Document KQ3k0NQByVqg2YG38wE6mqn6

rop 1040 Department of the Treasury--Internal Revenue Service U.S. individual Income Tax Return (R) 92 Label For (he year Jan. 1-Dec. 31, 1992, or other tax year beginning T Your first name and Initial Last name (See instiuctlons on page 10.) ' ast name Use the IRS label. Otherwise, please print or type. e page 10. Presidential Election Campaign k (See page 10.) r Do:you want $1 to go to this fund?............................................ If a joint return, does your spouse want $1 to go to this fund? tRS Use Only--Do not write or staple In this space. , 1992, ending . 19 OMB No. 1545-0074 Apt. no. page 10. Yes Yes For Privacy Act and Paperwork Reduction Act Notice, see page 4. Note: Checking "Yes' will not change your tax or reduce vour refund,______ Filing Status (See page 10.) Check only one box. Exemptions (See page 11.) If more than six dependents, see page 12. 1 Single 2 Married filing Joint return (even If only one had Income) 3 Married filing separate return. Enter spouse's social security no. above and full name here. 4 Head of household (with qualifying person). (See page 11.) If the qualifying person is a child but not your dependent, enter this child's name here. Qualifying wldow(er) with dependent child (year spouse died 19______ ) (See page 11.)______________________ 6a '3. Yourself. If your parent (or someone else) can claim you as a dependent on his or her tax return, do not check box 6a. But be sure to check the box on line 33b on page 2 b Sycl Spouse Dependents: (1) Name (first. Initial, and last name) (2) Check II under age 1 (3) II age 1 or older, dependent's social security number (4) Dependent's relationship to you (5) No. of months lived In your home In 1992 J?S&L. No. of boxes checked on 6a end 6b No. el your children on 6c who: lived with you didn't tlvo with you due to dWorco or separation (tee page 13) No. ot other dependents on 6c CDIf your child didn't live with you but Is claimed as your dependent under a pre-1985 agreement, check here Total number of exemptions claimed........................................................................................ Add numbers entered on lines above * 4/ Income Attach . Copy B of your Forms W-2, W-2G, and 1099-R hero. If you did not get a W-2, see 7 Wages, salaries, tips, etc. Attach Form(s) W-2 . . . 8a Taxable interest income. Attach Schedule B If over $400 b Tax-exempt Interest income (see page 15). DON'T include on line 8a 8b 9 Dividend Income. Attach Schedule B If over $400 ............................................................... 10 Taxable refunds, credits, or offsets of state and local income taxes from worksheet on page 16 11 Alimony received.............................................................................................................................. 12 Business Income or (loss). Attach Schedule C or C-EZ........................................................ 13 Capital gain or (loss). Attach Schedule D................................................................................. 14 Capital gain distributions not reported on line 13 (see page 15)...................................... Attach check or money order on top of any Forms W-2, W.-2G, or 1099-R. 15 Other gains or (losses). Attach Form 4797 . 16a Total IRA distributions . 16a 17a Total pensions and annuities 17a . b Taxable amount (see page 16) b Taxable amount (see page 16) 18 Rents, royalties, partnerships, estates, trusts, etc. Attach Schedule E......................... 19 Farm income or (loss). Attach Schedule F.................................................................................. 20 Unemployment compensation (see page 17)........................................................................... 21a Social security benefits 1 21a I I I b Taxable amount (see page 17) 22 Other Income. Ust type and amount--see page 18................................................................ 23 Adjustments to income (See page 18.) Adjusted Gross Income 24a b 25 26 27 28 Sft 30 31 Your IRA deduction from applicable worksheet on page 19 or 20 24a Spouse's IRA deduction trom applicable worksheet on page 19 or 20 One-half of self-employment tax (see page 20) ... 24b 25 Self-employed health Insurance deduction (see page 20) Keogh retirement plan and self-employed SEP deduction Penalty on early withdrawal of savings............................... 28 27 28 Ailfhbhy paid, fafciptertf's A _______ __________ Mj . Add lines 24a through 29, These are your total adjustments Subtract line 30 from line 23. This is your adjusted gross Income. II this amount is less than $22,370 and a child lived with you, see page EtC-1 to find out if you can claim the "Earned Income Credit" on line 56................................................................................................................. 8a 10 11 12 13 14 15 16b 17b 18 19 20 21b 22 23 30 31 ^53 Z.6/.2L % Z&2. iO_ Form 1040 (1992) Page 2 Tax Compu tation (See page 22.) 32 Amount from line 31 (adjusted gross Income)......................................................... 33a Check If: D You were 65 or older, O Blind; CD Spouse was 65 or older, O Blind. Add the number of boxes checked above and enter the total here . . . _. 33a b If your parent (or someone else) can claim you as a dependent, check here . 33b c If you are married filing separately and your spouse Itemizes deductions or you are a dual-status alien, see page 22 and check here............................................ 33c EH Itemized deductions from Schedule A, line 26, OR 34 Enter the Standard deduction shown below for your filing status. But If you checked any box on line 33a or b, go to page 22 to find your standard deduction. larger , If you checked box 33c, your standard deduction Is zero. of your: Single--$3,600 Head of household--$5,250 Married filing jointly or Qualifying wldow(er)--$6,000 . e Married filing separately--$3,000 35 Subtract line 34 from line 32.................................................................................................................. 35 3.&6Q 36 If you want the IRS to figure your tax, see page 23. 37 98 39 40 If line 32 is $78,950 or less, multiply $2,300 by the total number of exemptions claimed on line 6e. If line 32 is over $78,950, see the worksheet on page 23 for the amount to enter . Taxable Income. Subtract line 36 from line 35. If line 36 Is more than line 35, enter -0- . Enter tax. Check if from a O Tax Table, b CD Tax Rate Schedules, c CD Schedule D, or d CD Form 8615 (see page 23). Amount, if any, from Form(s) 8814 e--------------- 1------Additional taxes (see page 23). Check if from a CD Form 4970 b CD Form 4972 . . . Add lines 38 and 39..................................................................... 36 37 38 39 40 L Jl 0 Credits (See page 23.) 41 Credit for child and dependent care expenses. Attach Form 2441 42 Credit for the elderly or the disabled. Attach Schedule R . , 43 Foreign tax credit. Attach Form 1116 . . ..-.......................... CD44 Other credits (see page 24). Check If from'a Form 3800 b CD Form 8396 c D Form 8801 d CD Form (specify) 41 42 43 44 45 Add lines 41 through 44 46 Subtract line 45 from line 40. if line 45 Is more than line 40, enter -0- , Other Taxes Payments Attach Forms W-2, W-2G, and 1099-R on the front. 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Refund or 61 Amount 62 You Owe 63 Attach check or money order on top of Form(s) W-2, etc., on the front. 64 65 Self-employment tax. Attach Schedule SE. Also, see line 25................................................... Alternative minimum tax. Attach Form 6251 ............................................................................ a D bRecapture taxes (see page 25). Check if from Form 4255 CD Form 8611 c CD Form 8828 Social security and Medicare tax on tip Income not reported to employer. Attach Form 4137 Tax on qualified retirement plans, including IRAs. Attach Form 5329 ................................ Advance earned Income credit payments from Form W-2 ................................................... Add lines-46 through 52. This Is your total tax. . . . Federal income tax withheld. If any Is from Form(s) 1099, check CD 1992 estimated tax payments and amount applied from 1991 return . Earned Income credit. Attach Schedule EIC.......................... Amount paid with Form 4868 (extension request) .... Excess social security, Medicare, and RRTA tax withheld (see page 26) . 54 55 56 57 58 6% Other payments (see page 26). Check if from a CDForm 2439 bD Form 4136.................................................................................. Add lines 54 through 59. These are your total payments , 59 If line 60 Is more than line 53, subtract line 53 from line 60. This Is the amount you OVERPAID. . Amount of line 61 you want REFUNDED TO YOU. . . . . ^................................ _ Amount of line 61 you want APPLIED TO YOUR 1993 ESTIMATED TAX 63 If line 53 Is more than line 60, subtract line 60 from line 53. This Is the AMOUNT YOU OWE. Attach check or money order for full amount payable to "Internal Revenue Service." Write your name, address, social security number, daytime phone number, and "1992 Form 1040" on It Estimated tax penalty (see page 27). Also Include on line 64 I 65 |__________________|_ 45 46 47 48 49 50 51 52 53 60 61 JS. O Here Keep a copy torlyour'ilUln records. Paid Ld,u t rftfjJdlBI USB OftlV v miij Under penalties of perjury, f 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 ail Information ot which preparer has any knowledge. v Your signature Date Your occupation * W Spouse's signature. If a Joint return, BOTH must sign. Date Spouse's occupation f Preparer's signature Wf Date A/c j JIS- Check If self-employed LJ Preparer's social security no. ., 1: Firm's name (or yours ^ If self-employed) and ------------------------------------- address r E.I. No. " ZIP code 0007-SWP-005802964 CONFIDENTIAL SCHEDULE F . (Form 1040) Department of the Treasury Internal Revenue Service (X) Name of proprleto REDACTED Profit or Loss From Farming Attach to Form 1040, Form 1041, or Form 1065. See Instructions for Schedule F (Form 1040). OMB No. 1545-0074 1192 Attachment Sequence No. 14 Social security number (SSN) A Principal produci. uescriDe in one or two words your principal crop or activity tor the current tax year. TVa/ZsziS: BzeF' ft^y C Accounting method: (1) J^^Cash (2) 0 Accrual I B Enter principal agricultural activity code (from page 2) | fp| \ D Employer ID number (Not SSN) ..1 1 1 MINI ^fyesE Did you "materially participate" In the operation of this business during 1992? If "No," see page F-1 for llmItatlons bn losses, 0No Part 1 | Farm Income--Cash Method--Complete Parts 1 and II (Accrual method taxpayers complete Parts II and III, and tine 11 of Pert 1.) Do not Include sales of livestock held for draft, breeding, sport, or dairy purposes; report these sales on Form 4797. 1 Sales of livestock and other Items you bought for resale . . . 2 Cost or other basis of livestock and other Items reported on line 1 3 Subtract line 2 from line 1..................................................................... 4 Sales of livestock, produce, grains, and other products you raised 5a Total cooperative distributions (Form(s) 1099-PATR) 5a 6a Agricultural program payments (see page F-2) 6a 5b Taxable amount 6b Taxable amount m 3 4 5b 6b 7 Commodity Credit Corporation (CCC) loans (see page F-2): a CCC loans reported under election ... . b CCC loans forfeited or repaid with certificates 7b 7o Taxable amount 8 Crop Insurance proceeds and certalnCdlsasterlpayments (see page F-2h Amount received In 1992 ................................. If election to defer to 1993 Is attached, check here 0 8b Taxable amount 8d Amount deferred from 1991 . . 9 Custom hire (machine work) Income.............................................................................................................................. 10 Other Income, Including Federal and state gasoline or fuel tax credit or refund (see page F-3)......................... W%. 7a 7c 8b 8d 9 10 11 Gross Income. Add amounts In the right column for lines 3 through 10. If accrual method taxpayer, enter the amount from page 2, line 51. 11 Part II Farm Expenses--Cash and Accrual Method (Do not include personal or living expenses such as taxes, insurance, 12 Car and truck expenses (see page F-3--also attach Form 4562). . 13 Chemicals..................................... 14 Conservation expenses. Attach Form 8645................................ 15 Custom hire (machine work). . 16 Depreciation and section 179 expense deduction not claimed elsewhere (see page F-3) . . 17 Employee benefit programs other than on line 25. 18 Feed purchased , , 19 Fertilizers and lime . -20 Freight and trucking . 21 Gasoline, fuel, and oil 22 Insurance (other than health) . 23 Interest: Mortgage (paid to banks, etc.) . Other ............................................ 24 Labor hired (less jobs credit) , 12 13 14 15 16 17 18 19 20 21 22 23a 23b 24 . <?7& t Ts TT a ,##./ 25 Pension and profit-sharing plans...................................... 26 Rent or lease (see page F-4): a Vehicles, machinery, and equip merit. , . . . . . . b Otherdland, anlmais^etc.) . 27 Repairs and maintenance . 28 Seeds and plants purchased 29 Storage and warehousing . 30 Supplies purchased . . . 31 Taxes ...................................... 32 Utilities...................................... 33 Veterinary, breeding, and medicine 34 Other expenses (specify): b ........................ C ....................... d ........ e /&.CC0OMT/.4/&......... f 25 26a 26b 27 28 29 30 31 32 33 34a 34b 34c 34d 34e 34f 7$gf .Z/T 35 Total expenses. Add lines 12 through 34f........................................................................................ ...... . . 36 Net farm profit or (loss). Subtract line 35 from line 11. If a profit, enter on Form 1040, line 19, and on Schedule SE, line 1. If a loss, you MUST go on to line 37 (fiduciaries and partnerships, see page F-5)................................ 37 If you have a loss, you MUST check the box that describes your Investment In this activity (see page F-5). } If you checked 37a, enter the loss on Form 1040, line 19, and Schedule SE, line 1. If you checked 37b, you MUST attach Form 6198._______________ For Paperwork Reduction Act Notice, see Form 1040 Instructions. 131 Cat. No. 11346H N41622.01 35 36 37^0<AII Investment Is at risk. 37b 0 Some Investment Is nol at risk. Schedule P (Form 1040) 1992 107-SWP-005 802965 CONFIDENTIAL 1 4562 Department of the Treasury Internal Revenue Service (R) Name(s) she REDACTED Depreciation and Amortization (Including Information on Listed Property) See separate Instructions. Attach this form to your return. OMB No. 1545-0172 fl92 Attachment Sequence No. 67 Identifying number Business or activity to which this form relates Part I Election To Expense Certain Tangible Property (Section 179) (Note: If you have any "Listed Property," 1 Maximum dollar limitation (see instructions).................................................................................................... 1 2 Total cost of section 179 property placed in service during the tax year (see instructions). . 2 3 Threshold cost of section 179 property before reduction in limitation.................................................. 3 4 Reduction in limitation. Subtract line 3 from line 2, but do not enter less than -0- .... 4 5 Dollar limitation for tax year. Subtract line 4 from line 1, but do not enter less than -0- . . 5 (8) Description of property (b) Cost (c) Elected cost 6 $10,000 $200,000 ISM L7 Listed DroDertv. Enter amount from line 26........................................................ 7 8 Total elected cost of section 179 property. Add amounts in column (c), lines 6 and 7 . . . 8 9 Tentative deduction. Enter the smaller of line 5 or line 8............................................ ...... 9 10 Carryover of disallowed deduction from 1991 (see instruct ons)............................................................... 10 11 Taxable income limitation. Enter the smaller of taxable inc<ome or line 5 (see instructions) . . 11 12 Section 179 expense deduction. Add lines 9 and 10, but clo not enter more than line 11. . 12 13 Carryover of disallowed deduciion to 1993. Add lines 9 ahd 10, less line 12 13 Note: Do not use Part II or Part III below for automobiles, certain other vehicles, cellular telephones, computers, or property used for entertainment, recreation, or amusement (listed property). Instead, use Part V for listed property. Part II MACRS Depreciation For Assets Placed in Service ONLY During Your 1992 Tax Year (Do Not Include (a) Classification of property (b) Month and year placed in service (c) Basis for depreciation (business/investment use only--see instructions) (d) Recovery period (e) Convention (0 Method 14 a b General Depreciation System (GDS) (see instructions): 3-year property 5-year property c 7-year property d 10-year property e 15-year property f 20-year property g Residential rental Drooertv h Nonresidential real property IMBl ! '/ rT* // '/y i 27.5 yrs. 1 27.5 yrs. 31.5 yrs.i 31.5 yrs. MM MM MM MM S/L S/L S/L S/L 15 Alternative Depreciation System (ADS) (see instructions): a Class life 11111111P S/L b 12-year c 40-year 12 yrs. 40 yrs. MM S/L S/L (g) Depreciation deduction 1JW1I11 Other Depreciation (Do Not Include Listed Property) 16 GDS and ADS deductions for assets placed in service in tax years beginning before 1992 (see instructions) . ........................................................................................................................ 17 Property subject to section 168(f)(1) election (see instructions)............................................................... 18 ACRS and other depreciation (see instructions).............................................................................................. BsfffflLfl Summary -IQ 1 tctorl nrnrvarlv Fntar amount from linn ......................................................................................1 20 Total. Add deductions on line 12, lines 14 and 15 in column (g), and lines 16 through 19. Enter here and on the aoproDriate lines of vour return. (Partnerships and S corporations--see instructions) 16 17 18 19 20 the portion of the basis attributable to section 263A costs (see instructions) 21 For Paperwork Reduction Act Notice, see page 1 of the separate Instructions. Cat. No. 12906N Form 4562 (1992) N41622.02 0007-SWP-005 802966 CONFIDENTIAL REDACTED 5329form Return for Additional Taxes Attributable to Qualified Retirement Plans (Including IRAs), Annuities, and Modified Endowment Contracts Department of the Treasury Internal Revenue Service (Under Sections 72, 4973, 4974 and 4980A of the Internal Revenue Code) ____________ Attach to Form 1040. See separate Instructions.____________ Name ot individual subject to additional tax. (Enter the name ot one Individual only. See the instructions tor "Joint Returns.') OMB No. 1545-0203 HI92 Attachment Sequence No. 29 Your social security number ared to street address.) Apt. No. Uiy, tow. Part I If this Is an Amended Return, check here LJ Complete this part if, either in this year or in earlier years, you contributed more to your IRA than is or was allowable and you have an excess contribution subject to tax.___ 1 Excess contributions for 1992 (see instructions). Do not include this amount on Form 1040, line 24a or 24b................................................................................................................................................................................ Earlier year excess contributions not previously eliminated (see instructions)................................................................................................................. Contribution credit. (If your actual contribution for 1992 is less than your maximum allowable contribution, see instructions for line 3; otherwise, enter -0-.)............................................ .................................................. 4a 1992 distributions from your IRA account that are includible in taxable income............................................................................................................................. 3 4a 1991 tax year excess contributions (if any) withdrawn after the due date (including extensions) of your 1991 income tax return, and 1990 and earlier tax year excess contributions withdrawn in 1992 . . . 4b 4c Adjusted earlier year excess contributions. (Subtract line 4c from line 2. Enter the result, but not less than zero.).............................................................................................. .................................................................... 6 Total excess contributions (add lines 1 and 5).................................................................................. ...... 7 Tax due. (Enter the smaller of 6% of line 6 or 6% of the value of your IRA on the last day of 1992.) Also enter this amount on Form 1040, line 51........................................................................................ Part II Tax on Early Distributions (Section 72) Complete this part If a taxable distribution was made from your qualified retirement plan (including an IRA), modified endowment contract, or annuity contract before you reached age 59'/}. Note: You must enter the amount of the distribution on the appropriate line (or lines) of Form 1040 or Form 4972. 8 Early distributions included in gross income attributable to: a Qualified retirement plans (including IRAs)............................... b Annuity contracts............................................................................ c Modified endowment contracts................................................... d Prohibited transactions...................................................................... e Pledging of accounts as security ........ 8a 8b 8c 8d 8e f Cost of collectibles............................................................................ 8f g Total distributions (add lines 8a through 8f)........................................................................................................... Note: Include this amount on line 16b or 17b of Form 1040 or on the appropriate line of Form 4972 26,?6/. 9' Exceptions to distributions subject to additional taxes (see Instructions): a Due to death (does not apply to modified endowment contracts). . b Due to total and permanent disability............................................................... c As part of a series of substantially equal lifetime periodic payments. 9a 9b 9c 2 Lines 9d through 9f DO NOT apply to distributions from IRAs, annuities, or modified endowment contracts. d Due to separation from service in or after the year of reaching age 55 e Distributions to the extent of deductible medical expenses. . . . f Made to an alternate payee under a qualified domestic relations order g Other (specify).................................................................................................................. 9d 9e 9f 9g h Total amount excluded from additional tax (add lines 9a through 9g) . 10 Amount subject to additional tax (subtract line 9h from 8g). ii Total section 72 tax (multiply line 10 by 10% (.10)). Enter here and on Form 1040, line 51 For Paperwork Reduction Act Notice, see page 1 of separate Instructions. 289 Cat. No. 133290 5H10 11 Form 5329 (199Z) 0007-SWP-005802967 CONFIDENTIAL REDACTED SCHEDULE D Capital Gains and Losses w iv id No. 1545-0074 (Form 1040) Oepartmont of the Treasury . . Internal Revenue Service w (And Reconciliation of Forms 1099-B for Bartering Transactions) Attach to Form 1040. See Instructions for Schedule D (Form 1040). For more space to list transactions for lines la and 9a, get Schedule D-1 (Form 1040). 11)92 Attachment Sequence No. 12A Name(s) shown on Form indn- ] Your social security number Caution: Add mo mm/irnr^ amvuina lofsvrivu iv yvu ivi ij j uu tonvs 1099-B and 1099-S (of on substitute statements).' (9} proceeds from transactions involving stocks, bonds, and other securities, and (b) gross proceeds from real estate transactions not reported on another form or schedule. If this total does not equal the total of lines 1c and 9c, column (d), attach a statement explaining the difference. Part I Short-Term Capital Gains and Losses--Assets Held One Year or Less (a) Description of property (Example, 100 shares 7% preferred of "XYZ" Co.) (b) Date acquired (c) Date sold (Mo., day, yr.) (Mo., day, yr.) (d) Sales price (see page D-2) (e) Cost or other basis (see page D-3> (f) LOSS If (e) Is more than (d), subtract (d) from (e) (0) GAIN If (d) Is more than (e), subtract (e) from (dl la Stocks, Bonds, Other Securities, and Real Estate. Include Form 1099-B and 1099-S Transactions. See page D-3. 1b Amounts from Schedule D-1, line 1b. Attach Schedule D-1 1c Total of All Sales Price Amounts. Add column (d) of lines la and 1b Id Other Transactions. 1c 2 Short-term gain from sale or exchange of your home from Form 2119, line 17 or 23 3 Short-term gain from installment sales from Form 6252, line 26 or 37 . . . 4 Short-term gain or (loss) from Ilke-klnd exchanges from Form 8824 . . . 5 Net short-term gain or (loss) from partnerships, S corporations, and fiduciaries 6 Short-term capital loss carryover from 1991 Schedule D, line 36 .... 7 Add lines la, 1b, Id, and 2 through 6, in columns (f) and (g)................................ 8 Net short-term capital gain or (loss). Combine columns (f) and (g) of line 7 Part II Long-Term Capital Gains and Losses--Assets Held More Than One Year 9a Stocks, Bonds, Other Securities, and Real Estate. Include Form 1099-B and 1099-S Transactions. See page D-3. /-/-r7 3~3/-fX ~t~` ;j j j ji \ I i 9b Amounts from Schedule D-1, line 9b. Attach Schedule D-1 9c Total of Alt Sales Price Amounts. Add column (d) of lines 9a and 9b 9d Other Transactions. 9c 1 lllililllP llll 10 Long-term gain from sale or exchange of your home from Form 2119, line 17 or 23 . 11 Long-term gain from installment sales from Form 6252, line 26 or 37 . . . . 12 Long-term gain or (loss) from Ilke-klnd exchanges from Form 8824.......................... 13 Net long-term gain or (loss) from partnerships, S corporations, and fiduciaries . 14 Capital gain distributions........................................................................................................... 15 Gain from Form 4797, line 8 or 10...................................... .................................................. 16 Long-term capital loss carryover from 1991 Schedule D, tine 43.......................... 17 Add lines 9a, 9b, 9d, and 10 through 16, in columns (f) and (g)................................ 18 Net Iona-term capital gain or (loss). Combine columns (f) and (g) of line 17 For Paperwork Reduction Act Notice, see Form 1040 Instructions. 123 Cat. No. 11338H 1 is 1 ifim_ Schedule D (Form 1040) 1992 0007-SWP-005 802968 CONFIDENTIAL REDACTED 1 Control number - eii 2 Employer's name, address, and ZIP code OMB No. 1545-0008 CEDAR RIDGE NURSING CARE CTR RR #1 BOX iaas SKOWHEGAN, ME 04976 3 Employer's identification number 01-0442817 5 Employee's social security number 4 Employer's state I D. number 01-0442817 19 Employee's name, address, and ZIP code Copy B To be filed with employee's FEDERAL tax return_____________ 6 Statutory Deceased Pension legal employee plan rep 942 emp. Deferred compensation 7 Allocated tips 8 Advance EIC payment 9 federal income tax withheld lt=JCCO. viJO 11 Social security tax withheld 783.18 13 Social security tips 15 Medicare tax withheld 183.16 17 See Instrs. for Box 17 10 Wages, tips, other compensation 12, 631. 93 12 Social security wages 12, 631. 93 14 Medicare wages and tips 12, 631. 93 16 Nonqualified plans 18 Other 24 State income tax 25 State wages, tips. etc. 26 Name of state 28. 54 12631.93 ME 22 Dependent care benefits 23 Benetits included in Box 10 27 Local income tax 28 Local wages, tips. etc. 29 Name of locality Department of the Treasury--Internal Revenue Service **i Form W-2 Wage and Tax Statement 1992 (Rev. 4-92) 13 2678063 This information is being furnished to the Internal Revenue Service. GO00070 OMB No. 1545-0008 2 Employer's name, address, and ZIP code 3UC `7* StieRUI* WILLIAMS *RLFAR TRUST TRUST CCFPAHY 3AKK P 0 BOX 4655 A7LAK7A 3G302 3 Employer's identification number 5 Employee's social security number 4 Enpptoyer's state I.D|number M' t jr 19 Employee's name, address, and ZIP code 6!mSte Decease`i otenSion employee pty, -D_____ B 7 Allocated tips ,L,,en9al rep. n 942 Subtolal Deferred' Void emp. compensation h o____ n. 8 Advance EIC payment & federal income tax withheld To Wages, tips, other compensation r 15.34 24-451.65 "H Social security tax withheld 12 Social security wages 13 Social security tips 14 Medicare wages and tips 15 Medicare tax withheld 16 Nonqualified plans 17 See Instrs. for Box 17 18 Other NOR TAKAiLt 1*99?.g| 25 Stale wages, tips, etc. 26 Name of state 7*43-1.** 1 indent care benefits 23 Benefits included in Box 10 ? .... . - . f 27 Local income tax 28 Local wages, bps, etc. 29 Name of locality T -CG ; 2/4 51.55 ** Coffee A*. ' j \ Copy B To Be Filed With Employee's FEDERAL Tips Form W-2 Wage and Tax Stat This information is being furnished to the Internal 'IRS APP. 992 Dept of the Treasury--Internal Revenue Service 1 0007-SWP-005802969 CONFIDENTIAL MAINE INDIVIDUAL INCOME TAX 1040ME LONG FORM For the year ending December 31, 1992 or other tax year beginning _ YourTirsit name sand initial Last name REDACTED ________ Office Use Only 1992, ending. 19 Your social security number A Attach State copy of Form W-2 and Form 1099 to back SIEE.1 Use Preprinted Label, Otherwise Prim or Type Spou. Home V Check here if you were engaged in corrlrnercial farming or fishing during 1992, (See instructions on page 11). Ej Last name Spouse's social security number) Your occupation Check if: ZIP code 2a You were 2c Spouse was Spouse's occupation J Over 65 Over 65 2b 2d Blind Blind Single RESIDENCY STATUS SIEE2 Indicate Filing and Residency Status Married filing joint return (even if only one had income) Married filing separate return. Enter spouse's social security number above and full name here >Head of household (with qualifying person) (CHECK ONLY ONE) 8 CORESIDENT 9 PART-YEAR RESIDENT 10 NONRESIDENT Qualifying widow(er) with dependent child (year spouse died > 19 _ ) 11 NONRESIDENT ALIEN 12 a IB" Yourself. If your parent (or someone else) can claim you as a dependent on his or her tax return. . . . . , .. No. of boxes do not check box 12a................................................................................................................................................ checked on 12a SIEEL2 Enter Your b QL Spouse..........................................................................................................................................................................and 12b........................ Exemptions c Number of your dependents...................................... ....................................................................................................Total dependents...... vr Add numbers * ' ' entered on d Total number of exemptions claimed............................................................................................................................. lines above.............. > 13 FEDERAL ADJUSTED GROSS INCOME. (From your Federal Form 1040, line 31 or 1040A, line 16 or 1040EZ, line 3) (See Instructions if filing Schedule NRH)..................................................................................... SSSEA 14 INCOME MODIFICATIONS. (From Page 2, Schedule 1. line 33)....................'................................................... Figure Your Maine 15 MAINE ADJUSTED GROSS INCOME. Line 13 plus or minus line 14............................................................... Taxable 16 DEDUCTION. [JlSTANDARD (See Instructions) ITEMIZED (From Page 2. line 38). income 17 EXEMPTION. Multiply Number of Exemptions in Box 12d by $2,100.................................. 13 14 15 16 ( 17 ( 18 TAXABLE INCOME. Subtract line 16 and line 17 from line 15 . 18 19 INCOME TAX. Find the tax for the amount on line 18 in the tax table. 19 <P 20 TAX ADDITIONS. (From Maine Schedule A, line 4). 20 21 USE TAX (SALES TAX). (See Instructions, an entry must be made on this line),. 21 a SIERi 22 CONTRIBUTIONS. Figure Your Tax and Contri butions a Democratic Party..............................................D$1 0$5 D$10 Other $_ b Libertarian Party.............................................. .D$1 D$5 D$10 O Other $_ c Republican Party......................... 3$1 D$5 D$10 Other $_ d Endangered and NongameWildlife Fund...... D$1 $5 $10 Other $_ 22a 22b 22c 22d e Maine Children's Trust Fund........................]$1 $5 $10 Olher $_ 22e 23 TOTAL TAX AND CONTRIBUTIONS. (Add lines 19, 20, 21 and 22). 23 SIEB.fi Subtract Tax Credits 24 TAX CREDITS. (From Maine Schedule A, line 17). 25 NONRESIDENT CREDIT. (From Schedule NR or Schedule NRH) (Attach copy of federal return). 26 NET TAX AND CONTRIBUTIONS. (Subtract lines 24 and 25 from line 23),. 27 TAX PAYMENTS. a Maine Income Tax Withheld (Attach W-2 and 1099 forms). 24 ( 25 ( 26 27a SIEBI Enter Tex Payments b 1992 Estimated Payments.......................................................... c Paid with original return or deposit with extension request. d TOTAL (Add lines 27a, b and c)................................................ 28 If line 27d is larger than line 26, enter amount OVERPAID.. 27b 27c 27d sis' 28 STEPS Figure Refund or Amount Due 29 a Amount of line 28 to be applied to 1993 estimated tax.. Amount of line 28 to be REFUNDED.................................. 30 If line 26 is larger than line 27d, enter amount due........ Underpayment Penalty (attach Form 2210-ME).............. TOTAL AMOUNT DUE (Pay in full with return)............... ,29a 30a ,30b 29b 30c Next Year's To reduce state printing and postage costs, if you have your return done by a tax preparer and do not Return need Maine income tax forms and instructions mailed to you next year, check box at right /..................... SIGN ON REVERSE SIDE Make your check payable to TREASURER, STATE OF MAINE WRITE YOUR SOCIAL SECURITY NUMBER ON YOUR CHECK DO NOT SEND CASH File return with the: Office use only Q] NM CK MO CA Bureau of Taxation P.O. Box 1067 Augusta, ME 04332-1067 0007-SWP-005 802970 CONFIDENTIAL Attach check or money order here 90 "ssisr'i "'*'>< f|ww*?viy^ p it t s b u b q h p a ,S230.0569 RECIPIENT'S Name and Address * i ej I 8> Is 5 UI ifsftt z as 8. s. Sat' s% s 1 *3 -8 3 1 i sft 6 s8ft 8 T5 1 to .83 75 REDACTED fcfcuaw t l^^SeamouHT I not determined Q If" ----- 3A^n^r^4=L____ distribution Si t " C8Pi,al rFnn it I -------I OMBNo . 1545-0119 ,199; ions Frr R4reme-ntAonrXi; ,nsur4ecffinc%,Rei 1^ information? n'SSSJS,D#| REc,piE^iD# PAYER'S Name, Street Address, City. stale, and 2ip code C^O^MFiinN^OA^^ ESOP i- BOX S69A K NA TT^/AGT PITTSBURGH PA 15230-0569 RECIPIENTS Name and Address 4710 ^f^number (optional) A tOSe-RlReSSes FSTrn W-2P) 18459S to Back of Recipfems Copy Fo t 2b Taxable amount < ____rTT-----D <feb!b,,,,nn Federal income taxl^S $ lHoyee contributions I or insurance premiums $ TUismoution code 3 $ OMBNo. 1545-0119 -JQQO apSWsste 'nsurltelSfa^'^ 007.SWP-00580 2971 CONFIDENTIAL N4i 622.07