1040 U.S.

Individual Income Tax Return 2023

Form Department of the Treasury—Internal Revenue Service

OMB No. 1545-0074 IRS Use Only—Do not write or staple in this space.

For the year Jan. 1–Dec. 31, 2023, or other tax year beginning , 2023, ending , 20 See separate instructions.
Your first name and middle initial Last name Your social security number
Breanna P Willms 544 51 3602
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
92233 Carson St Check here if you, or your
City, town, or post office. If you have a foreign address, also complete spaces below. State ZIP code spouse if filing jointly, want $3
to go to this fund. Checking a
Marcola OR 974549794 box below will not change
Foreign country name Foreign province/state/county Foreign postal code your tax or refund.
You Spouse

Filing Status Single Head of household (HOH)

Married filing jointly (even if only one had income)
Check only
one box. Married filing separately (MFS) Qualifying surviving spouse (QSS)
If you checked the MFS box, enter the name of your spouse. If you checked the HOH or QSS box, enter the child’s name if the
qualifying person is a child but not your dependent:

Digital At any time during 2023, did you: (a) receive (as a reward, award, or payment for property or services); or (b) sell,
Assets exchange, or otherwise dispose of a digital asset (or a financial interest in a digital asset)? (See instructions.) Yes No
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, 1959 Are blind Spouse: Was born before January 2, 1959 Is blind
Dependents (see instructions): (2) Social security (3) Relationship (4) Check the box if qualifies for (see instructions):
(1) First name Last name number to you Child tax credit Credit for other dependents
If more
than four
dependents,
see instructions
and check
here . .

Income 1a Total amount from Form(s) W-2, box 1 (see instructions) . . . . . . . . . . . . . 1a 1,378.
b Household employee wages not reported on Form(s) W-2 . . . . . . . . . . . . . 1b
Attach Form(s)
W-2 here. Also c Tip income not reported on line 1a (see instructions) . . . . . . . . . . . . . . 1c
attach Forms d Medicaid waiver payments not reported on Form(s) W-2 (see instructions) . . . . . . . . 1d
W-2G and
1099-R if tax e Taxable dependent care benefits from Form 2441, line 26 . . . . . . . . . . . . 1e
was withheld. f Employer-provided adoption benefits from Form 8839, line 29 . . . . . . . . . . . 1f
If you did not g Wages from Form 8919, line 6 . . . . . . . . . . . . . . . . . . . . . 1g
get a Form
W-2, see
h Other earned income (see instructions) . . . . . . . . . . . . . . . . . . 1h 0.
instructions. i Nontaxable combat pay election (see instructions) . . . . . . . 1i
z Add lines 1a through 1h . . . . . . . . . . . . . . . . . . . . . . 1z 1,378.
Attach Sch. B 2a Tax-exempt interest . . . 2a b Taxable interest . . . . . 2b
if required. 3a Qualified dividends . . . 3a b Ordinary dividends . . . . . 3b
4a IRA distributions . . . . 4a b Taxable amount . . . . . . 4b
Standard
Deduction for— 5a Pensions and annuities . . 5a b Taxable amount . . . . . . 5b
• Single or 6a Social security benefits . . 6a b Taxable amount . . . . . . 6b
Married filing
separately, c If you elect to use the lump-sum election method, check here (see instructions) . . . . .
$13,850 7 Capital gain or (loss). Attach Schedule D if required. If not required, check here . . . . . 7
• Married filing
jointly or 8 Additional income from Schedule 1, line 10 . . . . . . . . . . . . . . . . . 8 0.
Qualifying
surviving spouse, 9 Add lines 1z, 2b, 3b, 4b, 5b, 6b, 7, and 8. This is your total income . . . . . . . . . . 9 1,378.
$27,700 10 Adjustments to income from Schedule 1, line 26 . . . . . . . . . . . . . . . 10
• Head of
household, 11 Subtract line 10 from line 9. This is your adjusted gross income . . . . . . . . . . 11 1,378.
$20,800
• If you checked
12 Standard deduction or itemized deductions (from Schedule A) . . . . . . . . . . 12 13,850.
any box under 13 Qualified business income deduction from Form 8995 or Form 8995-A . . . . . . . . . 13
Standard
Deduction, 14 Add lines 12 and 13 . . . . . . . . . . . . . . . . . . . . . . . . 14 13,850.
see instructions.
15 Subtract line 14 from line 11. If zero or less, enter -0-. This is your taxable income . . . . . 15 0.
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Form 1040 (2023)
Form 1040 (2023) Page 2

Tax and 16 Tax (see instructions). Check if any from Form(s): 1 8814 2 4972 3 . . 16 0.
Credits 17 Amount from Schedule 2, line 3 . . . . . . . . . . . . . . . . . . . . 17
18 Add lines 16 and 17 . . . . . . . . . . . . . . . . . . . . . . . . 18 0.
19 Child tax credit or credit for other dependents from Schedule 8812 . . . . . . . . . . 19
20 Amount from Schedule 3, line 8 . . . . . . . . . . . . . . . . . . . . 20
21 Add lines 19 and 20 . . . . . . . . . . . . . . . . . . . . . . . . 21
22 Subtract line 21 from line 18. If zero or less, enter -0- . . . . . . . . . . . . . . 22 0.
23 Other taxes, including self-employment tax, from Schedule 2, line 21 . . . . . . . . . 23 0.
24 Add lines 22 and 23. This is your total tax . . . . . . . . . . . . . . . . . 24 0.
Payments 25 Federal income tax withheld from:
a Form(s) W-2 . . . . . . . . . . . . . . . . . . 25a
b Form(s) 1099 . . . . . . . . . . . . . . . . . . 25b
c Other forms (see instructions) . . . . . . . . . . . . . 25c
d Add lines 25a through 25c . . . . . . . . . . . . . . . . . . . . . . 25d
If you have a 26 2023 estimated tax payments and amount applied from 2022 return . . . . . . . . . . 26
qualifying child, 27 Earned income credit (EIC) . . . . . . . . . . . . . . 27 105.
attach Sch. EIC.
28 Additional child tax credit from Schedule 8812 . . . . . . . . 28
29 American opportunity credit from Form 8863, line 8 . . . . . . . 29
30 Reserved for future use . . . . . . . . . . . . . . . 30
31 Amount from Schedule 3, line 15 . . . . . . . . . . . . 31
32 Add lines 27, 28, 29, and 31. These are your total other payments and refundable credits . . 32 105.
33 Add lines 25d, 26, and 32. These are your total payments . . . . . . . . . . . . 33 105.
Refund 34 If line 33 is more than line 24, subtract line 24 from line 33. This is the amount you overpaid . . 34 105.
35a Amount of line 34 you want refunded to you. If Form 8888 is attached, check here . . . . 35a 105.
Direct deposit? b Routing number 3 2 3 0 7 5 8 8 0 c Type: Checking Savings
See instructions.
d Account number 1 2 2 3 6 3 6 0
36 Amount of line 34 you want applied to your 2024 estimated tax . . . 36
Amount 37 Subtract line 33 from line 24. This is the amount you owe.
You Owe For details on how to pay, go to [Link]/Payments or see instructions . . . . . . . . 37
38 Estimated tax penalty (see instructions) . . . . . . . . . . 38
Third Party Do you want to allow another person to discuss this return with the IRS? See
Designee instructions . . . . . . . . . . . . . . . . . . . . . Yes. Complete below. No
Designee’s Phone Personal identification
name no. number (PIN)

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
Joint return? Housekeeper (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. (503)883-1326 Email address

Preparer’s name Preparer’s signature Date PTIN Check if:
Paid Self-employed
Preparer
Firm’s name Self-Prepared Phone no.
Use Only
Firm’s address Firm’s EIN
Go to [Link]/Form1040 for instructions and the latest information. BAA REV 01/21/24 [Link] Form 1040 (2023)
 Oregon Department of Revenue
2023 Form OR-40
Oregon Individual Income Tax Return for Full-year Residents

Page 1 of 8 • Use UPPERCASE letters. • Use blue or black ink. • Print actual size (100%). • Don’t submit photocopies or use staples.
Fiscal year ending date (MM/DD/YYYY) Space for 2-D barcode—do not write in box below

Extension filed

Amended return.
DO NOT MAIL
If amending for an
NOL, tax year the
NOL was generated:
NOL tax year (YYYY)
Form OR-24

Form OR-243

Federal Form 8379

Calculated with “as if” federal return Federal Form 8886

Short-year tax election Disaster relief

First name Initial Date of birth (MM/DD/YYYY)

BREANNA P 10/21/1997
Last name

WILLMS
Social Security number (SSN)

544-51-3602 First time using this SSN (see instructions) Applied for ITIN Deceased

E-FILE ONLY
Spouse first name Initial Spouse date of birth (MM/DD/YYYY)

Spouse last name F

Spouse SSN

First time using this SSN (see instructions) Applied for ITIN Deceased

Current mailing address

92233 CARSON ST
City State ZIP code

MARCOLA OR 97454-9794
Country Phone

USA 503-883-1326

Filing Status (check only one box)

1. X Single 2. Married filing jointly 3. Married filing separately (enter spouse information above)

4.

DO NOT MAIL
Head of household (with qualifying dependent) 5. Qualifying surviving spouse

150-101-040
(Rev. 08-23-23, ver. 01) 00462301011555
1555 REV 01/03/24 [Link]
 Oregon Department of Revenue
2023 Form OR-40

Page 2 of 8 • Use UPPERCASE letters. • Use blue or black ink. • Print actual size (100%). • Don’t submit photocopies or use staples.

Last name SSN

WILLMS 544-51-3602

Exemptions
DO NOT MAIL
Note: Reprint page 1 if you make changes to this page.

6a. Credits for yourself.........................................................................................................................................................................................6a. 1

Check boxes that apply: X Regular Severely disabled Someone else can claim you as a dependent

6b. Credits for your spouse .................................................................................................................................................................................6b.

Check boxes that apply: Regular Severely disabled Someone else can claim you as a dependent

Dependents
List your dependents in order from youngest to oldest. If you have more than three dependents, complete Schedule OR-ADD-DEP. Include the
schedule with your return.

Dependent 1: First name Initial Dependent 1: Last name

Dependent 1: Date of birth (MM/DD/YYYY) Dependent 1: SSN Code *

Dependent 1: Check if child
has a qualifying disability

Dependent 2: First name

E-FILE ONLY
Dependent 2: Date of birth (MM/DD/YYYY)
Initial

Dependent 2: SSN
Dependent 2: Last name

Code *
F

Dependent 2: Check if child

has a qualifying disability

Dependent 3: First name Initial Dependent 3: Last name

Dependent 3: Date of birth (MM/DD/YYYY) Dependent 3: SSN Code *

Dependent 3: Check if child
has a qualifying disability

*Dependent relationship code (see instructions).

6c. Total number of dependents .................................................................................................................................................................. 6c.

6d. Total number of dependent children with a qualifying disability (see instructions) ................................................................................6d.

DO NOT MAIL
6e. Total exemptions. Add lines 6a through 6d.................................................................................................................................. Total 6e.

150-101-040
(Rev. 08-23-23, ver. 01) 00462301021555
1555 REV 01/03/24 [Link]
 Oregon Department of Revenue
2023 Form OR-40

Page 3 of 8 • Use UPPERCASE letters. • Use blue or black ink. • Print actual size (100%). • Don’t submit photocopies or use staples.

Last name SSN

WILLMS 544-51-3602

DO NOT MAIL
Note: Reprint page 1 if you make changes to this page.
Taxable income
7. Federal adjusted gross income from federal Form 1040, 1040-SR, or
1040-NR, line 11; or 1040-X, line 1C (see instructions) .............................................. 7. 1,378.00

8. Total additions from Schedule OR-ASC, line A5 ........................................................ 8.

9. Income after additions. Add lines 7 and 8 .................................................................. 9. 1,378.00

Subtractions
10. 2023 federal tax liability (see instructions) ............................................................. 10.
0.00

11. Social Security amount on federal Form 1040 or 1040-SR, line 6b ......................... 11.

12. Oregon income tax refund included in federal income ............................................. 12.

E-FILE ONLY
13. Total subtractions from Schedule OR-ASC, line B7 ................................................. 13.

14. Total subtractions. Add lines 10 through 13 ............................................................. 14. F

0.00

15. Income after subtractions. Line 9 minus line 14 ....................................................... 15.

1,378.00
Deductions
16. Oregon itemized deductions. Enter your Oregon itemized deductions from
Schedule OR-A, line 23. If you are not itemizing your deductions, enter 0 .............. 16.
0.00

17. Standard deduction. Enter your standard deduction ............................................. 17.

2,605.00
You were: 17a. 65 or older 17b. Blind Your spouse was: 17c. 65 or older 17d. Blind

Standard Single Married filing jointly Married filing separately Qualifying surviving spouse Head of household
deductions $2,605 $5,210 $2,605 or $0 $5,210 $4,195
See instructions if you are age 65 or older, blind, or if someone can claim you as a dependent.
See instructions if you are married filing separately.

18. Enter the larger of line 16 or 17................................................................................. 18. 2,605.00

DO NOT MAIL
19. Oregon taxable income. Line 15 minus line 18. If line 18 is more than
line 15, enter 0 .......................................................................................................... 19. 0.00

150-101-040
(Rev. 08-23-23, ver. 01) 00462301031555
1555 REV 01/03/24 [Link]
 Oregon Department of Revenue
2023 Form OR-40

Page 4 of 8 • Use UPPERCASE letters. • Use blue or black ink. • Print actual size (100%). • Don’t submit photocopies or use staples.

Last name SSN

WILLMS 544-51-3602

Oregon tax
DO NOT MAIL
Note: Reprint page 1 if you make changes to this page.

20. Tax (see instructions) ................................................................................................ 20. 0.00

Check the appropriate box if you’re using an alternative method to calculate your tax:

20a. Schedule OR-FIA-40 20b. Worksheet FCG 20c. Schedule OR-PTE-FY

21. Interest on certain installment sales ......................................................................... 21.

22. Total tax recaptures from Schedule OR-ASC, line C5 .............................................. 22.

23. Total additions to tax. Line 21 plus line 22................................................................ 23.

24. Total tax before credits. Add lines 20 and 23 ........................................................... 24. 0.00

E-FILE ONLY
Standard and carryforward credits
25. Exemption credit. If the amount on line 7 is $100,000 or less, multiply your total
exemptions on line 6e by $236. Otherwise, see instructions ................................... 25. 236.00
F

26. Political contribution credit. See limits in instructions ........................................... 26.

27. Total standard credits from Schedule OR-ASC, line D16......................................... 27.

28. Total standard credits. Add lines 25 through 27 ....................................................... 28. 236.00

29. Tax minus standard credits. Line 24 minus line 28. If line 28 is more than
line 24, enter 0 .......................................................................................................... 29. 0.00

30. Total carryforward credits used this year from Schedule OR-ASC, line E9.
Line 30 can’t be more than line 29 (see Schedule OR-ASC instructions) ................ 30.

31. Tax after standard and carryforward credits. Line 29 minus line 30 ........................... 31. 0.00

DO NOT MAIL
150-101-040
(Rev. 08-23-23, ver. 01) 00462301041555
1555 REV 01/03/24 [Link]
 Oregon Department of Revenue
2023 Form OR-40

Page 5 of 8 • Use UPPERCASE letters. • Use blue or black ink. • Print actual size (100%). • Don’t submit photocopies or use staples.

Last name SSN

WILLMS 544-51-3602

DO NOT MAIL
Note: Reprint page 1 if you make changes to this page.

Payments and refundable credits

32. Oregon income tax withheld. Include a copy of your Forms W-2 and 1099 ........ 32.

33. Amount applied from your prior year’s tax refund .................................................... 33.

34. Estimated tax payments for 2023. Include all estimated payments you made
by April 15, 2024, including any extension payment (see instructions).
Do not include the amount on line 33 ....................................................................... 34.

35. Tax payments from a pass-through entity ................................................................ 35.

36. Earned income credit (see instructions).................................................................... 36. 9.00

37. Oregon Kids Credit (see instructions) ....................................................................... 37.

E-FILE ONLY
38. Kicker (Oregon surplus credit). Enter your kicker credit amount
(see instructions). If you elect to donate your kicker to the
State School Fund, enter 0 and see line 55 .......................................................... 38. 279.00
F

39. Total refundable credits from Schedule OR-ASC, line F7 ........................................ 39.

40. Total payments and refundable credits. Add lines 32 through 39 ............................ 40. 288.00

Tax to pay or refund

41. Overpayment of tax. If line 31 is less than line 40, you overpaid.
Line 40 minus line 31 ................................................................................................ 41. 288.00

42. Net tax. If line 31 is more than line 40, you have tax to pay.
Line 31 minus line 40 ................................................................................................ 42.

43. Penalty and interest for filing or paying late (see instructions) ................................. 43.

44. Interest on underpayment of estimated tax. Include Form OR-10 ......................... 44.

DO NOT MAIL
Exception number from Form OR-10, line 1 44a. Check box if you annualized: 44b.

150-101-040
(Rev. 08-23-23, ver. 01) 00462301051555
1555 REV 01/03/24 [Link]
 Oregon Department of Revenue
2023 Form OR-40

Page 6 of 8 • Use UPPERCASE letters. • Use blue or black ink. • Print actual size (100%). • Don’t submit photocopies or use staples.

Last name SSN

WILLMS 544-51-3602

DO NOT MAIL
Note: Reprint page 1 if you make changes to this page.

Tax to pay or refund (continued)

45. Total penalty and interest due. Add lines 43 and 44 ................................................ 45.

46. Net tax including penalty and interest.

Line 42 plus line 45 .................................................. This is the amount you owe. 46.

47. Overpayment less penalty and interest.

Line 41 minus line 45 ...............................................................This is your refund. 47. 288.00

48. Estimated tax. Fill in the portion of line 47 you want applied to your open
estimated tax account .............................................................................................. 48.

49. Charitable checkoff donations from Schedule OR-DONATE, line 30 ....................... 49.

50. Political party $3 checkoff ........................................................................................ 50.

E-FILE ONLY
Party code: 50a. You 50b. Spouse

51. Oregon 529 college savings plan deposits from Schedule OR-529, line 5 .............. 51.
F
52. Total. Add lines 48 through 51. Line 52 can’t be more than your
refund on line 47 ....................................................................................................... 52.

53. Net refund. Line 47 minus line 52 .................................... This is your net refund. 53. 288.00

Direct deposit
54. For direct deposit of your refund, see instructions. Check the box if the final deposit destination is outside the United States:

Type of account:
Account information:
Checking or Routing number Account number

X Savings 323075880 12236360

Kicker donation
55. If you elect to donate your kicker to the State School Fund, check this box. ......... 55a.

DO NOT MAIL
Complete the kicker worksheet in the instructions and enter the
amount here. ............................................................ This election is irrevocable. 55b.

150-101-040
(Rev. 08-23-23, ver. 01) 00462301061555
1555 REV 01/03/24 [Link]
 Oregon Department of Revenue
2023 Form OR-40

Page 7 of 8 • Use UPPERCASE letters. • Use blue or black ink. • Print actual size (100%). • Don’t submit photocopies or use staples.

Last name SSN

WILLMS 544-51-3602

DO NOT MAIL
Note: Reprint page 1 if you make changes to this page.
Sign here. Under penalty of false swearing, I declare that the information in this return and any attachments is true, correct and complete.

Your signature

X
Date (MM/DD/YYYY)

Spouse signature

X
Date (MM/DD/YYYY)

Signature of preparer other than taxpayer

X SELF PREPARED
Date (MM/DD/YYYY) Preparer phone Preparer license number

E-FILE ONLY
Preparer first name Initial Preparer last name

Preparer address F

City State ZIP code

Signing this return does not grant your preparer the right to represent you or make decisions on your behalf. For more information, see the instructions for
the Tax Information Authorization and Power of Attorney for Representation form on our website.

Important: Include a copy of your federal Form 1040, 1040-SR, 1040-X, or 1040-NR. We may adjust your return without it.

Pay the amount due (shown on line 45)

• Online: [Link]/dor.
• By mail: Payable to the Oregon Department of Revenue. Write “2023 Oregon Form OR-40” and the last four digits of your SSN or ITIN on your
check or money order. If you include a payment with your return, don’t include Form OR-40-V payment voucher.

Mail your return

• Non-2-D barcode. If the large 2-D barcode box on the first page of this form is blank:
— Mail tax-due returns to: Oregon Department of Revenue, PO Box 14555, Salem OR 97309-0940.
— Mail refund and no-tax-due returns to: Oregon Department of Revenue, PO Box 14700, Salem OR 97309-0930.

DO NOT MAIL
• 2-D barcode. If the large 2-D barcode box on the first page of this form is filled in:
— Mail tax-due returns to: Oregon Department of Revenue, PO Box 14720, Salem OR 97309-0463.
— Mail refund and no-tax-due returns to: Oregon Department of Revenue, PO Box 14710, Salem OR 97309-0460.

150-101-040
(Rev. 08-23-23, ver. 01) 00462301071555
1555 REV 01/03/24 [Link]
 Oregon Department of Revenue
2023 Form OR-40

Page 8 of 8 • Use UPPERCASE letters. • Use blue or black ink. • Print actual size (100%). • Don’t submit photocopies or use staples.

Last name SSN

WILLMS 544-51-3602

DO NOT MAIL
Note: Reprint page 1 if you make changes to this page.
Amended statement. Complete this section only if you’re amending your 2023 return or filing with a new SSN.

If filing an amended return, use this space to explain what you’re changing. Include the return line numbers and the reason for each change. If your
filing status has changed, explain why. Include all supporting forms and schedules when you file your amended return, even if you haven’t changed
anything on them.

If filing with a new SSN, enter your former identification number.

E-FILE ONLY F

DO NOT MAIL
150-101-040
(Rev. 08-23-23, ver. 01) 00462301081555
1555 REV 01/03/24 [Link]
 1040 U.S. Individual Income Tax Return 2023
Form Department of the Treasury—Internal Revenue Service

OMB No. 1545-0074 IRS Use Only—Do not write or staple in this space.

For the year Jan. 1–Dec. 31, 2023, or other tax year beginning , 2023, ending , 20 See separate instructions.
Your first name and middle initial Last name Your social security number
Breanna P Willms 544 51 3602
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
92233 Carson St Check here if you, or your
City, town, or post office. If you have a foreign address, also complete spaces below. State ZIP code spouse if filing jointly, want $3
to go to this fund. Checking a
Marcola OR 974549794 box below will not change
Foreign country name Foreign province/state/county Foreign postal code your tax or refund.
You Spouse

Filing Status Single Head of household (HOH)

Married filing jointly (even if only one had income)
Check only
one box. Married filing separately (MFS) Qualifying surviving spouse (QSS)
If you checked the MFS box, enter the name of your spouse. If you checked the HOH or QSS box, enter the child’s name if the
qualifying person is a child but not your dependent:

Digital At any time during 2023, did you: (a) receive (as a reward, award, or payment for property or services); or (b) sell,
Assets exchange, or otherwise dispose of a digital asset (or a financial interest in a digital asset)? (See instructions.) Yes No
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, 1959 Are blind Spouse: Was born before January 2, 1959 Is blind
Dependents (see instructions): (2) Social security (3) Relationship (4) Check the box if qualifies for (see instructions):
(1) First name Last name number to you Child tax credit Credit for other dependents
If more
than four
dependents,
see instructions
and check
here . .

Income 1a Total amount from Form(s) W-2, box 1 (see instructions) . . . . . . . . . . . . . 1a 1,378.
b Household employee wages not reported on Form(s) W-2 . . . . . . . . . . . . . 1b
Attach Form(s)
W-2 here. Also c Tip income not reported on line 1a (see instructions) . . . . . . . . . . . . . . 1c
attach Forms d Medicaid waiver payments not reported on Form(s) W-2 (see instructions) . . . . . . . . 1d
W-2G and
1099-R if tax e Taxable dependent care benefits from Form 2441, line 26 . . . . . . . . . . . . 1e
was withheld. f Employer-provided adoption benefits from Form 8839, line 29 . . . . . . . . . . . 1f
If you did not g Wages from Form 8919, line 6 . . . . . . . . . . . . . . . . . . . . . 1g
get a Form
W-2, see
h Other earned income (see instructions) . . . . . . . . . . . . . . . . . . 1h 0.
instructions. i Nontaxable combat pay election (see instructions) . . . . . . . 1i
z Add lines 1a through 1h . . . . . . . . . . . . . . . . . . . . . . 1z 1,378.
Attach Sch. B 2a Tax-exempt interest . . . 2a b Taxable interest . . . . . 2b
if required. 3a Qualified dividends . . . 3a b Ordinary dividends . . . . . 3b
4a IRA distributions . . . . 4a b Taxable amount . . . . . . 4b
Standard
Deduction for— 5a Pensions and annuities . . 5a b Taxable amount . . . . . . 5b
• Single or 6a Social security benefits . . 6a b Taxable amount . . . . . . 6b
Married filing
separately, c If you elect to use the lump-sum election method, check here (see instructions) . . . . .
$13,850 7 Capital gain or (loss). Attach Schedule D if required. If not required, check here . . . . . 7
• Married filing
jointly or 8 Additional income from Schedule 1, line 10 . . . . . . . . . . . . . . . . . 8 0.
Qualifying
surviving spouse, 9 Add lines 1z, 2b, 3b, 4b, 5b, 6b, 7, and 8. This is your total income . . . . . . . . . . 9 1,378.
$27,700 10 Adjustments to income from Schedule 1, line 26 . . . . . . . . . . . . . . . 10
• Head of
household, 11 Subtract line 10 from line 9. This is your adjusted gross income . . . . . . . . . . 11 1,378.
$20,800
• If you checked
12 Standard deduction or itemized deductions (from Schedule A) . . . . . . . . . . 12 13,850.
any box under 13 Qualified business income deduction from Form 8995 or Form 8995-A . . . . . . . . . 13
Standard
Deduction, 14 Add lines 12 and 13 . . . . . . . . . . . . . . . . . . . . . . . . 14 13,850.
see instructions.
15 Subtract line 14 from line 11. If zero or less, enter -0-. This is your taxable income . . . . . 15 0.
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Form 1040 (2023)
Form 1040 (2023) Page 2

Tax and 16 Tax (see instructions). Check if any from Form(s): 1 8814 2 4972 3 . . 16 0.
Credits 17 Amount from Schedule 2, line 3 . . . . . . . . . . . . . . . . . . . . 17
18 Add lines 16 and 17 . . . . . . . . . . . . . . . . . . . . . . . . 18 0.
19 Child tax credit or credit for other dependents from Schedule 8812 . . . . . . . . . . 19
20 Amount from Schedule 3, line 8 . . . . . . . . . . . . . . . . . . . . 20
21 Add lines 19 and 20 . . . . . . . . . . . . . . . . . . . . . . . . 21
22 Subtract line 21 from line 18. If zero or less, enter -0- . . . . . . . . . . . . . . 22 0.
23 Other taxes, including self-employment tax, from Schedule 2, line 21 . . . . . . . . . 23 0.
24 Add lines 22 and 23. This is your total tax . . . . . . . . . . . . . . . . . 24 0.
Payments 25 Federal income tax withheld from:
a Form(s) W-2 . . . . . . . . . . . . . . . . . . 25a
b Form(s) 1099 . . . . . . . . . . . . . . . . . . 25b
c Other forms (see instructions) . . . . . . . . . . . . . 25c
d Add lines 25a through 25c . . . . . . . . . . . . . . . . . . . . . . 25d
If you have a 26 2023 estimated tax payments and amount applied from 2022 return . . . . . . . . . . 26
qualifying child, 27 Earned income credit (EIC) . . . . . . . . . . . . . . 27 105.
attach Sch. EIC.
28 Additional child tax credit from Schedule 8812 . . . . . . . . 28
29 American opportunity credit from Form 8863, line 8 . . . . . . . 29
30 Reserved for future use . . . . . . . . . . . . . . . 30
31 Amount from Schedule 3, line 15 . . . . . . . . . . . . 31
32 Add lines 27, 28, 29, and 31. These are your total other payments and refundable credits . . 32 105.
33 Add lines 25d, 26, and 32. These are your total payments . . . . . . . . . . . . 33 105.
Refund 34 If line 33 is more than line 24, subtract line 24 from line 33. This is the amount you overpaid . . 34 105.
35a Amount of line 34 you want refunded to you. If Form 8888 is attached, check here . . . . 35a 105.
Direct deposit? b Routing number 3 2 3 0 7 5 8 8 0 c Type: Checking Savings
See instructions.
d Account number 1 2 2 3 6 3 6 0
36 Amount of line 34 you want applied to your 2024 estimated tax . . . 36
Amount 37 Subtract line 33 from line 24. This is the amount you owe.
You Owe For details on how to pay, go to [Link]/Payments or see instructions . . . . . . . . 37
38 Estimated tax penalty (see instructions) . . . . . . . . . . 38
Third Party Do you want to allow another person to discuss this return with the IRS? See
Designee instructions . . . . . . . . . . . . . . . . . . . . . Yes. Complete below. No
Designee’s Phone Personal identification
name no. number (PIN)

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
Joint return? Housekeeper (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. (503)883-1326 Email address

Preparer’s name Preparer’s signature Date PTIN Check if:
Paid Self-employed
Preparer
Firm’s name Self-Prepared Phone no.
Use Only
Firm’s address Firm’s EIN
Go to [Link]/Form1040 for instructions and the latest information. BAA REV 01/21/24 [Link] Form 1040 (2023)