2022 Tax Return

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 CORRECTED (if checked)
PAYER’S name, street address, city or town, state or province, 1 Gross distribution OMB No. 1545-0119 Distributions From
country, ZIP or foreign postal code, and telephone no. Pensions, Annuities,
Retirement or
FIDELITY INVESTMNTS
100 MAGELLAN WAY KW1C
$ 10792
2a Taxable amount 2022 Profit-Sharing Plans,
IRAs, Insurance
Contracts, etc.
LATONIA KY 41015 1099-R
$ 2158 Form
2b Taxable amount Total
not determined distribution X
PAYER’S TIN RECIPIENT’S TIN 3 Capital gain (included in 4 Federal income tax
box 2a) withheld

04-6568107 429-25-1289
$ $
RECIPIENT’S name 5 Employee contributions/ 6 Net unrealized
Designated Roth appreciation in
DAVID B ADAMS II contributions or employer’s securities
insurance premiums
$ $
Street address (including apt. no.) 7 Distribution IRA/ 8 Other
code(s) SEP/
500 PAKIS STREET SIMPLE This information is
1 $ % being furnished to
City or town, state or province, country, and ZIP or foreign postal code 9a Your percentage of total 9b Total employee contributions the IRS.
HOT SPRINGS NATL PARK AR 71913 distribution %$
10 Amount allocable to IRR 11 1st year of desig. 12 FATCA filing 14 State tax withheld 15 State/Payer’s state no. 16 State distribution
within 5 years Roth contrib. requirement
$ 539 $
AR AR 77463372WHP
$ 0 $ $
Account number (see instructions) 13 Date of 17 Local tax withheld 18 Name of locality 19 Local distribution
payment $ $
$ $
Form 1099-R (keep for your records) www.irs.gov/Form1099R Department of the Treasury - Internal Revenue Service

CORRECTED (if checked)

PAYER’S name, street address, city or town, state or province, 1 Gross distribution OMB No. 1545-0119 Distributions From
country, ZIP or foreign postal code, and telephone no. Pensions, Annuities,
Retirement or
$
2a Taxable amount 2022 Profit-Sharing Plans,
IRAs, Insurance
Contracts, etc.
$ Form 1099-R
2b Taxable amount Total
not determined distribution
PAYER’S TIN RECIPIENT’S TIN 3 Capital gain (included in 4 Federal income tax
box 2a) withheld

$ $
RECIPIENT’S name 5 Employee contributions/ 6 Net unrealized
Designated Roth appreciation in
contributions or employer’s securities
insurance premiums
$ $
Street address (including apt. no.) 7 Distribution IRA/ 8 Other
code(s) SEP/
SIMPLE This information is
$ % being furnished to
City or town, state or province, country, and ZIP or foreign postal code 9a Your percentage of total 9b Total employee contributions the IRS.
distribution %$
10 Amount allocable to IRR 11 1st year of desig. 12 FATCA filing 14 State tax withheld 15 State/Payer’s state no. 16 State distribution
within 5 years Roth contrib. requirement
$ $
$ $ $
Account number (see instructions) 13 Date of 17 Local tax withheld 18 Name of locality 19 Local distribution
payment $ $
$ $
Form 1099-R (keep for your records) www.irs.gov/Form1099R Department of the Treasury - Internal Revenue Service

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Form 8879 IRS e-file Signature Authorization
(Rev. January 2021) OMB No. 1545-0074
a
ERO must obtain and retain completed Form 8879.
Department of the Treasury
a Go to www.irs.gov/Form8879 for the latest information.
Internal Revenue Service

F
Submission Identification Number (SID)
Taxpayer’s name Social security number

DAVID B ADAMS II 429-25-1289

Spouse’s name Spouse’s social security number

Part I Tax Return Information — Tax Year Ending December 31, 2022 (Enter year you are authorizing.)
Enter whole dollars only on lines 1 through 5.
Note: Form 1040-SS filers use line 4 only. Leave lines 1, 2, 3, and 5 blank.
1 Adjusted gross income . . . . . . . . . . . . . . . . . . . . . . . . . . 1 100350
2 Total tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 15067
3 Federal income tax withheld from Form(s) W-2 and Form(s) 1099 . . . . . . . . . . . . . 3 11897
4 Amount you want refunded to you . . . . . . . . . . . . . . . . . . . . . . 4
5 Amount you owe . . . . . . . . . . . . . . . . . . . . . . .
3170 . . . . . 5
Part II Taxpayer Declaration and Signature Authorization (Be sure you get and keep a copy of your return)
Under penalties of perjury, I declare that I have examined a copy of the income tax return (original or amended) I am now authorizing, and to the best of
my knowledge and belief, it is true, correct, and complete. I further declare that the amounts in Part I above are the amounts from the income tax
return (original or amended) I am now authorizing. I consent to allow my intermediate service provider, transmitter, or electronic return originator (ERO)
to send my return to the IRS and to receive from the IRS (a) an acknowledgement of receipt or reason for rejection of the transmission, (b) the reason
for any delay in processing the return or refund, and (c) the date of any refund. If applicable, I authorize the U.S. Treasury and its designated Financial
Agent to initiate an ACH electronic funds withdrawal (direct debit) entry to the financial institution account indicated in the tax preparation software for
payment of my federal taxes owed on this return and/or a payment of estimated tax, and the financial institution to debit the entry to this account. This
authorization is to remain in full force and effect until I notify the U.S. Treasury Financial Agent to terminate the authorization. To revoke (cancel) a
payment, I must contact the U.S. Treasury Financial Agent at 1-888-353-4537. Payment cancellation requests must be received no later than 2
business days prior to the payment (settlement) date. I also authorize the financial institutions involved in the processing of the electronic payment of
taxes to receive confidential information necessary to answer inquiries and resolve issues related to the payment. I further acknowledge that the
personal identification number (PIN) below is my signature for the income tax return (original or amended) I am now authorizing and, if applicable, my
Electronic Funds Withdrawal Consent.
Taxpayer’s PIN: check one box only
0 0 0 0 0
I authorize to enter or generate my PIN as my
Enter five digits, but
ERO firm name don’t enter all zeros
signature on the income tax return (original or amended) I am now authorizing.
X I will enter my PIN as my signature on the income tax return (original or amended) I am now authorizing. 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 a Date a

Spouse’s PIN: check one box only

I authorize to enter or generate my PIN as my
ERO firm name Enter five digits, but
signature on the income tax return (original or amended) I am now authorizing. don’t enter all zeros

I will enter my PIN as my signature on the income tax return (original or amended) I am now authorizing. 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 signature a Date a

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.
Don’t enter all zeros

I certify that the above numeric entry is my PIN, which is my signature for the electronic individual income tax return (original or amended) I am now
authorized to file for tax year indicated above 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 Pub. 1345, Handbook for Authorized IRS e-file Providers of Individual Income Tax Returns.

ERO’s signature a TAXSLAYER 10/15/2024 Date a

ERO Must Retain This Form — See Instructions
Don’t Submit This Form to the IRS Unless Requested To Do So
For Paperwork Reduction Act Notice, see your tax return instructions. b
Form 8879 (Rev. 01-2021)
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 2022 Form 1040-V Department of the Treasury
Internal Revenue Service

What Is Form 1040-V? Notice to taxpayers presenting checks. When you provide a
check as payment, you authorize us either to use information
It’s a statement you send with your check or money order for from your check to make a one-time electronic fund transfer from
any balance due on the “Amount you owe” line of your 2022 your account or to process the payment as a check transaction.
Form 1040, 1040-SR, or 1040-NR. When we use information from your check to make an electronic
Consider Making Your Tax Payment fund transfer, funds may be withdrawn from your account as
soon as the same day we receive your payment, and you will not
Electronically—It’s Easy receive your check back from your financial institution.
You can make electronic payments online, by phone, or from a No checks of $100 million or more accepted. The IRS can’t
mobile device. Paying electronically is safe and secure. When accept a single check (including a cashier’s check) for amounts
you schedule your payment, you will receive immediate of $100,000,000 ($100 million) or more. If you are sending $100
confirmation from the IRS. Go to www.irs.gov/Payments to see million or more by check, you will need to spread the payments
all your electronic payment options. over two or more checks, with each check made out for an
amount less than $100 million.
How To Fill in Form 1040-V Pay by cash. This is an in-person payment option for
Line 1. Enter your social security number (SSN). individuals provided through retail partners with a maximum of
If you are filing a joint return, enter the SSN shown first on $1,000 per day per transaction. To make a cash payment, you
your return. must first be registered online at www.officialpayments.com/fed,
our Official Payment provider.
Line 2. If you are filing a joint return, enter the SSN shown
second on your return. How To Send in Your 2022 Tax Return,
Line 3. Enter the amount you are paying by check or money Payment, and Form 1040-V
order. If paying online at www.irs.gov/Payments, don’t complete
this form. • Don’t staple or otherwise attach your payment or Form 1040-V
to your return or to each other. Instead, just put them loose in
Line 4. Enter your name(s) and address exactly as shown on the envelope.
your return. Please print clearly.
• Mail your 2022 tax return, payment, and Form 1040-V to the
How To Prepare Your Payment address shown on the back that applies to you.
• Make your check or money order payable to “United States
Treasury.” Don’t send cash. If you want to pay in cash, in
How To Pay Electronically
person, see Pay by cash, later. Pay Online
• Make sure your name and address appear on your check or Paying online is convenient, secure, and helps make sure we
money order. get your payments on time. You can pay using either of the
• Enter your daytime phone number and your SSN on your following electronic payment methods. To pay your taxes online
check or money order. If you have an Individual Taxpayer or for more information, go to www.irs.gov/Payments.
Identification Number (ITIN), enter it wherever your SSN is IRS Direct Pay
requested. If you are filing a joint return, enter the SSN shown Pay your taxes directly from your checking or savings account
first on your return. Also, enter “2022 Form 1040,” “2022 Form at no cost to you. You receive instant confirmation that your
1040-SR,” or “2022 Form 1040-NR,” whichever is appropriate. payment has been made, and you can schedule your payment
• To help us process your payment, enter the amount on the up to 30 days in advance.
right side of your check like this: $ XXX.XX. Don’t use dashes or Debit or Credit Card
lines (for example, don’t enter “$ XXX—” or “$ XXX xx/100”).
The IRS doesn’t charge a fee for this service; the card
processors do. The authorized card processors and their phone
numbers are all online at www.irs.gov/Payments.

Form 1040-V (2022)

Detach Here and Mail With Your Payment and Return

1040-V Payment Voucher

Form

OMB No. 1545-0074

2022
Do not staple or attach this voucher to your payment or return.
Department of the Treasury
Internal Revenue Service Go to www.irs.gov/Payments for payment options and information.
1 Your social security number (SSN) 2 If a joint return, SSN shown second 3 Amount you are paying by check or
(if a joint return, SSN shown first on your return) on your return money order. Make your check or
money order payable to “United States 3170
429-25-1289 Treasury”
4 Your first name and middle initial Last name
Print or type

DAVID B ADAMS II
If a joint return, spouse’s first name and middle initial Last name

Home address (number and street) Apt. no. City, town, or post office. If you have a foreign address, also complete spaces below. State ZIP code
500 PAKIS STREET 1B HOT SPRINGS NATL PARK AR 71913
Foreign country name Foreign province/state/county Foreign postal code

For Paperwork Reduction Act Notice, see your tax return instructions.

QNA 429251289 SN ADAM 30 0 202212 610

Form 1040-V (2022) Page 2

IF you live in... THEN use this address to send in your payment...

Alabama, Florida, Georgia, Louisiana, Mississippi, North Internal Revenue Service

Carolina, South Carolina, Tennessee, Texas P.O. Box 1214
Charlotte, NC 28201-1214
Arkansas, Connecticut, Delaware, District of Columbia, Illinois,
Indiana, Iowa, Kentucky, Maine, Maryland, Massachusetts, Internal Revenue Service
Minnesota, Missouri, New Hampshire, New Jersey, New York, P.O. Box 931000
Oklahoma, Rhode Island, Vermont, Virginia, West Virginia, Louisville, KY 40293-1000
Wisconsin

Alaska, Arizona, California, Colorado, Hawaii, Idaho, Kansas,

Internal Revenue Service
Michigan, Montana, Nebraska, Nevada, New Mexico, North
P.O. Box 802501
Dakota, Ohio, Oregon, Pennsylvania, South Dakota, Utah,
Cincinnati, OH 45280-2501
Washington, Wyoming

A foreign country, American Samoa, or Puerto Rico (or are

excluding income under Internal Revenue Code section 933), or Internal Revenue Service
use an APO or FPO address, or file Form 2555 or 4563, or are a P.O. Box 1303
dual-status alien or nonpermanent resident of Guam or the U.S. Charlotte, NC 28201-1303
Virgin Islands

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 1040 U.S. Individual Income Tax Return 2022
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 x Single Married filing jointly Married filing separately (MFS) Head of household (HOH)
Qualifying surviving
Check only spouse (QSS)
one box. If you checked the MFS box, enter the name of your spouse. If you checked the HOH or QSS box, enter the child’s name if the qualifying
person is a child but not your dependent:
Your first name and middle initial Last name Your social security number
DAVID B ADAMS II 429-25-1289
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
500 PAKIS STREET 1B 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
HOT SPRINGS NATL PARK AR 71913 box below will not change
Foreign country name Foreign province/state/county Foreign postal code your tax or refund.
You Spouse

Digital At any time during 2022, did you: (a) receive (as a reward, award, or payment for property or services); or (b) sell,
Assets exchange, gift, or otherwise dispose of a digital asset (or a financial interest in a digital asset)? (See instructions.) Yes X 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, 1958 Are blind Spouse: Was born before January 2, 1958 Is blind
Dependents (see instructions): (2) Social security (3) Relationship (4) Check the box if qualifies for (see instructions):
(1) First name Last name number to you Child tax credit Credit for other dependents
If more
than four
dependents,
see instructions
and check
here . .
1a Total amount from Form(s) W-2, box 1 (see instructions) . . . . . . . . . . . . . 1a 95355
Income
b Household employee wages not reported on Form(s) W-2 . . . . . . . . . . . . . 1b
Attach Form(s) c Tip income not reported on line 1a (see instructions) . . . . . . . . . . . . . . 1c
W-2 here. Also
attach Forms d Medicaid waiver payments not reported on Form(s) W-2 (see instructions) . . . . . . . . 1d
W-2G and e Taxable dependent care benefits from Form 2441, line 26 . . . . . . . . . . . . 1e
1099-R if tax
was withheld. f Employer-provided adoption benefits from Form 8839, line 29 . . . . . . . . . . . 1f
If you did not g Wages from Form 8919, line 6 . . . . . . . . . . . . . . . . . . . . . 1g
get a Form h Other earned income (see instructions) . . . . . . . . . . . . . . . . . . 1h
W-2, see
instructions.
i Nontaxable combat pay election (see instructions) . . . . . . . 1i
z Add lines 1a through 1h . . . . . . . . . . . . . . . . . . . . . . 1z 95355
Attach Sch. B 2a Tax-exempt interest . . . 2a b Taxable interest . . . . . 2b
if required. 3a Qualified dividends . . . 3a b Ordinary dividends . . . . . 3b
4a IRA distributions . . . . 4a b Taxable amount . . . . . . 4b
Standard 5a Pensions and annuities . . 5a 10792 b Taxable amount . . . . . . 5b 2158
Deduction for—
6a Social security benefits . . 6a b Taxable amount . . . . . . 6b
• Single or
Married filing c If you elect to use the lump-sum election method, check here (see instructions) . . . . .
separately,
$12,950 7 Capital gain or (loss). Attach Schedule D if required. If not required, check here . . . . . 7
• Married filing 8 Other income from Schedule 1, line 10 . . . . . . . . . . . . . . . . . . 8 2837
jointly or
Qualifying 9 Add lines 1z, 2b, 3b, 4b, 5b, 6b, 7, and 8. This is your total income . . . . . . . . . . 9 100350
surviving spouse,
$25,900
10 Adjustments to income from Schedule 1, line 26 . . . . . . . . . . . . . . . 10
• Head of 11 Subtract line 10 from line 9. This is your adjusted gross income . . . . . . . . . . 11 100350
household,
$19,400 12 Standard deduction or itemized deductions (from Schedule A) . . . . . . . . . . 12 12950
• If you checked 13 Qualified business income deduction from Form 8995 or Form 8995-A . . . . . . . . . 13
any box under
Standard 14 Add lines 12 and 13 . . . . . . . . . . . . . . . . . . . . . . . . 14 12950
Deduction, 15 Subtract line 14 from line 11. If zero or less, enter -0-. This is your taxable income . . . . . 87400
see instructions.
15

For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Form 1040 (2022)
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 ADAMS 429-25-1289
Form 1040 (2022) Page 2

Tax and 16 Tax (see instructions). Check if any from Form(s): 1 8814 2 4972 3 . . 16 14851
Credits 17 Amount from Schedule 2, line 3 . . . . . . . . . . . . . . . . . . . . 17
18 Add lines 16 and 17 . . . . . . . . . . . . . . . . . . . . . . . . 18 14851
19 Child tax credit or credit for other dependents from Schedule 8812 . . . . . . . . . . 19
20 Amount from Schedule 3, line 8 . . . . . . . . . . . . . . . . . . . . 20
21 Add lines 19 and 20 . . . . . . . . . . . . . . . . . . . . . . . . 21
22 Subtract line 21 from line 18. If zero or less, enter -0- . . . . . . . . . . . . . . 22 14851
23 Other taxes, including self-employment tax, from Schedule 2, line 21 . . . . . . . . . 23 216
24 Add lines 22 and 23. This is your total tax . . . . . . . . . . . . . . . . . 24 15067
Payments 25 Federal income tax withheld from:
a Form(s) W-2 . . . . . . . . . . . . . . . . . . 25a 11614
b Form(s) 1099 . . . . . . . . . . . . . . . . . . 25b 283
c Other forms (see instructions) . . . . . . . . . . . . . 25c
d Add lines 25a through 25c . . . . . . . . . . . . . . . . . . . . . . 25d 11897
26 2022 estimated tax payments and amount applied from 2021 return . . . . . . . . . . 26
If you have a
qualifying child, 27 Earned income credit (EIC) . . . . . . . . . . . . . . 27
attach Sch. EIC.
28 Additional child tax credit from Schedule 8812 . . . . . . . . 28
29 American opportunity credit from Form 8863, line 8 . . . . . . . 29
30 Reserved for future use . . . . . . . . . . . . . . . 30
31 Amount from Schedule 3, line 15 . . . . . . . . . . . . 31
32 Add lines 27, 28, 29, and 31. These are your total other payments and refundable credits . . 32
33 Add lines 25d, 26, and 32. These are your total payments . . . . . . . . . . . . 33 11897
34 If line 33 is more than line 24, subtract line 24 from line 33. This is the amount you overpaid . . 34
Refund
35a Amount of line 34 you want refunded to you. If Form 8888 is attached, check here . . . . 35a
Direct deposit? b Routing number X X X X X X X X X c Type: Checking Savings
See instructions.
d Account number X X X X X X X X X X X X X X X X X
36 Amount of line 34 you want applied to your 2023 estimated tax . . . 36
Amount 37 Subtract line 33 from line 24. This is the amount you owe.
You Owe For details on how to pay, go to www.irs.gov/Payments or see instructions . . . . . . . . 37 3170
38 Estimated tax penalty (see instructions) . . . . . . . . . . 38
Third Party Do you want to allow another person to discuss this return with the IRS? See
Designee instructions . . . . . . . . . . . . . . . . . . . . . Yes. Complete below. No
Designee’s Phone Personal identification
name no. number (PIN)
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
Joint return? (see inst.)
RN
See instructions. Spouse’s signature. If a joint return, both must sign. Date Spouse’s occupation If the IRS sent your spouse an
Keep a copy for Identity Protection PIN, enter it here
your records. (see inst.)

Phone no. (501) 545-7574 Email address [email protected]

Preparer’s name Preparer’s signature Date PTIN Check if:
Paid Self-employed
Preparer
Firm’s name Phone no.
Use Only
Firm’s address Firm’s EIN
Go to www.irs.gov/Form1040 for instructions and the latest information. Form 1040 (2022)
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SCHEDULE 1 OMB No. 1545-0074
Additional Income and Adjustments to Income
(Form 1040)
Department of the Treasury
Attach to Form 1040, 1040-SR, or 1040-NR. 2022
Attachment
Go to www.irs.gov/Form1040 for instructions and the latest information.
Internal Revenue Service Sequence No. 01
Name(s) shown on Form 1040, 1040-SR, or 1040-NR Your social security number
DAVID ADAMS II 429-25-1289
Part I Additional Income
1 Taxable refunds, credits, or offsets of state and local income taxes . . . . . . . . . 1
2a Alimony received . . . . . . . . . . . . . . . . . . . . . . . . . . . 2a
b Date of original divorce or separation agreement (see instructions):
3 Business income or (loss). Attach Schedule C . . . . . . . . . . . . . . . . . 3
4 Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . . . . . . . 4
5 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E . 5
6 Farm income or (loss). Attach Schedule F . . . . . . . . . . . . . . . . . . . 6
7 Unemployment compensation . . . . . . . . . . . . . . . . . . . . . . . 7 2837
8 Other income:
a Net operating loss . . . . . . . . . . . . . . . . . . . 8a ( )
b Gambling . . . . . . . . . . . . . . . . . . . . . . 8b
c Cancellation of debt . . . . . . . . . . . . . . . . . . 8c
d Foreign earned income exclusion from Form 2555 . . . . . . . 8d ( )
e Income from Form 8853 . . . . . . . . . . . . . . . . . 8e
f Income from Form 8889 . . . . . . . . . . . . . . . . . 8f
g Alaska Permanent Fund dividends . . . . . . . . . . . . . 8g
h Jury duty pay . . . . . . . . . . . . . . . . . . . . . 8h
i Prizes and awards . . . . . . . . . . . . . . . . . . . 8i
j Activity not engaged in for profit income . . . . . . . . . . . 8j
k Stock options . . . . . . . . . . . . . . . . . . . . . 8k
l 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 . . . 8l
m Olympic and Paralympic medals and USOC prize money (see
instructions) . . . . . . . . . . . . . . . . . . . . . 8m
n Section 951(a) inclusion (see instructions) . . . . . . . . . . 8n
o Section 951A(a) inclusion (see instructions) . . . . . . . . . . 8o
p Section 461(l) excess business loss adjustment . . . . . . . . 8p
q Taxable distributions from an ABLE account (see instructions) . . . 8q
r Scholarship and fellowship grants not reported on Form W-2 . . . 8r
s Nontaxable amount of Medicaid waiver payments included on Form
1040, line 1a or 1d . . . . . . . . . . . . . . . . . . . 8s ( )
t Pension or annuity from a nonqualifed deferred compensation plan or
a nongovernmental section 457 plan . . . . . . . . . . . . 8t
u Wages earned while incarcerated . . . . . . . . . . . . . 8u
z Other income. List type and amount:
8z
9 Total other income. Add lines 8a through 8z . . . . . . . . . . . . . . . . . . 9
10 Combine lines 1 through 7 and 9. Enter here and on Form 1040, 1040-SR, or 1040-NR, line 8 10 2837
For Paperwork Reduction Act Notice, see your tax return instructions. Schedule 1 (Form 1040) 2022

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 DAVID ADAMS II 429-25-1289
Schedule 1 (Form 1040) 2022 Page 2

Part II Adjustments to Income

11 Educator expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
12 Certain business expenses of reservists, performing artists, and fee-basis government
officials. Attach Form 2106 . . . . . . . . . . . . . . . . . . . . . . . . 12
13 Health savings account deduction. Attach Form 8889 . . . . . . . . . . . . . . 13
14 Moving expenses for members of the Armed Forces. Attach Form 3903 . . . . . . . 14
15 Deductible part of self-employment tax. Attach Schedule SE . . . . . . . . . . . 15
16 Self-employed SEP, SIMPLE, and qualified plans . . . . . . . . . . . . . . . . 16
17 Self-employed health insurance deduction . . . . . . . . . . . . . . . . . . 17
18 Penalty on early withdrawal of savings . . . . . . . . . . . . . . . . . . . . 18
19a Alimony paid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19a
b Recipient’s SSN . . . . . . . . . . . . . . . . . . . . . .
c Date of original divorce or separation agreement (see instructions):
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 (see instructions) . . . . . . . . . . . . . . 24a
b Deductible expenses related to income reported on line 8l 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 8m . . . . . . . . . . 24c
d Reforestation amortization and expenses . . . . . . . . . . . 24d
e Repayment of supplemental unemployment benefits under the Trade
Act of 1974 . . . . . . . . . . . . . . . . . . . . . . 24e
f Contributions to section 501(c)(18)(D) pension plans . . . . . . . 24f
g Contributions by certain chaplains to section 403(b) plans . . . . 24g
h Attorney fees and court costs for actions involving certain unlawful
discrimination claims (see instructions) . . . . . . . . . . . . 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 Form 2555 . . . . . . . . . . . . . 24j
k Excess deductions of section 67(e) expenses from 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 lines 11 through 23 and 25. These are your adjustments to income. Enter here and on
Form 1040 or 1040-SR, line 10, or Form 1040-NR, line 10a . . . . . . . . . . . . 26
Schedule 1 (Form 1040) 2022
QNA
SCHEDULE 2 OMB No. 1545-0074
Additional Taxes
(Form 1040)
Department of the Treasury
Attach to Form 1040, 1040-SR, or 1040-NR. 2022
Attachment
Go to www.irs.gov/Form1040 for instructions and the latest information.
Internal Revenue Service Sequence No. 02
Name(s) shown on Form 1040, 1040-SR, or 1040-NR Your social security number
DAVID ADAMS II 429-25-1289
Part I Tax
1 Alternative minimum tax. Attach Form 6251 . . . . . . . . . . . . . . . . 1
2 Excess advance premium tax credit repayment. Attach Form 8962 . . . . . . . 2
3 Add lines 1 and 2. Enter here and on Form 1040, 1040-SR, or 1040-NR, line 17 . . 3
Part II Other Taxes
4 Self-employment tax. Attach Schedule SE . . . . . . . . . . . . . . . . . 4
5 Social security and Medicare tax on unreported tip income.
Attach Form 4137 . . . . . . . . . . . . . . . . . . 5
6 Uncollected social security and Medicare tax on wages. Attach
Form 8919 . . . . . . . . . . . . . . . . . . . . . 6
7 Total additional social security and Medicare tax. Add lines 5 and 6 . . . . . . 7
8 Additional tax on IRAs or other tax-favored accounts. Attach Form 5329 if required.
If not required, check here . . . . . . . . . . . . . . . . . . . . . 8 216
9 Household employment taxes. Attach Schedule H . . . . . . . . . . . . . 9
10 Repayment of first-time homebuyer credit. Attach Form 5405 if required . . . . . 10
11 Additional Medicare Tax. Attach Form 8959 . . . . . . . . . . . . . . . . 11
12 Net investment income tax. Attach Form 8960 . . . . . . . . . . . . . . . 12
13 Uncollected social security and Medicare or RRTA tax on tips or group-term life
insurance from Form W-2, box 12 . . . . . . . . . . . . . . . . . . . . 13
14 Interest on tax due on installment income from the sale of certain residential lots
and timeshares . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
15 Interest on the deferred tax on gain from certain installment sales with a sales price
over $150,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
16 Recapture of low-income housing credit. Attach Form 8611 . . . . . . . . . . 16
(continued on page 2)
For Paperwork Reduction Act Notice, see your tax return instructions. Schedule 2 (Form 1040) 2022
QNA
 DAVID ADAMS II 429-25-1289
Schedule 2 (Form 1040) 2022 Page 2

Part II Other Taxes (continued)

17 Other additional taxes:
a Recapture of other credits. List type, form number, and amount:
17a
b Recapture of federal mortgage subsidy, if you sold your home
see instructions . . . . . . . . . . . . . . . . . . . 17b
c Additional tax on HSA distributions. Attach Form 8889 . . . . 17c
d Additional tax on an HSA because you didn’t remain an eligible
individual. Attach Form 8889 . . . . . . . . . . . . . . 17d
e Additional tax on Archer MSA distributions. Attach Form 8853 . 17e
f Additional tax on Medicare Advantage MSA distributions. Attach
Form 8853 . . . . . . . . . . . . . . . . . . . . . 17f
g Recapture of a charitable contribution deduction related to a
fractional interest in tangible personal property . . . . . . . 17g
h Income you received from a nonqualified deferred compensation
plan that fails to meet the requirements of section 409A . . . 17h
i Compensation you received from a nonqualified deferred
compensation plan described in section 457A . . . . . . . 17i
j Section 72(m)(5) excess benefits tax . . . . . . . . . . . 17j
k Golden parachute payments . . . . . . . . . . . . . . 17k
l Tax on accumulation distribution of trusts . . . . . . . . . 17l
m Excise tax on insider stock compensation from an expatriated
corporation . . . . . . . . . . . . . . . . . . . . . 17m
n Look-back interest under section 167(g) or 460(b) from Form
8697 or 8866 . . . . . . . . . . . . . . . . . . . . 17n
o Tax on non-effectively connected income for any part of the
year you were a nonresident alien from Form 1040-NR . . . . 17o
p Any interest from Form 8621, line 16f, relating to distributions
from, and dispositions of, stock of a section 1291 fund . . . . 17p
q Any interest from Form 8621, line 24 . . . . . . . . . . . 17q
z Any other taxes. List type and amount:
17z
18 Total additional taxes. Add lines 17a through 17z . . . . . . . . . . . . . . 18
19 Reserved for future use . . . . . . . . . . . . . . . . . . . . . . . . 19
20 Section 965 net tax liability installment from Form 965-A . . . 20
21 Add lines 4, 7 through 16, and 18. These are your total other taxes. Enter here and
on Form 1040 or 1040-SR, line 23, or Form 1040-NR, line 23b . . . . . . . . . 21 216
Schedule 2 (Form 1040) 2022
QNA
Form 5329 Additional Taxes on Qualified Plans
(Including IRAs) and Other Tax-Favored Accounts
OMB No. 1545-0074

2022
Department of the Treasury Attach to Form 1040, 1040-SR, or 1040-NR. Attachment
Internal Revenue Service Go to www.irs.gov/Form5329 for instructions and the latest information. Sequence No. 29
Name of individual subject to additional tax. If married filing jointly, see instructions. Your social security number
DAVID B ADAMS II 429-25-1289
Home address (number and street), or P.O. box if mail is not delivered to your home Apt. no.

Fill in Your Address Only City, town or post office, state, and ZIP code. If you have a foreign address, also complete the spaces
if You Are Filing This below. See instructions.
Form by Itself and Not If this is an amended
With Your Tax Return return, check here
Foreign country name Foreign province/state/county Foreign postal code

If you only owe the additional 10% tax on the full amount of the early distributions, you may be able to report this tax directly on
Schedule 2 (Form 1040), line 8, without filing Form 5329. See instructions.
Part I Additional Tax on Early Distributions. Complete this part if you took a taxable distribution (other than a qualified
disaster distribution) before you reached age 59½ from a qualified retirement plan (including an IRA) or modified
endowment contract (unless you are reporting this tax directly on Schedule 2 (Form 1040)—see above). You may also
have to complete this part to indicate that you qualify for an exception to the additional tax on early distributions or for
certain Roth IRA distributions. See instructions.
1 Early distributions includible in income (see instructions). For Roth IRA distributions, see instructions . 1 2158
2 Early distributions included on line 1 that are not subject to the additional tax (see instructions).
Enter the appropriate exception number from the instructions: . . . . . . . . . . 2
3 Amount subject to additional tax. Subtract line 2 from line 1 . . . . . . . . . . . . . . 3 2158
4 Additional tax. Enter 10% (0.10) of line 3. Include this amount on Schedule 2 (Form 1040), line 8 . . 4 216
Caution: If any part of the amount on line 3 was a distribution from a SIMPLE IRA, you may have to
include 25% of that amount on line 4 instead of 10%. See instructions.
Part II Additional Tax on Certain Distributions From Education Accounts and ABLE Accounts. Complete this part
if you included an amount in income, on Schedule 1 (Form 1040), line 8z, from a Coverdell education savings account
(ESA) or a qualified tuition program (QTP), or on Schedule 1 (Form 1040), line 8q, from an ABLE account.
5 Distributions included in income from a Coverdell ESA, a QTP, or an ABLE account . . . . . . 5
6 Distributions included on line 5 that are not subject to the additional tax (see instructions) . . . . 6
7 Amount subject to additional tax. Subtract line 6 from line 5 . . . . . . . . . . . . . . 7
8 Additional tax. Enter 10% (0.10) of line 7. Include this amount on Schedule 2 (Form 1040), line 8 . . 8
Part III Additional Tax on Excess Contributions to Traditional IRAs. Complete this part if you contributed more to your
traditional IRAs for 2022 than is allowable or you had an amount on line 17 of your 2021 Form 5329.
9 Enter your excess contributions from line 16 of your 2021 Form 5329. See instructions. If zero, go to line 15 9
10 If your traditional IRA contributions for 2022 are less than your maximum
allowable contribution, see instructions. Otherwise, enter -0- . . . . . . 10
11 2022 traditional IRA distributions included in income (see instructions) . . . 11
12 2022 distributions of prior year excess contributions (see instructions) . . . 12
13 Add lines 10, 11, and 12 . . . . . . . . . . . . . . . . . . . . . . . . . . 13
14 Prior year excess contributions. Subtract line 13 from line 9. If zero or less, enter -0- . . . . . . 14
15 Excess contributions for 2022 (see instructions) . . . . . . . . . . . . . . . . . . 15
16 Total excess contributions. Add lines 14 and 15 . . . . . . . . . . . . . . . . . . 16
17 Additional tax. Enter 6% (0.06) of the smaller of line 16 or the value of your traditional IRAs on December
31, 2022 (including 2022 contributions made in 2023). Include this amount on Schedule 2 (Form 1040), line 8 17
Part IV Additional Tax on Excess Contributions to Roth IRAs. Complete this part if you contributed more to your Roth
IRAs for 2022 than is allowable or you had an amount on line 25 of your 2021 Form 5329.
18 Enter your excess contributions from line 24 of your 2021 Form 5329. See instructions. If zero, go to line 23 18
19 If your Roth IRA contributions for 2022 are less than your maximum allowable
contribution, see instructions. Otherwise, enter -0- . . . . . . . . . 19
20 2022 distributions from your Roth IRAs (see instructions) . . . . . . . 20
21 Add lines 19 and 20 . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
22 Prior year excess contributions. Subtract line 21 from line 18. If zero or less, enter -0- . . . . . . 22
23 Excess contributions for 2022 (see instructions) . . . . . . . . . . . . . . . . . . 23
24 Total excess contributions. Add lines 22 and 23 . . . . . . . . . . . . . . . . . . 24
25 Additional tax. Enter 6% (0.06) of the smaller of line 24 or the value of your Roth IRAs on December 31,
2022 (including 2022 contributions made in 2023). Include this amount on Schedule 2 (Form 1040), line 8 25
For Privacy Act and Paperwork Reduction Act Notice, see your tax return instructions. Form 5329 (2022)
QNA
 DAVID B ADAMS II 429-25-1289
Form 5329 (2022) Page 2
Part V Additional Tax on Excess Contributions to Coverdell ESAs. Complete this part if the contributions to your
Coverdell ESAs for 2022 were more than is allowable or you had an amount on line 33 of your 2021 Form 5329.
26 Enter the excess contributions from line 32 of your 2021 Form 5329. See instructions. If zero, go to line 31 26
27 If the contributions to your Coverdell ESAs for 2022 were less than the
maximum allowable contribution, see instructions. Otherwise, enter -0- . . 27
28 2022 distributions from your Coverdell ESAs (see instructions) . . . . . 28
29 Add lines 27 and 28 . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
30 Prior year excess contributions. Subtract line 29 from line 26. If zero or less, enter -0- . . . . . . 30
31 Excess contributions for 2022 (see instructions) . . . . . . . . . . . . . . . . . . 31
32 Total excess contributions. Add lines 30 and 31 . . . . . . . . . . . . . . . . . . 32
33 Additional tax. Enter 6% (0.06) of the smaller of line 32 or the value of your Coverdell ESAs on
December 31, 2022 (including 2022 contributions made in 2023). Include this amount on Schedule 2
(Form 1040), line 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Part VI Additional Tax on Excess Contributions to Archer MSAs. Complete this part if you or your employer contributed
more to your Archer MSAs for 2022 than is allowable or you had an amount on line 41 of your 2021 Form 5329.
34 Enter the excess contributions from line 40 of your 2021 Form 5329. See instructions. If zero, go to line 39 34
35 If the contributions to your Archer MSAs for 2022 are less than the maximum
allowable contribution, see instructions. Otherwise, enter -0- . . . . . . 35
36 2022 distributions from your Archer MSAs from Form 8853, line 8 . . . . 36
37 Add lines 35 and 36 . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
38 Prior year excess contributions. Subtract line 37 from line 34. If zero or less, enter -0- . . . . . . 38
39 Excess contributions for 2022 (see instructions) . . . . . . . . . . . . . . . . . . 39
40 Total excess contributions. Add lines 38 and 39 . . . . . . . . . . . . . . . . . . 40
41 Additional tax. Enter 6% (0.06) of the smaller of line 40 or the value of your Archer MSAs on
December 31, 2022 (including 2022 contributions made in 2023). Include this amount on Schedule 2
(Form 1040), line 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Part VII Additional Tax on Excess Contributions to Health Savings Accounts (HSAs). Complete this part if you,
someone on your behalf, or your employer contributed more to your HSAs for 2022 than is allowable or you had an
amount on line 49 of your 2021 Form 5329.
42 Enter the excess contributions from line 48 of your 2021 Form 5329. If zero, go to line 47 . . . . 42
43 If the contributions to your HSAs for 2022 are less than the maximum
allowable contribution, see instructions. Otherwise, enter -0- . . . . . . 43
44 2022 distributions from your HSAs from Form 8889, line 16 . . . . . . 44
45 Add lines 43 and 44 . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
46 Prior year excess contributions. Subtract line 45 from line 42. If zero or less, enter -0- . . . . . . 46
47 Excess contributions for 2022 (see instructions) . . . . . . . . . . . . . . . . . . 47
48 Total excess contributions. Add lines 46 and 47 . . . . . . . . . . . . . . . . . . 48
49 Additional tax. Enter 6% (0.06) of the smaller of line 48 or the value of your HSAs on December 31,
2022 (including 2022 contributions made in 2023). Include this amount on Schedule 2 (Form 1040), line 8 49
Part VIII Additional Tax on Excess Contributions to an ABLE Account. Complete this part if contributions to your ABLE
account for 2022 were more than is allowable.
50 Excess contributions for 2022 (see instructions) . . . . . . . . . . . . . . . . . . 50
51 Additional tax. Enter 6% (0.06) of the smaller of line 50 or the value of your ABLE account on
December 31, 2022. Include this amount on Schedule 2 (Form 1040), line 8 . . . . . . . . . 51
Part IX Additional Tax on Excess Accumulation in Qualified Retirement Plans (Including IRAs). Complete this part
if you did not receive the minimum required distribution from your qualified retirement plan.
52 Minimum required distribution for 2022 (see instructions) . . . . . . . . . . . . . . . 52
53 Amount actually distributed to you in 2022 . . . . . . . . . . . . . . . . . . . . 53
54 Subtract line 53 from line 52. If zero or less, enter -0- . . . . . . . . . . . . . . . . 54
55 Additional tax. Enter 50% (0.50) of line 54. Include this amount on Schedule 2 (Form 1040), line 8 . 55
Under penalties of perjury, I declare that I have examined this form, including accompanying attachments, and to the best of my knowledge and
Sign Here Only if You belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Are Filing This Form
by Itself and Not With
Your Tax Return Your signature Date
Print/Type preparer’s name Preparer’s signature Date PTIN
Check if
Paid self-employed
Preparer
Firm’s name Firm’s EIN
Use Only
Firm’s address Phone no.
QNA Form 5329 (2022)
Form 8880 Credit for Qualified Retirement Savings Contributions OMB No. 1545-0074

2022
Attach to Form 1040, 1040-SR, or 1040-NR.
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
DAVID ADAMS II 429-25-1289
You cannot take this credit if either of the following applies.

F
!
CAUTION
• The amount on Form 1040, 1040-SR, or 1040-NR, line 11, is more than $34,000 ($51,000 if head of household; $68,000 if
married filing jointly).
• The person(s) who made the qualified contribution or elective deferral (a) was born after January 1, 2005; (b) is claimed as a
dependent on someone else’s 2022 tax return; or (c) was a student (see instructions).
(a) You (b) Your spouse
1 Traditional and Roth IRA contributions, and ABLE account contributions by the
designated beneficiary for 2022. 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 2022 (see instructions) . . 2 12219
3 Add lines 1 and 2 . . . . . . . . . . . . . . . . . . . . . . 3 12219
4 Certain distributions received after 2019 and before the due date (including
extensions) of your 2022 tax return (see instructions). If married filing jointly, include
both spouses’ amounts in both columns. See instructions for an exception . . . 4 2158
5 Subtract line 4 from line 3. If zero or less, enter -0- . . . . . . . . . . . 5 10061
6 In each column, enter the smaller of line 5 or $2,000 . . . . . . . . . . 6 2000
7 Add the amounts on line 6. If zero, stop; you can’t take this credit . . . . . . . . . . . . 7 2000
8 Enter the amount from Form 1040, 1040-SR, or 1040-NR, line 11* . . . . 8 100350
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 surviving spouse
--- $20,500 0.5 0.5 0.5
$20,500 $22,000 0.5 0.5 0.2
$22,000 $30,750 0.5 0.5 0.1 9 x0.
$30,750 $33,000 0.5 0.2 0.1
$33,000 $34,000 0.5 0.1 0.1
$34,000 $41,000 0.5 0.1 0.0
$41,000 $44,000 0.2 0.1 0.0
$44,000 $51,000 0.1 0.1 0.0
$51,000 $68,000 0.1 0.0 0.0
$68,000 --- 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
11 Limitation based on tax liability. Enter the amount from the Credit Limit Worksheet in the instructions 11
12 Credit for qualified retirement savings contributions. Enter the smaller of line 10 or line 11 here
and on Schedule 3 (Form 1040), line 4 . . . . . . . . . . . . . . . . . . . . . 12

* 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 (2022)

QNA
 DAVID ADAMS II 429-25-1289
Form 8880 (2022) Page 2

Section references are to the Internal Revenue Code unless otherwise Note: Contributions designated under section 414(h)(2) are treated as
noted. employer contributions and, as such, they aren’t voluntary contributions
made by the employee. They don’t qualify for the credit and shouldn’t
Future Developments be included on line 2.
For the latest information about developments related to Form 8880 and Line 4
its instructions, such as legislation enacted after they were published,
go to www.irs.gov/Form8880. Enter the total amount of distributions you, and your spouse if filing
jointly, received after 2019 and before the due date of your 2022 return
Reminder (including extensions) from any of the following types of plans.
Contributions by a designated beneficiary to an Achieving a Better • Traditional or Roth IRAs, or ABLE accounts.
Life Experience (ABLE) account. A retirement savings contribution • 401(k), 403(b), governmental 457(b), 501(c)(18)(D), SEP, SIMPLE, or
credit may be claimed for the amount of contributions you, as the the federal TSP.
designated beneficiary of an ABLE account, make before January 1,
2026, to the ABLE account. See Pub. 907, Tax Highlights for Persons • Qualified retirement plans, as defined in section 4974(c).
With Disabilities, for more information. Don’t include any of the following.
General Instructions • Distributions not taxable as the result of a rollover or a trustee-to-
trustee transfer.
Purpose of Form • Distributions that are taxable as the result of an in-plan rollover to your
Use Form 8880 to figure the amount, if any, of your retirement savings designated Roth account.
contributions credit (also known as the saver’s credit). • Distributions from your eligible retirement plan (other than a Roth IRA)
rolled over or converted to your Roth IRA.
This credit can be claimed in addition to any IRA deduction • Loans from a qualified employer plan treated as a distribution.
TIP claimed on Schedule 1 (Form 1040), line 20. • Distributions of excess contributions or deferrals (and income
allocable to such contributions or deferrals).
Who Can Take This Credit • Distributions of contributions made to an IRA during a tax year and
You may be able to take this credit if you, or your spouse if filing jointly, returned (with any income allocable to such contributions) on or before
made (a) contributions (other than rollover contributions) to a traditional the due date (including extensions) for that tax year.
or Roth IRA; (b) elective deferrals to a 401(k), 403(b), governmental • Distributions of dividends paid on stock held by an employee stock
457(b), SEP, SIMPLE, or to the federal Thrift Savings Plan (TSP); (c) ownership plan under section 404(k).
voluntary employee contributions to a qualified retirement plan, as
• Distributions from a military retirement plan (other than the federal
defined in section 4974(c) (including the federal TSP); (d) contributions
TSP).
to a 501(c)(18)(D) plan; or (e) contributions, as a designated beneficiary
of an ABLE account, to the ABLE account, as defined in section 529A. • Distributions from an inherited IRA by a nonspousal beneficiary.
However, you can’t take the credit if either of the following applies. If you’re filing a joint return, include both spouses’ amounts in both
columns.
• The amount on Form 1040, 1040-SR, or 1040-NR, line 11, is more
than $34,000 ($51,000 if head of household; $68,000 if married filing Exception. Don’t include your spouse’s distributions with yours when
jointly). entering an amount on line 4 if you and your spouse didn’t file a joint
return for the year the distribution was received.
• The person(s) who made the qualified contribution or elective deferral
(a) was born after January 1, 2005; (b) is claimed as a dependent on Example. You received a distribution of $5,000 from a qualified
someone else’s 2022 tax return; or (c) was a student. retirement plan in 2022. Your spouse received a distribution of $2,000
from a Roth IRA in 2020. You and your spouse file a joint return in 2022,
You’ll need to refigure the amount on Form 1040 or

F
!
CAUTION
1040-SR, line 11, if you’re filing Form 2555 or Form 4563 or
you’re excluding income from Puerto Rico. See Pub. 590-A
at www.irs.gov/Pub590A for details.
but didn’t file a joint return in 2020. You would include $5,000 in column
(a) and $7,000 in column (b).
Line 7
You were a student if during any part of 5 calendar months of 2022 Add the amounts from line 6, columns (a) and (b), and enter the total.
you:
Line 11
• Were enrolled as a full-time student at a school; or
Before you complete the following worksheet, figure the amount of any
• Took a full-time, on-farm training course given by a school or a state, credit for the elderly or the disabled you’re claiming on Schedule 3
county, or local government agency. (Form 1040), line 6d. See Schedule R (Form 1040) to figure the credit.
A school includes technical, trade, and mechanical schools. It
doesn’t include on-the-job training courses, correspondence schools, or
Credit Limit Worksheet
schools offering courses only through the Internet. Complete this worksheet to figure the amount to enter on line 11.

Specific Instructions 1. Enter the amount from Form 1040, 1040-SR, or

1040-NR, line 18 . . . . . . . . . 1. 14851
Column (b)
2. Enter the total of your credits from Schedule 3,
Complete column (b) only if you’re filing a joint return. 2.
lines 1 through 3, 6d, and 6l . . . . . .
Line 2
3. Subtract line 2 from line 1. Also enter this amount
Include on line 2 any of the following amounts. on Form 8880, line 11. But if zero or less, stop;
• Elective deferrals (including designated Roth contributions under you can’t take the credit—don’t file this form . 3. 14851
section 402A, if applicable) to a 401(k), 403(b), governmental 457(b),
SEP, SIMPLE, or to the federal TSP.
• Voluntary employee contributions to a qualified retirement plan, as
defined in section 4974(c) (including the federal TSP).
• Contributions to a 501(c)(18)(D) plan.
These amounts may be shown in box 12 of your Form(s) W-2 for
2022.
AR8453-OL 2022
ARKANSAS INDIVIDUAL INCOME TAX
DECLARATION FOR ELECTRONIC FILING

Primary’s Legal First Name and Middle Initial Last Name 3ULPDU\¶V6RFLDO6HFXULW\1XPEHU
DAVID B ADAMS 429-25-1289
Spouse’s Legal First Name and Middle Initial Last Name 6SRXVH¶V6RFLDO6HFXULW\1XPEHU

Mailing Address (Number and Street, P.O. Box or Rural Route) Telephone
500 PAKIS STREET APT 1B (501) 545-7574
City State or Province ZIP &KHFNLIDGGUHVVLVRXWVLGH86
Foreign Country
HOT SPRINGS NATL PARK AR 71913
PART I - TAX RETURN INFORMATION (Whole Dollars Only)
1. Total Income (Form AR1000F or AR1000NR, Line 23) .......................................................................................... 1 100350 00
2. Net Tax (Form AR1000F or AR1000NR, Line 38) .................................................................................................. 2 4569 00
3. State Income Tax Withheld (Form AR1000F or AR1000NR, Line 39) .................................................................... 3 5229 00
4. Refund (Form AR1000F or AR1000NR, Line 47) ................................................................................................... 4 660 00
5. Tax Due (Form AR1000F or AR1000NR, Line 51) ................................................................................................. 5 00
PART II - DECLARATION OF TAXPAYER

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form (AR TAX PMT).

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transmission of my tax return electronically.

Sign
Here
Primary’s Signature Date Spouse’s Signature Date

DO NOT MAIL THIS FORM

AR8453-OL (R 5/25/2022)
TSCOM
2022 AR1000F
ARKANSAS INDIVIDUAL
P1
INCOME TAX RETURN
Full Year Resident
CHECK BOX IF
AMENDED RETURN Software ID
-DQ'HFRU¿VFDO\HDUHQGLQJ ____________ , 20 ____ TSCOM
3ULPDU\¶VOHJDO¿UVWQDPH MI /DVWQDPH 3ULPDU\¶VVRFLDOVHFXULW\QXPEHU
&KHFNLI
DAVID B ADAMS II 'HFHDVHG 429-25-1289
6SRXVH¶VOHJDO¿UVWQDPH MI /DVWQDPH 6SRXVH¶VVRFLDOVHFXULW\QXPEHU
&KHFNLI
'HFHDVHG
0DLOLQJDGGUHVV(number and street, P.O. box or rural route)
&KHFNLIDGGUHVVLVRXWVLGH86
500 PAKIS STREET APT 1B
&LW\ 6WDWHRUSURYLQFH ZIP )RUHLJQFRXQWU\QDPH
TAXPAYER INFORMATION

HOT SPRINGS NATL AR 71913

3ULPDU\HPDLO 6HFRQGDU\HPDLO
[email protected]
We will no longer automatically mail 1099-G forms. Instead, we ask that you get this information from our website
(www.atap.arkansas.gov). Check the box if you still want us to mail you a paper Form 1099-G next year.

Check here if you want a tax booklet mailed to you &KHFNWKLVER[LI\RXKDYHÀOHGDVWDWHH[WHQVLRQ

next year. or an automatic federal extension

,VVXHGDWH ([SLUDWLRQGDWH
'/6WDWH,' <RXUVWDWH PPGG\\\\ PPGG\\\\

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'/6WDWH,' 6SRXVHVWDWH PPGG\\\\ PPGG\\\\

 X 6LQJOH(Or widowed before 2022 or divorced at end of 2022)  0DUULHG¿OLQJVHSDUDWHO\RQWKHVDPHUHWXUQ
FILING STATUS

2. 0DUULHG¿OLQJMRLQW (Even if only one had income) 5. 0DUULHG¿OLQJVHSDUDWHO\RQGLႇHUHQWUHWXUQV

 (QWHUVSRXVH¶VQDPHKHUHDQG661DERYH _______________
3. +HDGRIKRXVHKROG(See instructions)
,IWKHTXDOLI\LQJSHUVRQZDV\RXUFKLOGEXWQRW\RXUGHSHQGHQW 6. 6XUYLYLQJVSRXVHZLWKGHSHQGHQWFKLOG
 HQWHUFKLOG¶VQDPHKHUH ______________________________  <HDUVSRXVHGLHG(See instructions) _____________________

7A. X <RXUVHOI 65 or over 6SHFLDO %OLQG 'HDI +HDGRIKRXVHKROGVXUYLYLQJVSRXVH

(Filing status 3 only) (Filing status 6 only)

6SRXVH 65 or over 6SHFLDO %OLQG 'HDI

0XOWLSO\QXPEHURIER[HVFKHFNHG .................................................................................................................................................7A 1 X $29 = 29 00

Dependents (Do not list yourself or spouse)
PERSONAL TAX CREDITS

)LUVWQDPH/DVWQDPH 'HSHQGHQW¶VVRFLDOVHFXULW\QXPEHU 'HSHQGHQW¶VUHODWLRQVKLSWR\RX

1.

2.

3.

4.

5.

%0XOWLSO\QXPEHURIDEPENDENTSIURPDERYH.......................................................................................7B X $29 = 00

7C. 0XOWLSO\QXPEHURITXDOLI\LQJLQGLYLGXDOVIURPAR1000RC5 (See instructions) .............................................. 7C X $500 = 00

7D. TOTAL PERSONAL TAX CREDITS: (Add lines 7A, 7B, and 7C. Enter total here and on line 34) ..................................7D 29 00

AR1000F, Page 1 (R 7/21/2022)

 P2
Primary SSN _______-
429 _____-
25 ________
1289
(A) Primary/Joint (B) Spouse’s Income
ROUND ALL AMOUNTS TO WHOLE DOLLARS Income Status 4 Only

8. :DJHVVDODULHVWLSVHWF(Attach W-2s) ..................................................................... 8 00 00

95355
9. 0LOLWDU\SD\ Primary 00 Spouse 00

10. ,QWHUHVWLQFRPH (If over $1,500, attach AR4) .............................................................10 00 00

11. 'LYLGHQGLQFRPH(If over $1,500, attach AR4) .........................................................11 00 00

12. $OLPRQ\DQGVHSDUDWHPDLQWHQDQFHUHFHLYHG 12 00 00

13. %XVLQHVVRUSURIHVVLRQDOLQFRPH(Attach federal Sch. C) ...........................................13 00 00

14. &DSLWDOJDLQV ORVVHV IURPVWRFNVERQGVHWF (Attach federal Sch. D) .......................... 14 00 00

15. 2WKHUJDLQVRU ORVVHV (See Instructions) .................................................................15 00 00

16. 1RQTXDOL¿HG,5$GLVWULEXWLRQVDQGWD[DEOHDQQXLWLHV(Attach All 1099Rs) ................16 2158 00 00

INCOME

17. 0LOLWDU\UHWLUHPHQWPrimary 00 Spouse 00

18A. 3ULPDU\HPSOR\HUSHQVLRQSODQ V TXDOL¿HG,5$ V (See inst., attach 1099Rs)

00 Taxable 00 Less 18A 00
Gross $6,000
18B. 6SRXVHHPSOR\HUSHQVLRQSODQ V TXDOL¿HG,5$ V (See inst., attach 1099Rs)
18B 00 00
Gross 00 Taxable 00 Less
$6,000
19. 5HQWVUR\DOWLHVSDUWQHUVKLSVHVWDWHVWUXVWVHWF(Attach federal Sch. E) ................19 00 00

20. )DUPLQFRPH(Attach federal Sch. F) ....................................................................... 20 00 00

21. 8QHPSOR\PHQW21 2837 00 00

22. 2WKHULQFRPHGHSUHFLDWLRQGLႇHUHQFHV (Attach Form AR-OI) .................................. 22 00 00

23. TOTAL INCOME: (Add lines 8 through 22) .......................................................... 23 100350 00 00

24. TOTAL ADJUSTMENTS: (Attach Form AR1000ADJ) .........................................24 00 00

25. ADJUSTED GROSS INCOME: (Subtract line 24 from line 23) ......................... 25 100350 00 00

26. 6HOHFWWD[WDEOH 6HOHFWRQO\RQH  26

27. /RZLQFRPHWDEOH  See line 26 instructions
X 6WDQGDUGGHGXFWLRQ 6HHLQVWUXFWLRQV 
,WHPL]HGGHGXFWLRQV (Attach AR3) 27 2270 00 00
TAX COMPUTATION

28. NET TAXABLE INCOME: (Subtract line 27 from line 25) ................................. 28 98080 00 00

29. TAX: (Enter tax from tax table) ................................................................................29 4636 00 00

30. &RPELQHGWD[ (Add amounts from line 29, columns A and B) .............................................................. 30 4636 00
31. (QWHUWD[IURP/XPS6XP'LVWULEXWLRQ$YHUDJLQJ6FKHGXOH(Attach AR1000TD) .................................... 31 00

32. $GGLWLRQDOWD[RQ,5$DQGTXDOL¿HGSODQZLWKGUDZDODQGRYHUSD\PHQW (See instructions) .......................... 32 22 00

33. TOTAL TAX: (Add lines 30 through 32) .................................................................................................33 4658 00
34. 3HUVRQDOWD[FUHGLW V (Enter total from line 7D) ...................................................... 34 29 00
TAX CREDITS

35. &KLOGFDUHFUHGLW(Attach AR2441) ............................................................................. 35 00

36. 2WKHUFUHGLWV(Attach AR1000TC) .............................................................................36 60 00

37. TOTAL CREDITS: (Add lines 34 through 36) ........................................................................................37 89 00
38. NET TAX: (Subtract line 37 from line 33. If line 37 is greater than line 33, enter 0) ...................................38 4569 00

AR1000F Page 2 (R 7/25/2022)

 P3
Primary SSN _______-
429 _____-
25 ________
1289

39. $UNDQVDVLQFRPHWD[ZLWKKHOG(Attach copies of W-2, 1099R, W2-G,1099-PT, and/or AR-K1) .................39 5229 00

40. (VWLPDWHGWD[SDLGRUFUHGLWEURXJKWIRUZDUGIURP 40 00

41. 3D\PHQWPDGHZLWKH[WHQVLRQ (See instructions) ....................................................................................... 41 00

PAYMENTS

42. AMENDED RETURNS ONLY3UHYLRXVSD\PHQWV(See instructions) ................................................. 42 00

43. (DUO\FKLOGKRRGSURJUDP&HUWL¿FDWLRQQXPEHU
(Attach AR1000EC and AR2441) .............................................................................................................................................. 43 00

44. TOTAL PAYMENTS: (Add lines 39 through 43) ...................................................................................... 44 5229 00

45. AMENDED RETURNS ONLY3UHYLRXVUHIXQG(See instructions) ...................................................... 45 00

46. $GMXVWHGWRWDOSD\PHQWV(Subtract line 45 from line 44) ............................................................................. 46 5229 00

47. AMOUNT OF OVERPAYMENT/REFUND: ,IOLQHLVJUHDWHUWKDQOLQHHQWHUGLႇHUHQFH .........47 660 00

48. $PRXQWWREHDSSOLHGWRHVWLPDWHGWD[ 48 00
REFUND OR TAX DUE

49. $PRXQWRI&KHFN2ႇFRQWULEXWLRQV(Attach Form AR1000CO) ............................... 49 00

50. AMOUNT TO BE REFUNDED TO YOU: (Subtract lines 48 and 49 from line 47) ...........REFUND 50 - 660 00

51. AMOUNT DUE: (If line 46 is less than line 38, enter difference; If over $1,000, continue to 52A) ...........TAX DUE 51 / 00

52A.UEP: $WWDFK)RUP$5RU$5$,IUHTXLUHGHQWHUH[FHSWLRQLQER[ 52A 3HQDOW\% 00

52C.$GGOLQHVDQG%(See instructions) .......................................................................... TOTAL DUE 52C 00

Direct deposit allowed to U.S. banks only. Check if either deposit(s) will ultimately be placed in a foreign account.

Routing number 1 Account number 1 &KHFNLQJRU 6DYLQJV

DIRECT DEPOSIT

Direct deposit 1 amt.

00

Routing number 2 Account number 2 &KHFNLQJRU 6DYLQJV Direct deposit 2 amt.

00

PLEASE SIGN HERE: 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.
SIGN HERE
PLEASE

3ULPDU\¶VVLJQDWXUH 'DWH 7HOHSKRQH May the Arkansas

(501) 545-7574 Revenue Division
discuss this return
6SRXVH¶VVLJQDWXUH 'DWH 7HOHSKRQH with the preparer?

3DLGSUHSDUHU¶VVLJQDWXUH 37,1,'QXPEHU Yes No

For Department Use Only

3UHSDUHU¶VQDPH 7HOHSKRQH
A
PREPARER

$GGUHVV
PAID

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(PDLO

PAY ONLINE:
Refund: Tax Due/No Tax:
3OHDVHYLVLWRXUVHFXUHZHEVLWH$7$3 $UNDQVDV7D[SD\HU$FFHVV3RLQW DWZZZDWDSDUNDQVDVJRY$7$3DOORZV
WD[SD\HUVRUWKHLUUHSUHVHQWDWLYHVWRORJRQPDNHSD\PHQWVDQGPDQDJHWKHLUDFFRXQWRQOLQH$7$3LVDYDLODEOH $UNDQVDV6WDWH,QFRPH7D[ $UNDQVDV6WDWH,QFRPH7D[
KRXUV 32%R[ 32%R[
/LWWOH5RFN$5 /LWWOH5RFN$5
PAY BY MAIL: (See instructions) PAY BY CREDIT CARD: (See instructions)
AR1000F Page 3 (R 8/25/2022)
AR1000TC 2022
ARKANSAS INDIVIDUAL INCOME TAX
TAX CREDITS
Primary’s legal name Primary’s social security number

DAVID B ADAMS 429-25-1289

IMPORTANT: SEE INSTRUCTIONS ON REVERSE SIDE OF THIS FORM

1. State political contribution credit: (See instructions) .......................................................................................... 1 00
2. Other state tax credit: [Attach copy of other state tax return(s)] ................................................................ 2 00
3. Credit for adoption expenses: (Attach federal Form 8839) .............................................................................. 3 00
4. Phenylketonuria disorder credit: (See instructions. Attach AR1113) ............................................................ 4 00
5. Stillborn child tax credit “Paisley’s Law”: $WWDFKFHUWLÀFDWHRIELUWKUHVXOWLQJLQVWLOOELUWK .................. 5 00
$GGLWLRQDOWD[FUHGLWIRUTXDOL¿HGLQGLYLGXDOV (See instructions) ...................................................................... 6 00
 ,QÀDWLRQDU\UHOLHILQFRPHWD[FUHGLW (See Instructions) ...................................................................................... 7 60 00

,IFHUWLÀFDWHLVLVVXHGWRDQLQGLYLGXDOOHDYH)(,1ER[EHORZEODQN

Primary: 8A. Code FEIN Amount 00

8B. Code FEIN Amount 00

8C. Code FEIN Amount 00

Spouse: 8D. Code FEIN Amount 00

8E. Code FEIN Amount 00

8F. Code FEIN Amount 00

8. Tax credit(s): $GGDPRXQWVIURP$)DERYH ..................................................................................................... 8 00

$FRS\RIWKHWD[FUHGLWFHUWLÀFDWH V RUDSSURSULDWHGRFXPHQWDWLRQRIWKHFUHGLW V FODLPHGPXVWEHDWWDFKHG

9. TOTAL CREDITS:
$GGOLQHVWKURXJK(QWHUWRWDORQOLQH)RUP$5)$515 ..................................................... 9 60 00

AR1000TC (R 08/16/2022)
TSCOM
 INFLATIONARY RELIEF INCOME-TAX CREDIT WORKSHEET

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LQFRPHXSWRRUMRLQW¿OHUVZLWKDQHWLQFRPHXSWRDUHDOORZHGDQLQFRPHWD[FUHGLWDJDLQVWWKHLQGLYLGXDOLQFRPHWD[
OLDELOLW\7KLVFUHGLWLVQRQUHIXQGDEOHDQGRQO\DYDLODEOHWR$UNDQVDVUHVLGHQWV

Filing Status 1,3,5,6

1. (QWHUDPRXQWIURPOLQHRI\RXU$5) 1. 98080

2. )LQGLQFRPHUDQJHLQWDEOHORFDWHGRQQH[WSDJH(QWHUFRUUHVSRQGLQJFUHGLW
KHUHDQGRQOLQHRIIRUP$57& 2. 60

Filing Status 2

1. (QWHUDPRXQWIURPOLQHRI\RXU$5) 1.

2. )LQGLQFRPHUDQJHRQWKHWDEOHORFDWHGRQQH[WSDJH(QWHUFRUUHVSRQGLQJ
FUHGLWKHUHDQGRQOLQHRI)RUP$57& 2.

Filing Status 4 Primary Spouse

1. (QWHUDPRXQWIURPOLQHRI\RXU$5)$ 1B.

2. )LQGLQFRPHUDQJHLQWDEOHORFDWHGRQQH[WSDJH
(QWHUFRUUHVSRQGLQJFUHGLWIRUHDFKVSRXVHKHUH $ 2B.

3. $GGSULPDU\DQGVSRXVHFROXPQVIURPOLQHDERYH(QWHUDPRXQWKHUHDQG
RQOLQHRIIRUP$57& 3.

,1)/$7,21$5<5(/,(),1&20( ,1)/$7,21$5<5(/,(),1&20(
7$;&5(',77$%/( 7$;&5(',77$%/(
)LOLQJ6WDWXVDQG )LOLQJ6WDWXV

Income Range Credit Income Range Credit

   

   
   
   
   
   
   
   
   
   
   
   
   
   
   
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TSCOM
IRITCWS (R 10/14/2022)