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D*purSr»n! OT !h* Tf*ałi*y—Wwn»l ft*%vnur Smrtc*    (99)

U.S. Individual Income Tax Return

ForlheywrJan. 1-0*c. 31.2011. or rtrwUiyw

Your *rst nam* urx! .nmal John S.

Lastname

Doe

If a jon! r«ixn. spcoses first nam© ano in.t>ai

Lastname

>©11

N

.2011.«ndng

OMB No 1545-007-1 iRSUs*Otfr-Oonol»r*«orsUc*i> nttw spocę

.20

See separata instructions. Your soclal security numbor 1 2 3 14 5 j 7 8 9 0

Spouses soc*ai security number

HeKetica ■» 112 »

Apf.no.

* Maso suro m© SSNsl abovc ^ and on linę 6c are correct.

Horn* itddroos (number and struci). If you hav* a P.O. bo*. so« nstnjcbonj 123 Main St.

Oty. :own or post ©łtce, sio!©, ano ZS> cod* t you have a foreiyt address. *so corręiete spaces betów (see nstruc&onst Atlanta. GA 30324

Foreipn country name	Foreign prownce^county	Fore«gn postał codę

*V-    CIaaI.    ---- ---

KresKWniioi tłtcuon

Oeck h»«ł 4 you. or yOJ spoute tUrg fiieOf .«** $3 io powito Kro Onding a txu bf*w» m« n« crano* >cui u« cr W*X«ł    0Y«I n Spooso

Filing Status

Check onły one bo*.

1    0 Single

2    D Married filing jointly (even if only one had income)

3    □ Married filing separately. Enter spouse's SSN above

and fuli name here. ►

D Head o» housebckJ (with oualfy**) person) (Seo instructoos.) If tho qualityr>g person « a cNkJ but not ><our dependent. entor ttw» ChikJ'* name hwe. ►

5 □ Oualifying widotf-ter) with dependent child

Exemptions

6a

b

0 Yoursełf. If someone can claim you as a dependent, do not check bo* 6a

If moro than four dependents. see instructions and check here ► □

c Dependents: (1) First njme last nar©	(2) Operom! s socisł secunty nurter	(3) OtpenJerts rUatensfio to you	(4) ✓ il cno urdw <** 17 guaUymj tor ctol ta. creKl (see nsauctcnsi
			~n~
			□
			n
			n

Dependent* on 6c n not ontorod abov* __

d Total number of exemptions claimed

Bores checked on 6a and 6b No. of chiidren on6c who:

•    lived with you

•    did not livc wrth you duo to drvorc*

or Mporotion (MO mt truć bont)

Add numbers on Unos obovo ►

□

Income

Attach Form(s) W-2 here. Also attach Forms W-2G and 1099-R if tax was withheld.

7

8a

b

9a

b

10

11

12

Wages. salanes. tips. etc. Attach Form(s) W-2    . .

Taxablc interest. Attach Schedule B if reguired . .

Tax-exempt interest. Do not mclude on linę 8a . .

Ordinary dividends. Attach Schedule B if required .

Oualifted divkłends.......... ____

Taxablo refunds. credits. or otfscts of State and łocal income taxes

Alimony received...............

Business income or (loss). Attach Schedule C or C-EZ ....

8b

9b

Ol 00

78000

2400

00

00

00

00