Department of the Treasury–Internal Revenue Service (99)

1040 2019
Form
U.S. Individual Income Tax Return OMB No. 1545-0074 IRS Use Only – Do not write or staple in this space.
Filing status: Single Married filing jointly Married filing separately (MFS) X Head of household (HOH) Qualifying widow(er) (QW)
Check only If you checked the MFS box, enter the name of spouse. If you checked the HOH or QW box, enter the child’s name if the qualifying person is
one box.
a child but not your dependent.
Your first name and middle initial Last name Your social security number

JOIETTE JAMISON 568-91-5555

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
Check here if you, or your spouse if filing
14803 SYLVAN ST 4 jointly, want $3 to go to this fund.
City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions). Checking a box below will not change

VAN NUYS, CA 91411 You Spouse

Foreign country name Foreign province/state/county Foreign postal code If more than four dependents,
see inst. and check here

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, 1955 Are blind Spouse: Was born before January 2, 1955 Is blind
Dependents (see instructions): (2) Social security number (3) Relationship to you (4) check if qualifies for (see inst.):
(1) First name Last name Child tax credit Credit for other dependents

TRISTAN ARMSTRONG 889-82-6568 Son X

DERRICK JAMISON 559-49-0994 Parent X

1 Wages, salaries, tips, etc. Attach Form(s) W-2 1 43,168.

2a Tax-exempt interest 2a b 2b
Standard
Deduction for - 3a Qualified dividends 3a 2. b 3b 2.
4a IRA distributions 4a b Taxable amount 4b
c Pensions and annuities 4c d Taxable amount 4d
5a Social security benefits 5a b Taxable amount 5b
6 Capital gain or (loss). Attach Schedule D if required. If not required, check here X 6 55.
7a Other income from Schedule 1, line 9 7a
b Add lines 1, 2b, 3b, 4b, 4d, 5b, 6, and 7a. This is your total income 7b 43,225.
8a Adjustments to income from Schedule 1, line 22 8a
b Subtract line 8a from line 7b. This is your adjusted gross income 8b 43,225.
9 Standard deduction or itemized deductions (from Schedule A) 9 18,350.
10 Qualified business income deduction. Attach Form 8995 or Form 8995-A 10
11a Add lines 9 and 10 11a 18,350.
b Taxable income. Subtract line 11a from line 8b. If zero or less, enter -0- 11b 24,875.
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. UYA Form 1040 (2019)
Form 1040 (2019) JOIETTE JAMISON 568-91-5555 Page 2
12a Tax (see inst.) Check if any from Form(s): 1 8814 2 4972 3 12a 2,702.
b Add Schedule 2, line 3, and line 12a and enter the total 12b 2,702.
13a Child tax credit or credit for other dependents 13a 1,180.
b Add Schedule 3, line 7, and line 13a and enter the total 13b 2,702.
14 Subtract line 13b from line 12b. If zero or less, enter -0- 14 0.
15 Other taxes, including self-employment tax, from Schedule 2, line 10 15 0.
16 Add lines 14 and 15. This is your total tax 16 0.
17 Federal income tax withheld from Forms W-2 and 1099 17 3,410.
If you have a 18 Other payments and refundable credits:
qualifying child,
attach Sch. EIC.
a Earned income credit (EIC) NO 18a
If you have b Additional child tax credit. Attach Schedule 8812 18b 1,320.
nontaxable
combat pay,
c American opportunity credit from Form 8863, line 8 18c 882.
see instructions. d Schedule 3, line 14 18d
e Add lines 18a through 18d. These are your total other payments and refundable credits 18e 2,202.
19 Add lines 17 and 18e. These are your total payments 19 5,612.
20 If line 19 is more than line 16, subtract line 16 from line 19. This is the amount you overpaid 20 5,612.
Refund 21a Amount of line 20 you want refunded to you. If Form 8888 is attached, check here 21a 5,612.
b Routing number c Type: Checking Savings
Direct deposit?
See instructions. d Account number
22 Amount of line 20 you want applied to your 2020 estimated tax 22
Amount 23 Amount you owe. Subtract line 19 from line 16. For details on how to pay, see instructions 23 0.
you owe 24 Estimated tax penalty (see instructions) 24
Third Party Do you want to allow another person (other than your paid preparer) to discuss this return with the IRS? See instructions. Yes. Complete below.
Designee Designee’s Phone Personal identification
No
(Other than
name no. number (PIN)
paid preparer)

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
Joint return?
Joiette Jamison (Feb 25, 2020)
See instructions. ADMIN CLERK
Keep a copy for Spouse's signature. If a joint return, both must sign. Date Spouse's occupation
your records.

Phone no. Email address

Preparer's name Preparer's signature Date PTIN Check if:
Paid
Preparer Steven D Nichols P01441405 X
Use Only Firm's name Steven D Nichols Phone no. (714)644-1586 X
Firm's address 38271 Pioneer Dr, Palmdale, CA, 93552 Firm's EIN 82-3977945
Go to www.irs.gov/Form1040 for instructions and the latest information. Form 1040 (2019)
UYA
SCHEDULE 3 Additional Credits and Payments OMB No. 1545-0074

(Form 1040 or 1040-SR)

Department of the Treasury

Attach to Form 1040 or 1040-SR. 2019
Attachment
Internal Revenue Service Go to www.irs.gov/Form1040 for instructions and the latest information. Sequence No. 03
Name(s) shown on Form 1040 or 1040-SR Your social security number
JOIETTE JAMISON 568-91-5555
Part I Nonrefundable Credits
1 Foreign tax credit. Attach Form 1116 if required 1
2 Credit for child and dependent care expenses. Attach Form 2441 2
3 Education credits from Form 8863, line 19 3 1,322.
4 Retirement savings contributions credit. Attach Form 8880 4 200.
5 Residential energy credits. Attach Form 5695 5
6 Other credits from Form: a 3800 b 8801 c 6
7 Add lines 1 through 6. Enter here and include on Form 1040 or 1040-SR, line 13b 7 1,522.
Part II Other Payments and Refundable Credits
8 2019 estimated tax payments and amount applied from 2018 return 8
9 Net premium tax credit. Attach Form 8962 9
10 Amount paid with request for extension to file (see instructions) 10
11 Excess social security and tier 1 RRTA tax withheld 11
12 Credit for federal tax on fuels. Attach Form 4136 12
13 Credits from Form: a 2439 b Reserved c 8885 d 13
14 Add lines 8 through 13. Enter here and on Form 1040 or 1040-SR, line 18d 14 0.
For Paperwork Reduction Act Notice, see your tax return instructions. UYA Schedule 3 (Form 1040 or 1040-SR) 2019
SCHEDULE 8812 OMB No. 1545-0074
Additional Child Tax Credit 1040
..........

Attach to Form 1040, 1040-SR, or 1040-NR. 2019

Go to www.irs.gov/Schedule8812 for instructions and the latest 8812 Attachment
Department of the Treasury
Internal Revenue Service (99) information. Sequence No. 47
Name(s) shown on return Your social security number
JOIETTE JAMISON 568-91-5555
Part I All Filers
Caution: If you file Form 2555, stop here; you cannot claim the additional child tax credit.
1 If you are required to use the worksheet in Pub. 972, enter the amount from line 10 of the Child Tax
Credit for Other Dependents Worksheet in the publication. Otherwise:
Enter the amount from line 8 of your Child Tax Credit and Credit for Other
Dependents Worksheet (see the instructions for Forms 1040 and 1040-SR, line 13a.) 1 2,500.
Enter the amount from line 8 of your Child Tax Credit and Credit for Other
Dependents Worksheet (see the instructions for Form 1040-NR. line 49).

2 Enter the amount from Form 1040, line 13a; Form 1040-SR, line 13a; or Form 1040-NR, line 49 2 1,180.
3 Subtract line 2 from line 1. If zero, stop here; you cannot claim this credit 3 1,320.
4 Number of qualifying children under 17 with the required social security number: 1 X $1,400.
Enter the result. If zero, stop here; you cannot claim this credit 4 1,400.
TIP: The number of children you use for this line is the same as the number of children you used
for line 1 of the Child Tax Credit and Credit for Other Dependents Worksheet.
5 Enter the smaller of line 3 or line 4 5 1,320.
6a Earned income (see instructions) 6a 43,168.
b Nontaxable combat pay (see
instructions) 6b
7 Is the amount on line 6a more than $2,500?
No. Leave line 7 blank and enter -0- on line 8.
X Yes. Subtract $2,500 from the amount on line 6a. Enter the result 7 40,668.
8 Multiply the amount on line 7 by 15% (0.15) and enter the result 8 6,100.
Next. On line 4, is the amount $4,200 or more?
X No. If line 8 is zero, stop here; you cannot claim this credit. Otherwise, skip Part II and enter
the smaller of line 5 or line 8 on line 15.
Yes. If line 8 is equal to or more than line 5, skip Part II and enter the amount from line 5 on
line 15. Otherwise, go to line 9.
Part II Certain Filers Who Have Three or More Qualifying Children
9 Withheld social security, Medicare, and Additional Medicare taxes from
Form(s) W-2, boxes 4 and 6. If married filing jointly, include your spouse’s
amounts with yours. If your employer withheld or you paid Additional
Medicare Tax or tier 1 RRTA taxes, see instructions 9
10

10
Enter the total of the amounts from Form 1040-NR,
lines 27 and 56, plus any taxes that you identified using
code “UT” and entered on line 60.
11 Add lines 9 and 10 11
12

Enter the amount from Form 1040-NR, line 67. 12

13 Subtract line 12 from line 11. If zero or less, enter -0- 13
14 Enter the larger of line 8 or line 13 14
Next, enter the smaller of line 5 or line 14 on line 15.
Part III Additional Child Tax Credit
15 This is your additional child tax credit 15 1,320.
Enter this amount on
1040
.......... Form 1040 line 18b;
Form 1040-SR, line 18b; or
Form 1040-NR, line 64.

For Paperwork Reduction Act Notice, see your tax return instructions. Schedule 8812 (Form 1040 or 1040-SR) 2019
UYA
 Education Credits
Form 8863 (American Opportunity and Lifetime Learning Credits)
OMB No. 1545-0074

Department of the Treasury

Attach to Form 1040 or 1040-SR. 2019
Attachment
Internal Revenue Service (99) Go to www.irs.gov/Form8863 for instructions and the latest information. Sequence No. 50
Name(s) shown on return Your social security number

JOIETTE JAMISON 568-91-5555

Complete a separate Part III on page 2 for each student for whom you're claiming either credit
! before you complete Parts I and II.
CAUTION

Part I Refundable American Opportunity Credit

1 After completing Part III for each student, enter the total of all amounts from all Parts III, line 30 1 2,204.
2 Enter: $180,000 if married filing jointly; $90,000 if single, head of
household, or qualifying widow(er) 2 90,000.
3 Enter the amount from Form 1040 or 1040-SR, line 8b. If you're filing Form
2555 or 4563, or you're excluding income from Puerto Rico, see Pub. 970 for
the amount to enter 3 43,225.
4 Subtract line 3 from line 2. If zero or less, stop ; you can't take any education
credit 4 46,775.
5 Enter: $20,000 if married filing jointly; $10,000 if single, head of household,
or qualifying widow(er) 5 10,000.
6 If line 4 is:
• Equal to or more than line 5, enter 1.000 on line 6
• Less than line 5, divide line 4 by line 5. Enter the result as a decimal (rounded to 6 1.0000
at least three places)
7 Multiply line 1 by line 6. Caution: If you were under age 24 at the end of the year and meet
the conditions described in the instructions, you can't take the refundable American opportunity
credit; skip line 8, enter the amount from line 7 on line 9, and check this box 7 2,204.
8 Refundable American opportunity credit. Multiply line 7 by 40% (0.40). Enter the amount here and
on Form 1040 or 1040-SR, line 18c. Then go to line 9 below 8 882.
Part II Nonrefundable Education Credits
9 Subtract line 8 from line 7. Enter here and on line 2 of the Credit Limit Worksheet (see instructions) 9 1,322.
10 After completing Part III for each student, enter the total of all amounts from all Parts III, line 31. If
zero, skip lines 11 through 17, enter -0- on line 18, and go to line 19 10
11 Enter the smaller of line 10 or $10,000 11
12 Multiply line 11 by 20% (0.20) 12
13 Enter: $136,000 if married filing jointly; $68,000 if single, head of
household, or qualifying widow(er) 13
14 Enter the amount from Form 1040 or 1040-SR, line 8b. If you're filing Form
2555 or 4563, or you’re excluding income from Puerto Rico, see Pub. 970
for the amount to enter 14
15 Subtract line 14 from line 13. If zero or less, skip lines 16 and 17, enter -0-
on line 18, and go to line 19 15
16 Enter: $20,000 if married filing jointly; $10,000 if single, head of household,
or qualifying widow(er) 16
17 If line 15 is:
• Equal to or more than line 16, enter 1.000 on line 17 and go to line 18
• Less than line 16, divide line 15 by line 16. Enter the result as a decimal (rounded to at least three
places) 17 0.0000
18 Multiply line 12 by line 17. Enter here and on line 1 of the Credit Limit Worksheet (see instructions) 18
19 Nonrefundable education credits. Enter the amount from line 7 of the Credit Limit Worksheet
(see instructions) here and on Schedule 3 (Form 1040 or 1040-SR), line 3 19 1,322.
For Paperwork Reduction Act Notice, see your tax return instructions. Form 8863 (2019)
UYA

02/25/2020 06:42:40PM
Form 8863 (2019) Page 2
Name(s) shown on return Your social security number

JOIETTE JAMISON 568-91-5555

Complete Part III for each student for whom you're claiming either the American
!
CAUTION
opportunity credit or lifetime learning credit. Use additional copies of page 2 as needed for
each student.
Part III Student and Educational Institution Information. See instructions.
20 Student name (as shown on page 1 of your tax return) 21 Student social security number (as shown on page 1 of your tax return)

JOIETTE JAMISON 568-91-5555

22 Educational institution information (see instructions)
a. Name of first educational institution b. Name of second educational institution (if any)
WALDEN UNIVERSITY
(1) Address. Number and street (or P.O. box). City, town or (1) Address. Number and street (or P.O. box). City, town or
post office, state, and ZIP code. If a foreign address, see post office, state, and ZIP code. If a foreign address, see
instructions. instructions.
7065 SAMUEL MORSE DRIVE
COLUMBIA, MD, 21046
(2) Did the student receive Form 1098-T X Yes No (2) Did the student receive Form 1098-T Yes No
from this institution for 2019? from this institution for 2019?
(3) Did the student receive Form 1098-T (3) Did the student receive Form 1098-T
from this institution for 2018 with box Yes X No from this institution for 2018 with box Yes No
7 checked? 7 checked?
(4) Enter the institution’s employer identification number (EIN) (4) Enter the institution’s employer identification number (EIN)
if you’re claiming the American opportunity credit or if you if you’re claiming the American opportunity credit or if you
checked “Yes” in (2) or (3). You can get the EIN from Form checked “Yes” in (2) or (3). You can get the EIN from Form
1098-T or from the institution. 1098-T or from the institution.

65-0353783
23 Has the Hope Scholarship Credit or American opportunity Yes — Stop! X No — Go to line 24.
credit been claimed for this student for any 4 tax years Go to line 31 for this
before 2019? student.
24 Was the student enrolled at least half-time for at least one
academic period that began or is treated as having begun in
2019 at an eligible educational institution in a program
leading towards a postsecondary degree, certificate, or X Yes — Go to line 25. No — Stop! Go to line 31
for this student.
other recognized postsecondary educational credential?
See instructions.
25 Did the student complete the first 4 years of postsecondary Yes — Stop!
education before 2019? See instructions. Go to line 31 for this X No — Go to line 26.
student.
26 Was the student convicted, before the end of 2019, of a Yes — Stop!
felony for possession or distribution of a controlled Go to line 31 for this X No — Complete lines 27
substance? student. through 30 for this student.

!
CAUTION
You can't take the American opportunity credit and the lifetime learning credit for the same student in the same year. If
you complete lines 27 through 30 for this student, don't complete line 31.
American Opportunity Credit
27 Adjusted qualified education expenses (see instructions). Don't enter more than $4,000 27 2,814.
28 Subtract $2,000 from line 27. If zero or less, enter -0- 28 814.
29 Multiply line 28 by 25% (0.25) 29 204.
30 If line 28 is zero, enter the amount from line 27. Otherwise, add $2,000 to the amount on line 29 and
enter the result. Skip line 31. Include the total of all amounts from all Parts III, line 30, on Part I, line 1 30 2,204.
Lifetime Learning Credit
31 Adjusted qualified education expenses (see instructions). Include the total of all amounts from all Parts
III, line 31, on Part II, line 10 31
UYA Form 8863 (2019)

02/25/2020 06:42:40PM
 OMB No. 1545-0074
Credit for Qualified Retirement Savings Contributions
Form 8880 Attach to Form 1040, 1040-SR, or 1040-NR.
2019
Department of the Treasury Attachment
Internal Revenue Service Go to www.irs.gov/Form8880 for the latest information. Sequence No. 54
Name(s) shown on return Your social security number

JOIETTE JAMISON 568-91-5555

You cannot take this credit if either of the following applies.
!
CAUTION

(a) You (b) Your spouse

1 Traditional and Roth IRA contributions, and ABLE account contributions
by the designated beneficiary for 2019. Do not include rollover
contributions 1
2 Elective deferrals to a 401(k) or other qualified employer plan, voluntary
employee contributions, and 501(c)(18)(D) plan contributions for 2019
(see instructions) 2 3,582.
3 Add lines 1 and 2 3 3,582.
4 Certain distributions received after 2016 and before the due date
(including extensions) of your 2019 tax return (see instructions). If
married filing jointly, include both spouses' amounts in both columns.
See instructions for an exception 4
5 Subtract line 4 from line 3. If zero or less, enter -0- 5 3,582.
6 In each column, enter the smaller of line 5 or $2,000 6 2,000.
7 Add the amounts on line 6. If zero, stop; you can't take this credit 7 2,000.
8 Enter the amount from Form 1040 or 1040-SR, line 8b;* or Form
1040-NR, line 35 8 43,225.
9 Enter the applicable decimal amount from the table below.

If line 8 is- And your filing status is-

Married Head of Single, Married filing
But not
Over- filing jointly household separately, or
over-
Enter on line 9- Qualifying widow(er)

--- $19,250 0.5 0.5 0.5

$19,250 $20,750 0.5 0.5 0.2
$20,750 $28,875 0.5 0.5 0.1
$28,875 $31,125 0.5 0.2 0.1 9 X . 10
$31,125 $32,000 0.5 0.1 0.1
$32,000 $38,500 0.5 0.1 0.0
$38,500 $41,500 0.2 0.1 0.0
$41,500 $48,000 0.1 0.1 0.0
$48,000 $64,000 0.1 0.0 0.0
$64,000 --- 0.0 0.0 0.0
Note: If line 9 is zero, stop; you can't take this credit.
10 Multiply line 7 by line 9 10 200.
11 Limitation based on tax liability. Enter the amount from the Credit Limit Worksheet in the
instructions 11 1,380.
12 Credit for qualified retirement savings contributions. Enter the smaller
and on Schedule 3 (Form 1040 or 1040-SR), line 4; or Form 1040-NR, line 48 12 200.
* See Pub. 590-A for the amount to enter if you claim any exclusion or deduction for foreign earned income, foreign housing, or income from
Puerto Rico or for bona fide residents of American Samoa.
For Paperwork Reduction Act Notice, see your tax return instructions. Form 8880 (2019)
UYA

02/25/2020 06:42:40PM
 Paid Preparer's Due Diligence Checklist
Form 8867 OMB No. 1545-0074

Department of the Treasury To be completed by preparer and filed with Form 1040, 1040-SR, 1040-NR, 1040-PR, or 1040-SS.
2019
Attachment
Internal Revenue Service Go to www.irs.gov/Form8867 for instructions and the latest information. Sequence No. 70
Taxpayer name(s) shown on return Taxpayer identification number

JOIETTE JAMISON 568-91-5555

Enter preparer's name and PTIN

Steven D Nichols P01441405

Part I Due Diligence Requirements
Please check the appropriate box for the credit(s) and/or HOH filing status claimed on the return and complete the related Parts I–V
for the benefit(s) claimed (check all that apply). EIC X CTC/ACTC/ODC X AOTC X HOH
1 Did you complete the return based on information for tax year 2019 provided by the taxpayer or Yes No N/A
reasonably obtained by you? X
2 If credits are claimed on the return, did you complete the applicable EIC and/or CTC/ACTC/ODC
worksheets found in the Form 1040, 1040-SR, 1040-NR, 1040-PR, or 1040-SS instructions, and/or the
AOTC worksheet found in the Form 8863 instructions, or your own worksheet(s) that provides the same
information, and all related forms and schedules for each credit claimed? X
3 Did you satisfy the knowledge requirement? To meet the knowledge requirement, you must do both of
the following.
Interview the taxpayer, ask questions, and contemporaneously document the taxpayer’s responses to
determine that the taxpayer is eligible to claim the credit(s) and/or HOH filing status.
Review information to determine that the taxpayer is eligible to claim the credit(s) and/or HOH filing
status and to compute the amount(s) of any credit(s) X
4 Did any information provided by the taxpayer or a third party for use in preparing the return, or
information reasonably known to you, appear to be incorrect, incomplete, or inconsistent? (If “Yes,”
answer questions 4a and 4b. If “No,” go to question 5.) X
a Did you make reasonable inquiries to determine the correct, complete, and consistent information?
b Did you contemporaneously document your inquiries? (Documentation should include the questions
you asked, whom you asked, when you asked, the information that was provided, and the impact the
information had on your preparation of the return.)
5 Did you satisfy the record retention requirement? To meet the record retention requirement, you must
keep a copy of your documentation referenced in 4b, a copy of this Form 8867, a copy of any
applicable worksheet(s), a record of how, when, and from whom the information used to prepare Form
8867 and any applicable worksheet(s) was obtained, and a copy of any document(s) provided by the
taxpayer that you relied on to determine eligibility for the credit(s) and/or HOH filing status or to
compute the amount(s) of the credit(s) X
List those documents, if any, that you relied on.

6 Did you ask the taxpayer whether he/she could provide documentation to substantiate eligibility for the
credit(s) and/or HOH filing status and the amount(s) of any credit(s) claimed on the return if his/her
return is selected for audit? X
7 Did you ask the taxpayer if any of these credits were disallowed or reduced in a previous year? X
(If credits were disallowed or reduced, go to question 7a; if not, go to question 8.)
a Did you complete the required recertification Form 8862? X
8 If the taxpayer is reporting self-employment income, did you ask questions to prepare a complete and
correct Schedule C (Form 1040 or 1040-SR)? X
For Paperwork Reduction Act Notice, see separate instructions. Form 8867 (2019)
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02/25/2020 06:42:40PM
Form 8867 (2019) JOIETTE JAMISON 568-91-5555 Page 2
Part II Due Diligence Questions for Returns Claiming EIC (If the return does not claim EIC, go to Part III.)
9 a Have you determined that the taxpayer is, in fact, eligible to claim the EIC for the number of qualifying Yes No N/A
children claimed, or is eligible to claim the EIC without a qualifying child? (Skip 9b and 9c if the taxpayer
is claiming the EIC and does not have a qualifying child.)
b Did you ask the taxpayer if the child lived with the taxpayer for over half of the year, even if the taxpayer
has supported the child the entire year?
c Did you explain to the taxpayer the rules about claiming the EIC when a child is the qualifying child of
more than one person (tiebreaker rules)?
Part III Due Diligence Questions for Returns Claiming CTC/ACTC/ODC (If the return does not claim CTC, ACTC, or ODC,
go to Part IV.)
10 Have you determined that each qualifying person for the CTC/ACTC/ODC is the taxpayer’s dependent Yes No N/A
who is a citizen, national, or resident of the United States? X
11 Did you explain to the taxpayer that he/she may not claim the CTC/ACTC if the taxpayer has not lived
with the child for over half of the year, even if the taxpayer has supported the child, unless the child’s
custodial parent has released a claim to exemption for the child? X
12 Did you explain to the taxpayer the rules about claiming the CTC/ACTC/ODC for a child of divorced or
separated parents (or parents who live apart), including any requirement to attach a Form 8332 or similar
statement to the return? X
Part IV Due Diligence Questions for Returns Claiming AOTC (If the return does not claim AOTC, go to Part V.)
13 Did the taxpayer provide substantiation for the credit, such as a Form 1098-T and/or receipts for the qualified Yes No
tuition and related expenses for the claimed AOTC? X
Part V Due Diligence Questions for Claiming HOH (If the return does not claim HOH filing status, go to Part VI.)
14 Have you determined that the taxpayer was unmarried or considered unmarried on the last day of the tax year Yes No
and provided more than half of the cost of keeping up a home for the year for a qualifying person? X
Part VI Eligibility Certification
You will have complied with all due diligence requirements for claiming the applicable credit(s) and/or HOH filing
status on the return of the taxpayer identified above if you:
A. Interview the taxpayer, ask adequate questions, contemporaneously document the taxpayer’s responses on the return or
in your notes, review adequate information to determine if the taxpayer is eligible to claim the credit(s) and/or HOH filing
status and to compute the amount(s) of the credit(s);
B. Complete this Form 8867 truthfully and accurately and complete the actions described in this checklist for any applicable
credit(s) claimed and HOH filing status, if claimed;
C. Submit Form 8867 in the manner required; and
D. Keep all five of the following records for 3 years from the latest of the dates specified in the Form 8867 instructions under
Document Retention.
1. A copy of this Form 8867.
2. The applicable worksheet(s) or your own worksheet(s) for any credit(s) claimed.
3. Copies of any documents provided by the taxpayer on which you relied to determine the taxpayer’s eligibility for the
credit(s) and/or HOH filing status and to compute the amount(s) of the credit(s).
4. A record of how, when, and from whom the information used to prepare this form and the applicable worksheet(s) was
obtained.
5. A record of any additional information you relied upon, including questions you asked and the taxpayer’s responses, to
determine the taxpayer’s eligibility for the credit(s) and/or, HOH filing status and to compute the amount(s) of the credit(s).
If you have not complied with all due diligence requirements, you may have to pay a $530 penalty for each failure
to comply related to a claim of an applicable credit or HOH filing status.
15 Do you certify that all of the answers on this Form 8867 are, to the best of your knowledge, true, correct, and Yes No
complete? X
UYA Form 8867 (2019)

02/25/2020 06:42:40PM
 TAXABLE YEAR FORM

2019 540
ATTACH FEDERAL RETURN

568-91-5555 JAMI 19
JOIETTE JAMISON

14803 SYLVAN ST APT 4

VAN NUYS CA 91411

09-29-1986

If your California filing status is different from your federal filing status, check the box here
Filing Status

1 Single 4 X Head of household (with qualifying person). See instructions.

2 Married/RDP filing jointly. See inst. 5 Qualifying widow(er). Enter year spouse/RDP died.

See instructions.

3 Married/RDP filing separately. Enter spouse’s/RDP’s SSN or ITIN above and full name here

6 If someone can claim you (or your spouse/RDP) as a dependent, check the box here. See inst 6

For line 7, line 8, line 9, and line 10: Multiply the number you enter in the box by the pre-printed dollar amount for that line. Whole dollars only
7 Personal: If you checked box 1, 3, or 4 above, enter 1 in the box. If you checked
box 2 or 5, enter 2 in the box. If you checked the box on line 6, see instructions. 7 1 X $122 = $ 122
8 Blind: If you (or your spouse/RDP) are visually impaired, enter 1;
$
Exemptions

if both are visually impaired, enter 2 8 X $122 =

9 Senior: If you (or your spouse/RDP) are 65 or older, enter 1;
if both are 65 or older, enter 2 9 X $122 = $
10 Dependents: Do not include yourself or your spouse/RDP.
Dependent 1 Dependent 2 Dependent 3
First Name TRISTAN DERRICK
Last Name
ARMSTRONG JAMISON
SSN
889826568 559490994
Dependent's
relationship SON PARENT
to you

Total dependent exemptions 10 2 X $378 = $ 756

031 3101194 Form 540 2019 Side 1

Your name: JAMISON Your SSN or ITIN: 568-91-5555

11 Exemption amount: Add line 7 through line 10. Transfer this amount to line 32 11 $ 878

12 State wages from your federal Form(s) W-2,

box 16 12 43,168 . 00

13 Enter federal adjusted gross income from federal Form 1040 or 1040-SR, line 8b 13 43,225 . 00
14 California adjustments – subtractions. Enter the amount from Schedule CA (540),
Part I, line 23, column B 14 . 00
15 Subtract line 14 from line 13. If less than zero, enter the result in parentheses.
See instructions 15 43,225
Taxable Income

. 00
16 California adjustments – additions. Enter the amount from Schedule CA (540),
Part I, line 23, column C 16 . 00

17 California adjusted gross income. Combine line 15 and line 16 17 43,225 . 00

18 Enter the Your California itemized deductions from Schedule CA (540), Part II, line 30; OR
larger of: Your California standard deduction shown below for your filing status:
Single or Married/RDP filing separately $4,537
Married/RDP filing jointly, Head of household, or Qualifying widow(er) $9,074
If Married/RDP filing separately or the box on line 6 is checked, STOP. See instructions 18 9,074 . 00
19 Subtract line 18 from line 17. This is your taxable income .
If less than zero, enter -0- 19 34,151 . 00

X Tax Table Tax Rate Schedule

31 Tax. Check the box if from:
FTB 3800 FTB 3803 31 508 . 00
32 Exemption credits. Enter the amount from line 11. If your federal AGI is more than $200,534,
see instructions 32 878 . 00
Tax

33 Subtract line 32 from line 31. If less than zero, enter -0- 33 0 . 00

34 Tax. See instructions. Check the box if from: Schedule G-1 FTB 5870A 34 . 00

35 Add line 33 and line 34 35 0 . 00

40 Nonrefundable Child and Dependent Care Expenses Credit. See instructions 40 . 00

43 Enter credit name code and amount 43 . 00

Special Credits

44 Enter credit name code and amount 44 . 00

45 To claim more than two credits. See instructions. Attach Schedule P (540) 45 . 00

46 Nonrefundable renter's credit. See instructions 46 . 00

47 Add line 40 through line 46. These are your total credits 47 0 . 00

48 Subtract line 47 from line 35. If less than zero, enter -0- 48 0 . 00

Side 2 Form 540 2019 031 3102194

Your name: JAMISON Your SSN or ITIN: 568-91-5555
61 Alternative minimum tax. Attach Schedule P (540) 61 . 00
Other Taxes

62 Mental Health Services Tax. See instructions 62 . 00

63 Other taxes and credit recapture. See instructions 63 . 00

64 Add line 48, line 61, line 62, and line 63. This is your total tax 64 0 . 00

71 California income tax withheld. See instructions 71 1,556 . 00

72 2019 CA estimated tax and other payments. See instructions 72

Payments

. 00

73 Withholding (Form 592-B and/or 593). See instructions 73 . 00

74 Excess SDI (or VPDI) withheld. See instructions 74 . 00

75 Earned Income Tax Credit (EITC) 75 . 00

76 Young Child Tax Credit (YCTC). See instructions 76 . 00

77 Add lines 71 through 76. These are your total payments.
See instructions 77 1,556 . 00

91 Use Tax. Do not leave blank. See instructions 91 0 . 00

Use Tax

If line 91 is zero, check if: X No use tax is owed.

You paid your use tax obligation directly to CDTFA.

92 Payments balance. If line 77 is more than line 91, subtract line 91 from line 77 92 1,556 . 00
Overpaid Tax/Tax Due

93 Use Tax balance. If line 91 is more than line 77, subtract line 77 from line 91 93 . 00

94 Overpaid tax. If line 92 is more than line 64, subtract line 64 from line 92 94 1,556 . 00

95 Amount of line 94 you want applied to your 2020 estimated tax 95 . 00

96 Overpaid tax available this year. Subtract line 95 from line 94 96 1,556 . 00

97 Tax due. If line 92 is less than line 64, subtract line 92 from line 64 97 . 00

031 3103194 Form 540 2019 Side 3

Your name: JAMISON Your SSN or ITIN: 568-91-5555

Code Amount

California Seniors Special Fund. See instructions 400 . 00

Alzheimer’s Disease and Related Dementia Voluntary Tax Contribution Fund 401 . 00

Rare and Endangered Species Preservation Voluntary Tax Contribution Program 403 . 00

California Breast Cancer Research Voluntary Tax Contribution Fund 405 . 00

California Firefighters’ Memorial Fund 406 . 00

Emergency Food for Families Voluntary Tax Contribution Fund 407 . 00

California Peace Officer Memorial Foundation Fund 408 . 00

California Sea Otter Fund 410 . 00

California Cancer Research Voluntary Tax Contribution Fund 413 . 00

School Supplies for Homeless Children Fund 422 . 00

Contributions

State Parks Protection Fund/Parks Pass Purchase 423 . 00

Protect Our Coast and Oceans Voluntary Tax Contribution Fund 424 . 00

Keep Arts in Schools Voluntary Tax Contribution Fund 425 . 00

Prevention of Animal Homelessness and Cruelty Voluntary Tax Contribution Fund 431 . 00

California Senior Citizen Advocacy Voluntary Tax Contribution Fund 438 . 00

Native California Wildlife Rehabilitation Voluntary Tax Contribution Fund 439 . 00

Rape Kit Backlog Voluntary Tax Contribution Fund 440 . 00

Organ and Tissue Donor Registry Voluntary Tax Contribution Fund 441 . 00

National Alliance on Mental Illness California Voluntary Tax Contribution Fund 442 . 00

Schools Not Prisons Voluntary Tax Contribution Fund 443 . 00

Suicide Prevention Voluntary Tax Contribution Fund 444 . 00

110 Add code 400 through code 444. This is your total contribution 110 . 00

Side 4 Form 540 2019 031 3104194

Your name: JAMISON Your SSN or ITIN: 568-91-5555
You Owe

111 AMOUNT YOU OWE. If you do not have an amount on line 96, add line 93, line 97, and line 110. See instructions. Do not send cash.
Amount

Mail to: FRANCHISE TAX BOARD, PO BOX 942867, SACRAMENTO CA 94267-0001 111 0 . 00
Pay Online – Go toftb.ca.gov/pay for more information.

112 Interest, late return penalties, and late payment penalties 112 . 00
Interest and
Penalties

113 Underpayment of estimated tax.

Check the box: FTB 5805 attached FTB 5805F attached 113 . 00

114 Total amount due. See instructions. Enclose, but do not staple, any payment 114 . 00

115 REFUND OR NO AMOUNT DUE. Subtract the sum of 110, line 112 and line 113 from line 96. See instructions.

Mail to: FRANCHISE TAX BOARD, PO BOX 942840, SACRAMENTO CA 94240-0001 115 1,556 . 00
Refund and Direct Deposit

Fill in the information to authorize direct deposit of your refund into one or two accounts. Do not attach a voided check or a deposit slip.
See instructions. Have you verified the routing and account numbers? Use whole dollars only.
All or the following amount of my refund (line 115) is authorized for direct deposit into the account shown below:
Type

Routing number X Checking Account number 116 Direct deposit amount

121000358 0350408636 1,556 . 00
Savings

The remaining amount of my refund (line 115) is authorized for direct deposit into the account shown below:
Type
Routing number Account number 117 Direct deposit amount
Checking
. 00
Savings

IMPORTANT: See the instructions to find out if you should attach a copy of your complete federal tax return.
To learn about your privacy rights, how we may use your information, and the consequences for not providing the requested information, go to
ftb.ca.gov/forms and search for 1131. To request this notice by mail, call 800.852.5711.
Under penalties of perjury, I declare that I have examined this tax return, including accompanying schedules and statements, and to the best of my
knowledge and belief, it is true, correct, and complete.
Your signature Spouse's/RDP's signature (if a joint tax return, both must sign)

Joiette Jamison (Feb 25, 2020)

Your email address. Enter only one email address. Preferred phone number
626-956-6732
Sign
Paid preparer's signature (declaration of preparer is based on all information of which preparer has any knowledge)
Here
It is unlawful
to forge a Firm's name (or yours, if self-employed) PTIN
spouse's/
RDP's STEVEN D NICHOLS P01441405
signature.
Firm's address Firm's FEIN
Joint tax
return? 38271 PIONEER DR PALMDALE, CA 93552 823977945
(See
instructions) Do you want to allow another person to discuss this tax return with us? See instructions X Yes No

Print Third Party Designee's Name Telephone Number

STEVEN NICHOLS 714-644-1586

031 3105194 Form 540 2019 Side 5

TAXABLE YEAR CALIFORNIA SCHEDULE

2019 Wage and Tax Statement W-2

Important: Attach this schedule to the back of your original or amended Form 540, 540 2EZ, or 540NR.
Caution: If this schedule is filled out, do not send your federal Form(s) W-2 to the Franchise Tax Board. If your federal Form(s) W-2 are from
multiple states, attach copies showing California tax withheld to this schedule. If this schedule is blank, attach your federal Form(s) W-2 to the
lower front of your tax return. DO NOT ATTACH PAYMENT TO THIS SCHEDULE.
*Employee’s social security number, name, and address must be the same as the information on federal Form(s) W-2.

W-2 Information
a. Employee’s social security number* c. Employer's name

568915555 COUNTY OF LOS ANGELES

b. Employer identification number (EIN) Employer's address

956000927 505 KENNETH HAHN HALL OF ADMIN

City State ZIP code

LOS ANGELES CA 90012

e. Employee’s first name* Initial* Last name* Suffix*

JOIETTE JAMISON
f. Employee's address*

14803 SYLVAN ST APT. 4

City* State* ZIP code*

VAN NUYS CA 91411

Wages, tips, other compensation Social security tax withheld Allocated tips (not included in box 1)

1.
43,168 4. 8.
Federal income tax withheld Medicare tax withheld Dependent care benefits

2. 3,410 6. 731 10.

Social security wages Social security tips Nonqualified plans

3. 7. 11.

12. Codes and amounts

Code Amount Code Amount

12a. C 26 12c. DD 17,883

Code Amount Code Amount

12b. G 3,582 12d.

13. Check the appropriate box for: Statutory employee, Retirement plan, or Third-party sick pay

Statutory employee Retirement plan Third-party sick pay

14. SDI, VPDI, or CA SDI (from box 14 or 19)

Type Amount 16. State wages, tips, etc.

43,168

15. State and employer’s state ID number

State Employer’s state ID number 17. State income tax

CA 93204402 1,556

031 8041194 Schedule W-2 2019

TAXABLE YEAR CALIFORNIA FORM

2019 Head of Household Filing Status Schedule 3532

Attach to your California Form 540, Form 540NR, or Form 540 2EZ.
Name(s) as shown on tax return SSN or ITIN
JOIETTE JAMISON 568-91-5555
Part I - Marital Status
1 Check one box below to identify your marital status. See instructions.
a Not legally married/RDP during 2019 1a X
b Widow/widower (my spouse/RDP died before 01/01/2019) 1b

c Marriage/RDP was annulled 1c

d Received final decree of divorce, legal separation, dissolution, or termination of marriage/RDP by 12/31/2019 1d

e Legally married/RDP and did not live with spouse/RDP during 2019 1e
f Legally married/RDP and lived with spouse/RDP during 2019. List the beginning and ending dates for each period when you
lived together 1f
(mm/dd/yyyy) (mm/dd/yyyy) (mm/dd/yyyy) (mm/dd/yyyy)
From: To: From: To:

Part II - Qualifying Person

2 Check one box below to identify the relationship of the person that qualifies you for the head of household filing status. See instructions.

a Son, daughter, stepson, or stepdaughter 2a X

b Grandchild, brother, sister, half brother, half sister, stepbrother, stepsister, nephew, or niece 2b

c Eligible foster child 2c

d Father, mother, stepfather, or stepmother 2d

e Grandfather, grandmother, son-in-law, daughter-in-law, father-in-law, mother-in-law, brother-in-law,
sister-in-law, uncle, or aunt 2e
Part III - Qualifying Person Information
3 Information about your qualifying person. See instructions.

First Name TRISTAN

Last Name ARMSTRONG
SSN 889-82-6568
DOB (mm/dd/yyyy) If your qualifying person is age 19 or older in 2019, go to line 3a. If not, go to line 4 08/24/2015

a Was your qualifying person a full time student under age 24 in 2019? 3a X Yes No

b Was your qualifying person permanently and totally disabled in 2019? 3b Yes X No

4 Enter qualifying person's gross income in 2019. See instructions 0

5 Number of days your qualifying person lived with you during 2019. See instructions 365

When calculating the total number of days your qualifying person lived with you, you may include any days your qualifying person was temporarily
absent from your home. For example, illness, education, business, vacation, military service, and incarceration. In the event of a birth or death of
your qualifying person during the year, enter 365 days.

For Privacy Notice, get FTB 1131 ENG/SP. 031 8481194

031 DO NOT MAIL THIS FORM TO THE FTB
TAXABLE YEAR FORM

2019 California e-file Signature Authorization for Individuals 8879

Your name Your SSN or ITIN
JOIETTE JAMISON 568-91-5555
Spouse's/RDP's name Spouse's/RDP's SSN or ITIN

Part I Tax Return Information (whole dollars only)

1 California Adjusted Gross Income. See instructions. 1 43,225.

2 Amount You Owe. See instructions. 2

3 Refund or No Amount Due. See instructions. 3 1,556.

Part II Taxpayer Declaration and Signature Authorization (Be sure you obtain and keep a copy of your return.)
Under penalties of perjury, I declare that I have examined a copy of my individual income tax return and accompanying schedules and statements for the tax
year ending December 31, 2019, and to the best of my knowledge and belief, it is true, correct, and complete. I further declare that the information I
provided to my electronic return originator (ERO), transmitter, or intermediate service provider (including my name, address, and social security number
or individual tax identification number) and the amounts shown in Part I above agree with the information and amounts shown on the corresponding lines
of my electronic income tax return. If applicable, I authorize an electronic funds withdrawal of the amount on line 2 and/or the estimated tax payments as
shown on my return and on form FTB 8455, California e-file Payment Record for Individuals, or a comparable form. If applicable, I declare that direct deposit
refund amount on line 3 agrees with the direct deposit authorization stated on my return. If I have filed a joint return, this is an irrevocable appointment of the
other spouse/RDP as an agent to authorize an electronic funds withdrawal or direct deposit. I authorize my ERO, transmitter, or intermediate service
provider to transmit my complete return to the Franchise Tax Board (FTB). If the processing of my return or refund is delayed, I authorize the FTB to
disclose to my ERO, intermediate service provider, and/or transmitter the reason(s) for the delay or the date when the refund was sent.
If I am filing a balance due return, I understand that if the FTB does not receive full and timely payment of my tax liability, I remain liable for the tax liability and
all applicable interest and penalties. I acknowledge that I have read and consent to the Electronic Funds Withdrawal Consent included on the copy of my
electronic income tax return. I have selected a personal identification number (PIN) as my signature for my electronic income tax return and, if applicable,
my Electronic Funds Withdrawal Consent.

Taxpayer's PIN: check one box only

X I authorize STEVEN D NICHOLS to enter my PIN
ERO firm name Do not enter all zeros
as my signature on my 2019 e-filed California individual income tax return.

I will enter my PIN as my signature on my 2019 e-filed California individual income tax return. Check this box only if you are entering your own PIN and
your return is filed using the Practitioner PIN method. The ERO must complete Part III below.
Your signature Joiette Jamison (Feb 25, 2020) Date

Spouse's/RDP's PIN: check one box only

I authorize to enter my PIN
ERO firm name Do not enter all zeros
as my signature on my 2019 e-filed California individual income tax return.

I will enter my PIN as my signature on my 2019 e-filed California individual income tax return. Check this box only if you are entering your own PIN
and your return is filed using the Practitioner PIN method. The ERO must complete Part III below.
Spouse's/RDP's signature Date

Practitioner PIN Method Returns Only - continue below

Part III Certification and Authentication - Practitioner PIN Method Only

ERO's EFIN/PIN. Enter your six-digit EFIN followed by your five-digit self-selected PIN. 9 5 4 2 4 7 9 6 3 9 9
Do not enter all zeros
I certify that the above numeric entry is my PIN, which is my signature for the 2019 California individual income tax return for the taxpayer(s) indicated above.
I confirm that I am submitting this return in accordance with the requirements of the Practitioner PIN method and FTB Pub. 1345, 2019 Handbook for Authorized
e-file Providers.
ERO's signature Date

For Privacy Notice, get FTB 1131 ENG/SP. FTB 8879 2019
ERO: PLEASE DELIVER TO TAXPAYER 2020 TAX SEASON

WHAT YOU NEED TO KNOW BEFORE SELECTING A REFUND TRANSFER

Republic Bank & Trust Company
Tax Refund Options:
Filing Refund Estimated Bank Fee Payment of
for Each
Method Transfer Disbursement Method Issuance of Add’l Tax Prep Fees
(RT) Federal Refund Funding
Paper No IRS Issued Check Sent Within 6 weeks4 None None None Paid Directly to Preparer
1
Return U.S. Mail
Paper No IRS Direct Deposit to Within 6 weeks4 None None None Paid Directly to Preparer
Return Your Account 1
E-File No IRS Issued Check Sent None None None Paid Directly to Preparer
U.S. Mail 1 4

E-File No IRS Direct Deposit to None None None Paid Directly to Preparer
Your Account 1 4

E-File Yes Bank Direct Deposit to Can Be Deducted From

Your Account 1 4 $ 39.95 $ 10.00 $ 7.00 Refund
E-File Yes Walmart Direct2Cash2 Can Be Deducted From
4 $ 46.95 $ 10.00 $ 7.00 Refund
E-File Yes Bank Issued Check From Can Be Deducted From
Tax Office 4 $ 39.95 $ 10.00 $ 7.00 Refund
E-File Yes Netspend Visa® Can Be Deducted From
Prepaid Card 3 4 $ 39.95 $ 10.00 $ 7.00 Refund
Additional Charges: You may be charged a Service Bureau Fee. Please consult your tax preparer and Bank Product Application and Agreement for specific
details. Netspend Visa Prepaid Card 3 customers will incur a $5.00 monthly Plan Fee beginning upon first load of funds and other usage fees may apply.
Please refer to your Cardholder Agreement for Terms and Conditions including fee schedule details or visit www.republictaxpayer.com.

Fees: The Refund Transfer and Tax Preparation Fees disclosed in Section 4 of the Bank Product Application and Agreement are not due until tax preparation
and any other services provided to you in relation to the Refund Transfer (Services) are complete. The Services are not complete until the earlier of (i) notification
to you that the proceeds of your Refund Transfer are available or (ii) the 60th day after your tax return has been e-filed with the IRS.

Filing Options With No Additional Filing Costs: You have many options for filing your tax return and receiving your refund, some of which have no additional
costs. With these options you will need to pay tax preparation fees directly to your preparer. Refer to the chart above for the estimated issuance of your federal
refund associated with each option:
Paper Return: You can mail your tax return to the IRS and/or state and have your refund issued as a check sent in the U.S. mail or by direct
deposit (if you have an existing account) without having to incur any additional cost for an RT.
E-File: You can e-file your federal and/or state tax return and have your refund issued as a check sent in the U.S. mail or by direct deposit (if you have
an existing account) within a similar time frame and without paying the additional fees associated with an RT.
Refund Transfer: You may choose to receive your refund as an RT which is a fee-based product provided by Republic Bank & Trust Company. If you choose
an RT, your income tax return will be filed electronically and your refund will be direct deposited in a bank account established for one-time use only for the receipt
of your refund and not intended for long term use. Typically, refund proceeds are issued from the IRS within an estimated 21 days after IRS acceptance of the return.
4
However, the IRS will not begin issuing refunds earlier than February 15th for EITC and ACTC-related tax returns. A Refund Transfer Fee will be deducted from your
refund amount. Additionally, a Transmitter and/or Service Bureau Fee, all tax preparation fees and any other authorized fees/amounts may be deducted from your
refund and forwarded to the appropriate authorized parties. The remainder of your refund will be issued to you by a Republic Bank & Trust Company check printed
at the tax office; direct deposited to your personal bank account; loaded to your Netspend Visa Prepaid Card3 ; or disbursed in the form of cash via Walmart
Direct2Cash. You can choose a filing option that does not require selecting the RT and paying the associated fees which reduce the amount you can expect
to receive from a tax refund.
An RT is not necessary to obtain your refund.
If you have an existing bank account, you can file a tax return electronically and receive your refund by direct deposit within a similar time frame and
without paying the additional fees associated with an RT.
Tax preparation fees are determined by your preparer and disclosed to you on the RT Application and Agreement.
Tax Refund Processing: For additional information on tax refund processing please consult www.irs.gov or your state’s tax authority website.
Withholding Change: Changing your income tax withholding might result in more income during the year rather than waiting for an income tax refund.
Information About Opening A Low-Cost Bank Account: Go to www.joinbankon.org for information about low-cost "starter" or “second chance” bank
accounts and access to financial education resources.

02/25/2020 06:42:40PM
 Bank Product Application and Agreement (Application/Agreement)
Republic Bank & Trust Company, 601 West Market Street, Louisville, Kentucky 40202
INSTRUCTIONS:

1. TAXPAYERS INFORMATION (Address must not be a P.O. Box)

Name: JOIETTE JAMISON Joint:

Address: 14803 SYLVAN ST Apt. 4 VAN NUYS, CA 91411
2. WHICH BANK PRODUCT(S) ARE YOU APPLYING FOR?

0.00 0.00

X REFUND TRANSFER:

3. DISBURSEMENT METHOD: SELECT ONE THAT WILL APPLY TO THE PRODUCT(S) SELECTED IN SECTION 2 ABOVE.
X ).
121000358 0350408636 X

Walmart Direct2Cash:
instructions and a reference number via text and/or email to provide to Walmart in order to obtain the Cash.
Check:
4. FEES:
relation to the Refund Transfer
th

Refund Transfer Fees Tax Preparation Fees

$ 39.95 $ 200.00
$ 10.00 TaxAct : $ 0.00
$ 0.00 $ 200.00
TaxAct : $ 7.00
TaxAct : $ 0.00Easy Advance Loan Fee (if approved)
$ 56.95 $ 0.00
XXXXXXXXXXXXXXXXXX

6. ACKNOWLEDGEMENT/CERTIFICATION/AGREEMENT
By signing this Agreement in the spaces provided below, I do the following:

x Joiette Jamison (Feb 25, 2020) x

Taxpayer Signature Date Joint Taxpayer Signature Date
Page 1 of 5
954247 02/25/2020 06:42:40PM
ADDITIONAL TERMS AND DISCLOSURES

7. EASY ADVANCE CERTIFICATIONS.

8. ACCEPTANCE OF EASY ADVANCE.

9. SECURITY INTEREST IN REFUND.

10. ACCOUNT AND RELATED TRANSFER.

11. AUTHORIZATIONS.

Page 2 of 5
02/25/2020 06:42:40PM
 timely deliver the check(s) to me.

12. RELEASE OF MY BANK PRODUCT INFORMATION

13. ADDITIONAL TERMS

14. REGULATORY DISCLOSURES

A. Federal Electronic Fund Transfer Act

Page 3 of 5
02/25/2020 06:42:40PM
15. WAIVER OF JURY TRIAL AND ARBITRATION

02/25/2020 06:42:40PM
If you have any questions regarding the Bank Product, please visit www.republictaxpayer.com or call
1-866-581-1040.

Page 5 of 5
02/25/2020 06:42:40PM
 Rev 05/2014

WHAT DOES REPUBLIC BANCORP, INC. DO

FACTS WITH YOUR PERSONAL INFORMATION?

Financial companies choose how they share your personal information. Federal law gives
Why? consumers the right to limit some but not all sharing. Federal law also requires us to tell you how
we collect, share, and protect your personal information. Please read this notice carefully to
understand what we do.

What? The types of personal information we collect and share depend on the product or service you
have with us. This information can include:
Social Security number and payment history
transaction history and credit history
credit card or other debt and employment information
When you are no longer our customer, we continue to share your information as described in this
notice.

All financial companies need to share customers' personal information to run their everyday
How? business. In the section below, we list the reasons financial companies can share their
customers' personal information; the reasons Republic Bancorp, Inc. chooses to share; and
whether you can limit this sharing.

Reasons we can share your personal information Does Republic Can you limit this sharing?
Bancorp, Inc. share?
For our everyday business purposes-
such as to process your transactions, maintain Yes No
your account(s), respond to court orders and legal
investigations, or report to credit bureaus

For our marketing purposes-

Yes No
to offer our products and services to you

For joint marketing with other financial companies No We don't share

For our affiliates' everyday business purposes- No We don't share

information about your transactions and experiences

For our affiliates' everyday business purposes-

No We don't share
information about your creditworthiness

For nonaffiliates to market to you No We don't share

Questions? Call 1-888-584-3600 or go to www.republicbank.com

02/25/2020 06:42:40PM
Page 2

Who we are
Who is providing this notice? The bank subsidiaries of Republic Bancorp, Inc. commonly known as
Republic Bank.

What we do
How does Republic Bancorp, Inc. To protect your personal information from unauthorized access
protect my personal information? and use, we use security measures that comply with federal law.
These measures include computer safeguards and secured files
and buildings.
How does Republic Bancorp, Inc. We collect your personal information, for example, when you
collect my personal information? open an account or apply for a loan
use your credit or debit card or make deposits or withdrawals from
your account
provide employment information
We also collect your personal information from others, such as credit
bureaus, affiliates, or other companies.
Federal law gives you the right to limit only
Why can't I limit all sharing?
sharing for affiliates' everyday business purposes-information
about your creditworthiness
affiliates from using your information to market to you
sharing for nonaffiliates to market to you
State laws and individual companies may give you additional rights to
limit sharing.

Definitions
Affiliates Companies related by common ownership or control. They can be
financial and nonfinancial companies.
Our affiliates include companies with a common corporate identity of
Republic Bancorp, Inc.

Nonaffiliates Companies not related by common ownership or control. They can be

financial and nonfinancial companies.
Republic Bancorp, Inc. does not share with nonaffiliates so they
can market to you

Joint marketing A formal agreement between nonaffiliated financial companies that

together market financial products or services to you.
Republic Bancorp, Inc. doesn't jointly market

02/25/2020 06:42:40PM
JOIETTE JAMISON 2019 Tax Return
Final Audit Report 2020-02-26

Created: 2020-02-26

By: steven Nichols ([email protected])

Status: Signed

Transaction ID: CBJCHBCAABAA5Rlg9A5akCapQCl3S8vdzb20WH0_BNs_

"JOIETTE JAMISON 2019 Tax Return" History

Document created by steven Nichols ([email protected])
2020-02-26 - 2:58:10 AM GMT- IP address: 104.32.146.203

Document emailed to Joiette Jamison ([email protected]) for signature

2020-02-26 - 2:59:56 AM GMT

Email viewed by Joiette Jamison ([email protected])

2020-02-26 - 3:30:38 AM GMT- IP address: 66.249.84.191

Document e-signed by Joiette Jamison ([email protected])

Signature Date: 2020-02-26 - 3:45:03 AM GMT - Time Source: server- IP address: 75.84.137.5

Signed document emailed to Joiette Jamison ([email protected]) and steven Nichols

([email protected])
2020-02-26 - 3:45:03 AM GMT