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D*p»Sr.>n! ©ł !h*Tr*i»K*y-W«rriłl«*\»nu»S«*vic* (99)

U.S. Individual Income Tax Return

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OMB No 1545-007-1 iRSUs*d*r-Oonol»r*«<yst**i> riitwjęoce

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

SpoWi soc«ai security numbw

Apt.no.

Mas© suro tn© SSN(s) abov© and on lin© 6c are correct.

Horn© itddrcos (numbor and str«»t). If you hav* a P.O. bo*. so« nstnjctions 123 Main St.

Oty. :own or post ©«■», siato, and Z& cod© t you hav© a *on»jn address. *so corrpiet© spaces betów (soe nstrucaonst Atlanta. GA 30324

Foreign country nam©	Fore^n prownce^county	Fore^n postał cod©

a txu M*w» »* not dongi ycm m cr llJ*X«ł 0 You n Spomo

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Filing Status

Check orty one box.

1    Q Single

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

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

and fuli name here. ►

D Head o» nousebokJ (with oualfyYig person) (See instructons.) If th© qualityog pimon «ł a cNkJ but not ><our depmdont. ©ntor tfw» cNIds nam© rw»© ►

5 □ Oualifying widow(or) with dependent child

Exemptions

B Yoursełf. If someone can claim you as a dependent, do not check bo* 6a.....1 ^Bo*^eł '^^S***¹

^ł on 6a and 6b

6a

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

c Dependents: (t) First njm© last nar©	(2) Otpwdmfs socisł secunty nurter	(3) Otpenderts rUatcrsTip 10 you	(4) /ilcft.Wund©r*jel7 duałfyms for cfw ta« crtdrt (sw nsauctcnsi
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No. of childron on 6c who:

•    liv«d with you

•    did not live w«h you do© to dryorc* or Mparation (M© mt truć bont)

□

Oepcndentt on 6c not ©ntored abov«

d Total number of exemptions claimed

Add numbers on Unos abov© ►

Income	7	Wages. saianes. tips. etc. Attach Form(s) W-2		....	7	78000	00
	8a	Taxablc interest. Attach Schedule B if reguired			8a	0	00
	b	Tax-cxcmpt mterest. Do not mclude on linę 8a	• - - l*> !	oj 0	n		rTj
Attach Forrn(s) W-2 here. Also attach Forms	9a	Ordinary dividends. Attach Schedule B if requirec			9a	0	00
	b	Ouaiified dividends........	. . . 1 M> i	0| 00
W-2G and	10	Taxablercfunds. credits, oroHsetsof State and local mcometaxes . .			19	2400	00
1099 R if tax	11	Alimony received.........			11	0	o~
was withheld.	12	Business income or (loss). Attach Schedule C or i	D-EZ.....	. . .	12	0	0