Acom U.S.Individual If total? is 310.000 or men, or it toldl Mono Horn interns. dive I-188 Income Tax Return "teliorc:17,,,'Imr"Ilign Is i ' .5 .;s1 eb; 1 Na we, use lust names aad middle initials ol toga our social security number 4. C one: . Sing, : 0 terniAt."" : 12, ".11,1.:a 0. r E a e :• •• Home address Musty shot or foul route) '7 -7e . ri :td:- AUg mesa s weal la income) O I.r._,11,,,isz Mint war, . K pj • S ib • • Id z S PI ___2] • Cdy, town or post office, Stets ad ZIP rade - 1 a Winn. enter her (his) mug ',Hurd number in gem 3 and give 6:3 ri me hear l/r. Enter below (If same as changing Is enter 1967 name and a--rest used your turn bove. write "Same.") If none tiled. give reason. If m separate to joint or joint to separate returns. ernes and addresses. Enter total wages, saki Forms W- 2. Copy 8. I Forms W-2 attach expl His, tips, etc. Enclose you,* p. not shown on enclosed nation. SpouSe's lo .e/ 14.(2 @Interest Yours * Spouse's * x..1 if ©Dividends: yours—before exclusion $ NW le • • If item 7 A 55.000 or more, compute tax A surcharge & pay (See instr.) Spouse's—before exclusion $ Aber P. item 10 in full with return. If under $5.000. IRS will compute tax if you omit items 8. 10 & 11 (but complete item 9). 7 Total income (add items S. 6a. and 6b) P. flip," for tax, see Instructions: pages 5-7 for regular tables, page 8 M 8 Tax S + b. Surcharge $ c. Total * -- 6 4 IM surcharge, page 4 for $5,000 or mole computatiyn. Total Federal Income tax withheld (from Forms W-2) IP BC/ aped y r U.S. Savings Bonds, Mond to: L. & excess refunded; or ..9/ Refund onl 0 If item 8c is larger than item 9, enter Balance doe le ..LQ UST YOUR EXEMPTIONS AND SIGN ON OTHER SIDE. II it item 9 is taro than item 8c, enter Refund 10* ji ;11777 ®EXEMPTIONS FOR YOURSELF—ANC. SPOUSE (only if all her (his) Income Is Included In this return, or she (he) had no income) Re r 65 or over