I Detach Here and Mail With Your Payment I

Calendar Year '

Department of the Treasury
Internal Revenue Service Due 04/18/2022 2022 Form 1040-ES Payment Voucher 1
File only if you are making a payment of estimated tax by check or money order. Mail this Amount of estimated tax
voucher with your check or money order payable to the 'United States Treasury.' Write your
social security number and ' 2022 Form 1040-ES' on your check or money order. Do not send you are paying by check
cash. Enclose, but do not staple or attach, your payment with this voucher. or money order . . . . . . . . . . G 680.
REV 04/09/22 INTUIT.CG.CFP.SP 1555

615-20-2273 458-37-2792
ERICA C VILLARREAL
BRYAN M VILLARREAL INTERNAL REVENUE SERVICE
1950 BOLIN RD PO BOX 1300
NORTH AUGUSTA SC 29841-2215 CHARLOTTE NC 28201-1300

615202273 RX VILL 30 0 202212 430

 I Detach Here and Mail With Your Payment I
Calendar Year '
Department of the Treasury
Internal Revenue Service Due 06/15/2022 2022 Form 1040-ES Payment Voucher 2
File only if you are making a payment of estimated tax by check or money order. Mail this Amount of estimated tax
voucher with your check or money order payable to the 'United States Treasury.' Write your
social security number and ' 2022 Form 1040-ES' on your check or money order. Do not send you are paying by check
cash. Enclose, but do not staple or attach, your payment with this voucher. or money order . . . . . . . . . . G 680.
REV 04/09/22 INTUIT.CG.CFP.SP 1555

615-20-2273 458-37-2792
ERICA C VILLARREAL
BRYAN M VILLARREAL INTERNAL REVENUE SERVICE
1950 BOLIN RD PO BOX 1300
NORTH AUGUSTA SC 29841-2215 CHARLOTTE NC 28201-1300

615202273 RX VILL 30 0 202212 430

 I Detach Here and Mail With Your Payment I
Calendar Year '
Department of the Treasury
Internal Revenue Service Due 09/15/2022 2022 Form 1040-ES Payment Voucher 3
File only if you are making a payment of estimated tax by check or money order. Mail this Amount of estimated tax
voucher with your check or money order payable to the 'United States Treasury.' Write your
social security number and ' 2022 Form 1040-ES' on your check or money order. Do not send you are paying by check
cash. Enclose, but do not staple or attach, your payment with this voucher. or money order . . . . . . . . . . G 680.
REV 04/09/22 INTUIT.CG.CFP.SP 1555

615-20-2273 458-37-2792
ERICA C VILLARREAL
BRYAN M VILLARREAL INTERNAL REVENUE SERVICE
1950 BOLIN RD PO BOX 1300
NORTH AUGUSTA SC 29841-2215 CHARLOTTE NC 28201-1300

615202273 RX VILL 30 0 202212 430

 I Detach Here and Mail With Your Payment I
Calendar Year '
Department of the Treasury
Internal Revenue Service Due 01/17/2023 2022 Form 1040-ES Payment Voucher 4
File only if you are making a payment of estimated tax by check or money order. Mail this Amount of estimated tax
voucher with your check or money order payable to the 'United States Treasury.' Write your
social security number and ' 2022 Form 1040-ES' on your check or money order. Do not send you are paying by check
cash. Enclose, but do not staple or attach, your payment with this voucher. or money order . . . . . . . . . . G 680.
REV 04/09/22 INTUIT.CG.CFP.SP 1555

615-20-2273 458-37-2792
ERICA C VILLARREAL
BRYAN M VILLARREAL INTERNAL REVENUE SERVICE
1950 BOLIN RD PO BOX 1300
NORTH AUGUSTA SC 29841-2215 CHARLOTTE NC 28201-1300

615202273 RX VILL 30 0 202212 430

 1040 U.S. Individual Income Tax Return 2021 (99)
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 Single Married filing jointly Married filing separately (MFS) Head of household (HOH) Qualifying widow(er) (QW)
Check only If you checked the MFS box, enter the name of your spouse. If you checked the HOH or QW box, enter the child’s name if the qualifying
one box.
person is a child but not your dependent a
Your first name and middle initial Last name Your social security number
Erica c Villarreal 615-20-2273
If joint return, spouse’s first name and middle initial Last name Spouse’s social security number
bryan m Villarreal 458-37-2792
Home address (number and street). If you have a P.O. box, see instructions. Apt. no. Presidential Election Campaign
1950 Bolin Rd 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
North Augusta SC 298412215 box below will not change
Foreign country name Foreign province/state/county Foreign postal code your tax or refund.
You Spouse

At any time during 2021, did you receive, sell, exchange, or otherwise dispose of any financial interest in any virtual currency? Yes 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: Were born before January 2, 1957 Are blind Spouse: Was born before January 2, 1957 Is blind
Dependents (see instructions): (2) Social security (3) Relationship (4)  if qualifies for (see instructions):
(1) First name Last name number to you Child tax credit Credit for other dependents
If more
than four molly villarreal 443-25-1429 Daughter
dependents,
see instructions
clare villarreal 644-29-2599 Daughter
and check cal villarreal 373-99-8025 Son
here a
1 Wages, salaries, tips, etc. Attach Form(s) W-2 . . . . . . . . . . . . . . . . 1 54,317.
Attach 2a Tax-exempt interest . . . 2a 2b
b Taxable interest . . . . .
Sch. B if
3a Qualified dividends . . . 3a b Ordinary dividends . . . . . 3b
required.
4a IRA distributions . . . . 4a b Taxable amount . . . . . . 4b
5a Pensions and annuities . . 5a b Taxable amount . . . . . . 5b
Standard 6a Social security benefits . . 6a b Taxable amount . . . . . . 6b
Deduction for— a
7 Capital gain or (loss). Attach Schedule D if required. If not required, check here . . . . 7
• Single or
Married filing 8 Other income from Schedule 1, line 10 . . . . . . . . . . . . . . . . . . 8 0.
separately,
$12,550 9 Add lines 1, 2b, 3b, 4b, 5b, 6b, 7, and 8. This is your total income . . . . . . . . . a 9 54,317.
• Married filing 10 Adjustments to income from Schedule 1, line 26 . . . . . . . . . . . . . . . 10 11,193.
jointly or
11 Subtract line 10 from line 9. This is your adjusted gross income . . . . . . . . . a 11 43,124.
Qualifying
widow(er),
$25,100
12a Standard deduction or itemized deductions (from Schedule A) . . 12a 25,100.
• Head of b Charitable contributions if you take the standard deduction (see instructions) 12b 600.
household,
$18,800 c Add lines 12a and 12b . . . . . . . . . . . . . . . . . . . . . . . 12c 25,700.
• If you checked 13 Qualified business income deduction from Form 8995 or Form 8995-A . . . . . . . . . 13
any box under
Standard 14 Add lines 12c and 13 . . . . . . . . . . . . . . . . . . . . . . . 14 25,700.
Deduction,
see instructions.
15 Taxable income. Subtract line 14 from line 11. If zero or less, enter -0- . . . . . . . . . 15 17,424.

For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Form 1040 (2021)
Form 1040 (2021) Page 2
16 Tax (see instructions). Check if any from Form(s): 1 8814 2 4972 3 . . 16 1,743.
17 Amount from Schedule 2, line 3 . . . . . . . . . . . . . . . . . . . . 17
18 Add lines 16 and 17 . . . . . . . . . . . . . . . . . . . . . . . . 18 1,743.
19 Nonrefundable child tax credit or credit for other dependents from Schedule 8812 . . . . . 19
20 Amount from Schedule 3, line 8 . . . . . . . . . . . . . . . . . . . . 20 200.
21 Add lines 19 and 20 . . . . . . . . . . . . . . . . . . . . . . . . 21 200.
22 Subtract line 21 from line 18. If zero or less, enter -0- . . . . . . . . . . . . . . 22 1,543.
23 Other taxes, including self-employment tax, from Schedule 2, line 21 . . . . . . . . . 23 10,386.
24 Add lines 22 and 23. This is your total tax . . . . . . . . . . . . . . . . a 24 11,929.
25 Federal income tax withheld from:
a Form(s) W-2 . . . . . . . . . . . . . . . . . . 25a 4,710.
b Form(s) 1099 . . . . . . . . . . . . . . . . . . 25b
c Other forms (see instructions) . . . . . . . . . . . . . 25c
d Add lines 25a through 25c . . . . . . . . . . . . . . . . . . . . . . 25d 4,710.
26 2021 estimated tax payments and amount applied from 2020 return . . . . . . . . . . 26
If you have a
qualifying child, 27a Earned income credit (EIC) . . . . . . . . . . . . . .
No 27a
attach Sch. EIC.
Check here if you were born after January 1, 1998, and before
January 2, 2004, and you satisfy all the other requirements for
taxpayers who are at least age 18, to claim the EIC. See instructions a
b Nontaxable combat pay election . . . . 27b
c Prior year (2019) earned income . . . . 27c
28 Refundable child tax credit or additional child tax credit from Schedule 8812 28 4,500.
29 American opportunity credit from Form 8863, line 8 . . . . . . . 29
30 Recovery rebate credit. See instructions . . . . . . . . . . 30
31 Amount from Schedule 3, line 15 . . . . . . . . . . . . 31 0.
32 Add lines 27a and 28 through 31. These are your total other payments and refundable credits a 32 4,500.
33 Add lines 25d, 26, and 32. These are your total payments . . . . . . . . . . . a 33 9,210.
34 If line 33 is more than line 24, subtract line 24 from line 33. This is the amount you overpaid . . 34
Refund
35a Amount of line 34 you want refunded to you. If Form 8888 is attached, check here . . . a 35a
Direct deposit? ab Routing number X X X X X X X X X a c Type: Checking Savings
See instructions. a
d Account number X X X X X X X X X X X X X X X X X
36 Amount of line 34 you want applied to your 2022 estimated tax . . a 36
Amount 37 Amount you owe. Subtract line 33 from line 24. For details on how to pay, see instructions . a 37 2,719.
You Owe 38 Estimated tax penalty (see instructions) . . . . . . . . . a 38
Third Party Do you want to allow another person to discuss this return with the IRS? See
Designee instructions . . . . . . . . . . . . . . . . . . . . a Yes. Complete below. No
Designee’s Phone Personal identification
name a no. a number (PIN) a
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
F

Joint return? stay at home parent (see inst.) a

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.) a
associate pastor
Phone no. (405)269-9332 Email address
Preparer’s name Preparer’s signature Date PTIN Check if:
Paid Self-employed
Preparer
Firm’s name a Self-Prepared Phone no.
Use Only a a
Firm’s address Firm’s EIN
Go to www.irs.gov/Form1040 for instructions and the latest information. BAA REV 04/09/22 Intuit.cg.cfp.sp Form 1040 (2021)
SCHEDULE 1 OMB No. 1545-0074
Additional Income and Adjustments to Income
(Form 1040)
Department of the Treasury
a Attach to Form 1040, 1040-SR, or 1040-NR. 2021
Attachment
Internal Revenue Service a Go to www.irs.gov/Form1040 for instructions and the latest information. Sequence No. 01
Name(s) shown on Form 1040, 1040-SR, or 1040-NR Your social security number
Erica c & bryan m Villarreal 615-20-2273
Part I Additional Income
1 Taxable refunds, credits, or offsets of state and local income taxes . . . . . . . 1 0.
2a Alimony received . . . . . . . . . . . . . . . . . . . . . . . . . . . 2a
b Date of original divorce or separation agreement (see instructions) a
3 Business income or (loss). Attach Schedule C . . . . . . . . . . . . . . . 3
4 Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . . . . . . 4
5 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach
Schedule E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
6 Farm income or (loss). Attach Schedule F . . . . . . . . . . . . . . . . . 6
7 Unemployment compensation . . . . . . . . . . . . . . . . . . . . . . 7
8 Other income:
a Net operating loss . . . . . . . . . . . . . . . . . . 8a ( )
b Gambling income . . . . . . . . . . . . . . . . . . . 8b
c Cancellation of debt . . . . . . . . . . . . . . . . . . 8c
d Foreign earned income exclusion from Form 2555 . . . . . 8d ( )
e Taxable Health Savings Account distribution . . . . . . . . 8e
f Alaska Permanent Fund dividends . . . . . . . . . . . . 8f
g Jury duty pay . . . . . . . . . . . . . . . . . . . . 8g
h Prizes and awards . . . . . . . . . . . . . . . . . . 8h
i Activity not engaged in for profit income . . . . . . . . . 8i
j Stock options . . . . . . . . . . . . . . . . . . . . 8j
k 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 . . . . . . . . . . . . . . . . . . . . . . 8k
l Olympic and Paralympic medals and USOC prize money (see
instructions) . . . . . . . . . . . . . . . . . . . . . 8l
m Section 951(a) inclusion (see instructions) . . . . . . . . . 8m
n Section 951A(a) inclusion (see instructions) . . . . . . . . 8n
o Section 461(l) excess business loss adjustment . . . . . . . 8o
p Taxable distributions from an ABLE account (see instructions) . 8p
z Other income. List type and amount a
8z
9 Total other income. Add lines 8a through 8z . . . . . . . . . . . . . . . . 9
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) 2021
Schedule 1 (Form 1040) 2021 Page 2

Part II Adjustments to Income

11 Educator expenses . . . . . . . . . . . . . . . . . . . . . . . . . . 11
12 Certain business expenses of reservists, performing artists, and fee-basis government
officials. Attach Form 2106 . . . . . . . . . . . . . . . . . . . . . . . 12
13 Health savings account deduction. Attach Form 8889 . . . . . . . . . . . . 13
14 Moving expenses for members of the Armed Forces. Attach Form 3903 . . . . . 14
15 Deductible part of self-employment tax. Attach Schedule SE . . . . . . . . . 15 5,193.
16 Self-employed SEP, SIMPLE, and qualified plans . . . . . . . . . . . . . . 16
17 Self-employed health insurance deduction . . . . . . . . . . . . . . . . . 17
18 Penalty on early withdrawal of savings . . . . . . . . . . . . . . . . . . 18
19a Alimony paid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19a
b Recipient’s SSN . . . . . . . . . . . . . . . . . . . . a
c Date of original divorce or separation agreement (see instructions) a
20 IRA deduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 6,000.
21 Student loan interest deduction . . . . . . . . . . . . . . . . . . . . . 21
22 Reserved for future use . . . . . . . . . . . . . . . . . . . . . . . . 22
23 Archer MSA deduction . . . . . . . . . . . . . . . . . . . . . . . . . 23
24 Other adjustments:
a Jury duty pay (see instructions) . . . . . . . . . . . . . 24a
b Deductible expenses related to income reported on line 8k from
the rental of personal property engaged in for profit . . . . . 24b
c Nontaxable amount of the value of Olympic and Paralympic
medals and USOC prize money reported on line 8l . . . . . 24c
d Reforestation amortization and expenses . . . . . . . . . 24d
e Repayment of supplemental unemployment benefits under the
Trade Act of 1974 . . . . . . . . . . . . . . . . . . . 24e
f Contributions to section 501(c)(18)(D) pension plans . . . . . 24f
g Contributions by certain chaplains to section 403(b) plans . . 24g
h Attorney fees and court costs for actions involving certain
unlawful discrimination claims (see instructions) . . . . . . 24h
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
j Housing deduction from Form 2555 . . . . . . . . . . . 24j
k Excess deductions of section 67(e) expenses from Schedule K-1
(Form 1041) . . . . . . . . . . . . . . . . . . . . . 24k
z Other adjustments. List type and amount a
24z
25 Total other adjustments. Add lines 24a through 24z . . . . . . . . . . . . . 25
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 11,193.
BAA REV 04/09/22 Intuit.cg.cfp.sp Schedule 1 (Form 1040) 2021
SCHEDULE 2 OMB No. 1545-0074
Additional Taxes
(Form 1040)
Department of the Treasury
a Attach to Form 1040, 1040-SR, or 1040-NR. 2021
Attachment
Internal Revenue Service a Go to www.irs.gov/Form1040 for instructions and the latest information. Sequence No. 02
Name(s) shown on Form 1040, 1040-SR, or 1040-NR Your social security number
Erica c & bryan m Villarreal 615-20-2273
Part I Tax
1 Alternative minimum tax. Attach Form 6251 . . . . . . . . . . . . . . . . 1
2 Excess advance premium tax credit repayment. Attach Form 8962 . . . . . . . 2
3 Add lines 1 and 2. Enter here and on Form 1040, 1040-SR, or 1040-NR, line 17 . . 3
Part II Other Taxes
4 Self-employment tax. Attach Schedule SE . . . . . . . . . . . . . . . . . 4 10,386.
5 Social security and Medicare tax on unreported tip income.
Attach Form 4137 . . . . . . . . . . . . . . . . . . 5
6 Uncollected social security and Medicare tax on wages. Attach
Form 8919 . . . . . . . . . . . . . . . . . . . . . 6
7 Total additional social security and Medicare tax. Add lines 5 and 6 . . . . . . 7
8 Additional tax on IRAs or other tax-favored accounts. Attach Form 5329 if required 8
9 Household employment taxes. Attach Schedule H . . . . . . . . . . . . . 9
10 Repayment of first-time homebuyer credit. Attach Form 5405 if required . . . . . 10
11 Additional Medicare Tax. Attach Form 8959 . . . . . . . . . . . . . . . . 11
12 Net investment income tax. Attach Form 8960 . . . . . . . . . . . . . . . 12
13 Uncollected social security and Medicare or RRTA tax on tips or group-term life
insurance from Form W-2, box 12 . . . . . . . . . . . . . . . . . . . . 13
14 Interest on tax due on installment income from the sale of certain residential lots
and timeshares . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
15 Interest on the deferred tax on gain from certain installment sales with a sales price
over $150,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
16 Recapture of low-income housing credit. Attach Form 8611 . . . . . . . . . . 16
(continued on page 2)
For Paperwork Reduction Act Notice, see your tax return instructions. Schedule 2 (Form 1040) 2021
Schedule 2 (Form 1040) 2021 Page 2

Part II Other Taxes (continued)

17 Other additional taxes:
a Recapture of other credits. List type, form number, and
amount a 17a
b Recapture of federal mortgage subsidy. If you sold your home in
2021, see instructions . . . . . . . . . . . . . . . . . 17b
c Additional tax on HSA distributions. Attach Form 8889 . . . . 17c
d Additional tax on an HSA because you didn’t remain an eligible
individual. Attach Form 8889 . . . . . . . . . . . . . . 17d
e Additional tax on Archer MSA distributions. Attach Form 8853 . 17e
f Additional tax on Medicare Advantage MSA distributions. Attach
Form 8853 . . . . . . . . . . . . . . . . . . . . . 17f
g Recapture of a charitable contribution deduction related to a
fractional interest in tangible personal property . . . . . . . 17g
h Income you received from a nonqualified deferred compensation
plan that fails to meet the requirements of section 409A . . . 17h
i Compensation you received from a nonqualified deferred
compensation plan described in section 457A . . . . . . . 17i
j Section 72(m)(5) excess benefits tax . . . . . . . . . . . 17j
k Golden parachute payments . . . . . . . . . . . . . . 17k
l Tax on accumulation distribution of trusts . . . . . . . . . 17l
m Excise tax on insider stock compensation from an expatriated
corporation . . . . . . . . . . . . . . . . . . . . . 17m
n Look-back interest under section 167(g) or 460(b) from Form
8697 or 8866 . . . . . . . . . . . . . . . . . . . . 17n
o Tax on non-effectively connected income for any part of the
year you were a nonresident alien from Form 1040-NR . . . . 17o
p Any interest from Form 8621, line 16f, relating to distributions
from, and dispositions of, stock of a section 1291 fund . . . . 17p
q Any interest from Form 8621, line 24 . . . . . . . . . . . 17q
z Any other taxes. List type and amount a
17z
18 Total additional taxes. Add lines 17a through 17z . . . . . . . . . . . . . . 18
19 Additional tax from Schedule 8812 . . . . . . . . . . . . . . . . . . . . 19
20 Section 965 net tax liability installment from Form 965-A . . . 20
21 Add lines 4, 7 through 16, 18, and 19. These are your total other taxes. Enter here
and on Form 1040 or 1040-SR, line 23, or Form 1040-NR, line 23b . . . . . . . 21 10,386.
BAA REV 04/09/22 Intuit.cg.cfp.sp Schedule 2 (Form 1040) 2021
SCHEDULE 3 OMB No. 1545-0074
Additional Credits and Payments
(Form 1040)
Department of the Treasury
a Attach to Form 1040, 1040-SR, or 1040-NR. 2021
Attachment
Internal Revenue Service a Go to www.irs.gov/Form1040 for instructions and the latest information. Sequence No. 03
Name(s) shown on Form 1040, 1040-SR, or 1040-NR Your social security number
Erica c & bryan m Villarreal 615-20-2273
Part I Nonrefundable Credits
1 Foreign tax credit. Attach Form 1116 if required . . . . . . . . . . . . . . 1
2 Credit for child and dependent care expenses from Form 2441, line 11. Attach
Form 2441 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Education credits from Form 8863, line 19 . . . . . . . . . . . . . . . . . 3
4 Retirement savings contributions credit. Attach Form 8880 . . . . . . . . . . 4 200.
5 Residential energy credits. Attach Form 5695 . . . . . . . . . . . . . . . 5
6 Other nonrefundable credits:
a General business credit. Attach Form 3800 . . . . . . . . 6a
b Credit for prior year minimum tax. Attach Form 8801 . . . . 6b
c Adoption credit. Attach Form 8839 . . . . . . . . . . . . 6c
d Credit for the elderly or disabled. Attach Schedule R . . . . . 6d
e Alternative motor vehicle credit. Attach Form 8910 . . . . . 6e
f Qualified plug-in motor vehicle credit. Attach Form 8936 . . . 6f
g Mortgage interest credit. Attach Form 8396 . . . . . . . . 6g
h District of Columbia first-time homebuyer credit. Attach Form 8859 6h
i Qualified electric vehicle credit. Attach Form 8834 . . . . . 6i
j Alternative fuel vehicle refueling property credit. Attach Form 8911 6j
k Credit to holders of tax credit bonds. Attach Form 8912 . . . 6k
l Amount on Form 8978, line 14. See instructions . . . . . . 6l
z Other nonrefundable credits. List type and amount a
6z
7 Total other nonrefundable credits. Add lines 6a through 6z . . . . . . . . . . 7
8 Add lines 1 through 5 and 7. Enter here and on Form 1040, 1040-SR, or 1040-NR,
line 20 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 200.
(continued on page 2)
For Paperwork Reduction Act Notice, see your tax return instructions. BAA REV 04/09/22 Intuit.cg.cfp.sp Schedule 3 (Form 1040) 2021
Schedule 3 (Form 1040) 2021 Page 2

Part II Other Payments and Refundable Credits

9 Net premium tax credit. Attach Form 8962 . . . . . . . . . . . . . . . . . 9
10 Amount paid with request for extension to file (see instructions) . . . . . . . . 10
11 Excess social security and tier 1 RRTA tax withheld . . . . . . . . . . . . . 11
12 Credit for federal tax on fuels. Attach Form 4136 . . . . . . . . . . . . . . 12
13 Other payments or refundable credits:
a Form 2439 . . . . . . . . . . . . . . . . . . . . . 13a
b Qualified sick and family leave credits from Schedule(s) H and
Form(s) 7202 for leave taken before April 1, 2021 . . . . . . 13b
c Health coverage tax credit from Form 8885 . . . . . . . . 13c
d Credit for repayment of amounts included in income from earlier
years . . . . . . . . . . . . . . . . . . . . . . . . 13d
e Reserved for future use . . . . . . . . . . . . . . . . 13e
f Deferred amount of net 965 tax liability (see instructions) . . . 13f
g Credit for child and dependent care expenses from Form 2441,
line 10. Attach Form 2441 . . . . . . . . . . . . . . . 13g
h Qualified sick and family leave credits from Schedule(s) H and
Form(s) 7202 for leave taken after March 31, 2021 . . . . . 13h 0.
z Other payments or refundable credits. List type and amount a
13z
14 Total other payments or refundable credits. Add lines 13a through 13z . . . . . 14 0.
15 Add lines 9 through 12 and 14. Enter here and on Form 1040, 1040-SR, or 1040-NR,
line 31 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 0.
BAA REV 04/09/22 Intuit.cg.cfp.sp Schedule 3 (Form 1040) 2021
SCHEDULE SE
Self-Employment Tax
OMB No. 1545-0074

2021
(Form 1040)
a Go to www.irs.gov/ScheduleSE for instructions and the latest information.
Department of the Treasury Attachment
Sequence No. 17
a Attach to Form 1040, 1040-SR, or 1040-NR.
Internal Revenue Service (99)
Name of person with self-employment income (as shown on Form 1040, 1040-SR, or 1040-NR) Social security number of person
bryan m Villarreal with self-employment income a 458-37-2792
Part I Self-Employment Tax
Note: If your only income subject to self-employment tax is church employee income, see instructions for how to report your income
and the definition of church employee income.
A If you are a minister, member of a religious order, or Christian Science practitioner and you filed Form 4361, but you had
$400 or more of other net earnings from self-employment, check here and continue with Part I . . . . . . . . a
Skip lines 1a and 1b if you use the farm optional method in Part II. See instructions.
1a Net farm profit or (loss) from Schedule F, line 34, and farm partnerships, Schedule K-1 (Form 1065),
box 14, code A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1a
b If you received social security retirement or disability benefits, enter the amount of Conservation Reserve
Program payments included on Schedule F, line 4b, or listed on Schedule K-1 (Form 1065), box 20, code AH 1b ( )
Skip line 2 if you use the nonfarm optional method in Part II. See instructions.
2 Net profit or (loss) from Schedule C, line 31; and Schedule K-1 (Form 1065), box 14, code A (other than
farming). See instructions for other income to report or if you are a minister or member of a religious order 2 73,505.
3 Combine lines 1a, 1b, and 2 . . . . . . . . . . . . . . . . . . . . . . . . . 3 73,505.
4a If line 3 is more than zero, multiply line 3 by 92.35% (0.9235). Otherwise, enter amount from line 3 . 4a 67,882.
Note: If line 4a is less than $400 due to Conservation Reserve Program payments on line 1b, see instructions.
b If you elect one or both of the optional methods, enter the total of lines 15 and 17 here . . . . . 4b
c Combine lines 4a and 4b. If less than $400, stop; you don’t owe self-employment tax. Exception: If
less than $400 and you had church employee income, enter -0- and continue . . . . . . . a 4c 67,882.
5a Enter your church employee income from Form W-2. See instructions for
definition of church employee income . . . . . . . . . . . . . 5a
b Multiply line 5a by 92.35% (0.9235). If less than $100, enter -0- . . . . . . . . . . . . . 5b 0.
6 Add lines 4c and 5b . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 67,882.
7 Maximum amount of combined wages and self-employment earnings subject to social security tax or
the 6.2% portion of the 7.65% railroad retirement (tier 1) tax for 2021 . . . . . . . . . . . 7 142,800
8a Total social security wages and tips (total of boxes 3 and 7 on Form(s) W-2)
and railroad retirement (tier 1) compensation. If $142,800 or more, skip lines
8b through 10, and go to line 11 . . . . . . . . . . . . . . . 8a 0.
b Unreported tips subject to social security tax from Form 4137, line 10 . . . 8b
c Wages subject to social security tax from Form 8919, line 10 . . . . . . 8c
d Add lines 8a, 8b, and 8c . . . . . . . . . . . . . . . . . . . . . . . . . . 8d 0.
9 Subtract line 8d from line 7. If zero or less, enter -0- here and on line 10 and go to line 11 . . . a 9 142,800.
10 Multiply the smaller of line 6 or line 9 by 12.4% (0.124) . . . . . . . . . . . . . . . . 10 8,417.
11 Multiply line 6 by 2.9% (0.029) . . . . . . . . . . . . . . . . . . . . . . . . 11 1,969.
12 Self-employment tax. Add lines 10 and 11. Enter here and on Schedule 2 (Form 1040), line 4 . . 12 10,386.
13 Deduction for one-half of self-employment tax.
Multiply line 12 by 50% (0.50). Enter here and on Schedule 1 (Form 1040),
line 15 . . . . . . . . . . . . . . . . . . . . . . . . 13 5,193.
Part II Optional Methods To Figure Net Earnings (see instructions)
Farm Optional Method. You may use this method only if (a) your gross farm income1 wasn’t more than
$8,820, or (b) your net farm profits2 were less than $6,367.
14 Maximum income for optional methods . . . . . . . . . . . . . . . . . . . . . 14 5,880
15 Enter the smaller of: two-thirds (2/3) of gross farm income1 (not less than zero) or $5,880. Also, include
this amount on line 4b above . . . . . . . . . . . . . . . . . . . . . . . . 15
Nonfarm Optional Method. You may use this method only if (a) your net nonfarm profits3 were less than $6,367
and also less than 72.189% of your gross nonfarm income,4 and (b) you had net earnings from self-employment
of at least $400 in 2 of the prior 3 years. Caution: You may use this method no more than five times.
16 Subtract line 15 from line 14 . . . . . . . . . . . . . . . . . . . . . . . . . 16
17 Enter the smaller of: two-thirds (2/3) of gross nonfarm income4 (not less than zero) or the amount on
line 16. Also, include this amount on line 4b above . . . . . . . . . . . . . . . . . 17
1 3
From Sch. F, line 9; and Sch. K-1 (Form 1065), box 14, code B. From Sch. C, line 31; and Sch. K-1 (Form 1065), box 14, code A.
2 4
From Sch. F, line 34; and Sch. K-1 (Form 1065), box 14, code A—minus the amount From Sch. C, line 7; and Sch. K-1 (Form 1065), box 14, code C.
you would have entered on line 1b had you not used the optional method.
For Paperwork Reduction Act Notice, see your tax return instructions. BAA REV 04/09/22 Intuit.cg.cfp.sp Schedule SE (Form 1040) 2021
SCHEDULE 8812 Credits for Qualifying Children `
OMB No. 1545-0074
(Form 1040) . .1040
and Other Dependents .......

a Attach to Form 1040, 1040-SR, or 1040-NR.

1040-SR
.........
1040-NR 2021
Department of the Treasury 8812 Attachment
Internal Revenue Service (99) a Go to www.irs.gov/Schedule8812 for instructions and the latest information. Sequence No. 47

Name(s) shown on return Your social security number

Erica c & bryan m Villarreal 615-20-2273
Part I-A Child Tax Credit and Credit for Other Dependents
1 Enter the amount from line 11 of your Form 1040, 1040-SR, or 1040-NR . . . . . . . . . . . . 1 43,124.
2a Enter income from Puerto Rico that you excluded . . . . . . . . . . . 2a
b Enter the amounts from lines 45 and 50 of your Form 2555 . . . . . . . . 2b 0.
c Enter the amount from line 15 of your Form 4563 . . . . . . . . . . . 2c
d Add lines 2a through 2c . . . . . . . . . . . . . . . . . . . . . . . . . . . 2d 0.
3 Add lines 1 and 2d . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 43,124.
4a Number of qualifying children under age 18 with the required social security number 4a 3.
b Number of children included on line 4a who were under age 6 at the end of 2021 . . 4b 0.
c Subtract line 4b from line 4a . . . . . . . . . . . . . . . . . 4c 3.
5 If line 4a is more than zero, enter the amount from the Line 5 Worksheet; otherwise, enter -0- . . . . . . 5 9,000.
6 Number of other dependents, including any qualifying children who are not under age
18 or who do not have the required social security number . . . . . . . . 6 0.
Caution: Do not include yourself, your spouse, or anyone who is not a U.S. citizen, U.S. national, or U.S. resident
alien. Also, do not include anyone you included on line 4a.
7 Multiply line 6 by $500 . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
8 Add lines 5 and 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 9,000.
9 Enter the amount shown below for your filing status.
• Married filing jointly—$400,000
• All other filing statuses—$200,000 }
. . . . . . . . . . . . . . . . . . . . . . 9 400,000.
10 Subtract line 9 from line 3.

}
• If zero or less, enter -0-.
• If more than zero and not a multiple of $1,000, enter the next multiple of $1,000. For
example, if the result is $425, enter $1,000; if the result is $1,025, enter $2,000, etc. . . . . . . . 10 0.
11 Multiply line 10 by 5% (0.05) . . . . . . . . . . . . . . . . . . . . . . . . . 11 0.
12 Subtract line 11 from line 8. If zero or less, enter -0- . . . . . . . . . . . . . . . . . . 12 9,000.
13 Check all the boxes that apply to you (or your spouse if married filing jointly).
A Check here if you (or your spouse if married filing jointly) had a principal place of abode in the United States
for more than half of 2021 . . . . . . . . . . . . . . . . . . . . . . . .
B Check here if you (or your spouse if married filing jointly) were a bona fide resident of Puerto Rico for 2021
Part I-B Filers Who Check a Box on Line 13
Caution: If you did not check a box on line 13, do not complete Part I-B; instead, skip to Part I-C.
14a Enter the smaller of line 7 or line 12 . . . . . . . . . . . . . . . . . . . . . . . 14a 0.
b Subtract line 14a from line 12 . . . . . . . . . . . . . . . . . . . . . . . . . 14b 9,000.
c If line 14a is zero, enter -0-; otherwise, enter the amount from the Credit Limit Worksheet A . . . . . . 14c 0.
d Enter the smaller of line 14a or line 14c . . . . . . . . . . . . . . . . . . . . . . 14d 0.
e Add lines 14b and 14d . . . . . . . . . . . . . . . . . . . . . . . . . . . 14e 9,000.
f Enter the aggregate amount of advance child tax credit payments you (and your spouse if filing jointly) received
for 2021. See your Letter(s) 6419 for the amounts to include on this line. If you are missing Letter 6419, see the
instructions before entering an amount on this line. If you didn’t receive any advance child tax credit payments
for 2021, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14f 4,500.
Caution: If the amount on this line doesn’t match the aggregate amounts reported to you (and your spouse if
filing jointly) on your Letter(s) 6419, the processing of your return will be delayed.
g Subtract line 14f from line 14e. If zero or less, enter -0- on lines 14g through 14i and go to Part III . . . . 14g 4,500.
h Enter the smaller of line 14d or line 14g. This is your credit for other dependents. Enter this amount on line
19 of your Form 1040, 1040-SR, or 1040-NR . . . . . . . . . . . . . . . . . . . . 14h 0.
i Subtract line 14h from line 14g. This is your refundable child tax credit. Enter this amount on line 28 of
your Form 1040, 1040-SR, or 1040-NR . . . . . . . . . . . . . . . . . . . . . . 14i 4,500.
For Paperwork Reduction Act Notice, see your tax return instructions. BAA REV 04/09/22 Intuit.cg.cfp.sp Schedule 8812 (Form 1040) 2021
Schedule 8812 (Form 1040) 2021 Page 2
Part I-C Filers Who Do Not Check a Box on Line 13
Caution: If you checked a box on line 13, do not complete Part I-C.
15a Enter the amount from the Credit Limit Worksheet A . . . . . . . . . . . . . . . . . 15a
b Enter the smaller of line 12 or line 15a . . . . . . . . . . . . . . . . . . . . . . 15b
Additional child tax credit. Complete Parts II-A through II-C if you meet each of the following items.
1. You are not filing Form 2555.
2. Line 4a is more than zero.
3. Line 12 is more than line 15a.
c If you completed Parts II-A through II-C, enter the amount from line 27; otherwise, enter -0- . . . . . . 15c
d Add lines 15b and 15c . . . . . . . . . . . . . . . . . . . . . . . . . . . 15d
e Enter the aggregate amount of advance child tax credit payments you (and your spouse if filing jointly) received
for 2021. See your Letter(s) 6419 for the amounts to include on this line. If you are missing Letter 6419, see the
instructions before entering an amount on this line. If you didn’t receive any advance child tax credit payments
for 2021, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15e
Caution: If the amount on this line doesn’t match the aggregate amounts reported to you (and your spouse if
filing jointly) on your Letter(s) 6419, the processing of your return will be delayed.
f Subtract line 15e from line 15d. If zero or less, enter -0- on lines 15f through 15h and go to Part III . . . . 15f
g Enter the smaller of line 15b or line 15f. This is your nonrefundable child tax credit and credit for other
dependents. Enter this amount on line 19 of your Form 1040, 1040-SR, or 1040-NR . . . . . . . . 15g
h Subtract line 15g from line 15f. This is your additional child tax credit. Enter this amount on line 28 of your
Form 1040, 1040-SR, or 1040-NR . . . . . . . . . . . . . . . . . . . . . . . 15h
Part II-A Additional Child Tax Credit (use only if completing Part I-C)
Caution: If you file Form 2555, do not complete Parts II-A through II-C; you cannot claim the additional child tax credit.
Caution: If you checked a box on line 13, do not complete Parts II-A through II-C; you cannot claim the additional child tax credit.
16a Subtract line 15b from line 12. If zero, skip Parts II-A and II-B and enter -0- on line 27 . . . . . . . . 16a
b Number of qualifying children under 18 with the required social security number: x $1,400.
Enter the result. If zero, skip Parts II-A and II-B and enter -0- on line 27 . . . . . . . . . . . . 16b
TIP: The number of children you use for this line is the same as the number of children you used for line 4a.
17 Enter the smaller of line 16a or line 16b . . . . . . . . . . . . . . . . . . . . . . 17
18a Earned income (see instructions) . . . . . . . . . . . . . . . . 18a
b Nontaxable combat pay (see instructions) . . . . . . 18b
19 Is the amount on line 18a more than $2,500?
No. Leave line 19 blank and enter -0- on line 20.
Yes. Subtract $2,500 from the amount on line 18a. Enter the result . . . . 19
20 Multiply the amount on line 19 by 15% (0.15) and enter the result . . . . . . . . . . . . . . 20
Next. On line 16b, is the amount $4,200 or more?
No. If line 20 is zero, enter -0- on line 15c. Otherwise, skip Part II-B and enter the smaller of line 17 or line
20 on line 27.
Yes. If line 20 is equal to or more than line 17, skip Part II-B and enter the amount from line 17 on line 27.
Otherwise, go to line 21.
Part II-B Certain Filers Who Have Three or More Qualifying Children
21 Withheld social security, Medicare, and Additional Medicare taxes from Form(s) W-2,
boxes 4 and 6. If married filing jointly, include your spouse’s amounts with yours. If
your employer withheld or you paid Additional Medicare Tax or tier 1 RRTA taxes, see
instructions . . . . . . . . . . . . . . . . . . . . . . 21
22 Enter the total of the amounts from Schedule 1 (Form 1040), line 15; Schedule 2 (Form
1040), line 5; Schedule 2 (Form 1040), line 6; and Schedule 2 (Form 1040), line 13 . 22
23 Add lines 21 and 22 . . . . . . . . . . . . . . . . . . . . 23
24 1040 and

}
1040-SR filers: Enter the total of the amounts from Form 1040 or 1040-SR, line 27a,
and Schedule 3 (Form 1040), line 11.
1040-NR filers: Enter the amount from Schedule 3 (Form 1040), line 11. 24
25 Subtract line 24 from line 23. If zero or less, enter -0- . . . . . . . . . . . . . . . . . . 25
26 Enter the larger of line 20 or line 25 . . . . . . . . . . . . . . . . . . . . . . . 26
Next, enter the smaller of line 17 or line 26 on line 27.
Part II-C Additional Child Tax Credit
27 Enter this amount on line 15c . . . . . . . . . . . . . . . . . . . . . . . . . 27
REV 04/09/22 Intuit.cg.cfp.sp Schedule 8812 (Form 1040) 2021
BAA
Schedule 8812 (Form 1040) 2021 Page 3
Part III Additional Tax (use only if line 14g or line 15f, whichever applies, is zero)
28a Enter the amount from line 14f or line 15e, whichever applies . . . . . . . . . . . . . . . 28a
b Enter the amount from line 14e or line 15d, whichever applies . . . . . . . . . . . . . . . 28b
29 Excess advance child tax credit payments. Subtract line 28b from line 28a. If zero, stop; you do not owe the
additional tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
30 Enter the number of qualifying children taken into account in determining the annual advance amount you
received for 2021. See your Letter 6419 for this number. If you are missing your Letter 6419, you are filing a joint
return, or you received more than one Letter 6419, see the instructions before entering a number on this line . . 30
Caution: If the amount on this line doesn’t match the number of qualifying children reported to you (and your
spouse if filing jointly) on your Letter(s) 6419, the processing of your return will be delayed.
31 Enter the smaller of line 4a or line 30 . . . . . . . . . . . . . . . . . . . . . . . 31
32 Subtract line 31 from line 30. If zero, skip to line 40 and enter the amount from line 29; otherwise, continue to
line 33 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
33 Enter the amount shown below for your filing status.

}
• Married filing jointly or Qualifying widow(er)—$60,000
• Head of household—$50,000
• All other filing statuses—$40,000 . . . . . . . . . . . . . . . 33
34 Subtract line 33 from line 3. If zero or less, enter -0- . . . . . . . . . . . . . . . . . . 34
35 Enter the amount from line 33 . . . . . . . . . . . . . . . . . . . . . . . . . 35
36 Divide line 34 by line 35. Enter the result as a decimal (rounded to at least three places). If the result is 1.000 or
more, enter 1.000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
37 Multiply line 32 by $2,000 . . . . . . . . . . . . . . . . . . . . . . . . . . 37
38 Multiply line 37 by line 36 . . . . . . . . . . . . . . . . . . . . . . . . . . 38
39 Subtract line 38 from line 37 . . . . . . . . . . . . . . . . . . . . . . . . . 39
40 Subtract line 39 from line 29. If zero or less, enter -0-. This is your additional tax. If more than zero, enter
this amount on Schedule 2 (Form 1040), line 19 . . . . . . . . . . . . . . . . . . . 40
BAA REV 04/09/22 Intuit.cg.cfp.sp Schedule 8812 (Form 1040) 2021
Form 8880 Credit for Qualified Retirement Savings Contributions OMB No. 1545-0074

2021
a Attach to Form 1040, 1040-SR, or 1040-NR.
Department of the Treasury Attachment
Internal Revenue Service a Go to www.irs.gov/Form8880 for the latest information. Sequence No. 54
Name(s) shown on return Your social security number
Erica c & bryan m Villarreal 615-20-2273
You cannot take this credit if either of the following applies.

F
!
CAUTION
• The amount on Form 1040, 1040-SR, or 1040-NR, line 11, is more than $33,000 ($49,500 if head of household; $66,000 if
married filing jointly).
• The person(s) who made the qualified contribution or elective deferral (a) was born after January 1, 2004; (b) is claimed as a
dependent on someone else’s 2021 tax return; or (c) was a student (see instructions).
(a) You (b) Your spouse
1 Traditional and Roth IRA contributions, and ABLE account contributions by the
designated beneficiary for 2021. Do not include rollover contributions . . . . . 1 6,000.
2 Elective deferrals to a 401(k) or other qualified employer plan, voluntary employee
contributions, and 501(c)(18)(D) plan contributions for 2021 (see instructions) . . 2
3 Add lines 1 and 2 . . . . . . . . . . . . . . . . . . . . . . 3 6,000.
4 Certain distributions received after 2018 and before the due date (including
extensions) of your 2021 tax return (see instructions). If married filing jointly, include
both spouses’ amounts in both columns. See instructions for an exception . . . 4
5 Subtract line 4 from line 3. If zero or less, enter -0- . . . . . . . . . . . 5 6,000.
6 In each column, enter the smaller of line 5 or $2,000 . . . . . . . . . . 6 2,000.
7 Add the amounts on line 6. If zero, stop; you can’t take this credit . . . . . . . . . . . . 7 2,000.
8 Enter the amount from Form 1040, 1040-SR, or 1040-NR, line 11* . . . . 8 43,124.
9 Enter the applicable decimal amount from the table below.

If line 8 is— And your filing status is—

Married Head of Single, Married filing
But not
Over— filing jointly household separately, or
over—
Enter on line 9— Qualifying widow(er)
--- $19,750 0.5 0.5 0.5
$19,750 $21,500 0.5 0.5 0.2
$21,500 $29,625 0.5 0.5 0.1 9 x0 .1
$29,625 $32,250 0.5 0.2 0.1
$32,250 $33,000 0.5 0.1 0.1
$33,000 $39,500 0.5 0.1 0.0
$39,500 $43,000 0.2 0.1 0.0
$43,000 $49,500 0.1 0.1 0.0
$49,500 $66,000 0.1 0.0 0.0
$66,000 --- 0.0 0.0 0.0
Note: If line 9 is zero, stop; you can’t take this credit.
10 Multiply line 7 by line 9 . . . . . . . . . . . . . . . . . . . . . . . . . . 10 200.
11 Limitation based on tax liability. Enter the amount from the Credit Limit Worksheet in the instructions 11 1,743.
12 Credit for qualified retirement savings contributions. Enter the smaller of line 10 or line 11 here
and on Schedule 3 (Form 1040), line 4 . . . . . . . . . . . . . . . . . . . . . 12 200.

* See Pub. 590-A for the amount to enter if you claim any exclusion or deduction for foreign earned income, foreign housing, or income from
Puerto Rico or for bona fide residents of American Samoa.
For Paperwork Reduction Act Notice, see your tax return instructions. REV 04/09/22 Intuit.cg.cfp.sp Form 8880 (2021)
BAA
 1555 STATE OF SOUTH CAROLINA
DEPARTMENT OF REVENUE SC8453
REV 04/13/22 Intuit.cg.cfp.sp
INDIVIDUAL INCOME TAX (Rev. 10/7/21)
dor.sc.gov DECLARATION FOR ELECTRONIC FILING 3299
First name and middle initial Last name Your social security number
ERICA C VILLARREAL 615-20-2273
Spouse's first name, if married filing jointly Last name Spouse's social security number
Print or
BRYAN M VILLARREAL 458-37-2792
type. Mailing address (number and street, PO Box) Daytime phone number
1950 BOLIN RD (405)269-9332
City State ZIP Tax Year
NORTH AUGUSTA SC 29841-2215 2021
Part I Information from your SC1040, Individual Income Tax Return
1. Federal taxable income (line 1 of your SC1040) ........................................................................... 1 17,424 00
2. SC tax (line 15 of your SC1040) ............................................................................................... 2 0 00
3. Use Tax (line 26 of your SC1040)............................................................................................. 3 0 00
4. Total Tax (add line 2 and line 3 ................................................................................................ 4 0 00
5. SC Income Tax Withheld (add line 16 and line 20 of your SC1040) ................................................ 5 00
6. Refundable credits (add line 21 and line 22 of your SC1040) ......................................................... 6 00
7. Refund (line 30 of your SC1040) .............................................................................................. 7 00
8. Balance due (line 34 of your SC1040) ...................................................................................... 8 0 00
Part II Bank information for Refund or Balance Due
Must be 9 digits. The first two numbers of the
9. Routing number (RTN) RTN must be 01 through 12 or 21 through 32.

10. Bank account number (BAN) 1-17 digits

11. Type of account: Checking Savings

For Balance Due:
12. Payment Withdrawal Date Payment Withdrawal Amount $
Part III Declaration of taxpayer
13. a. I consent for my refund to be directly deposited as designated in Part II. I declare that the information on line 1 through line 8 is correct. If I
filed a joint return, this is an irrevocable appointment of my spouse as an agent to receive the refund.
b. I authorize the South Carolina Department of Revenue (SCDOR) and its designated agents to initiate an ACH Debit request to my bank
account, provided in Part II, for payment of the South Carolina taxes I owe. I authorize my bank to debit my account for the requested
funds and consent to the sharing of financial information between institutions for the purpose of resolving issues related to my payment.

If the SCDOR does not receive full and timely payment of my tax liability, I understand that I am responsible for the balance due, including all penalties
and interest.
I declare that this return and all attachments are true, correct, and complete to the best of my knowledge. This declaration is based on all information of
which the preparer has any knowledge.
Do not submit a copy of this form to the SCDOR. Return the signed copy to your paid preparer. Keep a copy with your tax records.

Your signature Date Spouse's signature (If married filing jointly, BOTH must sign) Date
Part IV Declaration of Electronic Return Originator (ERO) and Paid Preparer
I declare that I have received the above taxpayer's return and the information is complete and accurate to the best of my knowledge. I have obtained the
taxpayer's signature on this form before submitting the SC1040 to the SCDOR. I have provided the taxpayer with a copy of all forms and information to
be filed with the IRS and the SCDOR and have followed all other requirements described in the IRS Pub. 1345 Authorized IRS e file Providers of
Individual Income Tax Returns, and requirements specified by the SCDOR. If I am the preparer, I declare that I have examined the above taxpayer's
return and accompanying schedules and statements, and to the best of my knowledge,they are true and complete. This declaration is based on all
information of which I have knowledge. I understand I do not mail the SC8453 to the SCDOR. I am required to keep the SC8453 and the
supporting documents for three years.
Date Check if Check if PTIN
ERO's ERO also paid self-
signature preparer employed
Use Firm name (or FEIN
Only yours if self-employed),
address, ZIP Phone

Paid Preparer
Date Check PTIN
if self-
Preparer's signature employed
Use Firm name (or FEIN
yours if self-employed),
Only address, ZIP Phone
 1555

STATE OF SOUTH CAROLINA SC1040

DEPARTMENT OF REVENUE (Rev. 8/11/21)
dor.sc.gov 2021 INDIVIDUAL INCOME TAX RETURN 3075

Your Social Security Number

Check if
deceased
615 20 2273
Spouse's Social Security Number
Check if
deceased
458 37 2792

For the year January 1 - December 31, 2021, or fiscal tax year beginning __________, 2021 and ending __________, 2022
First name and middle initial Last name Suffix
Erica C Villarreal
Spouse's first name, if married filing jointly Last name Suffix
bryan M Villarreal
Check if Mailing address (number and street, PO Box) County code
new address 1950 Bolin Rd 02
City State ZIP Daytime phone number with area code
North Augusta SC 29841-2215 (405)269-9332
Check if address Foreign country address including postal code
is outside US

• Amended Return: Check if this is an Amended Return. (Attach Schedule AMD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

• Check this box if you are a part-year or nonresident filing an SC Schedule NR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Check this box only if you are filing a composite return on behalf of a Partnership or
S Corporation. Do not check this box if you are an individual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Check this box if you have filed a federal or state extension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Check this box if you served in a military combat zone during the filing period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Name of the combat zone: _________________________________

CHECK YOUR (1) Single (3) Married filing separately - enter spouse's SSN: __________________
FEDERAL FILING STATUS (2) Married filing jointly (4) Head of household (5) Qualifying widow(er)

Number of dependents claimed on your 2021 federal return . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Number of dependents claimed that were under the age of 6 years as of December 31, 2021 . . . . . . . . .
Number of taxpayers age 65 or older as of December 31, 2021 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DEPENDENTS
First name Last name Social Security Number Relationship Date of birth (MM/DD/YYYY)
molly villarreal 443-25-1429 Daughter 08/19/2008
clare villarreal 644-29-2599 Daughter 03/23/2011
cal villarreal 373-99-8025 Son 08/23/2013

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 Page 2 of 3

INCOME AND ADJUSTMENTS Your SSN _____________

615-20-2273 2021
1 Enter federal taxable income from your federal form. If zero or less, enter zero here Dollars
Nonresident filers: complete Schedule NR and enter total from line 48 on line 5 below . . . . . . . . . . . 1 17,424 00
ADDITIONS TO FEDERAL TAXABLE INCOME
a State tax addback, if itemizing on federal return (see instructions) . . . . . . . a 00
b Out-of-state losses Type: _________________ . . . . . . . . . . . . . . . . . . . . b 00
c Expenses related to National Guard and Military Reserve Income . . . . . . . c 00
d Interest income on obligations of states and political subdivisions other than South Carolina d 00
e Other additions to income (attach explanation - see instructions) . . . . . . . . e 600 00
2 Total additions (add line a through line e) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 600 00
3 Add line 1 and line 2 and enter the total here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 18,024 00
SUBTRACTIONS FROM FEDERAL TAXABLE INCOME
f State tax refund, if included on your federal return . . . . . . . . . . . . . . . . . . . . f 0 00
g Total and permanent disability retirement income, if taxed on your federal return g 00
h Out-of-state income/gain (do not include personal service income)
Check type of income/gain: Rental Business Other ___________ h 00
i 44% of net capital gains held for more than one year. . . . . . . . . . . . . . . . . . i 00
j Volunteer deductions (see instructions) Type: _____________________ j 00
k Contributions to the SC College Investment Program (Future Scholar)
or the SC Tuition Prepayment Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . k 00
l Active Trade or Business Income deduction (see instructions) . . . . . . . . . . l 00
m Interest income from obligations of the US government . . . . . . . . . . . . . . . . m 00
n Certain nontaxable National Guard or Reserve pay . . . . . . . . . . . . . . . . . . . n 00
o Social Security and/or railroad retirement, if taxed on your federal return . . o 00
p Retirement Deduction (see instructions)
p-1 Taxpayer (date of birth: _____________) . . . . . . . . . . . . . . . . . . . . . . . p-1 00
p-2 Spouse (date of birth: _____________) . . . . . . . . . . . . . . . . . . . . . . . . p-2 00
p-3 Surviving spouse (date of birth of deceased spouse: _____________) p-3 00
Military Retirement Deduction (see instructions)
p-4 Taxpayer (date of birth: _____________) . . . . . . . . . . . . . . . . . . . . . . . p-4 00
p-5 Spouse (date of birth: _____________) . . . . . . . . . . . . . . . . . . . . . . . . p-5 00
p-6 Surviving spouse (date of birth of deceased spouse: _____________) p-6 00
q Age 65 and older deduction (see instructions)
q-1 Taxpayer (date of birth: _____________) . . . . . . . . . . . . . . . . . . . . . . . q-1 00
q-2 Spouse (date of birth: _____________) . . . . . . . . . . . . . . . . . . . . . . . . q-2 00
r Negative amount of federal taxable income . . . . . . . . . . . . . . . . . . . . . . . . . r 00
s Subsistence allowance (multiply ______ days by $8) . . . . . . . . . . . . . . . . . s 00
t Dependents under the age of 6 years on December 31 of the tax year . . . . t 00
u Consumer Protection Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . u 00
v Other subtractions (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v 00
w South Carolina Dependent Exemption (see instructions) . . . . . . . . . . . . . . . w 12,900 00
4 Total subtractions (add line f through line w) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 < 12,900 00 >
5 Residents: subtract line 4 from line 3 and enter the difference. Nonresidents: enter amount from Schedule NR,
line 48. If less than zero, enter zero here. This is your SOUTH CAROLINA INCOME SUBJECT TO TAX 5 5,124 00
6 TAX on your South Carolina Income Subject to Tax (see SC1040TT) . . . . . . . 6 60 00
7 TAX on Lump Sum Distribution (attach SC4972) . . . . . . . . . . . . . . . . . . . . . . . 7 00
8 TAX on Active Trade or Business Income (attach I-335) . . . . . . . . . . . . . . . . . 8 00
9 TAX on excess withdrawals from Catastrophe Savings Accounts . . . . . . . . . . 9 00
10 Add line 6 through line 9 and enter the total here. This is your TOTAL SOUTH CAROLINA TAX . . . . . . . 10 60 00

30752216 REV 04/13/22 Intuit.cg.cfp.sp

 Page 3 of 3
615-20-2273
Your SSN _____________ 2021
NON-REFUNDABLE CREDITS
11 Child and Dependent Care (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . 11 00
12 Two Wage Earner Credit (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 00
13 Other nonrefundable credits. Attach SC1040TC and other state returns . . . . . 13 60 00
14 Total nonrefundable credits (add line 11 through line 13) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 60 00
15 Subtract line 14 from line 10 and enter the difference. If less than zero, enter zero here . . . . . . . . . . . . . . 15 0 00
PAYMENTS AND REFUNDABLE CREDITS
16 SC income tax withheld (attach W-2 or SC41) . . . . . . . . . . . . . . . . . . . . . . . . . 16 00
17 2021 Estimated Tax payments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 00
18 Amount paid with extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 00
19 Nonresident sale of real estate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 00
20 Other SC withholding (attach 1099) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 00
21 Tuition tax credit (attach I-319) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 00
22 Other refundable credits:
22a Anhydrous Ammonia (attach I-333) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22a 00
22b Milk Credit (attach I-334) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22b 00
22c Classroom Teacher Expenses (attach I-360) . . . . . . . . . . . . . . . . . . . . . . 22c 00
22d Parental Refundable Credit (attach I-361) . . . . . . . . . . . . . . . . . . . . . . . . 22d 00
22e Motor Fuel Income Tax Credit (attach I-385) . . . . . . . . . . . . . . . . . . . . . . 22e 00
Total refundable credits (add line 22a through line 22e) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 00
AMENDED RETURN: Use Schedule AMD for line 23 calculation.
23 Add line 16 through line 22 and enter the total here . . . . . . . . . . These are your TOTAL PAYMENTS 23 00
24 If line 23 is larger than line 15, subtract line 15 from line 23 and enter the overpayment . . . . . . . . . . . . . . 24 00
25 If line 15 is larger than line 23, subtract line 23 from line 15 and enter the amount due . . . . . . . . . . . . . . . 25 0 00
AMENDED RETURN: Enter the amount from line 24 on line 30. Enter the amount from line 25 on line 31.
26 USE TAX due on online, mail-order, or out-of-state purchases . . . . . . . . . . . . 26 0 00
Use Tax is based on your county's Sales Tax rate. See instructions for more information.
If you certify that no Use Tax is due, check here . . . .
27 Amount of line 24 to be credited to your 2022 Estimated Tax . . . . . . . . . . . . . 27 00
28 Total Contributions for Check-offs (attach I-330) . . . . . . . . . . . . . . . . . . . . . . . 28 00
29 Add line 26 through line 28 and enter the total here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 0 00
30 If line 29 is larger than line 24, go to line 31. Otherwise, subtract line 29 from line 24 and enter the
amount to be refunded to you (line 35 check box entry is required) . . . . . . . . . . . . . . . . . . . REFUND 30 00
31 Add line 25 and line 29. If line 29 is larger than line 24, subtract line 24 from line 29, enter the total. This is your tax due 31 0 00
32 Late filing and/or late payment: Penalties___________ Interest __________ . . . . . . Enter total here 32 00
33 Penalty for Underpayment of Estimated Tax (attach SC2210)
Enter exception code from instructions here if applicable ______ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 00
34 Add line 31 through line 33 and enter your balance due (select payment option on line 36) BALANCE DUE 34 0 00
REFUND OPTIONS Getting a refund? Direct deposit is fast, accurate, and secure!
35 Select one: Direct Deposit (line 37 required) (for US accounts only) Debit Card Paper Check
PAYMENT OPTIONS Have a balance due? Pay electronically! It's quick and easy!
36 Select one: MyDORWAY (pay at dor.sc.gov/pay) ACH Debit (enter your US bank information on line 37)
37 Type of Account: Checking Savings
Routing Must be 9 digits. The first two numbers Bank Account 1-17
Number (RTN) of the RTN must be 01 through 32. Number (BAN) digits

For payments only: Withdrawal Date Withdrawal Amount 00

I declare that this return and all attachments are true, correct, and complete to the best of my knowledge. If prepared by a person other
than the taxpayer, this declaration is based on all information of which the preparer has any knowledge.
Your signature Date Spouse's signature (if married filing jointly, BOTH must sign)

I authorize the Director of the SCDOR or delegate to discuss this return, Preparer's printed name
attachments, and related tax matters with the preparer.
Yes No
Paid Preparer Date Check if self- PTIN
Preparer's signature Self prepared employed
Use Firm name (or yours if self- FEIN
Only employed), address, ZIP Phone

REFUNDS OR ZERO TAX: SC1040 Processing Center, PO Box 101100, Columbia, SC 29211-0100
MAIL TO:
BALANCE DUE: Taxable Processing Center, PO Box 101105, Columbia, SC 29211-0105
30753214 REV 04/13/22 Intuit.cg.cfp.sp
 1555

STATE OF SOUTH CAROLINA SC1040TC

DEPARTMENT OF REVENUE (Rev. 6/30/21)
dor.sc.gov
2021 TAX CREDITS 3913

Name Social Security Number

Erica C & bryan M Villarreal 615-20-2273

Most tax credits are computed on separate tax credit schedules. Attach tax credit schedules for all tax credits you claim, along
with the SC1040TC Worksheet and the SC1040TC, to your Income Tax return. The SCDOR may disallow your tax credits if you
do not attach the neccesary schedules to your return.

For line 6 through line 15, enter the credit description, the associated code, and the dollar amount of the credit claimed. You can find
credit codes and descriptions, along with the required tax schedule for each credit, beginning on page 4.

Credit Description Code Amount

1. Total credit for taxes paid to another state

(Attach SC1040TC worksheet for each state) ............................ 1. 100 $ 60 .00
2. Solar Energy or Small Hydropower System or
Geothermal Machinery and Equipment Credit ........................... 2. 038 $ .00
3. Excess Insurance Premium Credit .................................................. 3. 044 $ .00

4. New Jobs Credit .............................................................................. 4. 004 $ .00

5. Qualified Conservation Contribution Credit...................................... 5. 019 $ .00

6. 6. $ .00

7. 7. $ .00

8. 8. $ .00

9. 9. $ .00

10. 10. $ .00

11. 11. $ .00

12. 12. $ .00

13. 13. $ .00

14. 14. $ .00

15. 15. $ .00

16. Total nonrefundable tax credits (add line 1 through line 15) ...................................... 16. $ 60 .00

17. South Carolina Tax (from SC1040, line 10; SC1065, line 3, or SC1041, lines 8 and 9) ... 17. $ 60 .00
18. Enter the lesser of line 16 or line 17 .................................................................................. 18. $ 60 .00
For an Individual, enter this amount on SC1040, line 13.
For a Fiduciary, enter this amount on SC1041, line 10.
For a Partnership, enter this amount on SC1065, line 4.
SC1040 Filers: Include this form and a complete copy of your federal return with your SC1040. If claiming credit for taxes paid to
another state, also include a copy of each tax return filed with another state.
SC1041 or SC1065 Filers: Include this form with your SC1041 or SC1065.
REV 04/13/22 Intuit.cg.cfp.sp
39131214
 1555

STATE OF SOUTH CAROLINA

DEPARTMENT OF REVENUE
SC1040TC
(Rev. 6/30/21)
CREDIT FOR TAXES 3913
dor.sc.gov PAID TO ANOTHER STATE 2021

WORKSHEET FOR TAXES PAID TO Georgia

(enter name of state)

This credit is available for South Carolina residents and part-year residents only. Complete a separate worksheet for each state. Use
the SC1040TC instructions to complete this worksheet. Include the SC1040TC and SC1040TC Worksheet with your SC1040.

Dollars Cents

1. South Carolina gross income (enter amount from instructions for line 1, E) ..................................... 1. 42,017 00

2. Portion of line 1 taxed by another state (see instructions) ................................................................. 2. 42,524 00

3. Percentage (divide line 2 by line 1)
Round to two decimal places. Cannot be greater than 100%............................................................. 3. 100.00 %

4. Amount of South Carolina tax from SC1040, line 10.......................................................................... 4. 60 00

5. Tentative credit (multipy line 3 by line 4)............................................................................................ 5. 60 00

6. Net tax due the other state on income from line 2
See instructions. Do not use withholding from W-2 ............................................................................ 6. 922 00

7. Allowable credit (lesser of line 5 or line 6)........................................................................................... 7. 60 00

Add the amounts from line 7 of each state worksheet, and enter the total on SC1040TC, line 1.

WORKSHEET FOR TAXES PAID TO

(enter name of state)

This credit is available for South Carolina residents and part-year residents only. Complete a separate worksheet for each state. Use
the SC1040TC instructions to complete this worksheet. Include the SC1040TC and SC1040TC Worksheet with your SC1040.

Dollars Cents

1. South Carolina gross income (enter amount from instructions for line 1, E)....................................... 1. 00

2. Portion of line 1 taxed by another state (see instructions).................................................................. 2. 00

3. Percentage (divide line 2 by line 1)
Round to two decimal places. Cannot be greater than 100%............................................................. 3. %

4. Amount of South Carolina tax from SC1040, line 10.......................................................................... 4. 00

5. Tentative credit (multiply line 3 by line 4)........................................................................................... 5. 00

6. Net tax due the other state on the income from line 2
See instructions. Do not use withholding from W-2 ............................................................................ 6. 00

7. Allowable credit (lesser of line 5 or line 6).......................................................................................... 7. 00

Add the amounts from line 7 of each state worksheet, and enter the total on SC1040TC, line 1.
REV 04/13/22 Intuit.cg.cfp.sp

39132212
 1040 U.S. Individual Income Tax Return 2021 (99)
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 Single Married filing jointly Married filing separately (MFS) Head of household (HOH) Qualifying widow(er) (QW)
Check only If you checked the MFS box, enter the name of your spouse. If you checked the HOH or QW box, enter the child’s name if the qualifying
one box.
person is a child but not your dependent a
Your first name and middle initial Last name Your social security number
Erica c Villarreal 615-20-2273
If joint return, spouse’s first name and middle initial Last name Spouse’s social security number
bryan m Villarreal 458-37-2792
Home address (number and street). If you have a P.O. box, see instructions. Apt. no. Presidential Election Campaign
1950 Bolin Rd 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
North Augusta SC 298412215 box below will not change
Foreign country name Foreign province/state/county Foreign postal code your tax or refund.
You Spouse

At any time during 2021, did you receive, sell, exchange, or otherwise dispose of any financial interest in any virtual currency? Yes 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: Were born before January 2, 1957 Are blind Spouse: Was born before January 2, 1957 Is blind
Dependents (see instructions): (2) Social security (3) Relationship (4)  if qualifies for (see instructions):
(1) First name Last name number to you Child tax credit Credit for other dependents
If more
than four molly villarreal 443-25-1429 Daughter
dependents,
see instructions
clare villarreal 644-29-2599 Daughter
and check cal villarreal 373-99-8025 Son
here a
1 Wages, salaries, tips, etc. Attach Form(s) W-2 . . . . . . . . . . . . . . . . 1 54,317.
Attach 2a Tax-exempt interest . . . 2a 2b
b Taxable interest . . . . .
Sch. B if
3a Qualified dividends . . . 3a b Ordinary dividends . . . . . 3b
required.
4a IRA distributions . . . . 4a b Taxable amount . . . . . . 4b
5a Pensions and annuities . . 5a b Taxable amount . . . . . . 5b
Standard 6a Social security benefits . . 6a b Taxable amount . . . . . . 6b
Deduction for— a
7 Capital gain or (loss). Attach Schedule D if required. If not required, check here . . . . 7
• Single or
Married filing 8 Other income from Schedule 1, line 10 . . . . . . . . . . . . . . . . . . 8 0.
separately,
$12,550 9 Add lines 1, 2b, 3b, 4b, 5b, 6b, 7, and 8. This is your total income . . . . . . . . . a 9 54,317.
• Married filing 10 Adjustments to income from Schedule 1, line 26 . . . . . . . . . . . . . . . 10 11,193.
jointly or
11 Subtract line 10 from line 9. This is your adjusted gross income . . . . . . . . . a 11 43,124.
Qualifying
widow(er),
$25,100
12a Standard deduction or itemized deductions (from Schedule A) . . 12a 25,100.
• Head of b Charitable contributions if you take the standard deduction (see instructions) 12b 600.
household,
$18,800 c Add lines 12a and 12b . . . . . . . . . . . . . . . . . . . . . . . 12c 25,700.
• If you checked 13 Qualified business income deduction from Form 8995 or Form 8995-A . . . . . . . . . 13
any box under
Standard 14 Add lines 12c and 13 . . . . . . . . . . . . . . . . . . . . . . . 14 25,700.
Deduction,
see instructions.
15 Taxable income. Subtract line 14 from line 11. If zero or less, enter -0- . . . . . . . . . 15 17,424.

For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Form 1040 (2021)
Form 1040 (2021) Page 2
16 Tax (see instructions). Check if any from Form(s): 1 8814 2 4972 3 . . 16 1,743.
17 Amount from Schedule 2, line 3 . . . . . . . . . . . . . . . . . . . . 17
18 Add lines 16 and 17 . . . . . . . . . . . . . . . . . . . . . . . . 18 1,743.
19 Nonrefundable child tax credit or credit for other dependents from Schedule 8812 . . . . . 19
20 Amount from Schedule 3, line 8 . . . . . . . . . . . . . . . . . . . . 20 200.
21 Add lines 19 and 20 . . . . . . . . . . . . . . . . . . . . . . . . 21 200.
22 Subtract line 21 from line 18. If zero or less, enter -0- . . . . . . . . . . . . . . 22 1,543.
23 Other taxes, including self-employment tax, from Schedule 2, line 21 . . . . . . . . . 23 10,386.
24 Add lines 22 and 23. This is your total tax . . . . . . . . . . . . . . . . a 24 11,929.
25 Federal income tax withheld from:
a Form(s) W-2 . . . . . . . . . . . . . . . . . . 25a 4,710.
b Form(s) 1099 . . . . . . . . . . . . . . . . . . 25b
c Other forms (see instructions) . . . . . . . . . . . . . 25c
d Add lines 25a through 25c . . . . . . . . . . . . . . . . . . . . . . 25d 4,710.
26 2021 estimated tax payments and amount applied from 2020 return . . . . . . . . . . 26
If you have a
qualifying child, 27a Earned income credit (EIC) . . . . . . . . . . . . . .
No 27a
attach Sch. EIC.
Check here if you were born after January 1, 1998, and before
January 2, 2004, and you satisfy all the other requirements for
taxpayers who are at least age 18, to claim the EIC. See instructions a
b Nontaxable combat pay election . . . . 27b
c Prior year (2019) earned income . . . . 27c
28 Refundable child tax credit or additional child tax credit from Schedule 8812 28 4,500.
29 American opportunity credit from Form 8863, line 8 . . . . . . . 29
30 Recovery rebate credit. See instructions . . . . . . . . . . 30
31 Amount from Schedule 3, line 15 . . . . . . . . . . . . 31 0.
32 Add lines 27a and 28 through 31. These are your total other payments and refundable credits a 32 4,500.
33 Add lines 25d, 26, and 32. These are your total payments . . . . . . . . . . . a 33 9,210.
34 If line 33 is more than line 24, subtract line 24 from line 33. This is the amount you overpaid . . 34
Refund
35a Amount of line 34 you want refunded to you. If Form 8888 is attached, check here . . . a 35a
Direct deposit? ab Routing number X X X X X X X X X a c Type: Checking Savings
See instructions. a
d Account number X X X X X X X X X X X X X X X X X
36 Amount of line 34 you want applied to your 2022 estimated tax . . a 36
Amount 37 Amount you owe. Subtract line 33 from line 24. For details on how to pay, see instructions . a 37 2,719.
You Owe 38 Estimated tax penalty (see instructions) . . . . . . . . . a 38
Third Party Do you want to allow another person to discuss this return with the IRS? See
Designee instructions . . . . . . . . . . . . . . . . . . . . a Yes. Complete below. No
Designee’s Phone Personal identification
name a no. a number (PIN) a
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
F

Joint return? stay at home parent (see inst.) a

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.) a
associate pastor
Phone no. (405)269-9332 Email address
Preparer’s name Preparer’s signature Date PTIN Check if:
Paid Self-employed
Preparer
Firm’s name a Self-Prepared Phone no.
Use Only a a
Firm’s address Firm’s EIN
Go to www.irs.gov/Form1040 for instructions and the latest information. BAA REV 04/09/22 Intuit.cg.cfp.sp Form 1040 (2021)
SCHEDULE 1 OMB No. 1545-0074
Additional Income and Adjustments to Income
(Form 1040)
Department of the Treasury
a Attach to Form 1040, 1040-SR, or 1040-NR. 2021
Attachment
Internal Revenue Service a Go to www.irs.gov/Form1040 for instructions and the latest information. Sequence No. 01
Name(s) shown on Form 1040, 1040-SR, or 1040-NR Your social security number
Erica c & bryan m Villarreal 615-20-2273
Part I Additional Income
1 Taxable refunds, credits, or offsets of state and local income taxes . . . . . . . 1 0.
2a Alimony received . . . . . . . . . . . . . . . . . . . . . . . . . . . 2a
b Date of original divorce or separation agreement (see instructions) a
3 Business income or (loss). Attach Schedule C . . . . . . . . . . . . . . . 3
4 Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . . . . . . 4
5 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach
Schedule E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
6 Farm income or (loss). Attach Schedule F . . . . . . . . . . . . . . . . . 6
7 Unemployment compensation . . . . . . . . . . . . . . . . . . . . . . 7
8 Other income:
a Net operating loss . . . . . . . . . . . . . . . . . . 8a ( )
b Gambling income . . . . . . . . . . . . . . . . . . . 8b
c Cancellation of debt . . . . . . . . . . . . . . . . . . 8c
d Foreign earned income exclusion from Form 2555 . . . . . 8d ( )
e Taxable Health Savings Account distribution . . . . . . . . 8e
f Alaska Permanent Fund dividends . . . . . . . . . . . . 8f
g Jury duty pay . . . . . . . . . . . . . . . . . . . . 8g
h Prizes and awards . . . . . . . . . . . . . . . . . . 8h
i Activity not engaged in for profit income . . . . . . . . . 8i
j Stock options . . . . . . . . . . . . . . . . . . . . 8j
k 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 . . . . . . . . . . . . . . . . . . . . . . 8k
l Olympic and Paralympic medals and USOC prize money (see
instructions) . . . . . . . . . . . . . . . . . . . . . 8l
m Section 951(a) inclusion (see instructions) . . . . . . . . . 8m
n Section 951A(a) inclusion (see instructions) . . . . . . . . 8n
o Section 461(l) excess business loss adjustment . . . . . . . 8o
p Taxable distributions from an ABLE account (see instructions) . 8p
z Other income. List type and amount a
8z
9 Total other income. Add lines 8a through 8z . . . . . . . . . . . . . . . . 9
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) 2021
Schedule 1 (Form 1040) 2021 Page 2

Part II Adjustments to Income

11 Educator expenses . . . . . . . . . . . . . . . . . . . . . . . . . . 11
12 Certain business expenses of reservists, performing artists, and fee-basis government
officials. Attach Form 2106 . . . . . . . . . . . . . . . . . . . . . . . 12
13 Health savings account deduction. Attach Form 8889 . . . . . . . . . . . . 13
14 Moving expenses for members of the Armed Forces. Attach Form 3903 . . . . . 14
15 Deductible part of self-employment tax. Attach Schedule SE . . . . . . . . . 15 5,193.
16 Self-employed SEP, SIMPLE, and qualified plans . . . . . . . . . . . . . . 16
17 Self-employed health insurance deduction . . . . . . . . . . . . . . . . . 17
18 Penalty on early withdrawal of savings . . . . . . . . . . . . . . . . . . 18
19a Alimony paid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19a
b Recipient’s SSN . . . . . . . . . . . . . . . . . . . . a
c Date of original divorce or separation agreement (see instructions) a
20 IRA deduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 6,000.
21 Student loan interest deduction . . . . . . . . . . . . . . . . . . . . . 21
22 Reserved for future use . . . . . . . . . . . . . . . . . . . . . . . . 22
23 Archer MSA deduction . . . . . . . . . . . . . . . . . . . . . . . . . 23
24 Other adjustments:
a Jury duty pay (see instructions) . . . . . . . . . . . . . 24a
b Deductible expenses related to income reported on line 8k from
the rental of personal property engaged in for profit . . . . . 24b
c Nontaxable amount of the value of Olympic and Paralympic
medals and USOC prize money reported on line 8l . . . . . 24c
d Reforestation amortization and expenses . . . . . . . . . 24d
e Repayment of supplemental unemployment benefits under the
Trade Act of 1974 . . . . . . . . . . . . . . . . . . . 24e
f Contributions to section 501(c)(18)(D) pension plans . . . . . 24f
g Contributions by certain chaplains to section 403(b) plans . . 24g
h Attorney fees and court costs for actions involving certain
unlawful discrimination claims (see instructions) . . . . . . 24h
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
j Housing deduction from Form 2555 . . . . . . . . . . . 24j
k Excess deductions of section 67(e) expenses from Schedule K-1
(Form 1041) . . . . . . . . . . . . . . . . . . . . . 24k
z Other adjustments. List type and amount a
24z
25 Total other adjustments. Add lines 24a through 24z . . . . . . . . . . . . . 25
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 11,193.
BAA REV 04/09/22 Intuit.cg.cfp.sp Schedule 1 (Form 1040) 2021
SCHEDULE 2 OMB No. 1545-0074
Additional Taxes
(Form 1040)
Department of the Treasury
a Attach to Form 1040, 1040-SR, or 1040-NR. 2021
Attachment
Internal Revenue Service a Go to www.irs.gov/Form1040 for instructions and the latest information. Sequence No. 02
Name(s) shown on Form 1040, 1040-SR, or 1040-NR Your social security number
Erica c & bryan m Villarreal 615-20-2273
Part I Tax
1 Alternative minimum tax. Attach Form 6251 . . . . . . . . . . . . . . . . 1
2 Excess advance premium tax credit repayment. Attach Form 8962 . . . . . . . 2
3 Add lines 1 and 2. Enter here and on Form 1040, 1040-SR, or 1040-NR, line 17 . . 3
Part II Other Taxes
4 Self-employment tax. Attach Schedule SE . . . . . . . . . . . . . . . . . 4 10,386.
5 Social security and Medicare tax on unreported tip income.
Attach Form 4137 . . . . . . . . . . . . . . . . . . 5
6 Uncollected social security and Medicare tax on wages. Attach
Form 8919 . . . . . . . . . . . . . . . . . . . . . 6
7 Total additional social security and Medicare tax. Add lines 5 and 6 . . . . . . 7
8 Additional tax on IRAs or other tax-favored accounts. Attach Form 5329 if required 8
9 Household employment taxes. Attach Schedule H . . . . . . . . . . . . . 9
10 Repayment of first-time homebuyer credit. Attach Form 5405 if required . . . . . 10
11 Additional Medicare Tax. Attach Form 8959 . . . . . . . . . . . . . . . . 11
12 Net investment income tax. Attach Form 8960 . . . . . . . . . . . . . . . 12
13 Uncollected social security and Medicare or RRTA tax on tips or group-term life
insurance from Form W-2, box 12 . . . . . . . . . . . . . . . . . . . . 13
14 Interest on tax due on installment income from the sale of certain residential lots
and timeshares . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
15 Interest on the deferred tax on gain from certain installment sales with a sales price
over $150,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
16 Recapture of low-income housing credit. Attach Form 8611 . . . . . . . . . . 16
(continued on page 2)
For Paperwork Reduction Act Notice, see your tax return instructions. Schedule 2 (Form 1040) 2021
Schedule 2 (Form 1040) 2021 Page 2

Part II Other Taxes (continued)

17 Other additional taxes:
a Recapture of other credits. List type, form number, and
amount a 17a
b Recapture of federal mortgage subsidy. If you sold your home in
2021, see instructions . . . . . . . . . . . . . . . . . 17b
c Additional tax on HSA distributions. Attach Form 8889 . . . . 17c
d Additional tax on an HSA because you didn’t remain an eligible
individual. Attach Form 8889 . . . . . . . . . . . . . . 17d
e Additional tax on Archer MSA distributions. Attach Form 8853 . 17e
f Additional tax on Medicare Advantage MSA distributions. Attach
Form 8853 . . . . . . . . . . . . . . . . . . . . . 17f
g Recapture of a charitable contribution deduction related to a
fractional interest in tangible personal property . . . . . . . 17g
h Income you received from a nonqualified deferred compensation
plan that fails to meet the requirements of section 409A . . . 17h
i Compensation you received from a nonqualified deferred
compensation plan described in section 457A . . . . . . . 17i
j Section 72(m)(5) excess benefits tax . . . . . . . . . . . 17j
k Golden parachute payments . . . . . . . . . . . . . . 17k
l Tax on accumulation distribution of trusts . . . . . . . . . 17l
m Excise tax on insider stock compensation from an expatriated
corporation . . . . . . . . . . . . . . . . . . . . . 17m
n Look-back interest under section 167(g) or 460(b) from Form
8697 or 8866 . . . . . . . . . . . . . . . . . . . . 17n
o Tax on non-effectively connected income for any part of the
year you were a nonresident alien from Form 1040-NR . . . . 17o
p Any interest from Form 8621, line 16f, relating to distributions
from, and dispositions of, stock of a section 1291 fund . . . . 17p
q Any interest from Form 8621, line 24 . . . . . . . . . . . 17q
z Any other taxes. List type and amount a
17z
18 Total additional taxes. Add lines 17a through 17z . . . . . . . . . . . . . . 18
19 Additional tax from Schedule 8812 . . . . . . . . . . . . . . . . . . . . 19
20 Section 965 net tax liability installment from Form 965-A . . . 20
21 Add lines 4, 7 through 16, 18, and 19. These are your total other taxes. Enter here
and on Form 1040 or 1040-SR, line 23, or Form 1040-NR, line 23b . . . . . . . 21 10,386.
BAA REV 04/09/22 Intuit.cg.cfp.sp Schedule 2 (Form 1040) 2021
SCHEDULE 3 OMB No. 1545-0074
Additional Credits and Payments
(Form 1040)
Department of the Treasury
a Attach to Form 1040, 1040-SR, or 1040-NR. 2021
Attachment
Internal Revenue Service a Go to www.irs.gov/Form1040 for instructions and the latest information. Sequence No. 03
Name(s) shown on Form 1040, 1040-SR, or 1040-NR Your social security number
Erica c & bryan m Villarreal 615-20-2273
Part I Nonrefundable Credits
1 Foreign tax credit. Attach Form 1116 if required . . . . . . . . . . . . . . 1
2 Credit for child and dependent care expenses from Form 2441, line 11. Attach
Form 2441 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Education credits from Form 8863, line 19 . . . . . . . . . . . . . . . . . 3
4 Retirement savings contributions credit. Attach Form 8880 . . . . . . . . . . 4 200.
5 Residential energy credits. Attach Form 5695 . . . . . . . . . . . . . . . 5
6 Other nonrefundable credits:
a General business credit. Attach Form 3800 . . . . . . . . 6a
b Credit for prior year minimum tax. Attach Form 8801 . . . . 6b
c Adoption credit. Attach Form 8839 . . . . . . . . . . . . 6c
d Credit for the elderly or disabled. Attach Schedule R . . . . . 6d
e Alternative motor vehicle credit. Attach Form 8910 . . . . . 6e
f Qualified plug-in motor vehicle credit. Attach Form 8936 . . . 6f
g Mortgage interest credit. Attach Form 8396 . . . . . . . . 6g
h District of Columbia first-time homebuyer credit. Attach Form 8859 6h
i Qualified electric vehicle credit. Attach Form 8834 . . . . . 6i
j Alternative fuel vehicle refueling property credit. Attach Form 8911 6j
k Credit to holders of tax credit bonds. Attach Form 8912 . . . 6k
l Amount on Form 8978, line 14. See instructions . . . . . . 6l
z Other nonrefundable credits. List type and amount a
6z
7 Total other nonrefundable credits. Add lines 6a through 6z . . . . . . . . . . 7
8 Add lines 1 through 5 and 7. Enter here and on Form 1040, 1040-SR, or 1040-NR,
line 20 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 200.
(continued on page 2)
For Paperwork Reduction Act Notice, see your tax return instructions. BAA REV 04/09/22 Intuit.cg.cfp.sp Schedule 3 (Form 1040) 2021
Schedule 3 (Form 1040) 2021 Page 2

Part II Other Payments and Refundable Credits

9 Net premium tax credit. Attach Form 8962 . . . . . . . . . . . . . . . . . 9
10 Amount paid with request for extension to file (see instructions) . . . . . . . . 10
11 Excess social security and tier 1 RRTA tax withheld . . . . . . . . . . . . . 11
12 Credit for federal tax on fuels. Attach Form 4136 . . . . . . . . . . . . . . 12
13 Other payments or refundable credits:
a Form 2439 . . . . . . . . . . . . . . . . . . . . . 13a
b Qualified sick and family leave credits from Schedule(s) H and
Form(s) 7202 for leave taken before April 1, 2021 . . . . . . 13b
c Health coverage tax credit from Form 8885 . . . . . . . . 13c
d Credit for repayment of amounts included in income from earlier
years . . . . . . . . . . . . . . . . . . . . . . . . 13d
e Reserved for future use . . . . . . . . . . . . . . . . 13e
f Deferred amount of net 965 tax liability (see instructions) . . . 13f
g Credit for child and dependent care expenses from Form 2441,
line 10. Attach Form 2441 . . . . . . . . . . . . . . . 13g
h Qualified sick and family leave credits from Schedule(s) H and
Form(s) 7202 for leave taken after March 31, 2021 . . . . . 13h 0.
z Other payments or refundable credits. List type and amount a
13z
14 Total other payments or refundable credits. Add lines 13a through 13z . . . . . 14 0.
15 Add lines 9 through 12 and 14. Enter here and on Form 1040, 1040-SR, or 1040-NR,
line 31 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 0.
BAA REV 04/09/22 Intuit.cg.cfp.sp Schedule 3 (Form 1040) 2021
SCHEDULE SE
Self-Employment Tax
OMB No. 1545-0074

2021
(Form 1040)
a Go to www.irs.gov/ScheduleSE for instructions and the latest information.
Department of the Treasury Attachment
Sequence No. 17
a Attach to Form 1040, 1040-SR, or 1040-NR.
Internal Revenue Service (99)
Name of person with self-employment income (as shown on Form 1040, 1040-SR, or 1040-NR) Social security number of person
bryan m Villarreal with self-employment income a 458-37-2792
Part I Self-Employment Tax
Note: If your only income subject to self-employment tax is church employee income, see instructions for how to report your income
and the definition of church employee income.
A If you are a minister, member of a religious order, or Christian Science practitioner and you filed Form 4361, but you had
$400 or more of other net earnings from self-employment, check here and continue with Part I . . . . . . . . a
Skip lines 1a and 1b if you use the farm optional method in Part II. See instructions.
1a Net farm profit or (loss) from Schedule F, line 34, and farm partnerships, Schedule K-1 (Form 1065),
box 14, code A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1a
b If you received social security retirement or disability benefits, enter the amount of Conservation Reserve
Program payments included on Schedule F, line 4b, or listed on Schedule K-1 (Form 1065), box 20, code AH 1b ( )
Skip line 2 if you use the nonfarm optional method in Part II. See instructions.
2 Net profit or (loss) from Schedule C, line 31; and Schedule K-1 (Form 1065), box 14, code A (other than
farming). See instructions for other income to report or if you are a minister or member of a religious order 2 73,505.
3 Combine lines 1a, 1b, and 2 . . . . . . . . . . . . . . . . . . . . . . . . . 3 73,505.
4a If line 3 is more than zero, multiply line 3 by 92.35% (0.9235). Otherwise, enter amount from line 3 . 4a 67,882.
Note: If line 4a is less than $400 due to Conservation Reserve Program payments on line 1b, see instructions.
b If you elect one or both of the optional methods, enter the total of lines 15 and 17 here . . . . . 4b
c Combine lines 4a and 4b. If less than $400, stop; you don’t owe self-employment tax. Exception: If
less than $400 and you had church employee income, enter -0- and continue . . . . . . . a 4c 67,882.
5a Enter your church employee income from Form W-2. See instructions for
definition of church employee income . . . . . . . . . . . . . 5a
b Multiply line 5a by 92.35% (0.9235). If less than $100, enter -0- . . . . . . . . . . . . . 5b 0.
6 Add lines 4c and 5b . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 67,882.
7 Maximum amount of combined wages and self-employment earnings subject to social security tax or
the 6.2% portion of the 7.65% railroad retirement (tier 1) tax for 2021 . . . . . . . . . . . 7 142,800
8a Total social security wages and tips (total of boxes 3 and 7 on Form(s) W-2)
and railroad retirement (tier 1) compensation. If $142,800 or more, skip lines
8b through 10, and go to line 11 . . . . . . . . . . . . . . . 8a 0.
b Unreported tips subject to social security tax from Form 4137, line 10 . . . 8b
c Wages subject to social security tax from Form 8919, line 10 . . . . . . 8c
d Add lines 8a, 8b, and 8c . . . . . . . . . . . . . . . . . . . . . . . . . . 8d 0.
9 Subtract line 8d from line 7. If zero or less, enter -0- here and on line 10 and go to line 11 . . . a 9 142,800.
10 Multiply the smaller of line 6 or line 9 by 12.4% (0.124) . . . . . . . . . . . . . . . . 10 8,417.
11 Multiply line 6 by 2.9% (0.029) . . . . . . . . . . . . . . . . . . . . . . . . 11 1,969.
12 Self-employment tax. Add lines 10 and 11. Enter here and on Schedule 2 (Form 1040), line 4 . . 12 10,386.
13 Deduction for one-half of self-employment tax.
Multiply line 12 by 50% (0.50). Enter here and on Schedule 1 (Form 1040),
line 15 . . . . . . . . . . . . . . . . . . . . . . . . 13 5,193.
Part II Optional Methods To Figure Net Earnings (see instructions)
Farm Optional Method. You may use this method only if (a) your gross farm income1 wasn’t more than
$8,820, or (b) your net farm profits2 were less than $6,367.
14 Maximum income for optional methods . . . . . . . . . . . . . . . . . . . . . 14 5,880
15 Enter the smaller of: two-thirds (2/3) of gross farm income1 (not less than zero) or $5,880. Also, include
this amount on line 4b above . . . . . . . . . . . . . . . . . . . . . . . . 15
Nonfarm Optional Method. You may use this method only if (a) your net nonfarm profits3 were less than $6,367
and also less than 72.189% of your gross nonfarm income,4 and (b) you had net earnings from self-employment
of at least $400 in 2 of the prior 3 years. Caution: You may use this method no more than five times.
16 Subtract line 15 from line 14 . . . . . . . . . . . . . . . . . . . . . . . . . 16
17 Enter the smaller of: two-thirds (2/3) of gross nonfarm income4 (not less than zero) or the amount on
line 16. Also, include this amount on line 4b above . . . . . . . . . . . . . . . . . 17
1 3
From Sch. F, line 9; and Sch. K-1 (Form 1065), box 14, code B. From Sch. C, line 31; and Sch. K-1 (Form 1065), box 14, code A.
2 4
From Sch. F, line 34; and Sch. K-1 (Form 1065), box 14, code A—minus the amount From Sch. C, line 7; and Sch. K-1 (Form 1065), box 14, code C.
you would have entered on line 1b had you not used the optional method.
For Paperwork Reduction Act Notice, see your tax return instructions. BAA REV 04/09/22 Intuit.cg.cfp.sp Schedule SE (Form 1040) 2021
SCHEDULE 8812 Credits for Qualifying Children `
OMB No. 1545-0074
(Form 1040) . .1040
and Other Dependents .......

a Attach to Form 1040, 1040-SR, or 1040-NR.

1040-SR
.........
1040-NR 2021
Department of the Treasury 8812 Attachment
Internal Revenue Service (99) a Go to www.irs.gov/Schedule8812 for instructions and the latest information. Sequence No. 47

Name(s) shown on return Your social security number

Erica c & bryan m Villarreal 615-20-2273
Part I-A Child Tax Credit and Credit for Other Dependents
1 Enter the amount from line 11 of your Form 1040, 1040-SR, or 1040-NR . . . . . . . . . . . . 1 43,124.
2a Enter income from Puerto Rico that you excluded . . . . . . . . . . . 2a
b Enter the amounts from lines 45 and 50 of your Form 2555 . . . . . . . . 2b 0.
c Enter the amount from line 15 of your Form 4563 . . . . . . . . . . . 2c
d Add lines 2a through 2c . . . . . . . . . . . . . . . . . . . . . . . . . . . 2d 0.
3 Add lines 1 and 2d . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 43,124.
4a Number of qualifying children under age 18 with the required social security number 4a 3.
b Number of children included on line 4a who were under age 6 at the end of 2021 . . 4b 0.
c Subtract line 4b from line 4a . . . . . . . . . . . . . . . . . 4c 3.
5 If line 4a is more than zero, enter the amount from the Line 5 Worksheet; otherwise, enter -0- . . . . . . 5 9,000.
6 Number of other dependents, including any qualifying children who are not under age
18 or who do not have the required social security number . . . . . . . . 6 0.
Caution: Do not include yourself, your spouse, or anyone who is not a U.S. citizen, U.S. national, or U.S. resident
alien. Also, do not include anyone you included on line 4a.
7 Multiply line 6 by $500 . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
8 Add lines 5 and 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 9,000.
9 Enter the amount shown below for your filing status.
• Married filing jointly—$400,000
• All other filing statuses—$200,000 }
. . . . . . . . . . . . . . . . . . . . . . 9 400,000.
10 Subtract line 9 from line 3.

}
• If zero or less, enter -0-.
• If more than zero and not a multiple of $1,000, enter the next multiple of $1,000. For
example, if the result is $425, enter $1,000; if the result is $1,025, enter $2,000, etc. . . . . . . . 10 0.
11 Multiply line 10 by 5% (0.05) . . . . . . . . . . . . . . . . . . . . . . . . . 11 0.
12 Subtract line 11 from line 8. If zero or less, enter -0- . . . . . . . . . . . . . . . . . . 12 9,000.
13 Check all the boxes that apply to you (or your spouse if married filing jointly).
A Check here if you (or your spouse if married filing jointly) had a principal place of abode in the United States
for more than half of 2021 . . . . . . . . . . . . . . . . . . . . . . . .
B Check here if you (or your spouse if married filing jointly) were a bona fide resident of Puerto Rico for 2021
Part I-B Filers Who Check a Box on Line 13
Caution: If you did not check a box on line 13, do not complete Part I-B; instead, skip to Part I-C.
14a Enter the smaller of line 7 or line 12 . . . . . . . . . . . . . . . . . . . . . . . 14a 0.
b Subtract line 14a from line 12 . . . . . . . . . . . . . . . . . . . . . . . . . 14b 9,000.
c If line 14a is zero, enter -0-; otherwise, enter the amount from the Credit Limit Worksheet A . . . . . . 14c 0.
d Enter the smaller of line 14a or line 14c . . . . . . . . . . . . . . . . . . . . . . 14d 0.
e Add lines 14b and 14d . . . . . . . . . . . . . . . . . . . . . . . . . . . 14e 9,000.
f Enter the aggregate amount of advance child tax credit payments you (and your spouse if filing jointly) received
for 2021. See your Letter(s) 6419 for the amounts to include on this line. If you are missing Letter 6419, see the
instructions before entering an amount on this line. If you didn’t receive any advance child tax credit payments
for 2021, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14f 4,500.
Caution: If the amount on this line doesn’t match the aggregate amounts reported to you (and your spouse if
filing jointly) on your Letter(s) 6419, the processing of your return will be delayed.
g Subtract line 14f from line 14e. If zero or less, enter -0- on lines 14g through 14i and go to Part III . . . . 14g 4,500.
h Enter the smaller of line 14d or line 14g. This is your credit for other dependents. Enter this amount on line
19 of your Form 1040, 1040-SR, or 1040-NR . . . . . . . . . . . . . . . . . . . . 14h 0.
i Subtract line 14h from line 14g. This is your refundable child tax credit. Enter this amount on line 28 of
your Form 1040, 1040-SR, or 1040-NR . . . . . . . . . . . . . . . . . . . . . . 14i 4,500.
For Paperwork Reduction Act Notice, see your tax return instructions. BAA REV 04/09/22 Intuit.cg.cfp.sp Schedule 8812 (Form 1040) 2021
Schedule 8812 (Form 1040) 2021 Page 2
Part I-C Filers Who Do Not Check a Box on Line 13
Caution: If you checked a box on line 13, do not complete Part I-C.
15a Enter the amount from the Credit Limit Worksheet A . . . . . . . . . . . . . . . . . 15a
b Enter the smaller of line 12 or line 15a . . . . . . . . . . . . . . . . . . . . . . 15b
Additional child tax credit. Complete Parts II-A through II-C if you meet each of the following items.
1. You are not filing Form 2555.
2. Line 4a is more than zero.
3. Line 12 is more than line 15a.
c If you completed Parts II-A through II-C, enter the amount from line 27; otherwise, enter -0- . . . . . . 15c
d Add lines 15b and 15c . . . . . . . . . . . . . . . . . . . . . . . . . . . 15d
e Enter the aggregate amount of advance child tax credit payments you (and your spouse if filing jointly) received
for 2021. See your Letter(s) 6419 for the amounts to include on this line. If you are missing Letter 6419, see the
instructions before entering an amount on this line. If you didn’t receive any advance child tax credit payments
for 2021, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15e
Caution: If the amount on this line doesn’t match the aggregate amounts reported to you (and your spouse if
filing jointly) on your Letter(s) 6419, the processing of your return will be delayed.
f Subtract line 15e from line 15d. If zero or less, enter -0- on lines 15f through 15h and go to Part III . . . . 15f
g Enter the smaller of line 15b or line 15f. This is your nonrefundable child tax credit and credit for other
dependents. Enter this amount on line 19 of your Form 1040, 1040-SR, or 1040-NR . . . . . . . . 15g
h Subtract line 15g from line 15f. This is your additional child tax credit. Enter this amount on line 28 of your
Form 1040, 1040-SR, or 1040-NR . . . . . . . . . . . . . . . . . . . . . . . 15h
Part II-A Additional Child Tax Credit (use only if completing Part I-C)
Caution: If you file Form 2555, do not complete Parts II-A through II-C; you cannot claim the additional child tax credit.
Caution: If you checked a box on line 13, do not complete Parts II-A through II-C; you cannot claim the additional child tax credit.
16a Subtract line 15b from line 12. If zero, skip Parts II-A and II-B and enter -0- on line 27 . . . . . . . . 16a
b Number of qualifying children under 18 with the required social security number: x $1,400.
Enter the result. If zero, skip Parts II-A and II-B and enter -0- on line 27 . . . . . . . . . . . . 16b
TIP: The number of children you use for this line is the same as the number of children you used for line 4a.
17 Enter the smaller of line 16a or line 16b . . . . . . . . . . . . . . . . . . . . . . 17
18a Earned income (see instructions) . . . . . . . . . . . . . . . . 18a
b Nontaxable combat pay (see instructions) . . . . . . 18b
19 Is the amount on line 18a more than $2,500?
No. Leave line 19 blank and enter -0- on line 20.
Yes. Subtract $2,500 from the amount on line 18a. Enter the result . . . . 19
20 Multiply the amount on line 19 by 15% (0.15) and enter the result . . . . . . . . . . . . . . 20
Next. On line 16b, is the amount $4,200 or more?
No. If line 20 is zero, enter -0- on line 15c. Otherwise, skip Part II-B and enter the smaller of line 17 or line
20 on line 27.
Yes. If line 20 is equal to or more than line 17, skip Part II-B and enter the amount from line 17 on line 27.
Otherwise, go to line 21.
Part II-B Certain Filers Who Have Three or More Qualifying Children
21 Withheld social security, Medicare, and Additional Medicare taxes from Form(s) W-2,
boxes 4 and 6. If married filing jointly, include your spouse’s amounts with yours. If
your employer withheld or you paid Additional Medicare Tax or tier 1 RRTA taxes, see
instructions . . . . . . . . . . . . . . . . . . . . . . 21
22 Enter the total of the amounts from Schedule 1 (Form 1040), line 15; Schedule 2 (Form
1040), line 5; Schedule 2 (Form 1040), line 6; and Schedule 2 (Form 1040), line 13 . 22
23 Add lines 21 and 22 . . . . . . . . . . . . . . . . . . . . 23
24 1040 and

}
1040-SR filers: Enter the total of the amounts from Form 1040 or 1040-SR, line 27a,
and Schedule 3 (Form 1040), line 11.
1040-NR filers: Enter the amount from Schedule 3 (Form 1040), line 11. 24
25 Subtract line 24 from line 23. If zero or less, enter -0- . . . . . . . . . . . . . . . . . . 25
26 Enter the larger of line 20 or line 25 . . . . . . . . . . . . . . . . . . . . . . . 26
Next, enter the smaller of line 17 or line 26 on line 27.
Part II-C Additional Child Tax Credit
27 Enter this amount on line 15c . . . . . . . . . . . . . . . . . . . . . . . . . 27
REV 04/09/22 Intuit.cg.cfp.sp Schedule 8812 (Form 1040) 2021
BAA
Schedule 8812 (Form 1040) 2021 Page 3
Part III Additional Tax (use only if line 14g or line 15f, whichever applies, is zero)
28a Enter the amount from line 14f or line 15e, whichever applies . . . . . . . . . . . . . . . 28a
b Enter the amount from line 14e or line 15d, whichever applies . . . . . . . . . . . . . . . 28b
29 Excess advance child tax credit payments. Subtract line 28b from line 28a. If zero, stop; you do not owe the
additional tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
30 Enter the number of qualifying children taken into account in determining the annual advance amount you
received for 2021. See your Letter 6419 for this number. If you are missing your Letter 6419, you are filing a joint
return, or you received more than one Letter 6419, see the instructions before entering a number on this line . . 30
Caution: If the amount on this line doesn’t match the number of qualifying children reported to you (and your
spouse if filing jointly) on your Letter(s) 6419, the processing of your return will be delayed.
31 Enter the smaller of line 4a or line 30 . . . . . . . . . . . . . . . . . . . . . . . 31
32 Subtract line 31 from line 30. If zero, skip to line 40 and enter the amount from line 29; otherwise, continue to
line 33 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
33 Enter the amount shown below for your filing status.

}
• Married filing jointly or Qualifying widow(er)—$60,000
• Head of household—$50,000
• All other filing statuses—$40,000 . . . . . . . . . . . . . . . 33
34 Subtract line 33 from line 3. If zero or less, enter -0- . . . . . . . . . . . . . . . . . . 34
35 Enter the amount from line 33 . . . . . . . . . . . . . . . . . . . . . . . . . 35
36 Divide line 34 by line 35. Enter the result as a decimal (rounded to at least three places). If the result is 1.000 or
more, enter 1.000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
37 Multiply line 32 by $2,000 . . . . . . . . . . . . . . . . . . . . . . . . . . 37
38 Multiply line 37 by line 36 . . . . . . . . . . . . . . . . . . . . . . . . . . 38
39 Subtract line 38 from line 37 . . . . . . . . . . . . . . . . . . . . . . . . . 39
40 Subtract line 39 from line 29. If zero or less, enter -0-. This is your additional tax. If more than zero, enter
this amount on Schedule 2 (Form 1040), line 19 . . . . . . . . . . . . . . . . . . . 40
BAA REV 04/09/22 Intuit.cg.cfp.sp Schedule 8812 (Form 1040) 2021
Form 8880 Credit for Qualified Retirement Savings Contributions OMB No. 1545-0074

2021
a Attach to Form 1040, 1040-SR, or 1040-NR.
Department of the Treasury Attachment
Internal Revenue Service a Go to www.irs.gov/Form8880 for the latest information. Sequence No. 54
Name(s) shown on return Your social security number
Erica c & bryan m Villarreal 615-20-2273
You cannot take this credit if either of the following applies.

F
!
CAUTION
• The amount on Form 1040, 1040-SR, or 1040-NR, line 11, is more than $33,000 ($49,500 if head of household; $66,000 if
married filing jointly).
• The person(s) who made the qualified contribution or elective deferral (a) was born after January 1, 2004; (b) is claimed as a
dependent on someone else’s 2021 tax return; or (c) was a student (see instructions).
(a) You (b) Your spouse
1 Traditional and Roth IRA contributions, and ABLE account contributions by the
designated beneficiary for 2021. Do not include rollover contributions . . . . . 1 6,000.
2 Elective deferrals to a 401(k) or other qualified employer plan, voluntary employee
contributions, and 501(c)(18)(D) plan contributions for 2021 (see instructions) . . 2
3 Add lines 1 and 2 . . . . . . . . . . . . . . . . . . . . . . 3 6,000.
4 Certain distributions received after 2018 and before the due date (including
extensions) of your 2021 tax return (see instructions). If married filing jointly, include
both spouses’ amounts in both columns. See instructions for an exception . . . 4
5 Subtract line 4 from line 3. If zero or less, enter -0- . . . . . . . . . . . 5 6,000.
6 In each column, enter the smaller of line 5 or $2,000 . . . . . . . . . . 6 2,000.
7 Add the amounts on line 6. If zero, stop; you can’t take this credit . . . . . . . . . . . . 7 2,000.
8 Enter the amount from Form 1040, 1040-SR, or 1040-NR, line 11* . . . . 8 43,124.
9 Enter the applicable decimal amount from the table below.

If line 8 is— And your filing status is—

Married Head of Single, Married filing
But not
Over— filing jointly household separately, or
over—
Enter on line 9— Qualifying widow(er)
--- $19,750 0.5 0.5 0.5
$19,750 $21,500 0.5 0.5 0.2
$21,500 $29,625 0.5 0.5 0.1 9 x0 .1
$29,625 $32,250 0.5 0.2 0.1
$32,250 $33,000 0.5 0.1 0.1
$33,000 $39,500 0.5 0.1 0.0
$39,500 $43,000 0.2 0.1 0.0
$43,000 $49,500 0.1 0.1 0.0
$49,500 $66,000 0.1 0.0 0.0
$66,000 --- 0.0 0.0 0.0
Note: If line 9 is zero, stop; you can’t take this credit.
10 Multiply line 7 by line 9 . . . . . . . . . . . . . . . . . . . . . . . . . . 10 200.
11 Limitation based on tax liability. Enter the amount from the Credit Limit Worksheet in the instructions 11 1,743.
12 Credit for qualified retirement savings contributions. Enter the smaller of line 10 or line 11 here
and on Schedule 3 (Form 1040), line 4 . . . . . . . . . . . . . . . . . . . . . 12 200.

* See Pub. 590-A for the amount to enter if you claim any exclusion or deduction for foreign earned income, foreign housing, or income from
Puerto Rico or for bona fide residents of American Samoa.
For Paperwork Reduction Act Notice, see your tax return instructions. REV 04/09/22 Intuit.cg.cfp.sp Form 8880 (2021)
BAA
 2200411513

Georgia Form 500(Rev. 08/02/21)

Individual Income Tax Return
Georgia Department of Revenue
2021(Approved software version)
Page 1
Fiscal Year
Beginning STATE SC
ISSUED

rsion) YOUR DRIVER’S

Fiscal Year
LICENSE/STATE ID
Ending 105228091

YOUR FIRST NAME MI YOUR SOCIAL SECURITY NUMBER

1. ERICA C 615-20-2273
LAST NAME (For Name Change See IT-511 Tax Booklet) SUFFIX
VILLARREAL
SPOUSE’S FIRST NAME MI SPOUSE’S SOCIAL SECURITY NUMBER
BRYAN M 458-37-2792 DEPARTMENT USE ONLY

LAST NAME SUFFIX

VILLARREAL

ADDRESS (NUMBER AND STREET or P.O. BOX) (Use 2nd address line for Apt, Suite or Building Number) CHECK IF ADDRESS HAS CHANGED
2. 1950 BOLIN RD

CITY (Please insert a space if the city has multiple names) STATE ZIP CODE
3. NORTH AUGUSTA SC 298412215

(COUNTRY IF FOREIGN)
Residency Status
4. Enter your Residency Status with the appropriate number ....
...................................................................................................... 4. 3
1. FULL- YEAR RESIDENT 2. PART- YEAR RESIDENT TO 3. NONRESIDENT

Omit Lines 9 thru 14 and use Form 500 Schedule 3 if you are a part-year or nonresident filer.
Filing Status
5. Enter Filing Status with appropriate letter (See I T - 5 1 1 Tax Booklet)...................................................................................
.... .... 5. B
A. Single B.Married filing joint C.Married filing separate(Spouse’s social security number must be entered above) D. Head of Household or Qualifying Widow(er)

6. Number of exemptions (Check appropriate box(es) and enter total in 6c.) 6a. Yourself 6b. Spouse 6c. 2
7a. Number of Dependents (Enter details on Line 7b., and DO NOT include yourself or your spouse)...................................... 7a. 3

PAGES (1-5) ARE REQUIRED FOR PROCESSING REV 03/22/22 INTUIT.CG.CFP.SP

Georgia Form 500
Individual Income Tax Return
Georgia Department of Revenue 2200411523 YOUR SOCIAL SECURITY NUMBER
2021 615-20-2273
Pag e 2
7b. Dependents (If you have more than 4 dependents, attach a list of additional dependents)
First Name, MI. Last Name
MOLLY VILLARREAL
Social Security Number Relationship to You
443-25-1429 DAUGHTER
First Name, MI. Last Name
CLARE VILLARREAL

Social Security Number Relationship to You

644-29-2599 DAUGHTER

First Name, MI. Last Name

CAL VILLARREAL
Social Security Number Relationship to You
373-99-8025 SON
First Name, MI. Last Name

Social Security Number Relationship to You

INCOME COMPUTATIONS
If amount on line 8, 9, 10, 13 or 15 is negative, use the minus sign (-). Example -3456.

8. Federal adjusted gross income (From Federal Form 1040)..................................... 8. 43124

(Do not use FEDERAL TAXABLE INCOME) If the amount on Line 8 is $40,000 or more, or your gross income is less than your
W-2s you must include a copy of your Federal Form 1040 Pages 1, 2, and Schedule 1.
9. Adjustments from Form 500 Schedule 1 (See IT-511 Tax Booklet) ....................... 9.

10. Georgia adjusted gross income (Net total of Line 8 and Line 9)............................. 10.

11. Standard Deduction (Do not use FEDERAL STANDARD DEDUCTION).............. 11a.
(See IT-511 Tax Booklet)

b. Self: 65 or over? Blind? Total x 1,300=......................... 11b.

Spouse: 65 or over? Blind?
c. Total Standard Deduction (Line 11a + Line 11b)................................................... 11c.
Use EITHER Line 11c OR Line 12c (Do not write on both lines)

12. Total Itemized Deductions used in computing Federal Taxable Income. If you use itemized deductions, you must include Federal Schedule A.

a. Federal Itemized Deductions (Schedule A- Form 1040)............................... 12a.

b. Less adjustments: (See IT-511 Tax Booklet) ................................................ 12b.

c. Georgia Total Itemized Deductions.................................................................. 12c.

13. Subtract either Line 11c or Line 12c from Line 10; enter balance.......................... 13.

PAGES (1-5) ARE REQUIRED FOR PROCESSING REV 03/22/22 INTUIT.CG.CFP.SP

Georgia Form 500
Individual Income Tax Return
Georgia Department of Revenue 2200411533 YOUR SOCIAL SECURITY NUMBER
2021 615-20-2273
Pag e 3
14a. Enter the number from Line 6c. Multiply by $2,700 for filing status A or D 14a.
or multiply by $3,700 for filing status B or C

14b. Enter the number from Line 7a. Multiply by $3,000.......................................... 14b.

14c. Add Lines 14a. and 14b. Enter total ...................................................... 14c.

15a. Income before GA NOL (Line 13 less Line 14c or Schedule 3, Line 14)..... 15a. 20124
15b. Georgia NOL utilized (Cannot exceed Line 15a or the amount after
applying the 80% limitation, see IT-511 Tax Booklet for more information)....15b.

15c. Georgia Taxable Income (Line 15a less Line 15b)..................................... 15c. 20124
16. Tax (Use Tax Table or Tax Rate Schedule in the IT-511 Tax Booklet) ....... 16. 922

17. Low Income Credit 17a. 17b. ........................ 17c.

18. Other State(s) Tax Credit (Include a copy of the other state(s) return) ....... 18.

19. Credits used from IND-CR Summary Worksheet ........................................ 19.

20. Total Credits Used from Schedule 2 Georgia Tax Credits (must be filed 20.
electronically)
21. Total Credits Used (sum of Lines 17-20) cannot exceed Line 16 ............................. 21. 0
22. Balance (Line 16 less Line 21) if zero or less than zero, enter zero .......... 22. 922

INCOME STATEMENT DETAILS Only enter income on which Georgia tax was withheld. Enter income from W-2s, 1099s, and G2-As on Line 4
GA Wages/Income. For other income statements complete Line 4 using the income reported from Form G2-RP Line 12 or 13; Form G2-LP Line
11, or for Form G2-FL enter zero.
(INCOME STATEMENT A) (INCOME STATEMENT B) (INCOME STATEMENT C)

1. WITHHOLDING TYPE: 1. WITHHOLDING TYPE: 1. WITHHOLDING TYPE:

W-2 G2-A G2-LP W-2 G2-A G2-LP W-2 G2-A G2-LP
1099 G2-FL G2-RP 1099 G2-FL G2-RP 1099 G2-FL G2-RP
2. EMPLOYER/PAYER FEDERAL 2. EMPLOYER/PAYER FEDERAL 2. EMPLOYER/PAYER FEDERAL
ID NUMBER (FEIN) SSN ID NUMBER (FEIN) SSN ID NUMBER (FEIN) SSN

581554402

3. EMPLOYER/PAYER STATE WITHHOLDING ID 3. EMPLOYER/PAYER STATE WITHHOLDING ID 3. EMPLOYER/PAYER STATE WITHHOLDING ID

1853286ZX
4. GA WAGES / INCOME 4. GA WAGES / INCOME 4. GA WAGES / INCOME
54317

5. GA TAX WITHHELD 5. GA TAX WITHHELD 5. GA TAX WITHHELD

1211

PLEASE COMPLETE INCOME STATEMENT DETAILS ON PAGE 4.

PAGES (1-5) ARE REQUIRED FOR PROCESSING REV 03/22/22 INTUIT.CG.CFP.SP

INTUIT 01 1555 115 2021 GA 004 T1 21

Georgia Form 500
Individual Income Tax Return
Georgia Department of Revenue 2200411543 YOUR SOCIAL SECURITY NUMBER
2021 615-20-2273
Page 4
(INCOME STATEMENT D) (INCOME STATEMENT E) (INCOME STATEMENT F)
1. WITHHOLDING TYPE: 1. WITHHOLDING TYPE: 1. WITHHOLDING TYPE:
W-2 G2-A G2-LP W-2 G2-A G2-LP W-2 G2-A G2-LP
1099 G2-FL G2-RP 1099 G2-FL G2-RP 1099 G2-FL G2-RP
2. EMPLOYER/PAYER FEDERAL 2. EMPLOYER/PAYER FEDERAL 2. EMPLOYER/PAYER FEDERAL
ID NUMBER (FEIN) SSN ID NUMBER (FEIN) SSN ID NUMBER (FEIN) SSN

3. EMPLOYER/PAYER STATE WITHHOLDING ID 3. EMPLOYER/PAYER STATE WITHHOLDING ID 3. EMPLOYER/PAYER STATE WITHHOLDING ID

4. GA WAGES / INCOME 4. GA WAGES / INCOME 4. GA WAGES / INCOME

5. GA TAX WITHHELD 5. GA TAX WITHHELD 5. GA TAX WITHHELD

23. Georgia Income Tax Withheld on Wages and 1099s ............................. 23. 1211
(Enter Tax Withheld Only and include W-2s and/or 1099s)
24. Other Georgia Income Tax Withheld ........................................................ 24.
(Must include G2-A, G2-FL, G2-LP and/or G2-RP)
25. Estimated Tax paid for 2021 and Form IT-560 ......................................... 25.

26. Schedule 2B Refundable Tax Credits.......................................................... 26.

(Cannot be claimed unless filed electronically)
27. Total prepayment credits (Add Lines 23, 24, 25 and 26)........................... 27. 1211
28. If Line 22 exceeds Line 27, subtract Line 27 from Line 22 and enter
balance due............................................................................................... 28.
29. If Line 27 exceeds Line 22, subtract Line 22 from Line 27 and enter
overpayment .............................................................................................. 29. 289

30. Amount to be credited to 2022 ESTIMATED TAX ................................. 30. 0

31. Georgia Wildlife Conservation Fund (No gift of less than $1.00)............. 31.

32. Georgia Fund for Children and Elderly (No gift of less than $1.00)........ 32.

33. Georgia Cancer Research Fund (No gift of less than $1.00) ................. 33.

34. Georgia Land Conservation Program (No gift of less than $1.00)........... 34.

35. Georgia National Guard Foundation (No gift of less than $1.00) ............. 35.

36. Dog & Cat Sterilization Fund (No gift of less than $1.00) ....................... 36.

37. Saving the Cure Fund (No gift of less than $1.00)................................. 37.

38. Realizing Educational Achievement Can Happen (REACH) Program ............. 38.
(No gift of less than $1.00)
PAGES (1-5) ARE REQUIRED FOR PROCESSING
 Georgia Form 500
Individual Income Tax Return
Georgia Department of Revenue 2200411553 YOUR SOCIAL SECURITY NUMBER
2021 615-20-2273
Pag e 5
39. Public Safety Memorial Grant (No gift of less than $1.00)....................... 39.

40. Form 500 UET (Estimated tax penalty) 500 UET exception attached 40.

41. (If you owe) Add Lines 28, 31 thru 40 41.

MAKE CHECK PAYABLE TO GEORGIA DEPARTMENT OF REVENUE..

Amount Due Mail To:

GEORGIA DEPARTMENT OF REVENUE
PROCESSING CENTER, PO BOX 740399
ATLANTA, GA 30374-0399

42. (If you are due a refund) Subtract the sum of Lines 30 thru 40 from Line 29
THIS IS YOUR REFUND......................................................................... 42. 289
If you do not enter Direct Deposit information or if you are a first time filer you will be issued a paper check.
42a. Direct Deposit (U.S. Accounts Only)
Routing Refund Due Mail To:
Type: Checking Number 113000023 GEORGIA DEPARTMENT OF REVENUE
Savings Account PROCESSING CENTER, PO BOX 740380
Number 586030434393 ATLANTA, GA 30374-0380

INCLUDE ALL ITEMS IN ENVELOPE, DO NOT STAPLE YOUR CHECK, W-2s, OTHER WITHHOLDING DOCUMENTS, OR TAX RETURN.
I/We declare under the penalties of perjury that I/we have examined this return (including accompanying schedules and statements) and to the best of my/our knowledge
and belief, it is true, correct, and complete. If prepared by a person other than the taxpayer(s), this declaration is based on all information of which the preparer has knowledge.

Taxpayer’s Signature (Check box if deceased) Spouse’s Signature (Check box if deceased)

Taxpayer’s Date of Death Spouse’s Date of Death

Taxpayer’s Signature Date Taxpayer’s Phone Number Spouse’s Signature Date

405-269-9332

By providing my e-mail address I am authorizing the Georgia Department of Revenue to electronically notify me at the below e-ma il address regarding any updates to
my account(s).
Taxpayer’s E-mail Address
I authorize DOR to discuss this return
with the named preparer.

Preparer’s Phone Number

Signature of Preparer
Name of Preparer Other Than Taxpayer Preparer’s FEIN
SELF-PREPARED

Preparer’s Firm Name Preparer’s SSN/PTIN/SIDN

REV 03/22/22 INTUIT.CG.CFP.SP

PAGES (1-5) ARE REQUIRED FOR PROCESSING

 Schedule 1
Georgia Form
(Rev. 08/02/21)
500 Page 1
Schedule 1 2207211513 YOUR SOCIAL SECURITY NUMBER
Adjustments to Income 615-20-2273
2021 (Approved software version)

SCHEDULE 1 ADJUSTMENTS to INCOME BASED on GEORGIA LAW See IT-511 Tax Booklet

ADDITIONS to INCOME
1. Interest on Non-Georgia Municipal and State Bonds ................................... 1.

2. Lump Sum Distributions ......................................................................................... 2.

3. Reserved...................................................................................................................... 3.

4. Net operating loss carryover deducted on Federal return....................................... 4.

5. Other (Specify) 5.

6. Total Additions (Enter sum of Lines 1-5 here).............................................. 6.

SUBTRACTION from INCOME

7. Retirement Income Exclusion (See IT-511 Tax Booklet) Complete Schedule 1, page 2 if claiming Retirement Income Exclusion.
a. Self: Date of Birth Date of Disability: Type of Disability:

7a.

b. Spouse: Date of Birth Date of Disability: Type of Disability:

7b.

8. Social Security Benefits (Taxable portion from Federal return) .................... 8.

9. Path2College 529 Plan .............................................................................. 9.

10. Interest on United States Obligations (See IT-511 Tax Booklet ) 10.

11. Reserved .................................................................................................. 11.

12. Other Adjustments (Specify)

Adjustment CHARITABLE DED Amount 600

Adjustment Amount

Adjustment Amount

Adjustment Amount

Total .............................. 12. 600

13. Total Subtractions (Enter sum of Lines 7-12 here) ....................................... 13. 600

14. Net Adjustments (Line 6 less Line 13). Enter Net Total here and on
Line 9 of Page 2 (+ or -) of Form 500 or 500 X .......................................... 14. -600
REV 03/22/22 INTUIT.CG.CFP.SP
 Schedule 1
Georgia Form 500 Page 2
(Rev. 08/02/21)
Schedule 1 2207211523 YOUR SOCIAL SECURITY NUMBER
Adjustments to Income 615-20-2273
2021 (Approved software version)

SCHEDULE 1 RETIREMENT INCOME EXCLUSION See IT-511 Tax Booklet

(TAXPAYER) (SPOUSE)

1. Salary and wages......................................

2. Other Earned Income (Losses).....................

3. Total Earned Income....................................

4. Maximum Earned Income...........................

5. Smaller of Line 3 or 4; if zero or less, enter

zero ..........................................................

6. Interest Income.........................................

7. Dividend Income .......................................

8. Alimony......................................................

9. Capital Gains (Losses)...............................

10. Other Income (Losses)..............................

(See IT-511 Tax Booklet)

11. Taxable IRA Distributions.........................

12. Taxable Pensions .....................................

13. Rental, Royalty, Partnership, S Corp, etc.

Income (Losses).....(See IT-511 Tax Booklet)

14. Total of Lines 6 through 13; if zero or less,

enter zero ................................................

15. Add Lines 5 and 14 ....................................

16. Maximum Allowable Exclusion* ..................

17. Smaller of Lines 15 and 16; enter here and on

Form 500, Schedule 1, Lines 7a. & b........

*If age 62-64 or less than age 62 and permanently disabled enter $35,000, or if age 65 or older enter $65,000.

REV 03/22/22 INTUIT.CG.CFP.SP

 Schedule 3
Georgia Form
(Rev. 08/02/21)
500 Page 1
Schedule 3 2207411513 YOUR SOCIAL SECURITY NUMBER
Part-Year Nonresident 615-20-2273
2021 (Approved software version) DO NOT USE LINES 9 THRU 14 OF PAGES 2 AND 3 FORM 500 or 500X
SCHEDULE 3 COMPUTATION OF GEORGIA TAXABLE INCOME FOR ONLY PART-YEAR RESIDENTS AND NONRESIDENTS.
Income earned in another state as a Georgia resident is taxable but other state(s) tax credit may apply. See IT-511 Tax Booklet.
FEDERAL INCOME AFTER GEORGIA ADJUSTMENT INCOME NOT TAXABLE TO GEORGIA GEORGIA INCOME
(COLUMN A) (COLUMN B) (COLUMN C)

1. WAGES, SALARIES, TIPS, etc 1. WAGES, SALARIES, TIPS, etc 1. WAGES, SALARIES, TIPS, etc
54317 0 54317
2. INTEREST AND DIVIDENDS 2. INTEREST AND DIVIDENDS 2. INTEREST AND DIVIDENDS

3. BUSINESS INCOME OR (LOSS) 3. BUSINESS INCOME OR (LOSS) 3. BUSINESS INCOME OR (LOSS)

4. OTHER INCOME OR (LOSS) 4. OTHER INCOME OR (LOSS) 4. OTHER INCOME OR (LOSS)

0 0
5. TOTAL INCOME: TOTAL LINES 1 THRU 4 5. TOTAL INCOME: TOTAL LINES 1 THRU 4 5. TOTAL INCOME: TOTAL LINES 1 THRU 4
54317 0 54317
6. TOTAL ADJUSTMENTS FROM FORM 1040 6. TOTAL ADJUSTMENTS FROM FORM 1040 6. TOTAL ADJUSTMENTS FROM FORM 1040
11193 0 11193

7. TOTAL ADJUSTMENTS FROM FORM 500, 7. TOTAL ADJUSTMENTS FROM FORM 500, 7. TOTAL ADJUSTMENTS FROM FORM 500,
SCHEDULE 1 SCHEDULE 1 SCHEDULE 1
-600 0 -600
8. ADJUSTED GROSS INCOME: 8. ADJUSTED GROSS INCOME: 8. ADJUSTED GROSS INCOME:
LINE 5 PLUS OR MINUS LINES 6 AND 7 LINE 5 PLUS OR MINUS LINES 6 AND 7 LINE 5 PLUS OR MINUS LINES 6 AND 7

42524 0 42524

9. RATIO: Divide Line 8, Column C by Line 8, Column A enter percentage or % Not to exceed 100%
check the box for Time Ratio. Enter percentage...................................... 9. 100.00
10a. Itemized or Standard Deduction or Georgia Itemized (See IT-511 Tax Booklet) 10a. 6000
10b. Additional Standard Deduction
Self: 65 or over? Blind? Spouse: 65 or over? Blind? Total X 1,300= 10b.

11. Personal Exemptions from Form 500 or Form 500X (See IT-511 Tax Booklet)

11a. Enter the number on Line 6c from Form 500 or Form 500X 2 multiply by $2,700 for
filing status A or D or multiply by $3,700 for filing status B or C..................................... 11a. 7400
11b. Enter the number on Line 7a from Form 500 or Form 500X 3 multiply by $3,000 .. 11b. 9000
12. Total Deductions and Exemptions: Add Lines 10a, 10b, 11a, and 11b ............ 12. 22400
13. Multiply Line 12 by Ratio on Line 9 and enter result............................................ 13. 22400
14. Income before GA NOL: Subtract Line 13 from Line 8, Column C
Enter here and on Line 15a, Page 3 of Form 500 or Form 500X........................ 14. 20124

REV 03/22/22 INTUIT.CG.CFP.SP

 DO NOT ERO MUST RETAIN THIS FORM.
E
PLEAS DO NOT SUBMIT THIS FORM TO

MA
GEORGIA DEPARTMENT OF REVENUE

IL!
UNLESS REQUESTED TO DO SO.
IRS DCN OR SUBMISSION ID GA-8453
2021

GEORGIA INDIVIDUAL INCOME TAX DECLARATION FOR ELECTRONIC FILING

SUMMARY OF AGREEMENT BETWEEN TAXPAYER AND ERO OR PAID PREPARER
Amended Return
First Name and Initial Last Name Social Security Number

ERICA C VILLARREAL 615-20-2273

If Joint Return, Spouse’s First Name and Initial Spouse’s Last Name Spouse’s Social Security Number
BRYAN M VILLARREAL 458-37-2792
Home Address (number and street) Apt Number Daytime Telephone Number
1950 BOLIN RD 405-269-9332
City, Town or Post Office State Zip Code
NORTH AUGUSTA SC 29841-2215
PART I TAX RETURN INFORMATION
1. Federal Adjusted Gross Income (Form 500 , Line 8; Form 500EZ, Line 1) .................. 1. 43124
2. Georgia Taxable Income (Form 500 , Line 15c; Form 500EZ, Line 3) ......................... 2. 20124
3. Net Georgia Tax (Form 500 , Line 22; Form 500EZ, Line 6) ........................................ 3. 922
4.. Balance Due (Form 500, Line 41; Form 500X, Line 37; Form 500EZ, Line 20) ................................. 4.
5.. Refund (Form 500, Line 42; Form 500X, Line 38; Form 500EZ, Line 21) ............................................ 5. 289
PART II DECLARATION OF TAXPAYER(S)
Under penalties of perjury, I declare that the information I have provided to my Electronic Return Originator (ERO) and/or Online Service
Provider and/or Transmitter and the amounts shown in Part I agree with the amounts shown on the corresponding lines of the
electronic portion of my 2021 Georgia Income Tax Return. I declare that I have examined my tax return, including accompanying
schedules and statements, and to the best of my knowledge and belief, my return is true, correct and complete. I consent that the
electronic portion of my return may be sent by my ERO/Online Service Provider/Transmitter.

SIGN
HERE TAXPAYER’S SIGNATURE Date SPOUSE’S SIGNATURE (if joint return, both must sign) Date

PRINT NAME EMAIL ADDRESS

PART III DECLARATION OF ELECTRONIC RETURNS ORIGINATOR AND PAID PREPARER

I DECLARE THAT I HAVE REVIEWED THE ABOVE TAXPAYER’S RETURN AND THAT THE ENTRIES ON THE GA-8453 ARE COMPLETE
AND CORRECT TO THE BEST OF MY KNOWLEDGE.

ERO’s Signature _____________________________________________________________ Date ______________________

ERO’s
Firm’s Name _______________________________________________________________ Check also if paid preparer
Use
Address _______________________________________________________________ FEIN/PTIN
Only
City, State, & Zip Code_________________________________________________________ SSN/TIN
IF PREPARED BYANY PERSON OTHER THAN THE TAXPAYER, THIS DECLARATION IS BASED ON ALL INFORMATION OF WHICH
THE PREPARER HAS ANY KNOWLEDGE.

Paid Preparer’s Signature _____________________________________________________

SELF PREPARED Date ______________________
Paid
Firm’s Name _______________________________________________________________ FID/TIN
Preparer’s
Use Only Address _______________________________________________________________ SSN/TIN
City, State, & Zip Code_________________________________________________________
GA-8453 (REV 03/30/21)
KEEP A COPY WITH YOUR RECORDS
REV 03/22/22 INTUIT.CG.CFP.SP
INTUIT 01 115 2021
 2200411513

Georgia Form 500(Rev. 08/02/21)

Individual Income Tax Return
Georgia Department of Revenue
2021(Approved software version)
Page 1
Fiscal Year
Beginning STATE SC
ISSUED

rsion) YOUR DRIVER’S

Fiscal Year
LICENSE/STATE ID
Ending 105228091

YOUR FIRST NAME MI YOUR SOCIAL SECURITY NUMBER

1. ERICA C 615-20-2273
LAST NAME (For Name Change See IT-511 Tax Booklet) SUFFIX
VILLARREAL
SPOUSE’S FIRST NAME MI SPOUSE’S SOCIAL SECURITY NUMBER
BRYAN M 458-37-2792 DEPARTMENT USE ONLY

LAST NAME SUFFIX

VILLARREAL

ADDRESS (NUMBER AND STREET or P.O. BOX) (Use 2nd address line for Apt, Suite or Building Number) CHECK IF ADDRESS HAS CHANGED
2. 1950 BOLIN RD

CITY (Please insert a space if the city has multiple names) STATE ZIP CODE
3. NORTH AUGUSTA SC 298412215

(COUNTRY IF FOREIGN)
Residency Status
4. Enter your Residency Status with the appropriate number ....
...................................................................................................... 4. 3
1. FULL- YEAR RESIDENT 2. PART- YEAR RESIDENT TO 3. NONRESIDENT

Omit Lines 9 thru 14 and use Form 500 Schedule 3 if you are a part-year or nonresident filer.
Filing Status
5. Enter Filing Status with appropriate letter (See I T - 5 1 1 Tax Booklet)...................................................................................
.... .... 5. B
A. Single B.Married filing joint C.Married filing separate(Spouse’s social security number must be entered above) D. Head of Household or Qualifying Widow(er)

6. Number of exemptions (Check appropriate box(es) and enter total in 6c.) 6a. Yourself 6b. Spouse 6c. 2
7a. Number of Dependents (Enter details on Line 7b., and DO NOT include yourself or your spouse)...................................... 7a. 3

PAGES (1-5) ARE REQUIRED FOR PROCESSING REV 03/22/22 INTUIT.CG.CFP.SP

Georgia Form 500
Individual Income Tax Return
Georgia Department of Revenue 2200411523 YOUR SOCIAL SECURITY NUMBER
2021 615-20-2273
Pag e 2
7b. Dependents (If you have more than 4 dependents, attach a list of additional dependents)
First Name, MI. Last Name
MOLLY VILLARREAL
Social Security Number Relationship to You
443-25-1429 DAUGHTER
First Name, MI. Last Name
CLARE VILLARREAL

Social Security Number Relationship to You

644-29-2599 DAUGHTER

First Name, MI. Last Name

CAL VILLARREAL
Social Security Number Relationship to You
373-99-8025 SON
First Name, MI. Last Name

Social Security Number Relationship to You

INCOME COMPUTATIONS
If amount on line 8, 9, 10, 13 or 15 is negative, use the minus sign (-). Example -3456.

8. Federal adjusted gross income (From Federal Form 1040)..................................... 8. 43124

(Do not use FEDERAL TAXABLE INCOME) If the amount on Line 8 is $40,000 or more, or your gross income is less than your
W-2s you must include a copy of your Federal Form 1040 Pages 1, 2, and Schedule 1.
9. Adjustments from Form 500 Schedule 1 (See IT-511 Tax Booklet) ....................... 9.

10. Georgia adjusted gross income (Net total of Line 8 and Line 9)............................. 10.

11. Standard Deduction (Do not use FEDERAL STANDARD DEDUCTION).............. 11a.
(See IT-511 Tax Booklet)

b. Self: 65 or over? Blind? Total x 1,300=......................... 11b.

Spouse: 65 or over? Blind?
c. Total Standard Deduction (Line 11a + Line 11b)................................................... 11c.
Use EITHER Line 11c OR Line 12c (Do not write on both lines)

12. Total Itemized Deductions used in computing Federal Taxable Income. If you use itemized deductions, you must include Federal Schedule A.

a. Federal Itemized Deductions (Schedule A- Form 1040)............................... 12a.

b. Less adjustments: (See IT-511 Tax Booklet) ................................................ 12b.

c. Georgia Total Itemized Deductions.................................................................. 12c.

13. Subtract either Line 11c or Line 12c from Line 10; enter balance.......................... 13.

PAGES (1-5) ARE REQUIRED FOR PROCESSING REV 03/22/22 INTUIT.CG.CFP.SP

Georgia Form 500
Individual Income Tax Return
Georgia Department of Revenue 2200411533 YOUR SOCIAL SECURITY NUMBER
2021 615-20-2273
Pag e 3
14a. Enter the number from Line 6c. Multiply by $2,700 for filing status A or D 14a.
or multiply by $3,700 for filing status B or C

14b. Enter the number from Line 7a. Multiply by $3,000.......................................... 14b.

14c. Add Lines 14a. and 14b. Enter total ...................................................... 14c.

15a. Income before GA NOL (Line 13 less Line 14c or Schedule 3, Line 14)..... 15a. 20124
15b. Georgia NOL utilized (Cannot exceed Line 15a or the amount after
applying the 80% limitation, see IT-511 Tax Booklet for more information)....15b.

15c. Georgia Taxable Income (Line 15a less Line 15b)..................................... 15c. 20124
16. Tax (Use Tax Table or Tax Rate Schedule in the IT-511 Tax Booklet) ....... 16. 922

17. Low Income Credit 17a. 17b. ........................ 17c.

18. Other State(s) Tax Credit (Include a copy of the other state(s) return) ....... 18.

19. Credits used from IND-CR Summary Worksheet ........................................ 19.

20. Total Credits Used from Schedule 2 Georgia Tax Credits (must be filed 20.
electronically)
21. Total Credits Used (sum of Lines 17-20) cannot exceed Line 16 ............................. 21. 0
22. Balance (Line 16 less Line 21) if zero or less than zero, enter zero .......... 22. 922

INCOME STATEMENT DETAILS Only enter income on which Georgia tax was withheld. Enter income from W-2s, 1099s, and G2-As on Line 4
GA Wages/Income. For other income statements complete Line 4 using the income reported from Form G2-RP Line 12 or 13; Form G2-LP Line
11, or for Form G2-FL enter zero.
(INCOME STATEMENT A) (INCOME STATEMENT B) (INCOME STATEMENT C)

1. WITHHOLDING TYPE: 1. WITHHOLDING TYPE: 1. WITHHOLDING TYPE:

W-2 G2-A G2-LP W-2 G2-A G2-LP W-2 G2-A G2-LP
1099 G2-FL G2-RP 1099 G2-FL G2-RP 1099 G2-FL G2-RP
2. EMPLOYER/PAYER FEDERAL 2. EMPLOYER/PAYER FEDERAL 2. EMPLOYER/PAYER FEDERAL
ID NUMBER (FEIN) SSN ID NUMBER (FEIN) SSN ID NUMBER (FEIN) SSN

581554402

3. EMPLOYER/PAYER STATE WITHHOLDING ID 3. EMPLOYER/PAYER STATE WITHHOLDING ID 3. EMPLOYER/PAYER STATE WITHHOLDING ID

1853286ZX
4. GA WAGES / INCOME 4. GA WAGES / INCOME 4. GA WAGES / INCOME
54317

5. GA TAX WITHHELD 5. GA TAX WITHHELD 5. GA TAX WITHHELD

1211

PLEASE COMPLETE INCOME STATEMENT DETAILS ON PAGE 4.

PAGES (1-5) ARE REQUIRED FOR PROCESSING REV 03/22/22 INTUIT.CG.CFP.SP

INTUIT 01 1555 115 2021 GA 004 T1 21

Georgia Form 500
Individual Income Tax Return
Georgia Department of Revenue 2200411543 YOUR SOCIAL SECURITY NUMBER
2021 615-20-2273
Page 4
(INCOME STATEMENT D) (INCOME STATEMENT E) (INCOME STATEMENT F)
1. WITHHOLDING TYPE: 1. WITHHOLDING TYPE: 1. WITHHOLDING TYPE:
W-2 G2-A G2-LP W-2 G2-A G2-LP W-2 G2-A G2-LP
1099 G2-FL G2-RP 1099 G2-FL G2-RP 1099 G2-FL G2-RP
2. EMPLOYER/PAYER FEDERAL 2. EMPLOYER/PAYER FEDERAL 2. EMPLOYER/PAYER FEDERAL
ID NUMBER (FEIN) SSN ID NUMBER (FEIN) SSN ID NUMBER (FEIN) SSN

3. EMPLOYER/PAYER STATE WITHHOLDING ID 3. EMPLOYER/PAYER STATE WITHHOLDING ID 3. EMPLOYER/PAYER STATE WITHHOLDING ID

4. GA WAGES / INCOME 4. GA WAGES / INCOME 4. GA WAGES / INCOME

5. GA TAX WITHHELD 5. GA TAX WITHHELD 5. GA TAX WITHHELD

23. Georgia Income Tax Withheld on Wages and 1099s ............................. 23. 1211
(Enter Tax Withheld Only and include W-2s and/or 1099s)
24. Other Georgia Income Tax Withheld ........................................................ 24.
(Must include G2-A, G2-FL, G2-LP and/or G2-RP)
25. Estimated Tax paid for 2021 and Form IT-560 ......................................... 25.

26. Schedule 2B Refundable Tax Credits.......................................................... 26.

(Cannot be claimed unless filed electronically)
27. Total prepayment credits (Add Lines 23, 24, 25 and 26)........................... 27. 1211
28. If Line 22 exceeds Line 27, subtract Line 27 from Line 22 and enter
balance due............................................................................................... 28.
29. If Line 27 exceeds Line 22, subtract Line 22 from Line 27 and enter
overpayment .............................................................................................. 29. 289

30. Amount to be credited to 2022 ESTIMATED TAX ................................. 30. 0

31. Georgia Wildlife Conservation Fund (No gift of less than $1.00)............. 31.

32. Georgia Fund for Children and Elderly (No gift of less than $1.00)........ 32.

33. Georgia Cancer Research Fund (No gift of less than $1.00) ................. 33.

34. Georgia Land Conservation Program (No gift of less than $1.00)........... 34.

35. Georgia National Guard Foundation (No gift of less than $1.00) ............. 35.

36. Dog & Cat Sterilization Fund (No gift of less than $1.00) ....................... 36.

37. Saving the Cure Fund (No gift of less than $1.00)................................. 37.

38. Realizing Educational Achievement Can Happen (REACH) Program ............. 38.
(No gift of less than $1.00)
PAGES (1-5) ARE REQUIRED FOR PROCESSING
 Georgia Form 500
Individual Income Tax Return
Georgia Department of Revenue 2200411553 YOUR SOCIAL SECURITY NUMBER
2021 615-20-2273
Pag e 5
39. Public Safety Memorial Grant (No gift of less than $1.00)....................... 39.

40. Form 500 UET (Estimated tax penalty) 500 UET exception attached 40.

41. (If you owe) Add Lines 28, 31 thru 40 41.

MAKE CHECK PAYABLE TO GEORGIA DEPARTMENT OF REVENUE..

Amount Due Mail To:

GEORGIA DEPARTMENT OF REVENUE
PROCESSING CENTER, PO BOX 740399
ATLANTA, GA 30374-0399

42. (If you are due a refund) Subtract the sum of Lines 30 thru 40 from Line 29
THIS IS YOUR REFUND......................................................................... 42. 289
If you do not enter Direct Deposit information or if you are a first time filer you will be issued a paper check.
42a. Direct Deposit (U.S. Accounts Only)
Routing Refund Due Mail To:
Type: Checking Number 113000023 GEORGIA DEPARTMENT OF REVENUE
Savings Account PROCESSING CENTER, PO BOX 740380
Number 586030434393 ATLANTA, GA 30374-0380

INCLUDE ALL ITEMS IN ENVELOPE, DO NOT STAPLE YOUR CHECK, W-2s, OTHER WITHHOLDING DOCUMENTS, OR TAX RETURN.
I/We declare under the penalties of perjury that I/we have examined this return (including accompanying schedules and statements) and to the best of my/our knowledge
and belief, it is true, correct, and complete. If prepared by a person other than the taxpayer(s), this declaration is based on all information of which the preparer has knowledge.

Taxpayer’s Signature (Check box if deceased) Spouse’s Signature (Check box if deceased)

Taxpayer’s Date of Death Spouse’s Date of Death

Taxpayer’s Signature Date Taxpayer’s Phone Number Spouse’s Signature Date

405-269-9332

By providing my e-mail address I am authorizing the Georgia Department of Revenue to electronically notify me at the below e-ma il address regarding any updates to
my account(s).
Taxpayer’s E-mail Address
I authorize DOR to discuss this return
with the named preparer.

Preparer’s Phone Number

Signature of Preparer
Name of Preparer Other Than Taxpayer Preparer’s FEIN
SELF-PREPARED

Preparer’s Firm Name Preparer’s SSN/PTIN/SIDN

REV 03/22/22 INTUIT.CG.CFP.SP

PAGES (1-5) ARE REQUIRED FOR PROCESSING

 Schedule 1
Georgia Form
(Rev. 08/02/21)
500 Page 1
Schedule 1 2207211513 YOUR SOCIAL SECURITY NUMBER
Adjustments to Income 615-20-2273
2021 (Approved software version)

SCHEDULE 1 ADJUSTMENTS to INCOME BASED on GEORGIA LAW See IT-511 Tax Booklet

ADDITIONS to INCOME
1. Interest on Non-Georgia Municipal and State Bonds ................................... 1.

2. Lump Sum Distributions ......................................................................................... 2.

3. Reserved...................................................................................................................... 3.

4. Net operating loss carryover deducted on Federal return....................................... 4.

5. Other (Specify) 5.

6. Total Additions (Enter sum of Lines 1-5 here).............................................. 6.

SUBTRACTION from INCOME

7. Retirement Income Exclusion (See IT-511 Tax Booklet) Complete Schedule 1, page 2 if claiming Retirement Income Exclusion.
a. Self: Date of Birth Date of Disability: Type of Disability:

7a.

b. Spouse: Date of Birth Date of Disability: Type of Disability:

7b.

8. Social Security Benefits (Taxable portion from Federal return) .................... 8.

9. Path2College 529 Plan .............................................................................. 9.

10. Interest on United States Obligations (See IT-511 Tax Booklet ) 10.

11. Reserved .................................................................................................. 11.

12. Other Adjustments (Specify)

Adjustment CHARITABLE DED Amount 600

Adjustment Amount

Adjustment Amount

Adjustment Amount

Total .............................. 12. 600

13. Total Subtractions (Enter sum of Lines 7-12 here) ....................................... 13. 600

14. Net Adjustments (Line 6 less Line 13). Enter Net Total here and on
Line 9 of Page 2 (+ or -) of Form 500 or 500 X .......................................... 14. -600
REV 03/22/22 INTUIT.CG.CFP.SP
 Schedule 1
Georgia Form 500 Page 2
(Rev. 08/02/21)
Schedule 1 2207211523 YOUR SOCIAL SECURITY NUMBER
Adjustments to Income 615-20-2273
2021 (Approved software version)

SCHEDULE 1 RETIREMENT INCOME EXCLUSION See IT-511 Tax Booklet

(TAXPAYER) (SPOUSE)

1. Salary and wages......................................

2. Other Earned Income (Losses).....................

3. Total Earned Income....................................

4. Maximum Earned Income...........................

5. Smaller of Line 3 or 4; if zero or less, enter

zero ..........................................................

6. Interest Income.........................................

7. Dividend Income .......................................

8. Alimony......................................................

9. Capital Gains (Losses)...............................

10. Other Income (Losses)..............................

(See IT-511 Tax Booklet)

11. Taxable IRA Distributions.........................

12. Taxable Pensions .....................................

13. Rental, Royalty, Partnership, S Corp, etc.

Income (Losses).....(See IT-511 Tax Booklet)

14. Total of Lines 6 through 13; if zero or less,

enter zero ................................................

15. Add Lines 5 and 14 ....................................

16. Maximum Allowable Exclusion* ..................

17. Smaller of Lines 15 and 16; enter here and on

Form 500, Schedule 1, Lines 7a. & b........

*If age 62-64 or less than age 62 and permanently disabled enter $35,000, or if age 65 or older enter $65,000.

REV 03/22/22 INTUIT.CG.CFP.SP

 Schedule 3
Georgia Form
(Rev. 08/02/21)
500 Page 1
Schedule 3 2207411513 YOUR SOCIAL SECURITY NUMBER
Part-Year Nonresident 615-20-2273
2021 (Approved software version) DO NOT USE LINES 9 THRU 14 OF PAGES 2 AND 3 FORM 500 or 500X
SCHEDULE 3 COMPUTATION OF GEORGIA TAXABLE INCOME FOR ONLY PART-YEAR RESIDENTS AND NONRESIDENTS.
Income earned in another state as a Georgia resident is taxable but other state(s) tax credit may apply. See IT-511 Tax Booklet.
FEDERAL INCOME AFTER GEORGIA ADJUSTMENT INCOME NOT TAXABLE TO GEORGIA GEORGIA INCOME
(COLUMN A) (COLUMN B) (COLUMN C)

1. WAGES, SALARIES, TIPS, etc 1. WAGES, SALARIES, TIPS, etc 1. WAGES, SALARIES, TIPS, etc
54317 0 54317
2. INTEREST AND DIVIDENDS 2. INTEREST AND DIVIDENDS 2. INTEREST AND DIVIDENDS

3. BUSINESS INCOME OR (LOSS) 3. BUSINESS INCOME OR (LOSS) 3. BUSINESS INCOME OR (LOSS)

4. OTHER INCOME OR (LOSS) 4. OTHER INCOME OR (LOSS) 4. OTHER INCOME OR (LOSS)

0 0
5. TOTAL INCOME: TOTAL LINES 1 THRU 4 5. TOTAL INCOME: TOTAL LINES 1 THRU 4 5. TOTAL INCOME: TOTAL LINES 1 THRU 4
54317 0 54317
6. TOTAL ADJUSTMENTS FROM FORM 1040 6. TOTAL ADJUSTMENTS FROM FORM 1040 6. TOTAL ADJUSTMENTS FROM FORM 1040
11193 0 11193

7. TOTAL ADJUSTMENTS FROM FORM 500, 7. TOTAL ADJUSTMENTS FROM FORM 500, 7. TOTAL ADJUSTMENTS FROM FORM 500,
SCHEDULE 1 SCHEDULE 1 SCHEDULE 1
-600 0 -600
8. ADJUSTED GROSS INCOME: 8. ADJUSTED GROSS INCOME: 8. ADJUSTED GROSS INCOME:
LINE 5 PLUS OR MINUS LINES 6 AND 7 LINE 5 PLUS OR MINUS LINES 6 AND 7 LINE 5 PLUS OR MINUS LINES 6 AND 7

42524 0 42524

9. RATIO: Divide Line 8, Column C by Line 8, Column A enter percentage or % Not to exceed 100%
check the box for Time Ratio. Enter percentage...................................... 9. 100.00
10a. Itemized or Standard Deduction or Georgia Itemized (See IT-511 Tax Booklet) 10a. 6000
10b. Additional Standard Deduction
Self: 65 or over? Blind? Spouse: 65 or over? Blind? Total X 1,300= 10b.

11. Personal Exemptions from Form 500 or Form 500X (See IT-511 Tax Booklet)

11a. Enter the number on Line 6c from Form 500 or Form 500X 2 multiply by $2,700 for
filing status A or D or multiply by $3,700 for filing status B or C..................................... 11a. 7400
11b. Enter the number on Line 7a from Form 500 or Form 500X 3 multiply by $3,000 .. 11b. 9000
12. Total Deductions and Exemptions: Add Lines 10a, 10b, 11a, and 11b ............ 12. 22400
13. Multiply Line 12 by Ratio on Line 9 and enter result............................................ 13. 22400
14. Income before GA NOL: Subtract Line 13 from Line 8, Column C
Enter here and on Line 15a, Page 3 of Form 500 or Form 500X........................ 14. 20124

REV 03/22/22 INTUIT.CG.CFP.SP

 1040 U.S. Individual Income Tax Return 2021 (99)
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 Single Married filing jointly Married filing separately (MFS) Head of household (HOH) Qualifying widow(er) (QW)
Check only If you checked the MFS box, enter the name of your spouse. If you checked the HOH or QW box, enter the child’s name if the qualifying
one box.
person is a child but not your dependent a
Your first name and middle initial Last name Your social security number
Erica c Villarreal 615-20-2273
If joint return, spouse’s first name and middle initial Last name Spouse’s social security number
bryan m Villarreal 458-37-2792
Home address (number and street). If you have a P.O. box, see instructions. Apt. no. Presidential Election Campaign
1950 Bolin Rd 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
North Augusta SC 298412215 box below will not change
Foreign country name Foreign province/state/county Foreign postal code your tax or refund.
You Spouse

At any time during 2021, did you receive, sell, exchange, or otherwise dispose of any financial interest in any virtual currency? Yes 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: Were born before January 2, 1957 Are blind Spouse: Was born before January 2, 1957 Is blind
Dependents (see instructions): (2) Social security (3) Relationship (4)  if qualifies for (see instructions):
(1) First name Last name number to you Child tax credit Credit for other dependents
If more
than four molly villarreal 443-25-1429 Daughter
dependents,
see instructions
clare villarreal 644-29-2599 Daughter
and check cal villarreal 373-99-8025 Son
here a
1 Wages, salaries, tips, etc. Attach Form(s) W-2 . . . . . . . . . . . . . . . . 1 54,317.
Attach 2a Tax-exempt interest . . . 2a 2b
b Taxable interest . . . . .
Sch. B if
3a Qualified dividends . . . 3a b Ordinary dividends . . . . . 3b
required.
4a IRA distributions . . . . 4a b Taxable amount . . . . . . 4b
5a Pensions and annuities . . 5a b Taxable amount . . . . . . 5b
Standard 6a Social security benefits . . 6a b Taxable amount . . . . . . 6b
Deduction for— a
7 Capital gain or (loss). Attach Schedule D if required. If not required, check here . . . . 7
• Single or
Married filing 8 Other income from Schedule 1, line 10 . . . . . . . . . . . . . . . . . . 8 0.
separately,
$12,550 9 Add lines 1, 2b, 3b, 4b, 5b, 6b, 7, and 8. This is your total income . . . . . . . . . a 9 54,317.
• Married filing 10 Adjustments to income from Schedule 1, line 26 . . . . . . . . . . . . . . . 10 11,193.
jointly or
11 Subtract line 10 from line 9. This is your adjusted gross income . . . . . . . . . a 11 43,124.
Qualifying
widow(er),
$25,100
12a Standard deduction or itemized deductions (from Schedule A) . . 12a 25,100.
• Head of b Charitable contributions if you take the standard deduction (see instructions) 12b 600.
household,
$18,800 c Add lines 12a and 12b . . . . . . . . . . . . . . . . . . . . . . . 12c 25,700.
• If you checked 13 Qualified business income deduction from Form 8995 or Form 8995-A . . . . . . . . . 13
any box under
Standard 14 Add lines 12c and 13 . . . . . . . . . . . . . . . . . . . . . . . 14 25,700.
Deduction,
see instructions.
15 Taxable income. Subtract line 14 from line 11. If zero or less, enter -0- . . . . . . . . . 15 17,424.

For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Form 1040 (2021)
Form 1040 (2021) Page 2
16 Tax (see instructions). Check if any from Form(s): 1 8814 2 4972 3 . . 16 1,743.
17 Amount from Schedule 2, line 3 . . . . . . . . . . . . . . . . . . . . 17
18 Add lines 16 and 17 . . . . . . . . . . . . . . . . . . . . . . . . 18 1,743.
19 Nonrefundable child tax credit or credit for other dependents from Schedule 8812 . . . . . 19
20 Amount from Schedule 3, line 8 . . . . . . . . . . . . . . . . . . . . 20 200.
21 Add lines 19 and 20 . . . . . . . . . . . . . . . . . . . . . . . . 21 200.
22 Subtract line 21 from line 18. If zero or less, enter -0- . . . . . . . . . . . . . . 22 1,543.
23 Other taxes, including self-employment tax, from Schedule 2, line 21 . . . . . . . . . 23 10,386.
24 Add lines 22 and 23. This is your total tax . . . . . . . . . . . . . . . . a 24 11,929.
25 Federal income tax withheld from:
a Form(s) W-2 . . . . . . . . . . . . . . . . . . 25a 4,710.
b Form(s) 1099 . . . . . . . . . . . . . . . . . . 25b
c Other forms (see instructions) . . . . . . . . . . . . . 25c
d Add lines 25a through 25c . . . . . . . . . . . . . . . . . . . . . . 25d 4,710.
26 2021 estimated tax payments and amount applied from 2020 return . . . . . . . . . . 26
If you have a
qualifying child, 27a Earned income credit (EIC) . . . . . . . . . . . . . .
No 27a
attach Sch. EIC.
Check here if you were born after January 1, 1998, and before
January 2, 2004, and you satisfy all the other requirements for
taxpayers who are at least age 18, to claim the EIC. See instructions a
b Nontaxable combat pay election . . . . 27b
c Prior year (2019) earned income . . . . 27c
28 Refundable child tax credit or additional child tax credit from Schedule 8812 28 4,500.
29 American opportunity credit from Form 8863, line 8 . . . . . . . 29
30 Recovery rebate credit. See instructions . . . . . . . . . . 30
31 Amount from Schedule 3, line 15 . . . . . . . . . . . . 31 0.
32 Add lines 27a and 28 through 31. These are your total other payments and refundable credits a 32 4,500.
33 Add lines 25d, 26, and 32. These are your total payments . . . . . . . . . . . a 33 9,210.
34 If line 33 is more than line 24, subtract line 24 from line 33. This is the amount you overpaid . . 34
Refund
35a Amount of line 34 you want refunded to you. If Form 8888 is attached, check here . . . a 35a
Direct deposit? ab Routing number X X X X X X X X X a c Type: Checking Savings
See instructions. a
d Account number X X X X X X X X X X X X X X X X X
36 Amount of line 34 you want applied to your 2022 estimated tax . . a 36
Amount 37 Amount you owe. Subtract line 33 from line 24. For details on how to pay, see instructions . a 37 2,719.
You Owe 38 Estimated tax penalty (see instructions) . . . . . . . . . a 38
Third Party Do you want to allow another person to discuss this return with the IRS? See
Designee instructions . . . . . . . . . . . . . . . . . . . . a Yes. Complete below. No
Designee’s Phone Personal identification
name a no. a number (PIN) a
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
F

Joint return? stay at home parent (see inst.) a

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.) a
associate pastor
Phone no. (405)269-9332 Email address
Preparer’s name Preparer’s signature Date PTIN Check if:
Paid Self-employed
Preparer
Firm’s name a Self-Prepared Phone no.
Use Only a a
Firm’s address Firm’s EIN
Go to www.irs.gov/Form1040 for instructions and the latest information. BAA REV 04/09/22 Intuit.cg.cfp.sp Form 1040 (2021)
SCHEDULE 1 OMB No. 1545-0074
Additional Income and Adjustments to Income
(Form 1040)
Department of the Treasury
a Attach to Form 1040, 1040-SR, or 1040-NR. 2021
Attachment
Internal Revenue Service a Go to www.irs.gov/Form1040 for instructions and the latest information. Sequence No. 01
Name(s) shown on Form 1040, 1040-SR, or 1040-NR Your social security number
Erica c & bryan m Villarreal 615-20-2273
Part I Additional Income
1 Taxable refunds, credits, or offsets of state and local income taxes . . . . . . . 1 0.
2a Alimony received . . . . . . . . . . . . . . . . . . . . . . . . . . . 2a
b Date of original divorce or separation agreement (see instructions) a
3 Business income or (loss). Attach Schedule C . . . . . . . . . . . . . . . 3
4 Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . . . . . . 4
5 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach
Schedule E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
6 Farm income or (loss). Attach Schedule F . . . . . . . . . . . . . . . . . 6
7 Unemployment compensation . . . . . . . . . . . . . . . . . . . . . . 7
8 Other income:
a Net operating loss . . . . . . . . . . . . . . . . . . 8a ( )
b Gambling income . . . . . . . . . . . . . . . . . . . 8b
c Cancellation of debt . . . . . . . . . . . . . . . . . . 8c
d Foreign earned income exclusion from Form 2555 . . . . . 8d ( )
e Taxable Health Savings Account distribution . . . . . . . . 8e
f Alaska Permanent Fund dividends . . . . . . . . . . . . 8f
g Jury duty pay . . . . . . . . . . . . . . . . . . . . 8g
h Prizes and awards . . . . . . . . . . . . . . . . . . 8h
i Activity not engaged in for profit income . . . . . . . . . 8i
j Stock options . . . . . . . . . . . . . . . . . . . . 8j
k 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 . . . . . . . . . . . . . . . . . . . . . . 8k
l Olympic and Paralympic medals and USOC prize money (see
instructions) . . . . . . . . . . . . . . . . . . . . . 8l
m Section 951(a) inclusion (see instructions) . . . . . . . . . 8m
n Section 951A(a) inclusion (see instructions) . . . . . . . . 8n
o Section 461(l) excess business loss adjustment . . . . . . . 8o
p Taxable distributions from an ABLE account (see instructions) . 8p
z Other income. List type and amount a
8z
9 Total other income. Add lines 8a through 8z . . . . . . . . . . . . . . . . 9
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) 2021
Schedule 1 (Form 1040) 2021 Page 2

Part II Adjustments to Income

11 Educator expenses . . . . . . . . . . . . . . . . . . . . . . . . . . 11
12 Certain business expenses of reservists, performing artists, and fee-basis government
officials. Attach Form 2106 . . . . . . . . . . . . . . . . . . . . . . . 12
13 Health savings account deduction. Attach Form 8889 . . . . . . . . . . . . 13
14 Moving expenses for members of the Armed Forces. Attach Form 3903 . . . . . 14
15 Deductible part of self-employment tax. Attach Schedule SE . . . . . . . . . 15 5,193.
16 Self-employed SEP, SIMPLE, and qualified plans . . . . . . . . . . . . . . 16
17 Self-employed health insurance deduction . . . . . . . . . . . . . . . . . 17
18 Penalty on early withdrawal of savings . . . . . . . . . . . . . . . . . . 18
19a Alimony paid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19a
b Recipient’s SSN . . . . . . . . . . . . . . . . . . . . a
c Date of original divorce or separation agreement (see instructions) a
20 IRA deduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 6,000.
21 Student loan interest deduction . . . . . . . . . . . . . . . . . . . . . 21
22 Reserved for future use . . . . . . . . . . . . . . . . . . . . . . . . 22
23 Archer MSA deduction . . . . . . . . . . . . . . . . . . . . . . . . . 23
24 Other adjustments:
a Jury duty pay (see instructions) . . . . . . . . . . . . . 24a
b Deductible expenses related to income reported on line 8k from
the rental of personal property engaged in for profit . . . . . 24b
c Nontaxable amount of the value of Olympic and Paralympic
medals and USOC prize money reported on line 8l . . . . . 24c
d Reforestation amortization and expenses . . . . . . . . . 24d
e Repayment of supplemental unemployment benefits under the
Trade Act of 1974 . . . . . . . . . . . . . . . . . . . 24e
f Contributions to section 501(c)(18)(D) pension plans . . . . . 24f
g Contributions by certain chaplains to section 403(b) plans . . 24g
h Attorney fees and court costs for actions involving certain
unlawful discrimination claims (see instructions) . . . . . . 24h
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
j Housing deduction from Form 2555 . . . . . . . . . . . 24j
k Excess deductions of section 67(e) expenses from Schedule K-1
(Form 1041) . . . . . . . . . . . . . . . . . . . . . 24k
z Other adjustments. List type and amount a
24z
25 Total other adjustments. Add lines 24a through 24z . . . . . . . . . . . . . 25
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 11,193.
BAA REV 04/09/22 Intuit.cg.cfp.sp Schedule 1 (Form 1040) 2021
SCHEDULE 2 OMB No. 1545-0074
Additional Taxes
(Form 1040)
Department of the Treasury
a Attach to Form 1040, 1040-SR, or 1040-NR. 2021
Attachment
Internal Revenue Service a Go to www.irs.gov/Form1040 for instructions and the latest information. Sequence No. 02
Name(s) shown on Form 1040, 1040-SR, or 1040-NR Your social security number
Erica c & bryan m Villarreal 615-20-2273
Part I Tax
1 Alternative minimum tax. Attach Form 6251 . . . . . . . . . . . . . . . . 1
2 Excess advance premium tax credit repayment. Attach Form 8962 . . . . . . . 2
3 Add lines 1 and 2. Enter here and on Form 1040, 1040-SR, or 1040-NR, line 17 . . 3
Part II Other Taxes
4 Self-employment tax. Attach Schedule SE . . . . . . . . . . . . . . . . . 4 10,386.
5 Social security and Medicare tax on unreported tip income.
Attach Form 4137 . . . . . . . . . . . . . . . . . . 5
6 Uncollected social security and Medicare tax on wages. Attach
Form 8919 . . . . . . . . . . . . . . . . . . . . . 6
7 Total additional social security and Medicare tax. Add lines 5 and 6 . . . . . . 7
8 Additional tax on IRAs or other tax-favored accounts. Attach Form 5329 if required 8
9 Household employment taxes. Attach Schedule H . . . . . . . . . . . . . 9
10 Repayment of first-time homebuyer credit. Attach Form 5405 if required . . . . . 10
11 Additional Medicare Tax. Attach Form 8959 . . . . . . . . . . . . . . . . 11
12 Net investment income tax. Attach Form 8960 . . . . . . . . . . . . . . . 12
13 Uncollected social security and Medicare or RRTA tax on tips or group-term life
insurance from Form W-2, box 12 . . . . . . . . . . . . . . . . . . . . 13
14 Interest on tax due on installment income from the sale of certain residential lots
and timeshares . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
15 Interest on the deferred tax on gain from certain installment sales with a sales price
over $150,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
16 Recapture of low-income housing credit. Attach Form 8611 . . . . . . . . . . 16
(continued on page 2)
For Paperwork Reduction Act Notice, see your tax return instructions. Schedule 2 (Form 1040) 2021
Schedule 2 (Form 1040) 2021 Page 2

Part II Other Taxes (continued)

17 Other additional taxes:
a Recapture of other credits. List type, form number, and
amount a 17a
b Recapture of federal mortgage subsidy. If you sold your home in
2021, see instructions . . . . . . . . . . . . . . . . . 17b
c Additional tax on HSA distributions. Attach Form 8889 . . . . 17c
d Additional tax on an HSA because you didn’t remain an eligible
individual. Attach Form 8889 . . . . . . . . . . . . . . 17d
e Additional tax on Archer MSA distributions. Attach Form 8853 . 17e
f Additional tax on Medicare Advantage MSA distributions. Attach
Form 8853 . . . . . . . . . . . . . . . . . . . . . 17f
g Recapture of a charitable contribution deduction related to a
fractional interest in tangible personal property . . . . . . . 17g
h Income you received from a nonqualified deferred compensation
plan that fails to meet the requirements of section 409A . . . 17h
i Compensation you received from a nonqualified deferred
compensation plan described in section 457A . . . . . . . 17i
j Section 72(m)(5) excess benefits tax . . . . . . . . . . . 17j
k Golden parachute payments . . . . . . . . . . . . . . 17k
l Tax on accumulation distribution of trusts . . . . . . . . . 17l
m Excise tax on insider stock compensation from an expatriated
corporation . . . . . . . . . . . . . . . . . . . . . 17m
n Look-back interest under section 167(g) or 460(b) from Form
8697 or 8866 . . . . . . . . . . . . . . . . . . . . 17n
o Tax on non-effectively connected income for any part of the
year you were a nonresident alien from Form 1040-NR . . . . 17o
p Any interest from Form 8621, line 16f, relating to distributions
from, and dispositions of, stock of a section 1291 fund . . . . 17p
q Any interest from Form 8621, line 24 . . . . . . . . . . . 17q
z Any other taxes. List type and amount a
17z
18 Total additional taxes. Add lines 17a through 17z . . . . . . . . . . . . . . 18
19 Additional tax from Schedule 8812 . . . . . . . . . . . . . . . . . . . . 19
20 Section 965 net tax liability installment from Form 965-A . . . 20
21 Add lines 4, 7 through 16, 18, and 19. These are your total other taxes. Enter here
and on Form 1040 or 1040-SR, line 23, or Form 1040-NR, line 23b . . . . . . . 21 10,386.
BAA REV 04/09/22 Intuit.cg.cfp.sp Schedule 2 (Form 1040) 2021
SCHEDULE 3 OMB No. 1545-0074
Additional Credits and Payments
(Form 1040)
Department of the Treasury
a Attach to Form 1040, 1040-SR, or 1040-NR. 2021
Attachment
Internal Revenue Service a Go to www.irs.gov/Form1040 for instructions and the latest information. Sequence No. 03
Name(s) shown on Form 1040, 1040-SR, or 1040-NR Your social security number
Erica c & bryan m Villarreal 615-20-2273
Part I Nonrefundable Credits
1 Foreign tax credit. Attach Form 1116 if required . . . . . . . . . . . . . . 1
2 Credit for child and dependent care expenses from Form 2441, line 11. Attach
Form 2441 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Education credits from Form 8863, line 19 . . . . . . . . . . . . . . . . . 3
4 Retirement savings contributions credit. Attach Form 8880 . . . . . . . . . . 4 200.
5 Residential energy credits. Attach Form 5695 . . . . . . . . . . . . . . . 5
6 Other nonrefundable credits:
a General business credit. Attach Form 3800 . . . . . . . . 6a
b Credit for prior year minimum tax. Attach Form 8801 . . . . 6b
c Adoption credit. Attach Form 8839 . . . . . . . . . . . . 6c
d Credit for the elderly or disabled. Attach Schedule R . . . . . 6d
e Alternative motor vehicle credit. Attach Form 8910 . . . . . 6e
f Qualified plug-in motor vehicle credit. Attach Form 8936 . . . 6f
g Mortgage interest credit. Attach Form 8396 . . . . . . . . 6g
h District of Columbia first-time homebuyer credit. Attach Form 8859 6h
i Qualified electric vehicle credit. Attach Form 8834 . . . . . 6i
j Alternative fuel vehicle refueling property credit. Attach Form 8911 6j
k Credit to holders of tax credit bonds. Attach Form 8912 . . . 6k
l Amount on Form 8978, line 14. See instructions . . . . . . 6l
z Other nonrefundable credits. List type and amount a
6z
7 Total other nonrefundable credits. Add lines 6a through 6z . . . . . . . . . . 7
8 Add lines 1 through 5 and 7. Enter here and on Form 1040, 1040-SR, or 1040-NR,
line 20 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 200.
(continued on page 2)
For Paperwork Reduction Act Notice, see your tax return instructions. BAA REV 04/09/22 Intuit.cg.cfp.sp Schedule 3 (Form 1040) 2021
Schedule 3 (Form 1040) 2021 Page 2

Part II Other Payments and Refundable Credits

9 Net premium tax credit. Attach Form 8962 . . . . . . . . . . . . . . . . . 9
10 Amount paid with request for extension to file (see instructions) . . . . . . . . 10
11 Excess social security and tier 1 RRTA tax withheld . . . . . . . . . . . . . 11
12 Credit for federal tax on fuels. Attach Form 4136 . . . . . . . . . . . . . . 12
13 Other payments or refundable credits:
a Form 2439 . . . . . . . . . . . . . . . . . . . . . 13a
b Qualified sick and family leave credits from Schedule(s) H and
Form(s) 7202 for leave taken before April 1, 2021 . . . . . . 13b
c Health coverage tax credit from Form 8885 . . . . . . . . 13c
d Credit for repayment of amounts included in income from earlier
years . . . . . . . . . . . . . . . . . . . . . . . . 13d
e Reserved for future use . . . . . . . . . . . . . . . . 13e
f Deferred amount of net 965 tax liability (see instructions) . . . 13f
g Credit for child and dependent care expenses from Form 2441,
line 10. Attach Form 2441 . . . . . . . . . . . . . . . 13g
h Qualified sick and family leave credits from Schedule(s) H and
Form(s) 7202 for leave taken after March 31, 2021 . . . . . 13h 0.
z Other payments or refundable credits. List type and amount a
13z
14 Total other payments or refundable credits. Add lines 13a through 13z . . . . . 14 0.
15 Add lines 9 through 12 and 14. Enter here and on Form 1040, 1040-SR, or 1040-NR,
line 31 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 0.
BAA REV 04/09/22 Intuit.cg.cfp.sp Schedule 3 (Form 1040) 2021