest of line 39, 40, 41, or 42 0
44 Carryover. Subtract line 43 from line 42 0
45. PRIOR YEAR: Contributions subject to the limit based on 20% of AGI

Year Contributions subject to Subtract (until allowed Subtract 43 from 40 for the first Deductible amount Carryover.
20% deduction)from 11*0.5 row. From the second row subtract
(a) col e from previous row column d smallest of column b, Subtract column
(b) (c) column c, column d,
(d) or line 41 ( e) from column b
(e)
(f)

QCCs subject to limit based on 50% of AGI

46 Multiply line 11 by 0.5 31675

47 Add line 38,line 43 and line 45e 33580
48 Subtract line 47 from line 46 0
49 Deductible amount. Enter the smaller of line 2 or line 48 0
50 Carryover. Subtract line 49 from line 2 0
51. PRIOR YEAR: QCCs subject to limit based on 50% of AGI

Year Contributions subject to Subtract (until allowed deduction ) Deductible amount Carryover. Subtract
(a) QCCs 50% from line 11*.5 smallest of column b, column (d) from
(b) (c) column c or line 11*.5 column (b)
(d) (e)
QCCs subject to limit based on 100% of AGI

52 Enter the amount from line 11 63350

53 Add lines 47, line 49 and line 51d 33580
54 Subtract line 53 from line 52 29770
55 Deductible amount. Enter the smaller of line 1 or line 54 0
56 Carryover. Subtract line 55 from line 1 0
57. PRIOR YEAR: QCCs subject to limit based on 100% of AGI

Year Contributions subject to Subtract (until allowed deduction ) Deductible amount Carryover. Subtract
(a) QCCs 100% from line 11 smallest of column b, column (d) from
(b) (c) column c or line 11 column (b)
(d) (e)

Qualified contributions for certain disaster relief efforts

58 Enter the amount from line 11 63350

59 Add lines 53,line 55 and line 57d 33580
60 Subtract line 59 from line 58 29770
61 Deductible amount. Enter the smaller of line 3 or line 60 0
62 Carryover. Subtract line 61 from line 3 0
63. PRIOR YEAR: Qualified contributions for certain disaster relief efforts

Year Contributions subject to Subtract (until allowed deduction ) Deductible amount Carryover. Subtract
(a) 100% from line 11 smallest of column b, column (d) from
(b) (c) column c or line 11 column (b)
(d) (e)

Deduction for the year

64 Add lines 59, line 61 and line 63d Enter the total here and include the
deductible amounts on Schedule A (Form 1040 or 1040-SR), line 11 or line 12,
whichever is appropriate. Also, enter the amount from line 64 on the dotted
line next to the line 11 entry space 33580
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 STATEMENT#1

Name(s) shown on your return Identifying number

MARY H VANHAM 344461282

SCHEDULE A LINE 1 MEDICAL AND DENTAL EXPENSES

DESCRIPTION AMOUNT
DOCTORS AND PRESCRIPTION 13000
MEDICAL MILEAGE DRIVEN 4

FROM LONG TERM CARE PREMIUM

MARY H VANHAM 5640

TOTAL 18644
 STMT #2

Name(s) shown on your return Identifying number

MARY H VANHAM 344461282

Note: We include cents when adding the amounts and round off only the total.
SCHEDULE A LINE 11 GIFTS TO CHARITY
DESCRIPTION AMOUNT LIMIT OF %AGI
SMITH CHARITY SPRING AND TONOPAH 20000 60

SMITH SPARKS STATELINE SILVER SPRING CHARITIE

S 3080 60

Allowable Cash Donation 23080

 STMT #3

Name(s) shown on your return Identifying number

MARY H VANHAM 344461282

FORM 8889 - EXCESS CONTRIBUTION CARRYFORWARD TO NEXT YEAR

Excess still in account $ 4000

Current year $ 3000
Maximum allowable contribution $ 4650
Excess Contribution carryforward to next year $ 2350