1040 U.S.

Individual Income Tax Return 2021 (99)

Form Department of the Treasury—Internal Revenue Service

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) Head of household (HOH) Qualifying widow(er) (QW)
Check only If you checked the MFS box, enter the name of your spouse. If you checked the HOH or QW box, enter the child’s name if the qualifying
one box.
person is a child but not your dependent a
Your first name and middle initial Last name Your social security number
Joanna Marron 626-05-8176
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
38300 30th St E 228 Check here if you, or your
spouse if filing jointly, want $3
City, town, or post office. If you have a foreign address, also complete spaces below. State ZIP code
to go to this fund. Checking a
Palmdale CA 935501010 box below will not change
Foreign country name Foreign province/state/county Foreign postal code your tax or refund.
You Spouse

At any time during 2021, did you receive, sell, exchange, or otherwise dispose of any financial interest in any virtual currency? 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, 1957 Are blind Spouse: Was born before January 2, 1957 Is blind
Dependents (see instructions): (2) Social security (3) Relationship (4)  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 a
1 Wages, salaries, tips, etc. Attach Form(s) W-2 . . . . . . . . . . . . . . . . 1 9,196.
Attach 2a Tax-exempt interest . . . 2a 2b
b Taxable interest . . . . .
Sch. B if
3a Qualified dividends . . . 3a b Ordinary dividends . . . . . 3b
required.
4a IRA distributions . . . . 4a b Taxable amount . . . . . . 4b
5a Pensions and annuities . . 5a b Taxable amount . . . . . . 5b
Standard 6a Social security benefits . . 6a b Taxable amount . . . . . . 6b
Deduction for— a
7 Capital gain or (loss). Attach Schedule D if required. If not required, check here . . . . 7
• Single or
Married filing 8 Other income from Schedule 1, line 10 . . . . . . . . . . . . . . . . . . 8
separately,
$12,550 9 Add lines 1, 2b, 3b, 4b, 5b, 6b, 7, and 8. This is your total income . . . . . . . . . a 9 9,196.
• Married filing 10 Adjustments to income from Schedule 1, line 26 . . . . . . . . . . . . . . . 10
jointly or
11 Subtract line 10 from line 9. This is your adjusted gross income . . . . . . . . . a 11 9,196.
Qualifying
widow(er),
$25,100
12a Standard deduction or itemized deductions (from Schedule A) . . 12a 12,550.
• Head of b Charitable contributions if you take the standard deduction (see instructions) 12b
household,
$18,800 c Add lines 12a and 12b . . . . . . . . . . . . . . . . . . . . . . . 12c 12,550.
• If you checked 13 Qualified business income deduction from Form 8995 or Form 8995-A . . . . . . . . . 13
any box under
Standard 14 Add lines 12c and 13 . . . . . . . . . . . . . . . . . . . . . . . 14 12,550.
Deduction,
see instructions.
15 Taxable income. Subtract line 14 from line 11. If zero or less, enter -0- . . . . . . . . . 15 0.

For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Form 1040 (2021)
Form 1040 (2021) Page 2
16 Tax (see instructions). Check if any from Form(s): 1 8814 2 4972 3 . . 16 0.
17 Amount from Schedule 2, line 3 . . . . . . . . . . . . . . . . . . . . 17
18 Add lines 16 and 17 . . . . . . . . . . . . . . . . . . . . . . . . 18 0.
19 Nonrefundable 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 . . . . . . . . . . . . . . . . a 24 0.
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
26 2021 estimated tax payments and amount applied from 2020 return . . . . . . . . . . 26
If you have a
qualifying child, 27a Earned income credit (EIC) . . . . . . . . . . . . . . 27a 1,404.
attach Sch. EIC.
Check here if you were born after January 1, 1998, and before
January 2, 2004, and you satisfy all the other requirements for
taxpayers who are at least age 18, to claim the EIC. See instructions a
b Nontaxable combat pay election . . . . 27b
c Prior year (2019) earned income . . . . 27c
28 Refundable child tax credit or additional child tax credit from Schedule 8812 28
29 American opportunity credit from Form 8863, line 8 . . . . . . . 29
30 Recovery rebate credit. See instructions . . . . . . . . . . 30 1,400.
31 Amount from Schedule 3, line 15 . . . . . . . . . . . . 31
32 Add lines 27a and 28 through 31. These are your total other payments and refundable credits a 32 2,804.
33 Add lines 25d, 26, and 32. These are your total payments . . . . . . . . . . . a 33 2,804.
34 If line 33 is more than line 24, subtract line 24 from line 33. This is the amount you overpaid . . 34 2,804.
Refund
35a Amount of line 34 you want refunded to you. If Form 8888 is attached, check here . . . a 35a 2,804.
Direct deposit? ab Routing number 1 2 4 3 0 3 1 2 0 a c Type: Checking Savings
See instructions. a
d Account number 3 9 8 1 8 7 3 8 6 6 0 9
36 Amount of line 34 you want applied to your 2022 estimated tax . . a 36
Amount 37 Amount you owe. Subtract line 33 from line 24. For details on how to pay, see instructions . a 37
You Owe 38 Estimated tax penalty (see instructions) . . . . . . . . . a 38
Third Party Do you want to allow another person to discuss this return with the IRS? See
Designee instructions . . . . . . . . . . . . . . . . . . . . a Yes. Complete below. No
Designee’s Phone Personal identification
name a no. a number (PIN) a
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
Sign 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
F

Joint return? retired (see inst.) a

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.) a
Phone no. (405)294-5003 Email address
Preparer’s name Preparer’s signature Date PTIN Check if:
Paid Self-employed
Preparer
Firm’s name a Self-Prepared Phone no.
Use Only a a
Firm’s address Firm’s EIN
Go to www.irs.gov/Form1040 for instructions and the latest information. BAA REV 04/09/22 Intuit.cg.cfp.sp Form 1040 (2021)
175
Date Accepted DO NOT MAIL THIS FORM TO THE FTB
TAXABLE YEAR California Online e-file Return Authorization FORM

2021 for Individuals 8453-OL

Your first name and initial Last name Suffix Your SSN or I T I N
JOANNA MARRON 626-05-8176
If filing jointly, spouse’s/RDP’s first name and initial Last name Suffix Spouse’s/RDP’s SSN or ITIN

Street address (number and street) or PO box Apt. no./ste. no. PMB/private mailbox Daytime telephone number
38300 30TH ST E APT 228 (405)294-5003
City State ZIP code
PALMDALE CA 93550-1010
Foreign country name Foreign province/state/county Foreign postal code

Part I Tax Return Information (whole dollars only)

1 California adjusted gross income. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 9,196.
2 Refund or no amount due. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 171.
3 Amount you owe. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Part II Settle Your Account Electronically for Taxable Year 2021 (Pay by 4/18/2022)
4 □ Direct deposit of refund
5 □ Electronic funds withdrawal 5a Amount 5b Withdrawal date (mm/dd/yyyy)
Part III Make Estimated Tax Payments for Taxable Year 2022 These are NOT installment payments for the current amount you owe.
First Payment Second Payment Third Payment Fourth Payment
4/18/2022 6/15/2022 9/15/2022 1/17/2023
6 Amount
7 Withdrawal date
Part IV Banking Information (Have you verified your banking information?)
8 Amount of refund to be directly deposited 12 The remaining amount of my refund
to account below 171. for direct deposit
9 Routing number 124303120 13 Routing number
10 Account number 398187386609 14 Account number
11 Type of account: □ Checking □ Savings 15 Type of account: □ Checking □ Savings
Part V Declaration of Taxpayer(s)
I authorize my account to be settled as designated in Part II. If I check Part II, box 4, I declare that the direct deposit refund information in
Part IV agrees with the authorization stated on my return. If I check Part II, box 5, I authorize an electronic funds withdrawal for the amount
listed on line 5a and any estimated payment amounts listed on line 6 from the bank account listed on lines 9, 10, and 11. If I have filed a
joint return, this is an irrevocable appointment of the other spouse/registered domestic partner (RDP) as an agent to receive the refund or
authorize an electronic funds withdrawal.
Under penalties of perjury, I declare that the information I provided to the Franchise Tax Board (FTB), either directly or through e-file
software, including my name, address, and social security number (SSN) or individual taxpayer identification number (ITIN), and the
amounts shown in Part I above, agrees with the information and amounts shown on the corresponding lines of my 2021 California income
tax return. To the best of my knowledge and belief, my return is true, correct, and complete. 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 authorize my return and accompanying schedules and statements to be transmitted to the FTB directly or through the e-file
software. If the processing of my return or refund is delayed, I authorize the FTB to disclose to me, either directly or through the e-file
software, the reason(s) for the delay or the date when the refund was sent.

Sign Your signature Date

Here

Spouse’s/RDP’s signature. If filing jointly, both must sign. Date

It is unlawful to forge a spouse’s/RDP’s signature.

For Privacy Notice, get FTB 1131 EN-SP. REV 03/29/22 INTUIT.CG.CFP.SP FTB 8453-OL 2021
 TAXABLE YEAR FORM

2021 California Resident Income Tax Return 540

APE DO NOT ATTACH FEDERAL RETURN
626-05-8176 MARR 21
JOANNA MARRON

38300 30TH ST E APT 228

PALMDALE CA 93550-1010

06-29-1977

Enter your county at time of filing (see instructions)

LOS ANGELES
Principal Residence

If your address above is the same as your principal/physical residence address at the time of filing, check this box . . .
If not, enter below your principal/physical residence address at the time of filing.
Street address (number and street) (If foreign address, see instructions.) Apt. no/ste. no.

City State ZIP code

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

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

Filing Status

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
Exemptions

box 2 or 5, enter 2 in the box. If you checked the box on line 6, see instructions. 7 1 X $129 = 쐌 $ 129
8 Blind: If you (or your spouse/RDP) are visually impaired, enter 1;
if both are visually impaired, enter 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 X $129 = $
9 Senior: If you (or your spouse/RDP) are 65 or older, enter 1;
if both are 65 or older, enter 2. See instructions. . . . . . . . . . . . . . . . . . . . . . . . . . ●9 X $129 = $

175 3101214 REV 03/29/22 INTUIT.CG.CFP.SP Form 540 2021 Side 1

Your name: MARRON Your SSN or ITIN: 626-05-8176
10 Dependents: Do not include yourself or your spouse/RDP.
Dependent 1 Dependent 2 Dependent 3
First Name

Last Name
Exemptions

SSN. See
instructions. ● ● ●
Dependent’s
relationship
to you

Total dependent exemptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 10 X $400 = $

11 Exemption amount: Add line 7 through line 10. Transfer this amount to line 32 . . . . . . . . . . . . . 11 $ 129

12 State wages from your federal

Form(s) W-2, box 16 . . . . . . . . . . . . . . . . . . . . . . ● 12 9196 . 00

13 Enter federal adjusted gross income from federal Form 1040 or 1040-SR, line 11 . . . . . . . . 13 9196 . 00
14 California adjustments – subtractions. Enter the amount from Schedule CA (540),
Part I, line 27, column B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 14 . 00
15 Subtract line 14 from line 13. If less than zero, enter the result in parentheses.
9196 . 00
Taxable Income

See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
16 California adjustments – additions. Enter the amount from Schedule CA (540),
Part I, line 27, column C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 16 . 00

17 California adjusted gross income. Combine line 15 and line 16 . . . . . . . . . . . . . . . . . . . . . . . ● 17 9196 . 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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . $4,803
• Married/RDP filing jointly, Head of household, or Qualifying widow(er) . . . . $9,606
If Married/RDP filing separately or the box on line 6 is checked, STOP. See instructions ● 18
4803 . 00
19 Subtract line 18 from line 17. This is your taxable income.
If less than zero, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 4393 . 00

Tax Table Tax Rate Schedule

31 Tax. Check the box if from:
● FTB 3800 ● FTB 3803 . . . . . . . . . . . . . . . . ● 31 44 . 00
32 Exemption credits. Enter the amount from line 11. If your federal AGI is more than
$212,288, see instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 129 . 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

●
Special Credits

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

43 Enter credit name code ● and amount. . . ● 43 . 00

44 Enter credit name code ● and amount. . . ● 44 . 00

Side 2 Form 540 2021 175 3102214 REV 03/29/22 INTUIT.CG.CFP.SP

 Your name: MARRON Your SSN or ITIN: 626-05-8176

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

46 Nonrefundable Renter’s Credit. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 46 . 00

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

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

61 Alternative Minimum Tax. Attach Schedule P (540) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 61 . 00

62 Mental Health Services Tax. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 62 . 00

Other Taxes

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

64 Excess Advance Premium Assistance Subsidy (APAS) repayment. See instructions. . . . . . . ● 64 . 00

65 Add line 48, line 61, line 62, line 63, and line 64. This is your total tax . . . . . . . . . . . . . . . . . ● 65 0 . 00

71 California income tax withheld. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 71 . 00

72 2021 CA estimated tax and other payments. See instructions . . . . . . . . . . . . . . . . . . . . . . . . ● 72 . 00

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

Payments

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

75 Earned Income Tax Credit (EITC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 75 174 . 00

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

77 Net Premium Assistance Subsidy (PAS). See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 77 . 00

78 Add line 71 through line 77. These are your total payments.
See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 174 . 00

●
Use Tax

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

If line 91 is zero, check if: No use tax is owed. You paid your use tax obligation directly to CDTFA.

92 If you and your household had full-year health care coverage, check the box.
●
Penalty

See instructions. Medicare Part A or C coverage is qualifying health care coverage. . . . . . . .

ISR

If you did not check the box, see instructions.

Individual Shared Responsibility (ISR) Penalty. See instructions . . . . . . . . ● 92 0 . 00

Overpaid Tax/Tax Due

93 Payments balance. If line 78 is more than line 91, subtract line 91 from line 78 . . . . . . . . . . 93 174 . 00

94 Use Tax balance. If line 91 is more than line 78, subtract line 78 from line 91 . . . . . . . . . . . 94 . 00
95 Payments after Individual Shared Responsibility Penalty. If line 93 is more than line 92,
subtract line 92 from line 93. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 174 . 00
96 Individual Shared Responsibility Penalty Balance. If line 92 is more than line 93, then
subtract line 93 from line 92. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 . 00

175 3103214 REV 03/29/22 INTUIT.CG.CFP.SP Form 540 2021 Side 3

Your name: MARRON Your SSN or ITIN: 626-05-8176
Overpaid Tax/Tax Due

97 Overpaid tax. If line 95 is more than line 65, subtract line 65 from line 95. . . . . . . . . . . . . . . 97 174 . 00

98 Amount of line 97 you want applied to your 2022 estimated tax . . . . . . . . . . . . . . . . . . . . . . ● 98 . 00

99 Overpaid tax available this year. Subtract line 98 from line 97 . . . . . . . . . . . . . . . . . . . . . . . . ● 99 174 . 00

100 Tax due. If line 95 is less than line 65, subtract line 95 from line 65 . . . . . . . . . . . . . . . . . . . 100 . 00

Code Amount

California Seniors Special Fund. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 400 . 00

Alzheimer’s Disease and Related Dementia Voluntary Tax Contribution Fund . . . . . . . . . . . . . ● 401 3 . 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 Voluntary Tax Contribution Fund . . . . . . . . . . . . . . . . . . . . . ● 406 . 00

Emergency Food for Families Voluntary Tax Contribution Fund . . . . . . . . . . . . . . . . . . . . . . . ● 407 . 00

California Peace Officer Memorial Foundation Voluntary Tax Contribution Fund. . . . . . . . . . . ● 408 . 00

California Sea Otter Voluntary Tax Contribution Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 410 . 00

California Cancer Research Voluntary Tax Contribution Fund . . . . . . . . . . . . . . . . . . . . . . . . . ● 413 . 00

●
Contributions

School Supplies for Homeless Children Voluntary Tax Contribution Fund . . . . . . . . . . . . . . . 422 . 00

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

Schools Not Prisons Voluntary Tax Contribution Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 443 . 00

Suicide Prevention Voluntary Tax Contribution Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 444 . 00

Mental Health Crisis Prevention Voluntary Tax Contribution Fund. . . . . . . . . . . . . . . . . . . . . . ● 445 . 00

California Community and Neighborhood Tree Voluntary Tax Contribution Fund . . . . . . . . . . ● 446 . 00

110 Add code 400 through code 446. This is your total contribution . . . . . . . . . . . . . . . . . . . . . . ● 110 3 . 00

Side 4 Form 540 2021 175 3104214 REV 03/29/22 INTUIT.CG.CFP.SP

Your name: MARRON Your SSN or ITIN: 626-05-8176
You Owe
Amount

111 AMOUNT YOU OWE. If you do not have an amount on line 99, add line 94, line 96, line 100, and line 110. See instructions. Do not send cash.
Mail to: FRANCHISE TAX BOARD, PO BOX 942867, SACRAMENTO CA 94267-0001. . . . . ● 111 . 00
Pay Online – Go to ftb.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 line 110, line 112 and line 113 from line 99. See instructions.

Mail to: FRANCHISE TAX BOARD, PO BOX 942840, SACRAMENTO CA 94240-0001. . . . . . . ● 115 171 . 00

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.
Refund and Direct Deposit

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 Checking ● Account number ● 116 Direct deposit amount
124303120 398187386609 171 . 00
Savings

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

. 00
Savings

IMPORTANT: See the instructions to find out if you should attach a copy of your complete federal tax return.
Our privacy notice can be found in annual tax booklets or online. Go to ftb.ca.gov/privacy to learn about our privacy policy statement, or go to ftb.ca.gov/forms and search for 1131
to locate FTB 1131 EN-SP, Franchise Tax Board Privacy Notice on Collection. To request this notice by mail, call 800.338.0505 and enter form code 948 when instructed.
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 Date Spouse’s/RDP’s signature (if a joint tax return, both must sign)

Your email address. Enter only one email address. Preferred phone number

4052945003
Sign
Paid preparer’s signature (declaration of preparer is based on all information of which preparer has any knowledge)
Here SELF-PREPARED
It is unlawful
to forge a
spouse’s/
Firm’s name (or yours, if self-employed) ● PTIN
RDP’s
signature.
Firm’s address ● Firm’s FEIN
Joint tax
return?
(See
instructions)
Do you want to allow another person to discuss this tax return with us? See instructions . . . . . . . ● Yes No
Print Third Party Designee’s Name Telephone Number

175 3105214 REV 03/29/22 INTUIT.CG.CFP.SP Form 540 2021 Side 5

 TAXABLE YEAR SCHEDULE

2021 California Adjustments — Residents CA (540)

Important: Attach this schedule behind Form 540, Side 5 as a supporting California schedule.
Name(s) as shown on tax return SSN or ITIN

JOANNA MARRON 626058176

Part I Income Adjustment Schedule Federal Amounts Subtractions Additions
Section A – Income from federal Form 1040 or 1040-SR
A (taxable amounts from your
federal tax return)
B See instructions C See instructions

1 Wages, salaries, tips, etc. See instructions before

making an entry in column B or C . . . . . . . . . . . . . . .1 9,196.

2 Taxable interest. a 2b
3 Ordinary dividends.
See instructions. a 3b
4 IRA distributions.
See instructions. a 4b
5 Pensions and
annuities. See
instructions. a 5b
6 Social security
benefits. a 6b

7 Capital gain or (loss). See instructions. . . . . . . . . . . .7

Section B – Additional Income from federal Schedule 1 (Form 1040)
1 Taxable refunds, credits, or offsets of state
and local income taxes . . . . . . . . . . . . . . . . . . . . .1

2a Alimony received. See instructions. . . . . . . . . . . .2a

3 Business income or (loss). See instructions. . . . .3

4 Other gains or (losses) . . . . . . . . . . . . . . . . . . . . .4

5 Rental real estate, royalties, partnerships,
S corporations, trusts, etc. . . . . . . . . . . . . . . . . . .5

6 Farm income or (loss) . . . . . . . . . . . . . . . . . . . . .6

7 Unemployment compensation . . . . . . . . . . . . . . .7
8 Other income:
a Federal net operating loss . . . . . . . . . . . . . . . . .8a

b Gambling income. . . . . . . . . . . . . . . . . . . . . . . 8b

c Cancellation of debt . . . . . . . . . . . . . . . . . . . . . 8c
d Foreign earned income exclusion from
federal Form 2555 . . . . . . . . . . . . . . . . . . . . . . 8d

e Taxable Health Savings Account distribution . . 8e

f Alaska Permanent Fund dividends . . . . . . . . . . 8f

g Jury duty pay. . . . . . . . . . . . . . . . . . . . . . . . . . 8g

h Prizes and awards . . . . . . . . . . . . . . . . . . . . . . 8h

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For Privacy Notice, get FTB 1131 EN-SP. 175 7731214 Schedule CA (540) 2021 Side 1
Section B – Additional Income Federal Amounts Subtractions Additions
Continued A (taxable amounts from your B See instructions C See instructions
federal tax return)

i Activity not engaged in for profit income . . . . . 8i

j Stock options . . . . . . . . . . . . . . . . . . . . . . . . . . 8j
k Income from the rental of personal property
if you engaged in the rental for profit but were
not in the business of renting such property . . 8k
l Olympic and Paralympic medals and USOC
prize money . . . . . . . . . . . . . . . . . . . . . . . . . . . 8l

m IRC Section 951(a) inclusion . . . . . . . . . . . . . 8m

n IRC Section 951A(a) inclusion. . . . . . . . . . . . . 8n

o IRC Section 461(l) excess business loss adjustment 8o

p Taxable distributions from an ABLE account . . 8p

z Other income. List type and amount.

8z

9 a Total other income. Add lines 8a through 8z. 9a

b1 Disaster loss deduction from form FTB 3805V . 9b1

b2 NOL deduction from form FTB 3805V . . . . . . 9b2

b3 NOL from form FTB 3805Z, 3807, or 3809 . . 9b3

b4 Student loan discharged due to closure of a
for-profit school. . . . . . . . . . . . . . . . . . . . . . . 9b4
10 Total. Combine Section A, line 1 through line 7,
and Section B, line 1 through line 7, line 9a, and line 9b4
in column A (as applicable). Add Section A, line 1 through
line 7, and Section B, line 1 through line 7, line 9a and
line 9b1 through line 9b4 in column B and column C 9,196.
(as applicable). See instructions. . . . . . . . . . . . . . . . . .10

Section C – Adjustments to Income

from federal Schedule 1 (Form 1040)

11 Educator expenses . . . . . . . . . . . . . . . . . . . . . . .11

12 Certain business expenses of reservists, performing
artists, and fee-basis government officials. . . . . . .12

13 Health savings account deduction . . . . . . . . . . .13

14 Moving expenses. Attach form FTB 3913.
See instructions . . . . . . . . . . . . . . . . . . . . . . . . .14
15 Deductible part of self-employment tax.
See instructions. . . . . . . . . . . . . . . . . . . . . . . . .15

16 Self-employed SEP, SIMPLE, and qualified plans. .16

17 Self-employed health insurance deduction.
See instructions. . . . . . . . . . . . . . . . . . . . . . . . .17

Side 2 Schedule CA (540) 2021 175 7732214 REV 03/29/22 INTUIT.CG.CFP.SP

Section C – Adjustments to Income Federal Amounts Subtractions Additions
Continued A (taxable amounts from your B See instructions C See instructions
federal tax return)

18 Penalty on early withdrawal of savings. . . . . . . . . . . 18

19 a Alimony paid. . . . . . . . . . . . . . . . . . . . . . . . . . . . 19a

b Recipient’s: SSN

Last Name

20 IRA deduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

21 Student loan interest deduction . . . . . . . . . . . . . . . . 21

22 Reserved for future use . . . . . . . . . . . . . . . . . . . . . . 22

23 Archer MSA deduction . . . . . . . . . . . . . . . . . . . . . . . 23

24 Other adjustments:
a Jury duty pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24a
b Deductible expenses related to income reported
on line 8k from the rental of personal property
engaged in for profit. . . . . . . . . . . . . . . . . . . . . . . 24b
c Nontaxable amount of the value of Olympic and
Paralympic medals and USOC prize money
reported on line 8l . . . . . . . . . . . . . . . . . . . . . . . . 24c

d Reforestation amortization and expenses. . . . . . . 24d

e Repayment of supplemental unemployment
benefits under the Trade Act of 1974 . . . . . . . . . . 24e
f Contributions to IRC Section 501(c)(18)(D)
pension plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24f
g Contributions by certain chaplains to
IRC Section 403(b) plans . . . . . . . . . . . . . . . . . . . 24g
h Attorney fees and court costs for actions involving
certain unlawful discrimination claims . . . . . . . . . 24h
i Attorney fees and court costs you paid in connection
with an award from the IRS for information you provided
that helped the IRS detect tax law violations. . . . . . . 24i

j Housing deduction from federal Form 2555 . . . . . 24j

k Excess deductions of IRC Section 67(e) expenses
from federal Schedule K-1 (Form 1041) . . . . . . . . 24k
z Other adjustments. List type and amount.

24z
25 Total other adjustments. Add lines 24a through
24z . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
26 Add line 11 through line 23 and line 25 in
columns A, B, and C. See instructions . . . . . . . . . . . 26
27 Total. Subtract line 26 from line 10 in
columns A, B, and C. See instructions . . . . . . . . . . . 27 9,196.
REV 03/29/22 INTUIT.CG.CFP.SP

175 7733214 Schedule CA (540) 2021 Side 3

Part II Adjustments to Federal Itemized Deductions

Check the box if you did NOT itemize for federal but will itemize for California . . . . . . . . . . .
Federal Amounts Subtractions Additions
A (from federal Schedule A B See instructions C See instructions
(Form 1040))
Medical and Dental Expenses See instructions.
1 Medical and
dental expenses . . . . 1
2 Enter amount from
federal Form 1040
or 1040-SR, line 11. . 9,196. 2
3 Multiply line 2
by 7.5% (0.075) . . . . 690. 3
4 Subtract line 3 from line 1.
If line 3 is more than line 1, enter 0 . . . . . . . . . . . . . .4
Taxes You Paid
5 a State and local income tax or general sales taxes. .5a

b State and local real estate taxes . . . . . . . . . . . . . . .5b

c State and local personal property taxes . . . . . . . . .5c 0.

d Add line 5a through line 5c. . . . . . . . . . . . . . . . . . .5d 0.

e Enter the smaller of line 5d or $10,000 ($5,000 if
married filing separately) in column A.
Enter the amount from line 5a, column B
in line 5e, column B.
Enter the difference from line 5d and line 5e,
column A in line 5e, column C . . . . . . . . . . . . . . . .5e 0. 0.

6 Other taxes. List type 6

7 Add line 5e and line 6 . . . . . . . . . . . . . . . . . . . . . . . . .7 0. 0.

Interest You Paid
8 a Home mortgage interest and points reported to
you on federal Form 1098 . . . . . . . . . . . . . . . . . . .8a
b Home mortgage interest not reported to you
on federal Form 1098 . . . . . . . . . . . . . . . . . . . . . . .8b

c Points not reported to you on federal Form 1098. .8c

d Mortgage insurance premiums . . . . . . . . . . . . . . .8d

e Add line 8a through line 8d . . . . . . . . . . . . . . . . . .8e

9 Investment interest. . . . . . . . . . . . . . . . . . . . . . . . . . .9

10 Add line 8e and line 9 . . . . . . . . . . . . . . . . . . . . . . . .10

Side 4 Schedule CA (540) 2021 175 7734214 REV 03/29/22 INTUIT.CG.CFP.SP

Part II Adjustments to Federal Itemized Deductions Federal Amounts Subtractions Additions
Continued
A (from federal Schedule A B See instructions C See instructions
(Form 1040))
Gifts to Charity
11 Gifts by cash or check. . . . . . . . . . . . . . . . . . . . . . . .11

12 Other than by cash or check. . . . . . . . . . . . . . . . . . .12

13 Carryover from prior year. . . . . . . . . . . . . . . . . . . . .13

14 Add line 11 through line 13 . . . . . . . . . . . . . . . . . . .14

Casualty and Theft Losses
15 Casualty or theft loss(es) (other than net qualified disaster
losses). Attach federal Form 4684. See instructions . .15

Other Itemized Deductions

16 Other—from list in federal instructions.. . . . . . . . . .16
17 Add lines 4, 7, 10, 14, 15, and 16 in
columns A, B, and C. . . . . . . . . . . . . . . . . . . . . . . . .17 0. 0.

18 Total. Combine line 17 column A less column B plus column C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 0.

Job Expenses and Certain Miscellaneous Deductions

19 Unreimbursed employee expenses - job travel, union dues, job education, etc.
Attach federal Form 2106 if required. See instructions . . . . . . . . . . . . . . . . . . . . . . . 19

20 Tax preparation fees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

21 Other expenses - investment, safe deposit
box, etc. List type . . . . . . . . . . . . . . . . . . . . . . 21 0.

22 Add line 19 through line 21 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 0.

23 Enter amount from federal Form 1040
or 1040-SR, line 11 . . . . . . . . . . . . . . . . . . . . 9,196.

24 Multiply line 23 by 2% (0.02). If less than zero, enter 0. . . . . . . . . . . . . . . . . . . . . . . 24 184.

25 Subtract line 24 from line 22. If line 24 is more than line 22, enter 0. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 0.

26 Total Itemized Deductions. Add line 18 and line 25 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 0.

27 Other adjustments. See instructions. Specify. 27

28 Combine line 26 and line 27 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 0.

29 Is your federal AGI (Form 540, line 13) more than the amount shown below for your filing status?
Single or married/RDP filing separately . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $212,288
Head of household . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $318,437
Married/RDP filing jointly or qualifying widow(er) . . . . . . . . . . . . . . . . . . . . . . . . . $424,581
No. Transfer the amount on line 28 to line 29.
Yes. Complete the Itemized Deductions Worksheet in the instructions for Schedule CA (540), line 29 . . . . . . . . . . . 29 0.

30 Enter the larger of the amount on line 29 or your standard deduction listed below
Single or married/RDP filing separately. See instructions . . . . . . . . . . . . . . . . . . . . . $4,803
Married/RDP filing jointly, head of household, or qualifying widow(er) . . . . . . . . . . . $9,606
Transfer the amount on line 30 to Form 540, line 18 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 4,803.
REV 03/29/22 INTUIT.CG.CFP.SP

175 7735214 Schedule CA (540) 2021 Side 5

 TAXABLE YEAR FORM

2021 California Earned Income Tax Credit 3514

Attach to your California Form 540, Form 540 2EZ or Form 540NR.
Name(s) as shown on tax return Your SSN or ITIN

JOANNA MARRON 626058176

Before you begin:
If you claim the California Earned Income Tax Credit (EITC) even though you know you are not eligible, you may not be allowed to take the credit for up
to 10 years.
If you are claiming the California EITC, you must provide your date of birth (DOB), and spouse’s/ Registered Domestic Partner’s (RDP’s) DOB if filing
jointly, on your California Form 540, Form 540 2EZ, or Form 540NR.
If you qualify for the California EITC you may also qualify for the Young Child Tax Credit (YCTC). See instructions for additional information.
Follow Step 1 through Step 9 in the instructions to determine if you meet the requirements, to complete this form, and to figure the amount of
the credit(s).
Part I Qualifying Information See Specific Instructions.

1 a Has the Internal Revenue Service (IRS) previously disallowed your federal Earned Income Credit (EIC)? . . Yes No

b Has the Franchise Tax Board (FTB) previously disallowed your California EITC?. . . . . . . . . . . . . . . . . . . . . . Yes No

2 Federal AGI (federal Form 1040 or 1040-SR, line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 2 9196 . 00

3 Federal EIC (federal Form 1040 or 1040-SR, line 27a) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 3 1404 . 00

Part II Investment Income Information

4 Investment Income. See instructions for Step 2 – Investment Income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 4 . 00

Part III Qualifying Child Information
You must complete Part I and Part II before filling out Part III. If you are not claiming a qualifying child, skip Part III and go to Step 4 in the instructions.
Qualifying Child Information (Complete line 5 through line 12 for each child under Child 1, Child 2 or Child 3, as applicable.)
Child 1 Child 2 Child 3

5 First name . . . . . .

6 Last name . . . . . .
7 SSN or ITIN.
See instructions. ● ● ●
8 Date of birth (mm/dd/yyyy). If born after 2002 and the child is younger than you (or your spouse/RDP, if filing jointly),
skip line 9a and line 9b; go to line 10.

9 a Was the child under age 24 at the end of 2021, a student, and younger than you (or your spouse/RDP, if filing jointly)?
If yes, go to line 10. If no, go to line 9b. See instructions.

Yes No Yes No Yes No

b Was the child permanently and totally disabled during any part of 2021? If yes, go to line 10. If no, stop here.
The child is not a qualifying child.

Yes No Yes No Yes No

10 Child’s relationship to you. See instructions.

11 Number of days child lived with you in California during 2021. Do not enter more than 365 days. See instructions.

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For Privacy Notice, get FTB 1131 EN-SP. 175 8461214 FTB 3514 2021 Side 1
12 Child’s physical address during 2021. See instructions.
a Street address (number and street and apt. no./ste. no.)

Child 1

b City c State d ZIP code

a Street address (number and street and apt. no./ste. no.)

Child 2
b City c State d ZIP code

a Street address (number and street and apt. no./ste. no.)

Child 3
b City c State d ZIP code

Part IV California Earned Income

13 Wages, salaries, tips, and other employee compensation, subject to California withholding. See instructions. . ● 13 9196 . 00

14 IHSS payments. See instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 . 00

15 Prison inmate wages and/or pension or annuity from a nonqualified deferred compensation plan or a
nongovernmental IRC Section 457 plan. See instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 . 00
16 Subtract line 14 and line 15 from line 13. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 16 9196 . 00

17 Nontaxable combat pay. See instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 . 00

18 Business income or (loss). Enter amount from Worksheet 3, line 5. See instructions. . . . . . . . . . . . . . . . . . . 18 . 00
a Business name . . . . . . . . . . . . . . .
Street address (number and street and apt. no./ste. no.)

b Business address . . . . . . . . . . . . .
City State ZIP code

c Business license number . . . . . . .

d SEIN . . . . . . . . . . . . . . . . . . . . . . .

e Business code . . . . . . . . . . . . . . .

19 California Earned Income. Add line 16, line 17, and line 18. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 19 9196 . 00
Part V California Earned Income Tax Credit (Complete Step 6 in the instructions.)

20 California EITC. Enter amount from California Earned Income Tax Credit Worksheet, Part III, line 6.
This amount should also be entered on Form 540, line 75; or Form 540 2EZ, line 23 . . . . . . . . . . . . . . . . . . . ● 20 174 . 00

Side 2 FTB 3514 2021 175 8462214 REV 03/29/22 INTUIT.CG.CFP.SP

Part VI Nonresident or Part-Year Resident California Earned Income Tax Credit

21 CA Exemption Credit Percentage from Form 540NR, line 38. See instructions. . . . 21
22 Nonresident or Part-Year Resident EITC. Multiply line 20 by line 21.
This amount should also be entered on Form 540NR, line 85 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 22 . 00
Part VII Young Child Tax Credit (See Step 8 in the instructions before completing this part.)

23 California Earned Income. Enter the amount from form FTB 3514, line 19. . . . . . . . . . . . . . . . . . . . . . . . . . 23 . 00
24 Available Young Child Tax Credit.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 1,000 . 00
• If the amount on line 23 is $25,000 or less, skip lines 25 through 27 and enter $1,000 on line 28.
If applicable, complete lines 29 and 30.
• If the amount on line 23 is greater than $25,000, complete lines 25 through 28. If applicable,
complete lines 29 and 30.

25 Excess Earned Income over threshold. Subtract $25,000 from line 23 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 25 . 00

26 Divide line 25 by 100. Enter the result as a decimal out to two decimal places, do not round. . . . . . . . . . . . . 26
27 Reduction amount. Multiply line 26 by $20. Enter the result as a decimal out to two decimal places,
do not round. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 27

28 Young Child Tax Credit.

• If you did not need to complete lines 25 through 27, your credit is the $1,000 from line 24.
• If you completed lines 25 through 27, to compute your credit, subtract line 27 from line 24. If your credit
amount is between $0 and $1, enter $1. If your credit amount is over $1, round to the nearest whole dollar.
This amount should also be entered on Form 540, line 76; or Form 540 2EZ, line 24 . . . . . . . . . . . . . . . . . . . ● 28 . 00
Part VIII Nonresident or Part-Year Resident Young Child Tax Credit (See Step 9 in the instructions.)

29 CA Exemption Credit Percentage from Form 540NR, line 38. See instructions . . . . 29

30 Nonresident or Part-Year Resident YCTC. Multiply line 28 by line 29.

This amount should also be entered on Form 540NR, line 86 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 30 . 00

175 8463214 REV 03/29/22 INTUIT.CG.CFP.SP

FTB 3514 2021 Side 3
 TAXABLE YEAR CALIFORNIA FORM
Health Coverage Exemptions and Individual
2021 Shared Responsibility Penalty 3853
Attach to your California Form 540, Form 540NR, or Form 540 2EZ.
Name(s) as shown on your California tax return SSN or ITIN
JOANNA MARRON 626-05-8176
Part I Applicable Household Members. List all members of your applicable household whether or not they have an exemption or an Exemption
Certificate Number (ECN) granted by the Marketplace. See instructions.
First Name Initial SSN Date of Birth (mm/dd/yyyy) Modified AGI
JOANNA 626-05-8176 06/29/1977 9,196.
1 Last Name ECN 1 ECN 2 ECN 3
MARRON
First Name Initial SSN Date of Birth (mm/dd/yyyy) Modified AGI

2 Last Name ECN 1 ECN 2 ECN 3

First Name Initial SSN Date of Birth (mm/dd/yyyy) Modified AGI

3 Last Name ECN 1 ECN 2 ECN 3

First Name Initial SSN Date of Birth (mm/dd/yyyy) Modified AGI

4 Last Name ECN 1 ECN 2 ECN 3

First Name Initial SSN Date of Birth (mm/dd/yyyy) Modified AGI

5 Last Name ECN 1 ECN 2 ECN 3

First Name Initial SSN Date of Birth (mm/dd/yyyy) Modified AGI

6 Last Name ECN 1 ECN 2 ECN 3

First Name Initial SSN Date of Birth (mm/dd/yyyy) Modified AGI

7 Last Name ECN 1 ECN 2 ECN 3

First Name Initial SSN Date of Birth (mm/dd/yyyy) Modified AGI

8 Last Name ECN 1 ECN 2 ECN 3

First Name Initial SSN Date of Birth (mm/dd/yyyy) Modified AGI

9 Last Name ECN 1 ECN 2 ECN 3

First Name Initial SSN Date of Birth (mm/dd/yyyy) Modified AGI

10 Last Name ECN 1 ECN 2 ECN 3

First Name Initial SSN Date of Birth (mm/dd/yyyy) Modified AGI

11 Last Name ECN 1 ECN 2 ECN 3

First Name Initial SSN Date of Birth (mm/dd/yyyy) Modified AGI

12 Last Name ECN 1 ECN 2 ECN 3

Part II Coverage Exemption Claimed on Your Tax Return for Your Household
1 If you are claiming a coverage exemption because your applicable household income or gross income is below the filing threshold, check
the box here. See instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . □

For Privacy Notice, get FTB 1131 EN-SP. 175 8661214 REV 03/29/22 INTUIT.CG.CFP.SP FTB 3853 2021 Side 1
Part III Coverage and Exemptions Claimed on Your Tax Return for Individuals. If you and/or a member of your applicable household are reporting
any coverage or are claiming exemptions for the tax year, complete Part III. See instructions.

Coverage and Exemption Codes

(a) (b) (c) (d) (e) (f) (g) (h) (i) (j) (k) (l) (m)
Full-year Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
First Name Initial

1 Last Name

First Name Initial

2 Last Name

First Name Initial

3 Last Name

First Name Initial

4 Last Name

First Name Initial

5 Last Name

First Name Initial

6 Last Name

First Name Initial

7 Last Name

First Name Initial

8 Last Name

First Name Initial

9 Last Name

First Name Initial

10 Last Name

First Name Initial

11 Last Name

First Name Initial

12 Last Name

Part IV Individual Shared Responsibility Penalty

1 Your Individual Shared Responsibility Penalty. Enter on Form 540, line 92; Form 540NR, line 91; or Form 540 2EZ, line 27.
See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 1. 0.

Side 2 FTB 3853 2021 175 8662214 REV 03/29/22 INTUIT.CG.CFP.SP