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- = aeoar,ment cT t.^.e "•easury-�nterna� Fevenue Service � �( !'�F�Z' J C�'Tl
<br />�" A � �I �1� � ...
<br />', � ��� U.S. !ndividu�l !ncome Tax Re+urn _ _ � �
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<br />Use IRS labal,
<br />Otherwise,
<br />please print
<br />or Npe.
<br />Presidentlal
<br />Electlon Carr
<br />�N 475-23-5664 399-24-5111
<br />�1�RBERT �J . k T�TT�NIFRED � BRICK
<br />1166 ENGEL'f�GOD AVE.
<br />ST. PAUL MN 55104
<br />n
<br />�Do you want 51 to go to this fund? . . . . . . . . . . . . . . . .
<br />If joint raturn, does vour spouse want �1 to ao to this lund7 ..
<br />1
<br />Filing Status 2
<br />Check only 3
<br />one box. 4
<br />5
<br />Exemptions
<br />6a
<br />b
<br />C
<br />;Yes
<br />3 . ; r}.1B ":o. i545-�-074
<br />� `��,ur soual secur:ty r.vmcer
<br />j 475-28-5664
<br />i _..e;.sa'� �ac�a� sacur�:y numoer
<br />399-24—�111
<br />=or Pnvacy Act and P3oerwark r7e-
<br />duction Act Natice, see Instructions.
<br />-�-r—
<br />V � "�0 �`iOtB:Checkinq'Yea'w�U
<br />� not cnange vour �sx or
<br />.i NO reouce vaurretuna.
<br />I Sina�e
<br />Married filing joint return (even ii only one had income)
<br />Married fi8ng separate return. Enter spouse's SSN above and full name here.
<br />Heaa ot househoid, II Qualilymg peroon �s your cn11d but not your dependent, �nter cndd'e name here.
<br />Cuaufvin widow(erl wnh deQendent child (year seouse died ► �9 ).
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