1040 U.S.

Individual Income Tax Return 2019

Form Department of the Treasury—Internal Revenue Service (99)
OMB No. 1545-0074 IRS Use Only—Do not write or staple in this space.

Filing Status Single Married filing jointly Married filing separately (MFS) Head of household (HOH) Qualifying widow(er) (QW)
Check only If you checked the MFS box, enter the name of spouse. If you checked the HOH or QW box, enter the child’s name if the qualifying person is
one box.
a child but not your dependent. a
Your first name and middle initial Last name Your social security number
Haley S Davis 632-42-9281
If joint return, spouse’s first name and middle initial Last name Spouse’s social security number

Home address (number and street). If you have a P.O. box, see instructions. Apt. no. Presidential Election Campaign
Check here if you, or your spouse if filing
2212 Montauk Rd NW 10
jointly, want $3 to go to this fund.
City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions). Checking a box below will not change your
Roanoke VA 24017-1228 tax or refund. You Spouse
Foreign country name Foreign province/state/county Foreign postal code If more than four dependents,
see instructions and  here a

Standard Someone can claim: You as a dependent Your spouse as a dependent

Deduction Spouse itemizes on a separate return or you were a dual-status alien

Age/Blindness You: Were born before January 2, 1955 Are blind Spouse: Was born before January 2, 1955 Is blind
Dependents (see instructions): (2) Social security number (3) Relationship to you (4)  if qualifies for (see instructions):
(1) First name Last name Child tax credit Credit for other dependents

1 Wages, salaries, tips, etc. Attach Form(s) W-2 . . . . . . . . . . . . . . . . . . 1 26,495.

2a Tax-exempt interest . . . . 2a b Taxable interest. Attach Sch. B if required 2b
3a Qualified dividends . . . . 3a b Ordinary dividends. Attach Sch. B if required 3b
Standard
Deduction for— 4a IRA distributions . . . . . 4a b Taxable amount . . . . . . 4b
• Single or Married
filing separately,
c Pensions and annuities . . . 4c d Taxable amount . . . . . . 4d
$12,200 5a Social security benefits . . . 5a b Taxable amount . . . . . . 5b
• Married filing
6 Capital gain or (loss). Attach Schedule D if required. If not required, check here . . . . . . . a 6
jointly or Qualifying
widow(er), 7a Other income from Schedule 1, line 9 . . . . . . . . . . . . . . . . . . . . 7a 2,882.
$24,400
• Head of b Add lines 1, 2b, 3b, 4b, 4d, 5b, 6, and 7a. This is your total income . . . . . . . . . . . a 7b 29,377.
household, 49.
$18,350
8a Adjustments to income from Schedule 1, line 22 . . . . . . . . . . . . . . . . . 8a
• If you checked b Subtract line 8a from line 7b. This is your adjusted gross income . . . . . . . . . . . a 8b 29,328.
any box under
Standard 9 Standard deduction or itemized deductions (from Schedule A) . . . . . 9 12,200.
Deduction, 10 Qualified business income deduction. Attach Form 8995 or Form 8995-A . . . 10
see instructions.
11a Add lines 9 and 10 . . . . . . . . . . . . . . . . . . . . . . . . . 11a 12,200.
b Taxable income. Subtract line 11a from line 8b. If zero or less, enter -0- . . . . . . . . . . . 11b 17,128.
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Form 1040 (2019)
 Form 1040 (2019) Page 2
12a Tax (see inst.) Check if any from Form(s): 1 8814 2 4972 3 12a 1,861.
b Add Schedule 2, line 3, and line 12a and enter the total . . . . . . . . . . . . . . a 12b 1,861.
13a Child tax credit or credit for other dependents . . . . . . . . . . 13a
b Add Schedule 3, line 7, and line 13a and enter the total . . . . . . . . . . . . . . a 13b 1,500.
14 Subtract line 13b from line 12b. If zero or less, enter -0- . . . . . . . . . . . . . . . 14 361.
15 Other taxes, including self-employment tax, from Schedule 2, line 10 . . . . . . . . . . . . 15 0.
16 Add lines 14 and 15. This is your total tax . . . . . . . . . . . . . . . . . . a 16 361.
17 Federal income tax withheld from Forms W-2 and 1099 . . . . . . . . . . . . . . . 17 735.
• If you have a
18 Other payments and refundable credits:
qualifying child, a Earned income credit (EIC) . . . . . . . . . . . . No
. . . 18a
attach Sch. EIC.
• If you have b Additional child tax credit. Attach Schedule 8812 . . . . . . . . . 18b
nontaxable c American opportunity credit from Form 8863, line 8 . . . . . . . . 18c 1,000.
combat pay, see
instructions. d Schedule 3, line 14 . . . . . . . . . . . . . . . . . 18d
e Add lines 18a through 18d. These are your total other payments and refundable credits . . . . . a 18e 1,000.
19 Add lines 17 and 18e. These are your total payments . . . . . . . . . . . . . . . a 19 1,735.
Refund 20 If line 19 is more than line 16, subtract line 16 from line 19. This is the amount you overpaid . . . . . . 20 1,374.
21a Amount of line 20 you want refunded to you. If Form 8888 is attached, check here . . . . . . a 21a 1,374.
Direct deposit? a b Routing number 1 1 1 0 0 0 0 2 5 a c Type: Checking Savings
See instructions.
a d Account number 4 8 8 0 3 6 9 9 3 9 7 8
22 Amount of line 20 you want applied to your 2020 estimated tax . . . . a 22
Amount 23 Amount you owe. Subtract line 19 from line 16. For details on how to pay, see instructions . . . . . a 23
You Owe 24 Estimated tax penalty (see instructions) . . . . . . . . . . . a 24
Third Party Do you want to allow another person (other than your paid preparer) to discuss this return with the IRS? See instructions. Yes. Complete below.
Designee No
(Other than Designee’s Phone Personal identification
paid preparer) name a no. a number (PIN) a

Sign Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true,
correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Here Your signature Date Your occupation If the IRS sent you an Identity
Protection PIN, enter it here
F

Joint return? Student (see inst.)

See instructions. Spouse’s signature. If a joint return, both must sign. Date Spouse’s occupation If the IRS sent your spouse an
Keep a copy for Identity Protection PIN, enter it here
your records. (see inst.)

Phone no. Email address

Preparer’s name Preparer’s signature Date PTIN Check if:
Paid 3rd Party Designee
Preparer Self-employed
Firm’s name a Self-Prepared Phone no.
Use Only
Firm’s address a Firm’s EIN a

Go to www.irs.gov/Form1040 for instructions and the latest information. BAA REV 02/14/20 Intuit.cg.cfp.sp Form 1040 (2019)
SCHEDULE 1 OMB No. 1545-0074
Additional Income and Adjustments to Income
2019
(Form 1040 or 1040-SR)
a Attach to Form 1040 or 1040-SR.
Department of the Treasury Attachment
Internal Revenue Service a Go to www.irs.gov/Form1040 for instructions and the latest information. Sequence No. 01
Name(s) shown on Form 1040 or 1040-SR Your social security number
Haley S Davis 632-42-9281
At any time during 2019, did you receive, sell, send, exchange, or otherwise acquire any financial interest in any
virtual currency? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
Part I Additional Income
1 Taxable refunds, credits, or offsets of state and local income taxes . . . . . . . . . . . . 1
2a Alimony received . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2a
b Date of original divorce or separation agreement (see instructions) a
3 Business income or (loss). Attach Schedule C . . . . . . . . . . . . . . . . . . . 3
4 Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . . . . . . . . . 4
5 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E . . . . . 5
6 Farm income or (loss). Attach Schedule F . . . . . . . . . . . . . . . . . . . . 6
7 Unemployment compensation . . . . . . . . . . . . . . . . . . . . . . . . 7 2,882.
8 Other income. List type and amount a
8
9 Combine lines 1 through 8. Enter here and on Form 1040 or 1040-SR, line 7a . . . . . . . . 9 2,882.
Part II Adjustments to Income
10 Educator expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
11 Certain business expenses of reservists, performing artists, and fee-basis government officials. Attach
Form 2106 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
12 Health savings account deduction. Attach Form 8889 . . . . . . . . . . . . . . . . 12
13 Moving expenses for members of the Armed Forces. Attach Form 3903 . . . . . . . . . . 13
14 Deductible part of self-employment tax. Attach Schedule SE . . . . . . . . . . . . . . 14
15 Self-employed SEP, SIMPLE, and qualified plans . . . . . . . . . . . . . . . . . . 15
16 Self-employed health insurance deduction . . . . . . . . . . . . . . . . . . . . 16
17 Penalty on early withdrawal of savings . . . . . . . . . . . . . . . . . . . . . 17
18a Alimony paid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18a
b Recipient’s SSN . . . . . . . . . . . . . . . . . . . . . a
c Date of original divorce or separation agreement (see instructions) a
19 IRA deduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
20 Student loan interest deduction . . . . . . . . . . . . . . . . . . . . . . . 20 49.
21 Tuition and fees. Attach Form 8917 . . . . . . . . . . . . . . . . . . . . . . 21
22 Add lines 10 through 21. These are your adjustments to income. Enter here and on Form 1040 or
1040-SR, line 8a . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 49.
For Paperwork Reduction Act Notice, see your tax return instructions. REV 02/14/20 Intuit.cg.cfp.sp Schedule 1 (Form 1040 or 1040-SR) 2019
SCHEDULE 3 OMB No. 1545-0074
Additional Credits and Payments
2019
(Form 1040 or 1040-SR)
a Attach to Form 1040 or 1040-SR.
Department of the Treasury Attachment
Internal Revenue Service a Go to www.irs.gov/Form1040 for instructions and the latest information. Sequence No. 03
Name(s) shown on Form 1040 or 1040-SR Your social security number
Haley S Davis 632-42-9281
Part I Nonrefundable Credits
1 Foreign tax credit. Attach Form 1116 if required . . . . . . . . . . . . . . . . . . 1
2 Credit for child and dependent care expenses. Attach Form 2441 . . . . . . . . . . . . 2
3 Education credits from Form 8863, line 19 . . . . . . . . . . . . . . . . . . . . 3 1,500.
4 Retirement savings contributions credit. Attach Form 8880 . . . . . . . . . . . . . . 4
5 Residential energy credits. Attach Form 5695 . . . . . . . . . . . . . . . . . . . 5
6 Other credits from Form: a 3800 b 8801 c 6
7 Add lines 1 through 6. Enter here and include on Form 1040 or 1040-SR, line 13b . . . . . . . 7 1,500.
Part II Other Payments and Refundable Credits
8 2019 estimated tax payments and amount applied from 2018 return . . . . . . . . . . . 8
9 Net premium tax credit. Attach Form 8962 . . . . . . . . . . . . . . . . . . . . 9
10 Amount paid with request for extension to file (see instructions) . . . . . . . . . . . . . 10
11 Excess social security and tier 1 RRTA tax withheld . . . . . . . . . . . . . . . . . 11
12 Credit for federal tax on fuels. Attach Form 4136 . . . . . . . . . . . . . . . . . . 12
13 Credits from Form: a 2439 b Reserved c 8885 d 13
14 Add lines 8 through 13. Enter here and on Form 1040 or 1040-SR, line 18d . . . . . . . . . 14
For Paperwork Reduction Act Notice, see your tax return instructions. REV 02/14/20 Intuit.cg.cfp.sp Schedule 3 (Form 1040 or 1040-SR) 2019
 8863 Education Credits OMB No. 1545-0074
(American Opportunity and Lifetime Learning Credits)
2019
Form
a Attach to Form 1040 or 1040-SR.
Department of the Treasury Attachment
Internal Revenue Service (99) a Go to www.irs.gov/Form8863 for instructions and the latest information. Sequence No. 50
Name(s) shown on return Your social security number
Haley S Davis 632-42-9281

F
!
CAUTION
Complete a separate Part III on page 2 for each student for whom you’re claiming either credit before
you complete Parts I and II.

Part I Refundable American Opportunity Credit

1 After completing Part III for each student, enter the total of all amounts from all Parts III, line 30 . . 1 2,500.
2 Enter: $180,000 if married filing jointly; $90,000 if single, head of household,
or qualifying widow(er) . . . . . . . . . . . . . . . . . . 2 90,000.
3 Enter the amount from Form 1040 or 1040-SR, line 8b. If you’re filing Form
2555 or 4563, or you’re excluding income from Puerto Rico, see Pub. 970 for
the amount to enter . . . . . . . . . . . . . . . . . . . 3 29,328.
4 Subtract line 3 from line 2. If zero or less, stop; you can’t take any education
credit . . . . . . . . . . . . . . . . . . . . . . . . 4 60,672.
5 Enter: $20,000 if married filing jointly; $10,000 if single, head of household, or
qualifying widow(er) . . . . . . . . . . . . . . . . . . . 5 10,000.
6 If line 4 is:
• Equal to or more than line 5, enter 1.000 on line 6 . . . . . . . . . . . . .
• Less than line 5, divide line 4 by line 5. Enter the result as a decimal (rounded to
at least three places) . . . . . . . . . . . . . . . . . . . . . .
} . . . 6 1.000

7 Multiply line 1 by line 6. Caution: If you were under age 24 at the end of the year and meet the
conditions described in the instructions, you can’t take the refundable American opportunity credit;
skip line 8, enter the amount from line 7 on line 9, and check this box . . . . . . . . a 7 2,500.
8 Refundable American opportunity credit. Multiply line 7 by 40% (0.40). Enter the amount here and
on Form 1040 or 1040-SR, line 18c. Then go to line 9 below . . . . . . . . . . . . . . 8 1,000.
Part II Nonrefundable Education Credits
9 Subtract line 8 from line 7. Enter here and on line 2 of the Credit Limit Worksheet (see instructions) . 9 1,500.
10 After completing Part III for each student, enter the total of all amounts from all Parts III, line 31. If
zero, skip lines 11 through 17, enter -0- on line 18, and go to line 19 . . . . . . . . . . . 10
11 Enter the smaller of line 10 or $10,000 . . . . . . . . . . . . . . . . . . . . . 11
12 Multiply line 11 by 20% (0.20) . . . . . . . . . . . . . . . . . . . . . . . . 12
13 Enter: $136,000 if married filing jointly; $68,000 if single, head of household, or
qualifying widow(er) . . . . . . . . . . . . . . . . . . . 13
14 Enter the amount from Form 1040 or 1040-SR, line 8b. If you're filing Form
2555 or 4563, or you’re excluding income from Puerto Rico, see Pub. 970 for
the amount to enter . . . . . . . . . . . . . . . . . . . 14
15 Subtract line 14 from line 13. If zero or less, skip lines 16 and 17, enter -0- on
line 18, and go to line 19 . . . . . . . . . . . . . . . . . 15
16 Enter: $20,000 if married filing jointly; $10,000 if single, head of household, or
qualifying widow(er) . . . . . . . . . . . . . . . . . . . 16
17 If line 15 is:
• Equal to or more than line 16, enter 1.000 on line 17 and go to line 18
• Less than line 16, divide line 15 by line 16. Enter the result as a decimal (rounded to at least three
places) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
18 Multiply line 12 by line 17. Enter here and on line 1 of the Credit Limit Worksheet (see instructions) a 18
19 Nonrefundable education credits. Enter the amount from line 7 of the Credit Limit Worksheet (see
instructions) here and on Schedule 3 (Form 1040 or 1040-SR), line 3 . . . . . . . . . . . 19 1,500.
For Paperwork Reduction Act Notice, see your tax return instructions. REV 02/14/20 Intuit.cg.cfp.sp Form 8863 (2019)
BAA
Form 8863 (2019) Page 2
Name(s) shown on return Your social security number
Haley S Davis 632-42-9281

F
!
CAUTION
Complete Part III for each student for whom you’re claiming either the American
opportunity credit or lifetime learning credit. Use additional copies of page 2 as needed for
each student.
Part III Student and Educational Institution Information. See instructions.
20 Student name (as shown on page 1 of your tax return) 21 Student social security number (as shown on page 1 of
Haley S your tax return)
Davis 632-42-9281
22 Educational institution information (see instructions)
a. Name of first educational institution b. Name of second educational institution (if any)
Jefferson College of Health Sciences
(1) Address. Number and street (or P.O. box). City, town or (1) Address. Number and street (or P.O. box). City, town or
post office, state, and ZIP code. If a foreign address, see post office, state, and ZIP code. If a foreign address, see
instructions. instructions.
101 Elm Ave. SW
Raonoke VA 24013
(2) Did the student receive Form 1098-T (2) Did the student receive Form 1098-T
Yes No Yes No
from this institution for 2019? from this institution for 2019?
(3) Did the student receive Form 1098-T (3) Did the student receive Form 1098-T
from this institution for 2018 with box Yes No from this institution for 2018 with box Yes No
7 checked? 7 checked?
(4) Enter the institution’s employer identification number (EIN) (4) Enter the institution’s employer identification number
if you’re claiming the American opportunity credit or if you (EIN) if you’re claiming the American opportunity credit or
checked “Yes” in (2) or (3). You can get the EIN from Form if you checked “Yes” in (2) or (3). You can get the EIN
1098-T or from the institution. from Form 1098-T or from the institution.
54-0506332

23 Has the Hope Scholarship Credit or American opportunity

Yes — Stop!
credit been claimed for this student for any 4 tax years Go to line 31 for this student. No — Go to line 24.
before 2019?
24 Was the student enrolled at least half-time for at least one
academic period that began or is treated as having begun in
2019 at an eligible educational institution in a program
Yes — Go to line 25. No — Stop! Go to line 31
leading towards a postsecondary degree, certificate, or
for this student.
other recognized postsecondary educational credential?
See instructions.
25 Did the student complete the first 4 years of postsecondary Yes — Stop!
education before 2019? See instructions. Go to line 31 for this No — Go to line 26.
student.
26 Was the student convicted, before the end of 2019, of a Yes — Stop! No — Complete lines 27
felony for possession or distribution of a controlled Go to line 31 for this through 30 for this student.
substance? student.

F
!
CAUTION
You can't take the American opportunity credit and the lifetime learning credit for the same student in the same year. If
you complete lines 27 through 30 for this student, don’t complete line 31.

American Opportunity Credit

27 Adjusted qualified education expenses (see instructions). Don’t enter more than $4,000 . . . . . 27 4,000.
28 Subtract $2,000 from line 27. If zero or less, enter -0- . . . . . . . . . . . . . . . . . 28 2,000.
29 Multiply line 28 by 25% (0.25) . . . . . . . . . . . . . . . . . . . . . . . . 29 500.
30 If line 28 is zero, enter the amount from line 27. Otherwise, add $2,000 to the amount on line 29 and
enter the result. Skip line 31. Include the total of all amounts from all Parts III, line 30, on Part I, line 1 . 30 2,500.
Lifetime Learning Credit
31 Adjusted qualified education expenses (see instructions). Include the total of all amounts from all Parts
III, line 31, on Part II, line 10 . . . . . . . . . . . . . . . . . . . . . . . . . 31
Form 8863 (2019)
 Mail 760ES Voucher 1 To:

Commissioner of the Revenue, P.O. Box 718, Roanoke, VA 24004

' Cut Here '

2020 FORM 760ES - Voucher

REV 02/14/20 INTUIT.CG.CFP.SP 1555
1  Check if this is a new address. LOCALITY NO. FOR OFFICE USE
Doc ID 762
VIRGINIA ESTIMATED INCOME TAX  Check here if this is your first payment for
PAYMENT VOUCHER FOR INDIVIDUALS this taxable year. 770
CALENDAR YEAR FILERS DUE: 05-01-20 FISCAL YEAR FILERS: BEGINNING MONTH:

Mail your voucher and payment to the Virginia Department of

Taxation, P. O. Box 1478, Richmond, VA 23218-1478, or see
6324292819 7621555 120057 770 pages 7-8 and use the address listed for the city or county
where you intend to file.
If you file with the Department, make your check payable to
Y our Social Security Number (SSN) Spouses SSN (if filing a joint return)
the Department of Taxation. If you file locally, make your check
632429281 payable to your local Treasurer.
HALEY S DAVIS
Amount of payment
2212 MONTAUK RD NW APT # 10
81. 00
ROANOKE VA 24017-1228

Daytime Phone Number 817-776-7163

 Mail 760ES Voucher 2 To:

Treasurer, City of Roanoke, P.O. Box 1451, Roanoke, VA 24007

' Cut Here '

2020 FORM 760ES - Voucher

REV 02/14/20 INTUIT.CG.CFP.SP 1555
2  Check if this is a new address. LOCALITY NO. FOR OFFICE USE
Doc ID 762
VIRGINIA ESTIMATED INCOME TAX  Check here if this is your first payment for
PAYMENT VOUCHER FOR INDIVIDUALS this taxable year. 770
CALENDAR YEAR FILERS DUE: 06-15-20 FISCAL YEAR FILERS: BEGINNING MONTH:

Mail your voucher and payment to the Virginia Department of

Taxation, P. O. Box 1478, Richmond, VA 23218-1478, or see
6324292819 7621555 120065 770 pages 7-8 and use the address listed for the city or county
where you intend to file.
If you file with the Department, make your check payable to
Y our Social Security Number (SSN) Spouses SSN (if filing a joint return)
the Department of Taxation. If you file locally, make your check
632429281 payable to your local Treasurer.
HALEY S DAVIS
Amount of payment
2212 MONTAUK RD NW APT # 10
81. 00
ROANOKE VA 24017-1228

Daytime Phone Number 817-776-7163

 Mail 760ES Voucher 3 To:

Treasurer, City of Roanoke, P.O. Box 1451, Roanoke, VA 24007

' Cut Here '

2020 FORM 760ES - Voucher

REV 02/14/20 INTUIT.CG.CFP.SP 1555
3  Check if this is a new address. LOCALITY NO. FOR OFFICE USE
Doc ID 762
VIRGINIA ESTIMATED INCOME TAX  Check here if this is your first payment for
PAYMENT VOUCHER FOR INDIVIDUALS this taxable year. 770
CALENDAR YEAR FILERS DUE: 09-15-20 FISCAL YEAR FILERS: BEGINNING MONTH:

Mail your voucher and payment to the Virginia Department of

Taxation, P. O. Box 1478, Richmond, VA 23218-1478, or see
6324292819 7621555 120091 770 pages 7-8 and use the address listed for the city or county
where you intend to file.
If you file with the Department, make your check payable to
Y our Social Security Number (SSN) Spouses SSN (if filing a joint return)
the Department of Taxation. If you file locally, make your check
632429281 payable to your local Treasurer.
HALEY S DAVIS
Amount of payment
2212 MONTAUK RD NW APT # 10
81. 00
ROANOKE VA 24017-1228

Daytime Phone Number 817-776-7163

 Mail 760ES Voucher 4 To:

Treasurer, City of Roanoke, P.O. Box 1451, Roanoke, VA 24007

' Cut Here '

2020 FORM 760ES - Voucher

REV 02/14/20 INTUIT.CG.CFP.SP 1555
4  Check if this is a new address. LOCALITY NO. FOR OFFICE USE
Doc ID 762
VIRGINIA ESTIMATED INCOME TAX  Check here if this is your first payment for
PAYMENT VOUCHER FOR INDIVIDUALS this taxable year. 770
CALENDAR YEAR FILERS DUE: 01-15-21 FISCAL YEAR FILERS: BEGINNING MONTH:

Mail your voucher and payment to the Virginia Department of

Taxation, P. O. Box 1478, Richmond, VA 23218-1478, or see
6324292819 7621555 121010 770 pages 7-8 and use the address listed for the city or county
where you intend to file.
If you file with the Department, make your check payable to
Y our Social Security Number (SSN) Spouses SSN (if filing a joint return)
the Department of Taxation. If you file locally, make your check
632429281 payable to your local Treasurer.
HALEY S DAVIS
Amount of payment
2212 MONTAUK RD NW APT # 10
81. 00
ROANOKE VA 24017-1228

Daytime Phone Number 817-776-7163

 ' Cut Here '

Form 760-PMT 2019 Payment Coupon Your Social Security Number Spouse’s Social Security Number
(DOC ID 761) Please do not staple 632429281
To Be Used For Payments On Previously
Filed 2019 Individual Income Tax Returns Only
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Daytime Phone Number: 817-776-7163 REV 02/14/20 INTUIT.CG.CFP.SP

2019 VA760CG Page 1 [ ]
Individual Income Tax Return

HALEY S DAVIS

2212 MONTAUK RD NW APT 10

ROANOKE VA 240171228

SSN - You DAVI 632429281 Vendor ID 1555 XXXXX

SSN - Spouse

Fed Adj Gross Income (FAGI) 1. 29328. Withholding (VA) - You 19A. 629.

Additions 2. Withholding (VA) - Spouse 19B.

Subtotal 3. 29328. Estimated Payments 20.

Age Deduction - You 4A. 2018 Overpayment 21.

Age Deduction - Spouse 4B. Extension Payments 22.

Soc Sec & Tier 1 Railroad 5. Credit - Low-Income or EIC 23.

State Income Tax Overpayment 6. Credit - Schedule OSC 24.

Subtractions 7. 2882. Credits - Schedule CR 25.

Subtotal Subtractions 8. 2882. Total Payments / Credits 26. 629.

Total VA Adj Gross Income (VAGI) 9. 26446. Tax You Owe 27. 322.

Itemized Deductions - VA Sch A 10. Tax Overpayment 28.

Standard Deduction 11. 4500. Overpayment Credited to Next Year 29.

Exemptions 12. 930. VAC - Virginia 529 / ABLEnow 30.

Deductions 13. VAC - Other Contributions 31.

Subtotal (Deductions & Exemptions) 14. 5430. Addition to Tax, Penalty & Interest 32. 11.

VA Taxable Income 15. 21016. Sales and Use Tax 33.

Amount of Tax 16. 951. Amount You Owe 333.

Will Pay by Credit/Debit Card N
Spouse Tax Adjustment (STA) 17. Your Refund

VAGI - Spouse 17A.

Bank Routing #
Net Amount of Tax 18. 951.
Bank Account #

LAR DLAR DTD LTD $ Page 1 of 2

REV 02/14/20 INTUIT.CG.CFP.SP
2019 VA760CG Page 2 632429281

Filing Status, Age & License Information Additional Filing Information

Filing Status 1 Locality 770

Federal Head of Household Name or Filing Status Change

DOB - You 05181994 Address Change

VA Driver’s License ID - You B69757633 VA Return Not Filed Last Year

VA Driver’s License - Iss. Date - You 03302018 Dependent on Another’s Return

Spouse Name (Filing Status 3 Only) Farmer / Fisherman / Merchant Seaman

Amended
DOB - Spouse
NOL
VA Driver’s License ID - Spouse
Overseas on Due Date
VA Driver’s License - Iss. Date - Spouse
Federal EIC & Amount
Exemptions (A) Exemptions (B)
You 1 65 & Over - You Deceased Indicator

Spouse 65 & Over - Spouse No Sales & Use Tax Due Indicator X

Dependents Blind - You Obtain Electronic 1099G

Total (A) 1 Blind - Spouse ID Theft PIN

Total (B)

Contact Information
I (We), the undersigned, declare under penalty of law that I (we) have examined this return & to the best of my (our) knowledge, it is a true, correct & complete return. If you are requesting direct
deposit of your refund by providing bank information on your return, you are certifying that the information provided is for a domestic account within the territorial jurisdiction of the United States.

Signature - You ____________________________________ Date Phone - You 8177767163

Signature - Spouse _________________________________ Date Phone - Spouse

Signature - Preparer ________________________________

SELF-PREPARED Date Phone - Preparer

The Tax Department may discuss my/our return with my/our preparer. Preparer Information 7

File by May 1, 2020

Include Page 1, Page 2 and all
supporting 760CG documents. Page 2 of 2
1555 REV 02/14/20 INTUIT.CG.CFP.SP
2019 Schedule ADJ/CG 632429281

Additions Low-Income Credit or VA EIC (con’t)

Interest on obligations (other state) 1. Total Exemptions 11.
Other Additions
Fixed Date Conformity 2A. # of Personal Exemptions 12.

2B. Total Exemptions Amount or $0 13.

2C. Federal EIC 14.

Total Additions 3. 20% of Line 14 15.

Subtractions Greater of Line 13 or Line 15 16.

Income (US obligations / securities) 4.
Credit 17.
Disability Income (wages) - You 5A.
Addition to Tax, Penalty & Interest
Disability Income (wages) - Spouse 5B. Addition to Tax 18. 11.

Other Subtractions Form 760C Addition X

Fixed Date Conformity 6A.
Form 760F Addition
6B. Code 37 2882.
Penalty 19.
6C. Code
Late Filing Penalty
6D. Code
Extension Penalty
Total Subtractions 7. 2882.
Interest 20.
Deductions 8A.
Total Adjustments 21. 11.
8B.

8C.

Total Deductions 9.

Claiming More Adjustments - Schedule ADJS

Low-Income Credit or VA EIC

Family Name SSN VAGI

You

Spouse

Dependent

Dependent

Total Family VAGI 10.

1555 REV 02/14/20 INTUIT.CG.CFP.SP

2019 Schedule INC/CG 632429281
Report all W-2s, 1099s & VK-1s with VA Withholding

HALEY S DAVIS

Your/ Withholding VA Employer VA VA Wages, tips,

Spouse SSN Type Withholding FEIN Account Number other comp.

632429281 W 451. 261091992 30261091992F001 14393.

632429281 W 36. 540852697 30540852697F001 3687.

632429281 W 142. 541119345 30541119345F001 8415.

Total VA Withholding SSN VA Withholding

You 632429281 629.

Spouse

Total # of W-2s,1099s & VK-1s 03

To avoid delays - be sure to enter all information, including the Employer’s FEIN.
1555 REV 02/14/20 INTUIT.CG.CFP.SP
 760C - 2019 Underpayment of Virginia Estimated
Tax by Individuals, Estates and Trusts
• Enclose this form with Form 760, 763, 760PY or 770.
Fiscal Year Filers: Enter beginning date 20 , ending date 20 , and check here

•
First Name, Middle Initial and Last Name (of Both If Joint) - OR - Name of Estate or Trust Your Social Security Number or FEIN

HALEY S DAVIS 632-42-9281

If Estate or Trust, Name and Title of Fiduciary Spouse's Social Security Number

•
2ႈFH8VH6& 2ႈFH8VH3D\PHQW

Part I - Compute Your Underpayment

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1.
,IRUOHVV\RXDUHQRWUHTXLUHGWR¿OH)RUP& 951.
2. Enter 90% of the Amount Shown on Line 1 2.
856.
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951.
4. Enter the Amount From Line 2 or Line 3, Whichever is Less 4.
856.
5. (QWHUWKH1XPEHURI,QVWDOOPHQW3HULRGVIRU:KLFK<RX:HUH/LDEOHWR0DNH3D\PHQWV 5.
4
Line 6 Through 14: Complete Each Line Across All Columns Before Continuing to Next Line

A B & D
 'XH'DWHVRI,QVWDOOPHQW3D\PHQWV May 1, 2019 June 15, 2019 Sept. 15, 2019 Jan. 15, 2020
 Tax Liability
(Divide the amount on Line 4 by the number of installments
reported on Line 5 and enter the result in the appropriate
columns) 214. 214. 214. 214.
8. (QWHUWKH,QFRPH7D[:LWKKHOGIRU(DFK,QVWDOOPHQW3HULRG
157. 157. 157. 158.
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Return
10. Enter the Amount of Any Timely 3D\PHQW 0DGH IRU (DFK
,QVWDOOPHQW3HULRGLQWKH$SSURSULDWH&ROXPQ
(Do not enter any late payments)
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overpayment) 57. 57. 57. 56.
12. 2WKHU3D\PHQWV
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9$'HSWRI7D[DWLRQ&:5HY

Due Date From Lines 8, 9, 10 and 12

)RUH[LQ&ROXPQ$HQWHUDOOSD\PHQWVPDGHE\0D\2019) 157. 157. 157. 158.
14. 6XEWUDFW/LQHIURP/LQH
(If the sum of all underpayments (do not include any
OVERPAYMENTS) reported is $150 or less, stop here; you are
not subject to an addition to tax. If your underpayments total
PRUHWKDQSURFHHGWR3DUW,, 57. 57. 57. 56.
Continued on Back
Late Payment/Overpayment Table (See Instructions for Lines 11 and 12.)
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$ $ $ $

REV 02/14/20 INTUIT.CG.CFP.SP 1555

760C - 2019
Page 2

Part II - Exceptions That Void the Addition to Tax A B C D

May 1, 2019 June 15, 2019 Sept. 15, 2019 Jan. 15, 2020
15. 7RWDO$PRXQW3DLGDQG:LWKKHOGIURP-DQXDU\WKURXJKWKH
Installment Date Indicated 157. 314. 471. 629.
 Exception 1:3ULRU<HDU V7D[ 100% of 2018 Tax 25% 50%  100%
(Multiply the 2018 tax by the percentage in each col.)
 Exception 2:7D[RQ3ULRU<HDU V,QFRPH8VLQJWKH 100% of Tax 25% 50%  100%
2019 Rates and Exemptions
(Multiply the 2018 tax by the percentage in each col.)
18. Exception 3 Worksheet:7D[RQ$QQXDOL]HG,QFRPH 8VHWKHIRUPXODEHORZWRFRPSXWHWKHDPRXQWRQ/LQHVDEDQGFIRUHDFKFRO
Lines 18a, b and c: April 30 column: Multiply the actual amount for the period ended April 30, 2019, by 3.
May 31 column: Multiply the actual amount for the period ended May 31, 2019, by 2.4.
August 31 column: Multiply the actual amount for the period ended August 31, 2019, by 1.5.
From January 1 to: April 30 May 31 August 31
D $QQXDOL]HG9LUJLQLD$GMXVWHG*URVV,QFRPH 9$*, IRU(DFK3HULRG
Note
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of March
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31, April 30
e. Virginia Taxable Income & July 31.
(Subtract Lines 18b, c and d from Line 18a)
f. Virginia Tax
(Enter the Virginia income tax for the amount(s) on Line 18e)
J 0XOWLSO\/LQHIE\WKH3HUFHQWDJH6KRZQIRU(DFK3HULRG 22.5% 45% 

Note
19. Exception 4 Worksheet:7D[RQ,QFRPH2YHUDDQG0RQWK3HULRG  DQGPRQWKVIRUHVWDWHVDQGWUXVWV Exceptions
From January 1 to: April 30 May 31 August 31 3 and 4 do
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the fourth
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period.
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'HGXFWLRQVIRU(DFK3HULRG
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e. Virginia Taxable Income
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f. Virginia Tax
(Enter the Virginia income tax for the amount(s) on Line 19e)
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Part III - Compute the Addition to Tax
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A B C D
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20. $PRXQWRI8QGHUSD\PHQWIURP3DUW,/LQH 57. 57. 57. 56.
21. 'DWHRI3D\PHQWIURP3DUW,/LQH
(If no payments were entered on Line 12, enter the actual date of
payment or May 1, 2020, whichever is earlier.) 05/01/2020 05/01/2020 05/01/2020 05/01/2020
22. D1XPEHURI'D\V$IWHU,QVWDOOPHQW'XH'DWH7KURXJK'DWH3DLGRU
June 30, 2019, Whichever Is Earlier
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E 1XPEHURI'D\V$IWHU-XQH7KURXJK'DWH3DLGRU0D\
2020, Whichever Is Earlier
,I0D\LVHDUOLHUHQWHUDQG 306 306 229 107
23. D0XOWLSO\WKH1XPEHURI'D\VLQ(DFK&ROXPQRQ/LQHDE\WKH
'DLO\5DWH 3HU$QQXP 0.01320 0.00330
E 0XOWLSO\WKH1XPEHURI'D\VLQ(DFK&ROXPQRQ/LQHEE\WKH
'DLO\5DWH 3HU$QQXP 0.05814 0.05814 0.04351 0.02033
F $GG/LQHVDDQGELQ(DFK&ROXPQDQG(QWHUWKH7RWDO+HUH 0.07134 0.06144 0.04351 0.02033
24. 0XOWLSO\WKH$PRXQWRQ/LQHE\/LQHFIRU(DFK&ROXPQ 4.07 3.50 2.48 1.14
Addition to Tax
25 7RWDOWKHDPRXQWVRQ/LQH(QWHUKHUHDQGRQWKH$GGLWLRQWR7D[OLQHRQ\RXU
income tax return) 11. •
REV 02/14/20 INTUIT.CG.CFP.SP 1555
 1040 U.S. Individual Income Tax Return 2019
Form Department of the Treasury—Internal Revenue Service (99)
OMB No. 1545-0074 IRS Use Only—Do not write or staple in this space.

Filing Status Single Married filing jointly Married filing separately (MFS) Head of household (HOH) Qualifying widow(er) (QW)
Check only If you checked the MFS box, enter the name of spouse. If you checked the HOH or QW box, enter the child’s name if the qualifying person is
one box.
a child but not your dependent. a
Your first name and middle initial Last name Your social security number
Haley S Davis 632-42-9281
If joint return, spouse’s first name and middle initial Last name Spouse’s social security number

Home address (number and street). If you have a P.O. box, see instructions. Apt. no. Presidential Election Campaign
Check here if you, or your spouse if filing
2212 Montauk Rd NW 10
jointly, want $3 to go to this fund.
City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions). Checking a box below will not change your
Roanoke VA 24017-1228 tax or refund. You Spouse
Foreign country name Foreign province/state/county Foreign postal code If more than four dependents,
see instructions and  here a

Standard Someone can claim: You as a dependent Your spouse as a dependent

Deduction Spouse itemizes on a separate return or you were a dual-status alien

Age/Blindness You: Were born before January 2, 1955 Are blind Spouse: Was born before January 2, 1955 Is blind
Dependents (see instructions): (2) Social security number (3) Relationship to you (4)  if qualifies for (see instructions):
(1) First name Last name Child tax credit Credit for other dependents

1 Wages, salaries, tips, etc. Attach Form(s) W-2 . . . . . . . . . . . . . . . . . . 1 26,495.

2a Tax-exempt interest . . . . 2a b Taxable interest. Attach Sch. B if required 2b
3a Qualified dividends . . . . 3a b Ordinary dividends. Attach Sch. B if required 3b
Standard
Deduction for— 4a IRA distributions . . . . . 4a b Taxable amount . . . . . . 4b
• Single or Married
filing separately,
c Pensions and annuities . . . 4c d Taxable amount . . . . . . 4d
$12,200 5a Social security benefits . . . 5a b Taxable amount . . . . . . 5b
• Married filing
6 Capital gain or (loss). Attach Schedule D if required. If not required, check here . . . . . . . a 6
jointly or Qualifying
widow(er), 7a Other income from Schedule 1, line 9 . . . . . . . . . . . . . . . . . . . . 7a 2,882.
$24,400
• Head of b Add lines 1, 2b, 3b, 4b, 4d, 5b, 6, and 7a. This is your total income . . . . . . . . . . . a 7b 29,377.
household, 49.
$18,350
8a Adjustments to income from Schedule 1, line 22 . . . . . . . . . . . . . . . . . 8a
• If you checked b Subtract line 8a from line 7b. This is your adjusted gross income . . . . . . . . . . . a 8b 29,328.
any box under
Standard 9 Standard deduction or itemized deductions (from Schedule A) . . . . . 9 12,200.
Deduction, 10 Qualified business income deduction. Attach Form 8995 or Form 8995-A . . . 10
see instructions.
11a Add lines 9 and 10 . . . . . . . . . . . . . . . . . . . . . . . . . 11a 12,200.
b Taxable income. Subtract line 11a from line 8b. If zero or less, enter -0- . . . . . . . . . . . 11b 17,128.
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Form 1040 (2019)
 Form 1040 (2019) Page 2
12a Tax (see inst.) Check if any from Form(s): 1 8814 2 4972 3 12a 1,861.
b Add Schedule 2, line 3, and line 12a and enter the total . . . . . . . . . . . . . . a 12b 1,861.
13a Child tax credit or credit for other dependents . . . . . . . . . . 13a
b Add Schedule 3, line 7, and line 13a and enter the total . . . . . . . . . . . . . . a 13b 1,500.
14 Subtract line 13b from line 12b. If zero or less, enter -0- . . . . . . . . . . . . . . . 14 361.
15 Other taxes, including self-employment tax, from Schedule 2, line 10 . . . . . . . . . . . . 15 0.
16 Add lines 14 and 15. This is your total tax . . . . . . . . . . . . . . . . . . a 16 361.
17 Federal income tax withheld from Forms W-2 and 1099 . . . . . . . . . . . . . . . 17 735.
• If you have a
18 Other payments and refundable credits:
qualifying child, a Earned income credit (EIC) . . . . . . . . . . . . No
. . . 18a
attach Sch. EIC.
• If you have b Additional child tax credit. Attach Schedule 8812 . . . . . . . . . 18b
nontaxable c American opportunity credit from Form 8863, line 8 . . . . . . . . 18c 1,000.
combat pay, see
instructions. d Schedule 3, line 14 . . . . . . . . . . . . . . . . . 18d
e Add lines 18a through 18d. These are your total other payments and refundable credits . . . . . a 18e 1,000.
19 Add lines 17 and 18e. These are your total payments . . . . . . . . . . . . . . . a 19 1,735.
Refund 20 If line 19 is more than line 16, subtract line 16 from line 19. This is the amount you overpaid . . . . . . 20 1,374.
21a Amount of line 20 you want refunded to you. If Form 8888 is attached, check here . . . . . . a 21a 1,374.
Direct deposit? a b Routing number 1 1 1 0 0 0 0 2 5 a c Type: Checking Savings
See instructions.
a d Account number 4 8 8 0 3 6 9 9 3 9 7 8
22 Amount of line 20 you want applied to your 2020 estimated tax . . . . a 22
Amount 23 Amount you owe. Subtract line 19 from line 16. For details on how to pay, see instructions . . . . . a 23
You Owe 24 Estimated tax penalty (see instructions) . . . . . . . . . . . a 24
Third Party Do you want to allow another person (other than your paid preparer) to discuss this return with the IRS? See instructions. Yes. Complete below.
Designee No
(Other than Designee’s Phone Personal identification
paid preparer) name a no. a number (PIN) a

Sign Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true,
correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Here Your signature Date Your occupation If the IRS sent you an Identity
Protection PIN, enter it here
F

Joint return? Student (see inst.)

See instructions. Spouse’s signature. If a joint return, both must sign. Date Spouse’s occupation If the IRS sent your spouse an
Keep a copy for Identity Protection PIN, enter it here
your records. (see inst.)

Phone no. Email address

Preparer’s name Preparer’s signature Date PTIN Check if:
Paid 3rd Party Designee
Preparer Self-employed
Firm’s name a Self-Prepared Phone no.
Use Only
Firm’s address a Firm’s EIN a

Go to www.irs.gov/Form1040 for instructions and the latest information. BAA REV 02/14/20 Intuit.cg.cfp.sp Form 1040 (2019)
SCHEDULE 1 OMB No. 1545-0074
Additional Income and Adjustments to Income
2019
(Form 1040 or 1040-SR)
a Attach to Form 1040 or 1040-SR.
Department of the Treasury Attachment
Internal Revenue Service a Go to www.irs.gov/Form1040 for instructions and the latest information. Sequence No. 01
Name(s) shown on Form 1040 or 1040-SR Your social security number
Haley S Davis 632-42-9281
At any time during 2019, did you receive, sell, send, exchange, or otherwise acquire any financial interest in any
virtual currency? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
Part I Additional Income
1 Taxable refunds, credits, or offsets of state and local income taxes . . . . . . . . . . . . 1
2a Alimony received . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2a
b Date of original divorce or separation agreement (see instructions) a
3 Business income or (loss). Attach Schedule C . . . . . . . . . . . . . . . . . . . 3
4 Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . . . . . . . . . 4
5 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E . . . . . 5
6 Farm income or (loss). Attach Schedule F . . . . . . . . . . . . . . . . . . . . 6
7 Unemployment compensation . . . . . . . . . . . . . . . . . . . . . . . . 7 2,882.
8 Other income. List type and amount a
8
9 Combine lines 1 through 8. Enter here and on Form 1040 or 1040-SR, line 7a . . . . . . . . 9 2,882.
Part II Adjustments to Income
10 Educator expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
11 Certain business expenses of reservists, performing artists, and fee-basis government officials. Attach
Form 2106 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
12 Health savings account deduction. Attach Form 8889 . . . . . . . . . . . . . . . . 12
13 Moving expenses for members of the Armed Forces. Attach Form 3903 . . . . . . . . . . 13
14 Deductible part of self-employment tax. Attach Schedule SE . . . . . . . . . . . . . . 14
15 Self-employed SEP, SIMPLE, and qualified plans . . . . . . . . . . . . . . . . . . 15
16 Self-employed health insurance deduction . . . . . . . . . . . . . . . . . . . . 16
17 Penalty on early withdrawal of savings . . . . . . . . . . . . . . . . . . . . . 17
18a Alimony paid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18a
b Recipient’s SSN . . . . . . . . . . . . . . . . . . . . . a
c Date of original divorce or separation agreement (see instructions) a
19 IRA deduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
20 Student loan interest deduction . . . . . . . . . . . . . . . . . . . . . . . 20 49.
21 Tuition and fees. Attach Form 8917 . . . . . . . . . . . . . . . . . . . . . . 21
22 Add lines 10 through 21. These are your adjustments to income. Enter here and on Form 1040 or
1040-SR, line 8a . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 49.
For Paperwork Reduction Act Notice, see your tax return instructions. REV 02/14/20 Intuit.cg.cfp.sp Schedule 1 (Form 1040 or 1040-SR) 2019
SCHEDULE 3 OMB No. 1545-0074
Additional Credits and Payments
2019
(Form 1040 or 1040-SR)
a Attach to Form 1040 or 1040-SR.
Department of the Treasury Attachment
Internal Revenue Service a Go to www.irs.gov/Form1040 for instructions and the latest information. Sequence No. 03
Name(s) shown on Form 1040 or 1040-SR Your social security number
Haley S Davis 632-42-9281
Part I Nonrefundable Credits
1 Foreign tax credit. Attach Form 1116 if required . . . . . . . . . . . . . . . . . . 1
2 Credit for child and dependent care expenses. Attach Form 2441 . . . . . . . . . . . . 2
3 Education credits from Form 8863, line 19 . . . . . . . . . . . . . . . . . . . . 3 1,500.
4 Retirement savings contributions credit. Attach Form 8880 . . . . . . . . . . . . . . 4
5 Residential energy credits. Attach Form 5695 . . . . . . . . . . . . . . . . . . . 5
6 Other credits from Form: a 3800 b 8801 c 6
7 Add lines 1 through 6. Enter here and include on Form 1040 or 1040-SR, line 13b . . . . . . . 7 1,500.
Part II Other Payments and Refundable Credits
8 2019 estimated tax payments and amount applied from 2018 return . . . . . . . . . . . 8
9 Net premium tax credit. Attach Form 8962 . . . . . . . . . . . . . . . . . . . . 9
10 Amount paid with request for extension to file (see instructions) . . . . . . . . . . . . . 10
11 Excess social security and tier 1 RRTA tax withheld . . . . . . . . . . . . . . . . . 11
12 Credit for federal tax on fuels. Attach Form 4136 . . . . . . . . . . . . . . . . . . 12
13 Credits from Form: a 2439 b Reserved c 8885 d 13
14 Add lines 8 through 13. Enter here and on Form 1040 or 1040-SR, line 18d . . . . . . . . . 14
For Paperwork Reduction Act Notice, see your tax return instructions. REV 02/14/20 Intuit.cg.cfp.sp Schedule 3 (Form 1040 or 1040-SR) 2019
 8863 Education Credits OMB No. 1545-0074
(American Opportunity and Lifetime Learning Credits)
2019
Form
a Attach to Form 1040 or 1040-SR.
Department of the Treasury Attachment
Internal Revenue Service (99) a Go to www.irs.gov/Form8863 for instructions and the latest information. Sequence No. 50
Name(s) shown on return Your social security number
Haley S Davis 632-42-9281

F
!
CAUTION
Complete a separate Part III on page 2 for each student for whom you’re claiming either credit before
you complete Parts I and II.

Part I Refundable American Opportunity Credit

1 After completing Part III for each student, enter the total of all amounts from all Parts III, line 30 . . 1 2,500.
2 Enter: $180,000 if married filing jointly; $90,000 if single, head of household,
or qualifying widow(er) . . . . . . . . . . . . . . . . . . 2 90,000.
3 Enter the amount from Form 1040 or 1040-SR, line 8b. If you’re filing Form
2555 or 4563, or you’re excluding income from Puerto Rico, see Pub. 970 for
the amount to enter . . . . . . . . . . . . . . . . . . . 3 29,328.
4 Subtract line 3 from line 2. If zero or less, stop; you can’t take any education
credit . . . . . . . . . . . . . . . . . . . . . . . . 4 60,672.
5 Enter: $20,000 if married filing jointly; $10,000 if single, head of household, or
qualifying widow(er) . . . . . . . . . . . . . . . . . . . 5 10,000.
6 If line 4 is:
• Equal to or more than line 5, enter 1.000 on line 6 . . . . . . . . . . . . .
• Less than line 5, divide line 4 by line 5. Enter the result as a decimal (rounded to
at least three places) . . . . . . . . . . . . . . . . . . . . . .
} . . . 6 1.000

7 Multiply line 1 by line 6. Caution: If you were under age 24 at the end of the year and meet the
conditions described in the instructions, you can’t take the refundable American opportunity credit;
skip line 8, enter the amount from line 7 on line 9, and check this box . . . . . . . . a 7 2,500.
8 Refundable American opportunity credit. Multiply line 7 by 40% (0.40). Enter the amount here and
on Form 1040 or 1040-SR, line 18c. Then go to line 9 below . . . . . . . . . . . . . . 8 1,000.
Part II Nonrefundable Education Credits
9 Subtract line 8 from line 7. Enter here and on line 2 of the Credit Limit Worksheet (see instructions) . 9 1,500.
10 After completing Part III for each student, enter the total of all amounts from all Parts III, line 31. If
zero, skip lines 11 through 17, enter -0- on line 18, and go to line 19 . . . . . . . . . . . 10
11 Enter the smaller of line 10 or $10,000 . . . . . . . . . . . . . . . . . . . . . 11
12 Multiply line 11 by 20% (0.20) . . . . . . . . . . . . . . . . . . . . . . . . 12
13 Enter: $136,000 if married filing jointly; $68,000 if single, head of household, or
qualifying widow(er) . . . . . . . . . . . . . . . . . . . 13
14 Enter the amount from Form 1040 or 1040-SR, line 8b. If you're filing Form
2555 or 4563, or you’re excluding income from Puerto Rico, see Pub. 970 for
the amount to enter . . . . . . . . . . . . . . . . . . . 14
15 Subtract line 14 from line 13. If zero or less, skip lines 16 and 17, enter -0- on
line 18, and go to line 19 . . . . . . . . . . . . . . . . . 15
16 Enter: $20,000 if married filing jointly; $10,000 if single, head of household, or
qualifying widow(er) . . . . . . . . . . . . . . . . . . . 16
17 If line 15 is:
• Equal to or more than line 16, enter 1.000 on line 17 and go to line 18
• Less than line 16, divide line 15 by line 16. Enter the result as a decimal (rounded to at least three
places) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
18 Multiply line 12 by line 17. Enter here and on line 1 of the Credit Limit Worksheet (see instructions) a 18
19 Nonrefundable education credits. Enter the amount from line 7 of the Credit Limit Worksheet (see
instructions) here and on Schedule 3 (Form 1040 or 1040-SR), line 3 . . . . . . . . . . . 19 1,500.
For Paperwork Reduction Act Notice, see your tax return instructions. REV 02/14/20 Intuit.cg.cfp.sp Form 8863 (2019)
BAA
Form 8863 (2019) Page 2
Name(s) shown on return Your social security number
Haley S Davis 632-42-9281

F
!
CAUTION
Complete Part III for each student for whom you’re claiming either the American
opportunity credit or lifetime learning credit. Use additional copies of page 2 as needed for
each student.
Part III Student and Educational Institution Information. See instructions.
20 Student name (as shown on page 1 of your tax return) 21 Student social security number (as shown on page 1 of
Haley S your tax return)
Davis 632-42-9281
22 Educational institution information (see instructions)
a. Name of first educational institution b. Name of second educational institution (if any)
Jefferson College of Health Sciences
(1) Address. Number and street (or P.O. box). City, town or (1) Address. Number and street (or P.O. box). City, town or
post office, state, and ZIP code. If a foreign address, see post office, state, and ZIP code. If a foreign address, see
instructions. instructions.
101 Elm Ave. SW
Raonoke VA 24013
(2) Did the student receive Form 1098-T (2) Did the student receive Form 1098-T
Yes No Yes No
from this institution for 2019? from this institution for 2019?
(3) Did the student receive Form 1098-T (3) Did the student receive Form 1098-T
from this institution for 2018 with box Yes No from this institution for 2018 with box Yes No
7 checked? 7 checked?
(4) Enter the institution’s employer identification number (EIN) (4) Enter the institution’s employer identification number
if you’re claiming the American opportunity credit or if you (EIN) if you’re claiming the American opportunity credit or
checked “Yes” in (2) or (3). You can get the EIN from Form if you checked “Yes” in (2) or (3). You can get the EIN
1098-T or from the institution. from Form 1098-T or from the institution.
54-0506332

23 Has the Hope Scholarship Credit or American opportunity

Yes — Stop!
credit been claimed for this student for any 4 tax years Go to line 31 for this student. No — Go to line 24.
before 2019?
24 Was the student enrolled at least half-time for at least one
academic period that began or is treated as having begun in
2019 at an eligible educational institution in a program
Yes — Go to line 25. No — Stop! Go to line 31
leading towards a postsecondary degree, certificate, or
for this student.
other recognized postsecondary educational credential?
See instructions.
25 Did the student complete the first 4 years of postsecondary Yes — Stop!
education before 2019? See instructions. Go to line 31 for this No — Go to line 26.
student.
26 Was the student convicted, before the end of 2019, of a Yes — Stop! No — Complete lines 27
felony for possession or distribution of a controlled Go to line 31 for this through 30 for this student.
substance? student.

F
!
CAUTION
You can't take the American opportunity credit and the lifetime learning credit for the same student in the same year. If
you complete lines 27 through 30 for this student, don’t complete line 31.

American Opportunity Credit

27 Adjusted qualified education expenses (see instructions). Don’t enter more than $4,000 . . . . . 27 4,000.
28 Subtract $2,000 from line 27. If zero or less, enter -0- . . . . . . . . . . . . . . . . . 28 2,000.
29 Multiply line 28 by 25% (0.25) . . . . . . . . . . . . . . . . . . . . . . . . 29 500.
30 If line 28 is zero, enter the amount from line 27. Otherwise, add $2,000 to the amount on line 29 and
enter the result. Skip line 31. Include the total of all amounts from all Parts III, line 30, on Part I, line 1 . 30 2,500.
Lifetime Learning Credit
31 Adjusted qualified education expenses (see instructions). Include the total of all amounts from all Parts
III, line 31, on Part II, line 10 . . . . . . . . . . . . . . . . . . . . . . . . . 31
Form 8863 (2019)