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line 36 from line 22. This is your adjusted gross Income 37 Last name (2)Orneridenre Serial security number O.04endenEs relatkentalp 10 you Boxes aced on Ea and Ea No of children thig 6c ho. min age 17 p lend with you 1004019 NI hr4 did not Ma with grardt you due tO Ovate a Separatio
ets of state and local income taxes 10 1099-R if tax was withheld. 11 Alimony received 11 12 Business income or (loss). Attach Schedule C or C-EZ 12 13 Capital gain or (loss). Attach Schedule D U required. If not required, ohm* here 13 If you did not get a W-2, 14 Other gains or (los
ndents social way numb. (310ependenrs m you asonsuo to IAm o Al Mid iallUil fleichl iaw 17 wow SON X d Total number of exemptions claimed Boxes checked en Ca and (1b No. of children on 6c who: * Ned with you • did nettle., with you OA to &KW9 Cr separation lane rtstructmal Oroenclant
STMT 3 $TMT 5 10 0. 1099-R if tax was withheld. 11 Alimony received 11 12 -99,490. 12 Business income or (loss). Attach Schedule C or C-EZ If you did not get a W-2, see instructions. 13 14 15a Capital gain or (loss). Attach Schedu Other gains or (losses). Attach Form IRA distri
ttach Schedule D if required. If not required, check here Other gains or (losses). Attach Form 4797 IRA distnbutians 1 151 I b Taxable amount Boxes checked on 6a and Etc No 01 children o 6c tio. *Pad with you %did not We with you due to OlvOrCe a Separation InStructiathl Dapanden% on 6c
dividends Taxable refunds, credits, or offsets of state and local income taxes Alimony received Business income or (loss). Attach Schedule C or C-EZ Capital gain or (loss). Attach Schedule D if required. If not required, check here Other gains or (losses). Attach Form 4797 IRA distnbutians
Entities connected to both Boxes and C-EZ

United States
LOCATIONSchedule SE
PERSONthe Foreign Earned Income Tax Worksheet
ORGANIZATIONthe U.S. Treasury Financial Agent
ORGANIZATION
U.S. Treasury
ORGANIZATIONERO Signature
ORGANIZATIONSpouse
ORGANIZATION
Joi Ito
PERSONUtilities
ORGANIZATION
FinCEN
ORGANIZATIONConservation Reserve Program
ORGANIZATIONFiler
PERSONConservation Reserve
ORGANIZATIONJurat/Disclosure
ORGANIZATIONBusiness Property
ORGANIZATIONBox F
ORGANIZATIONSchedules 0
ORGANIZATIONIndividual, Estate
ORGANIZATIONExchanges of Property
ORGANIZATIONOther Than Casualty or Theft-Most Property
ORGANIZATION