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<br />U.S. Inai iidual lncome Tax Return Uc•--J� ��
<br />For the vear,;anuarv i-i.acrm�rr � '3;;. :r : `.,,r �ax �n�r =a :�r^ .00v .�y�.,,. �o � C)�1 !� �
<br />Use
<br />B No. �5-r,07�
<br />IRS �our aoc�al secunty numoer
<br />label. 21 475-28-5664
<br />Other- N�RBERT J. & WINNI FRED M. BR� CK
<br />Soous�'a soual s�cunty numo�r
<br />wtse, 1166 EPIGELWOOD AVE. 399-24-5111
<br />piease ST . PAUL
<br />prmt MN � a 1�� For PnvaCv ACt ind P�ouwotk Fi�-
<br />or e.
<br />aucaon acc rio��eo, �e� insuucuon�.
<br />PresldenUal � �o you weni 3� ta go to th�s fund? .
<br />IYas X 1 No �Note�ChtCk�np•v,�»,n
<br />Electlon Campal n If {oint return, does vour scouso want 51 ►o �o to this fund� . yQ� �o� cna�,a• yo�► a, o►
<br />X NO naua• vour ruuna
<br />�iling Status
<br />�heCK onty
<br />one box.
<br />Exemptions
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<br />on p�� 7.)
<br />0� t1'1Q/Q OR�D11 �$1tQf1
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<br />X I MarrrQd filing joint rotum (avon il Onty ono had incomej
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<br />tt � � r4o� r���+a 13 ��r��-� imc�nn� Qr t��D Ca.��� ��:p��c�`� �� . . . . . . . . . . , . .. , . 13 � � . � � � . �
<br />g 4�-t�. �� 14 Cac�«a g�n a� t�a��sl t���t� �.:��*�:�:� �! , . . . . � . . . � . . . . , . , . . 1� �
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<br />F�a� 19 Un�pn�t�yrt�nt ��rtfaQn��uan �En„urart�r . . . i9 � �, , � 3 9 .
<br />�iS��h CrQC�c 6Q � � 71 3�?�L-rtT1 �+�n�ti�s . . . . . , ^ . . . . �. `^� Y , -
<br />C( t�nQy b Tsi.'�C+t� ��mount. ,1 �ny . , . . . . . . . < . . . , , , . _.
<br />....... 20b1
<br />t�rQ�a n�r�. � 1 �IRQr �nC ------
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<br />22 ac;a tr,� �mr�cancs �r, an�s �. � 1n� �o u,ra=:cn �z, vour tatal �ncam� . . . t� I 22 I 2�,? 1�.
<br />23 Fiet�rt�ourdvd �2m�ic�yq� tiu;�nQ;:� �xp�r�MQa 'r@rtt Fc?fnl �tCG . 23 ; �_-
<br />AdJustments 2�1� Your IR,� , , , , , , "__
<br />c3Qdt��;►on . . , . , , . . � � 2a� � =
<br />t0 InCOm� b �po�:;a�a 1R�1 da�uc;;on . . . . . . . . . . . . . , . . 2�q� �__=_
<br />25 Sult-�?mDlayqd hoa�lh in;,urar�CR Ce�uC,�cn . , . , . . , , , �5 � ��
<br />(S� 26 K�ogh r��uramQnt plan an� ;,cif-�n`pl0ytlC S�� C�CUC;�an .. 26 � ��
<br />�nsvuc;igns 27 Runa�ry en oArry w�thdrawnl ol �awngs. . , , . . . . . , , 27 I - _
<br />on paCo t:,) 2$ Al�mony M�id (reG�piern's nnmo -_-� �==- _
<br />__ _ k'=�...--v_Y.
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<br />an� �oc�a� socunry no, ).,.,. 28 ' f�-
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<br />2� Add iines 23 ;hrouah �p, Th�se �rQ v�ur total �dlustmQnts ... ,� ( 29 �
<br />Adi Gr Inco,7la 30 �u�;r�c; ',r.e �� 'rorn !ir� �'" T��� ; �; v��;r 7dlustcd nross Inr.ome. ► I 30 � � 3. 7 1:�
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