EFTA01222047.pdf

Form 1040 Other Income Statement 2017 Line 21 Statement Name(s) Shown on Return Social Security Number (a) (b) Taxpayer Spouse 1 Child's investment income, from Form 8814 2 Gambling winnings: a From Form W-2G b Winnings (prizes, etc ) from Form 1099-MISC, box 3 c Not reported on Form W-2G or Form 1099-MISC 3 Taxable income from Form 1099-MISC: a Substitute payments in lieu of interest or dividends b Other income from box 3 c Alaska Permanent Fund d Tribal Gaming e Non-Employee Compensation from Form 1099 MISC box 7 f Rent from personal property from Form 1099-MISC box 1 4 Taxable income from Form 1099-O or 1099-QA: a Qualified tuition program distributions b Coverdell ESA distributions c ABLE account distributions 5 Taxable income from Form 1099-G: a Grants b RTAA payments 6 Foreign earned income and housing exclusion, from Form 2555 7 Net operating loss carryover from a prior year 8 Other income, from Schedule(s) K-1 9 Taxable distribution from: a Form 8853: 1 Taxable Archer MSA distributions MSA 2 Taxable Medicare Advantage distributions Med MSA 3 Taxable long term care distributions LTC 4 Total Form 8853 b Form 8889, Health Savings Accounts 10 Refunds or reimbursements of deductions claimed in a prior year: a Reimbursement for deducted medical expenses b Refunds of deducted taxes (not state or local income taxes) Type of Tax State or Local ID c Recapture of deducte moving expenses d Reimbursement for deducted casualty or theft loss e Reimbursement for deducted employee business expenses. . f Other refunds or reimbursements 11 Recoveries of bad debts deducted in a prior year 12 Jury duty pay 13 Bartering income not reported elsewhere 14 Income from the rental of personal property 15 Income from the Cancellation of Debt: a From Form 1099-C: 1 Amount of debt canceled from box 2 2 Amount of canceled debt excluded from income 3 Taxable amount of canceled debt b From Schedule(s) K-1 16 Taxable income from Form 1099-K: a Payment Card/Third Party Network Transactions 17 Income from *not for profit* activities (hobbies)- 18 Other taxable income: a Union unemployment benefits b Private fund unemployment benefits c State employee unemployment benefits d 19 Income from Community Property: a Positive community property adjustment b Negative community property adjustment (enter as positive) . . 20 Total. Add lines 1 through 14,15a(3), 15b, 16 through 19. Enter here and on Form 1040 or Form 1040NR, line 21 EFTA01222047