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

Under “Label”:
Your first name and initial” field contains Sara L
Last name” field contains Brown
Your social security number” field contains 111-00-1111
Home address (number and street). If you have a Post Office box, see page 18.” field contains 1040A Main Street
City, town or post office, state, and ZIP code. If you have a foreign address, see page 18.” field contains Hometown Arizona 85240
Presidential Election Campaign
Do you, or your spouse if filing a joint return, want $3 to go to this fund? You: Yes Note. Checking Yes will not change your tax or reduce your refund. Do you, or your spouse if filing a joint return, want $3 to go to this fund? You: Yes” checkbox checked
Under “Filing Status”:
1. Single” checkbox checked
Under “Exemptions”:
6d. Total number of exemptions claimed. Add numbers on line above” field contains 0
Under “Income”:
7. Wages, salaries, tips, etc. Attach Form(s) W-2.” field contains 1,550
8a. Taxable interest. Attach Schedule 1 if required.” field contains 1,050
9. Ordinary dividends. Attach Schedule 1 if required.” field contains 1,050
10. Capital gain distributions (see page 27).” field contains 700
15. Add lines 7 through 14b (far right column). This is your total income” field contains 4,350
Under “Adjusted gross income”:
21. Subtract line 20 from line 15. This is your adjusted gross income.” field contains 4,350