2021 Income Tax Return

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 Instructions to Mail Federal Tax Return for:
LEVI E HEARN
5 E BIJOU APT 332
COLORADO SPRINGS, CO 80903

Your federal tax return shows a refund of $4,319. Please be sure to complete the following checklist to finish filing your taxes.
Your federal tax return is due April 18, 2022.

__________________________________________________________________________________________________

Print and Sign Your Return

__________________________________________________________________________________________________

__ Print a copy of your tax return.

__ Sign and date the Form 1040 in the Sign Here section.

__________________________________________________________________________________________________

Mail Your Return

__________________________________________________________________________________________________

__ Keep these instructions along with a copy of your tax return for your records.
__ Mail your federal tax return to the IRS address listed below.

Check the IRS website to find the current address for filing your tax return by mail
https://www.irs.gov/filing/where-to-file-addresses-for-taxpayers-and-tax-professionals-filing-form-1040

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 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 X 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
LEVI E HEARN 521 61 6460
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
5 E BIJOU 332 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
COLORADO SPRINGS CO 80903 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 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, 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
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—
• Single or
7 Capital gain or (loss). Attach Schedule D if required. If not required, check here . . . . a 7 0.
Married filing 8 Other income from Schedule 1, line 10 . . . . . . . . . . . . . . . . . . 8 3,604.
separately,
$12,550 9 Add lines 1, 2b, 3b, 4b, 5b, 6b, 7, and 8. This is your total income . . . . . . . . . a 9 3,604.
• Married filing 10 Adjustments to income from Schedule 1, line 26 . . . . . . . . . . . . . . . 10 255.
jointly or
Qualifying 11 Subtract line 10 from line 9. This is your adjusted gross income . . . . . . . . . a 11 3,349.
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 300.
household,
$18,800 c Add lines 12a and 12b . . . . . . . . . . . . . . . . . . . . . . . 12c 12,850.
• 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 12,850.
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. Cat. No. 11320B Form 1040 (2021)

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Form 1040 (2021) LEVI E HEARN 521-61-6460 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 0.
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 0.
21 Add lines 19 and 20 . . . . . . . . . . . . . . . . . . . . . . . . 21 0.
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 . . . . . . . . . 23 510.
24 Add lines 22 and 23. This is your total tax . . . . . . . . . . . . . . . . a 24 510.
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 509.
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
31 Amount from Schedule 3, line 15 . . . . . . . . . . . . 31 4,320.
32 Add lines 27a and 28 through 31. These are your total other payments and refundable credits a 32 4,829.
33 Add lines 25d, 26, and 32. These are your total payments . . . . . . . . . . . a 33 4,829.
Refund 34 If line 33 is more than line 24, subtract line 24 from line 33. This is the amount you overpaid . . 34 4,319.
35a Amount of line 34 you want refunded to you. If Form 8888 is attached, check here . . . a 35a 4,319.
Direct deposit? ab Routing number 1 2 4 3 0 3 1 6 2 a c Type: X Checking Savings
See instructions. ad Account number 1 5 2 1 1 1 3 8 9 4 2 1 1 1 6
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 0.
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. X 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? ARTIST (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. 719-310-5321 Email address
Preparer’s name Preparer’s signature Date PTIN Check if:
Paid Self-employed
SELF-PREPARED
Preparer a
Firm’s name Phone no.
Use Only a a
Firm’s address Firm’s EIN
Go to www.irs.gov/Form1040 for instructions and the latest information. Form 1040 (2021)

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SCHEDULE 1 OMB No. 1545-0074
Additional Income and Adjustments to Income
(Form 1040)
Department of the Treasury
a Attach to Form 1040, 1040-SR, or 1040-NR. 2021
Attachment
Internal Revenue Service a Go to www.irs.gov/Form1040 for instructions and the latest information. Sequence No. 01
Name(s) shown on Form 1040, 1040-SR, or 1040-NR Your social security number
LEVI E HEARN 521-61-6460
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) a
3 Business income or (loss). Attach Schedule C . . . . . . . . . . . . . . . 3 3,604.
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
8 Other income:
a Net operating loss . . . . . . . . . . . . . . . . . . 8a ( )
b Gambling income . . . . . . . . . . . . . . . . . . . 8b
c Cancellation of debt . . . . . . . . . . . . . . . . . . 8c
d Foreign earned income exclusion from 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
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 (see
instructions) . . . . . . . . . . . . . . . . . . . . . 8l
m Section 951(a) inclusion (see instructions) . . . . . . . . . 8m
n Section 951A(a) inclusion (see instructions) . . . . . . . . 8n
o Section 461(l) excess business loss adjustment . . . . . . . 8o
p Taxable distributions from an ABLE account (see instructions) . 8p
z Other income. List type and amount a
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 3,604.
For Paperwork Reduction Act Notice, see your tax return instructions. Cat. No. 71479F Schedule 1 (Form 1040) 2021

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Schedule 1 (Form 1040) 2021 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 . . . . . . . . . 15 255.
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 . . . . . . . . . . . . . . . . . . . . a
c Date of original divorce or separation agreement (see instructions) a
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 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 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 a
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 . . . . . 26 255.
Schedule 1 (Form 1040) 2021

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SCHEDULE 2 OMB No. 1545-0074
Additional Taxes
(Form 1040)
Department of the Treasury
a Attach to Form 1040, 1040-SR, or 1040-NR. 2021
Attachment
Internal Revenue Service a Go to www.irs.gov/Form1040 for instructions and the latest information. Sequence No. 02
Name(s) shown on Form 1040, 1040-SR, or 1040-NR Your social security number
LEVI E HEARN 521-61-6460
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 . . . . . . . . . . . . . . . . . . 4 510.
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 8
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. Cat. No. 71478U Schedule 2 (Form 1040) 2021

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Schedule 2 (Form 1040) 2021 Page 2

Part II Other Taxes (continued)

17 Other additional taxes:
a Recapture of other credits. List type, form number, and
amount a 17a
b Recapture of federal mortgage subsidy. If you sold your home in
2021, 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 a
17z
18 Total additional taxes. Add lines 17a through 17z . . . . . . . . . . . . . . 18
19 Additional tax from Schedule 8812 . . . . . . . . . . . . . . . . . . . . 19
20 Section 965 net tax liability installment from Form 965-A . . . 20
21 Add lines 4, 7 through 16, 18, and 19. These are your total other taxes. Enter here
and on Form 1040 or 1040-SR, line 23, or Form 1040-NR, line 23b . . . . . . . 21 510.
Schedule 2 (Form 1040) 2021

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SCHEDULE 3 OMB No. 1545-0074
Additional Credits and Payments
(Form 1040)
Department of the Treasury
a Attach to Form 1040, 1040-SR, or 1040-NR. 2021
Attachment
Internal Revenue Service a Go to www.irs.gov/Form1040 for instructions and the latest information. Sequence No. 03
Name(s) shown on Form 1040, 1040-SR, or 1040-NR Your social security number
LEVI E HEARN 521-61-6460
Part I Nonrefundable Credits
1 Foreign tax credit. Attach Form 1116 if required . . . . . . . . . . . . . . 1
2 Credit for child and dependent care expenses from Form 2441, line 11. Attach
Form 2441 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Education credits from Form 8863, line 19 . . . . . . . . . . . . . . . . . 3
4 Retirement savings contributions credit. Attach Form 8880 . . . . . . . . . . 4
5 Residential energy credits. Attach Form 5695 . . . . . . . . . . . . . . . 5
6 Other nonrefundable credits:
a General business credit. Attach Form 3800 . . . . . . . . 6a
b Credit for prior year minimum tax. Attach Form 8801 . . . . 6b
c Adoption credit. Attach Form 8839 . . . . . . . . . . . . 6c
d Credit for the elderly or disabled. Attach Schedule R . . . . . 6d
e Alternative motor vehicle credit. Attach Form 8910 . . . . . 6e
f Qualified plug-in motor vehicle credit. Attach Form 8936 . . . 6f
g Mortgage interest credit. Attach Form 8396 . . . . . . . . 6g
h District of Columbia first-time homebuyer credit. Attach Form 8859 6h
i Qualified electric vehicle credit. Attach Form 8834 . . . . . 6i
j Alternative fuel vehicle refueling property credit. Attach Form 8911 6j
k Credit to holders of tax credit bonds. Attach Form 8912 . . . 6k
l Amount on Form 8978, line 14. See instructions . . . . . . 6l
z Other nonrefundable credits. List type and amount a
6z
7 Total other nonrefundable credits. Add lines 6a through 6z . . . . . . . . . . 7
8 Add lines 1 through 5 and 7. Enter here and on Form 1040, 1040-SR, or 1040-NR,
line 20 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
(continued on page 2)
For Paperwork Reduction Act Notice, see your tax return instructions. Cat. No. 71480G Schedule 3 (Form 1040) 2021

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Schedule 3 (Form 1040) 2021 Page 2

Part II Other Payments and Refundable Credits

9 Net premium tax credit. Attach Form 8962 . . . . . . . . . . . . . . . . . 9
10 Amount paid with request for extension to file (see instructions) . . . . . . . . 10
11 Excess social security and tier 1 RRTA tax withheld . . . . . . . . . . . . . 11
12 Credit for federal tax on fuels. Attach Form 4136 . . . . . . . . . . . . . . 12
13 Other payments or refundable credits:
a Form 2439 . . . . . . . . . . . . . . . . . . . . . 13a
b Qualified sick and family leave credits from Schedule(s) H and
Form(s) 7202 for leave taken before April 1, 2021 . . . . . . 13b 720.
c Health coverage tax credit from Form 8885 . . . . . . . . 13c
d Credit for repayment of amounts included in income from earlier
years . . . . . . . . . . . . . . . . . . . . . . . . 13d
e Reserved for future use . . . . . . . . . . . . . . . . 13e
f Deferred amount of net 965 tax liability (see instructions) . . . 13f
g Credit for child and dependent care expenses from Form 2441,
line 10. Attach Form 2441 . . . . . . . . . . . . . . . 13g
h Qualified sick and family leave credits from Schedule(s) H and
Form(s) 7202 for leave taken after March 31, 2021 . . . . . 13h 3,600.
z Other payments or refundable credits. List type and amount a
13z
14 Total other payments or refundable credits. Add lines 13a through 13z . . . . . 14 4,320.
15 Add lines 9 through 12 and 14. Enter here and on Form 1040, 1040-SR, or 1040-NR,
line 31 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 4,320.
Schedule 3 (Form 1040) 2021

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SCHEDULE C Profit or Loss From Business OMB No. 1545-0074

2021
(Form 1040) (Sole Proprietorship)
a Go to www.irs.gov/ScheduleC for instructions and the latest information.
Department of the Treasury Attachment
Internal Revenue Service (99) a Attach to Form 1040, 1040-SR, 1040-NR, or 1041; partnerships must generally file Form 1065. Sequence No. 09
Name of proprietor Social security number (SSN)
LEVI E HEARN 521-61-6460
A Principal business or profession, including product or service (see instructions) B Enter code from instructions
I SELL ORIGINAL ARTWORKS TO PRIVATE BUYERS a 7 1 1 5 1 0
C Business name. If no separate business name, leave blank. D Employer ID number (EIN) (see instr.)

E Business address (including suite or room no.) a

City, town or post office, state, and ZIP code
F Accounting method: (1) X Cash (2) Accrual (3) Other (specify) a
G Did you “materially participate” in the operation of this business during 2021? If “No,” see instructions for limit on losses . X Yes No
H If you started or acquired this business during 2021, check here . . . . . . . . . . . . . . . . . a

I Did you make any payments in 2021 that would require you to file Form(s) 1099? See instructions . . . . . . . . Yes X No
J If “Yes,” did you or will you file required Form(s) 1099? . . . . . . . . . . . . . . . . . . . . . Yes No
Part I Income
1 Gross receipts or sales. See instructions for line 1 and check the box if this income was reported to you on
Form W-2 and the “Statutory employee” box on that form was checked . . . . . . . . . a 1 5,000.
2 Returns and allowances . . . . . . . . . . . . . . . . . . . . . . . . . 2 500.
3 Subtract line 2 from line 1 . . . . . . . . . . . . . . . . . . . . . . . . 3 4,500.
4 Cost of goods sold (from line 42) . . . . . . . . . . . . . . . . . . . . . . 4 4,896.
5 Gross profit. Subtract line 4 from line 3 . . . . . . . . . . . . . . . . . . . . 5 -396.
6 Other income, including federal and state gasoline or fuel tax credit or refund (see instructions) . . . . 6 5,000.
7 Gross income. Add lines 5 and 6 . . . . . . . . . . . . . . . . . . . . . a 7 4,604.
Part II Expenses. Enter expenses for business use of your home only on line 30.
8 Advertising . . . . . 8 18 Office expense (see instructions) . 18
9 Car and truck expenses (see 19 Pension and profit-sharing plans . 19
instructions) . . . . 9 20 Rent or lease (see instructions):
10 Commissions and fees . 10 a Vehicles, machinery, and equipment 20a
11 Contract labor (see instructions) 11 b Other business property . . . 20b
12 Depletion . . . . . 12 21 Repairs and maintenance . . . 21
13 Depreciation and section 179 22 Supplies (not included in Part III) . 22 800.
expense deduction (not
included in Part III) (see 23 Taxes and licenses . . . . . 23
instructions) . . . . 13 24 Travel and meals:
14 Employee benefit programs a Travel . . . . . . . . . 24a 200.
(other than on line 19) . 14 b Deductible meals (see
15 Insurance (other than health) 15 instructions) . . . . . . . 24b
16 Interest (see instructions): 25 Utilities . . . . . . . . 25
a Mortgage (paid to banks, etc.) 16a 26 Wages (less employment credits) 26
b Other . . . . . . 16b 27a Other expenses (from line 48) . . 27a
17 Legal and professional services
17 b Reserved for future use . . . 27b
28 Total expenses before expenses for business use of home. Add lines 8 through 27a . . . . . . a 28 1,000.
29 Tentative profit or (loss). Subtract line 28 from line 7 . . . . . . . . . . . . . . . . . 29 3,604.
30 Expenses for business use of your home. Do not report these expenses elsewhere. Attach Form 8829
unless using the simplified method. See instructions.
Simplified method filers only: Enter the total square footage of (a) your home:
and (b) the part of your home used for business: . Use the Simplified
Method Worksheet in the instructions to figure the amount to enter on line 30 . . . . . . . . . 30

}
31 Net profit or (loss). Subtract line 30 from line 29.
• If a profit, enter on both Schedule 1 (Form 1040), line 3, and on Schedule SE, line 2. (If you
checked the box on line 1, see instructions). Estates and trusts, enter on Form 1041, line 3. 31 3,604.
• If a loss, you must go to line 32.

}
32 If you have a loss, check the box that describes your investment in this activity. See instructions.
• If you checked 32a, enter the loss on both Schedule 1 (Form 1040), line 3, and on Schedule
SE, line 2. (If you checked the box on line 1, see the line 31 instructions.) Estates and trusts, enter on 32a X All investment is at risk.
Form 1041, line 3. 32b Some investment is not
• If you checked 32b, you must attach Form 6198. Your loss may be limited. at risk.
For Paperwork Reduction Act Notice, see the separate instructions. Cat. No. 11334P Schedule C (Form 1040) 2021

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Schedule C (Form 1040) 2021 Page 2
Part III Cost of Goods Sold (see instructions)

33 Method(s) used to
value closing inventory: a X Cost b Lower of cost or market c Other (attach explanation)
34 Was there any change in determining quantities, costs, or valuations between opening and closing inventory?
If “Yes,” attach explanation . . . . . . . . . . . . . . . . . . . . . . . . . . Yes X No

35 Inventory at beginning of year. If different from last year’s closing inventory, attach explanation . . . 35 1,000.
36 Purchases less cost of items withdrawn for personal use . . . . . . . . . . . . . . 36 999.
37 Cost of labor. Do not include any amounts paid to yourself . . . . . . . . . . . . . . 37

38 Materials and supplies . . . . . . . . . . . . . . . . . . . . . . . . 38 1,900.

39 Other costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 999.
40 Add lines 35 through 39 . . . . . . . . . . . . . . . . . . . . . . . . 40 4,898.
41 Inventory at end of year . . . . . . . . . . . . . . . . . . . . . . . . 41 2.
42 Cost of goods sold. Subtract line 41 from line 40. Enter the result here and on line 4 . . . . . . 42 4,896.
Part IV Information on Your Vehicle. Complete this part only if you are claiming car or truck expenses on line 9 and
are not required to file Form 4562 for this business. See the instructions for line 13 to find out if you must file
Form 4562.

43 When did you place your vehicle in service for business purposes? (month/day/year) a

44 Of the total number of miles you drove your vehicle during 2021, enter the number of miles you used your vehicle for:

a Business b Commuting (see instructions) c Other

45 Was your vehicle available for personal use during off-duty hours? . . . . . . . . . . . . . . . Yes No

46 Do you (or your spouse) have another vehicle available for personal use?. . . . . . . . . . . . . . Yes No

47a Do you have evidence to support your deduction? . . . . . . . . . . . . . . . . . . . . Yes No

b If “Yes,” is the evidence written? . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

Part V Other Expenses. List below business expenses not included on lines 8–26 or line 30.

48 Total other expenses. Enter here and on line 27a . . . . . . . . . . . . . . . . 48

Schedule C (Form 1040) 2021
CDA
SCHEDULE SE
Self-Employment Tax
OMB No. 1545-0074

2021
(Form 1040)
a Go to www.irs.gov/ScheduleSE for instructions and the latest information.
Department of the Treasury Attachment
Sequence No. 17
a Attach to Form 1040, 1040-SR, or 1040-NR.
Internal Revenue Service (99)
Name of person with self-employment income (as shown on Form 1040, 1040-SR, or 1040-NR) Social security number of person
LEVI E HEARN with self-employment income a 521-61-6460
Part I Self-Employment Tax
Note: If your only income subject to self-employment tax is church employee income, see instructions for how to report your income
and the definition of church employee income.
A If you are a minister, member of a religious order, or Christian Science practitioner and you filed Form 4361, but you had
$400 or more of other net earnings from self-employment, check here and continue with Part I . . . . . . . . a
Skip lines 1a and 1b if you use the farm optional method in Part II. See instructions.
1a Net farm profit or (loss) from Schedule F, line 34, and farm partnerships, Schedule K-1 (Form 1065),
box 14, code A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1a
b If you received social security retirement or disability benefits, enter the amount of Conservation Reserve
Program payments included on Schedule F, line 4b, or listed on Schedule K-1 (Form 1065), box 20, code AH 1b ( )
Skip line 2 if you use the nonfarm optional method in Part II. See instructions.
2 Net profit or (loss) from Schedule C, line 31; and Schedule K-1 (Form 1065), box 14, code A (other than
farming). See instructions for other income to report or if you are a minister or member of a religious order 2 3,604.
3 Combine lines 1a, 1b, and 2 . . . . . . . . . . . . . . . . . . . . . . . . . 3 3,604.
4a If line 3 is more than zero, multiply line 3 by 92.35% (0.9235). Otherwise, enter amount from line 3 . 4a 3,328.
Note: If line 4a is less than $400 due to Conservation Reserve Program payments on line 1b, see instructions.
b If you elect one or both of the optional methods, enter the total of lines 15 and 17 here . . . . . 4b
c Combine lines 4a and 4b. If less than $400, stop; you don’t owe self-employment tax. Exception: If
less than $400 and you had church employee income, enter -0- and continue . . . . . . . a 4c 3,328.
5a Enter your church employee income from Form W-2. See instructions for
definition of church employee income . . . . . . . . . . . . . 5a
b Multiply line 5a by 92.35% (0.9235). If less than $100, enter -0- . . . . . . . . . . . . . 5b
6 Add lines 4c and 5b . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 3,328.
7 Maximum amount of combined wages and self-employment earnings subject to social security tax or
the 6.2% portion of the 7.65% railroad retirement (tier 1) tax for 2021 . . . . . . . . . . . 7 142,800.
8a Total social security wages and tips (total of boxes 3 and 7 on Form(s) W-2)
and railroad retirement (tier 1) compensation. If $142,800 or more, skip lines
8b through 10, and go to line 11 . . . . . . . . . . . . . . . 8a
b Unreported tips subject to social security tax from Form 4137, line 10 . . . 8b
c Wages subject to social security tax from Form 8919, line 10 . . . . . . 8c
d Add lines 8a, 8b, and 8c . . . . . . . . . . . . . . . . . . . . . . . . . . 8d
9 Subtract line 8d from line 7. If zero or less, enter -0- here and on line 10 and go to line 11 . . . a 9 142,800.
10 Multiply the smaller of line 6 or line 9 by 12.4% (0.124) . . . . . . . . . . . . . . . . 10 413.
11 Multiply line 6 by 2.9% (0.029) . . . . . . . . . . . . . . . . . . . . . . . . 11 97.
12 Self-employment tax. Add lines 10 and 11. Enter here and on Schedule 2 (Form 1040), line 4 . . 12 510.
13 Deduction for one-half of self-employment tax.
Multiply line 12 by 50% (0.50). Enter here and on Schedule 1 (Form 1040),
line 15 . . . . . . . . . . . . . . . . . . . . . . . . 13 255.
Part II Optional Methods To Figure Net Earnings (see instructions)
Farm Optional Method. You may use this method only if (a) your gross farm income1 wasn’t more than
$8,820, or (b) your net farm profits2 were less than $6,367.
14 Maximum income for optional methods . . . . . . . . . . . . . . . . . . . . . 14
15 Enter the smaller of: two-thirds (2/3) of gross farm income1 (not less than zero) or $5,880. Also, include
this amount on line 4b above . . . . . . . . . . . . . . . . . . . . . . . . 15
Nonfarm Optional Method. You may use this method only if (a) your net nonfarm profits3 were less than $6,367
and also less than 72.189% of your gross nonfarm income,4 and (b) you had net earnings from self-employment
of at least $400 in 2 of the prior 3 years. Caution: You may use this method no more than five times.
16 Subtract line 15 from line 14 . . . . . . . . . . . . . . . . . . . . . . . . . 16
17 Enter the smaller of: two-thirds (2/3) of gross nonfarm income4 (not less than zero) or the amount on
line 16. Also, include this amount on line 4b above . . . . . . . . . . . . . . . . . 17
1 3
From Sch. F, line 9; and Sch. K-1 (Form 1065), box 14, code B. From Sch. C, line 31; and Sch. K-1 (Form 1065), box 14, code A.
2 4
From Sch. F, line 34; and Sch. K-1 (Form 1065), box 14, code A—minus the amount From Sch. C, line 7; and Sch. K-1 (Form 1065), box 14, code C.
you would have entered on line 1b had you not used the optional method.
For Paperwork Reduction Act Notice, see your tax return instructions. Cat. No. 11358Z Schedule SE (Form 1040) 2021

CDA
SCHEDULE C OMB No. 1545-2294
Loss Netting and Carryforward
(Form 8995-A)
Department of the Treasury
a Attach to Form 8995-A. 2021
Attachment
Internal Revenue Service a Go to www.irs.gov/Form8995A for instructions and the latest information. Sequence No. 55D
Name(s) shown on return Your taxpayer identification number

LEVI E HEARN 521-61-6460

If you have more than three trades, businesses, or aggregations, complete and attach as many Schedules C as needed. See instructions.

1 Trade, business, or aggregation name (a) Qualified (b) Reduction for (c) Adjusted qualified
business loss netting business income
income/(loss) (see instructions) (Combine (a) and (b).
If zero or less,
enter -0-.)

I SELL ORIGINAL ARTWORKS TO PRIVA 521-61-6460 3,349.( 778.) 2,571.

( )
( )

2 Qualified business net (loss) carryforward from prior years. See instructions . . . . . . . . . 2 ( 778.)

3 Total of the trades, businesses, or aggregations losses. Combine the negative amounts on lines 1,
column (a), and 2 for all trades, businesses, or aggregations . . . . . . . . . . . . . . 3 ( 778.)

4 Total of the trades, businesses, or aggregations income. Add the positive amounts on line 1, column
(a), for all trades, businesses, or aggregations . . . . . . . . . . . . . . . . . . . 4 3,349.

5 Losses netted with income of other trades, businesses, or aggregations. Enter in the parentheses on
line 5 the smaller of the absolute value of line 3 or line 4. Allocate this amount to each of the trades,
businesses, or aggregations on line 1, column (b) . . . . . . . . . . . . . . . . . 5 ( 778.)
6 Qualified business net (loss) carryforward. Subtract line 5 from line 3. If zero or more, enter -0- . . 6 ( )
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 72684K Schedule C (Form 8995-A) 2021

CDA
Form 7202 Credits for Sick Leave and Family Leave
for Certain Self-Employed Individuals
OMB No. 1545-0074

2021
Department of the Treasury aAttach to Form 1040, 1040-SR, or 1040-NR. Attachment
Internal Revenue Service a Go to www.irs.gov/Form7202 for instructions and the latest information. Sequence No. 202
Name of person with self-employment income (as shown on Form 1040, 1040-SR, or 1040-NR) Social security number of person with
self-employment income

LEVI E HEARN 521-61-6460

Part I Credit for Sick Leave for Certain Self-Employed Individuals (January 1, 2021, through March 31, 2021, only)
1 Number of days after December 31, 2020, and before April 1, 2021, you were unable to perform services as
a self-employed individual because of certain coronavirus-related care you required. See instructions . . 1 65
2 Number of days after December 31, 2020, and before April 1, 2021, you were unable to perform services as
a self-employed individual because of certain coronavirus-related care you provided to another. (Don’t
include days you included on line 1.) See instructions . . . . . . . . . . . . . . . . . 2 65
3a Enter the number from line 4 of your 2020 Form 7202. If you didn’t file a 2020 Form 7202, enter -0- . . . 3a
b Enter the number from line 6 of your 2020 Form 7202. If you didn’t file a 2020 Form 7202, enter -0- . . . 3b
c Add lines 3a and 3b . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3c
d Subtract line 3c from the number 10 . . . . . . . . . . . . . . . . . . . . . . 3d 10
4a Enter the smaller of line 1 or line 3d . . . . . . . . . . . . . . . . . . . . . . . 4a 10
b List each day included on line 4a (MM/DD): 01/02 01/03 01/04 01/05 01/06 01/07 01/08 01/09 01/10 01/
5 Subtract line 4a from line 3d . . . . . . . . . . . . . . . . . . . . . . . . . 5
6a Enter the smaller of line 2 or line 5 . . . . . . . . . . . . . . . . . . . . . . . 6a
b List each day included on line 6a (MM/DD):
Caution: The total of line 4a plus line 6a cannot exceed 10 days or line 3d, whichever is smaller.
7a Net earnings from self-employment (see instructions) . . . . . . . . . . . . . . . . . 7a 18,678.
b Check this box if you are electing to use prior year net earnings from self-employment on line 7a . . a X
8 Divide line 7a by 260 (round to nearest whole number) . . . . . . . . . . . . . . . . . 8 72.
9 Enter the smaller of line 8 or $511 . . . . . . . . . . . . . . . . . . . . . . . 9 72.
10 Multiply line 4a by line 9 . . . . . . . . . . . . . . . . . . . . . . . . . . 10 720.
11 Multiply line 8 by 67% (0.67) . . . . . . . . . . . . . . . . . . . . . . . . . 11 48.
12 Enter the smaller of line 11 or $200 . . . . . . . . . . . . . . . . . . . . . . . 12 48.
13 Multiply line 6a by line 12 . . . . . . . . . . . . . . . . . . . . . . . . . . 13
14 Add lines 10 and 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 720.
15a Amount of qualified sick leave wages subject to the $511 per day limit you received from an employer for
periods of leave taken after December 31, 2020, and before April 1, 2021 (see instructions) . . . . . 15a
b Enter the amount from line 15 of your 2020 Form 7202. If you didn’t file a 2020 Form 7202, see instructions
for amount to enter . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15b
c Add lines 15a and 15b . . . . . . . . . . . . . . . . . . . . . . . . . . . 15c
16a Amount of qualified sick leave wages subject to the $200 per day limit you received from an employer for
periods of leave taken after December 31, 2020, and before April 1, 2021 (see instructions) . . . . . 16a
b Enter the amount from line 16 of your 2020 Form 7202. If you didn’t file a 2020 Form 7202, see instructions
for amount to enter . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16b
c Add lines 16a and 16b . . . . . . . . . . . . . . . . . . . . . . . . . . . 16c
If line 15c and line 16c are both zero, skip to line 24 and enter the amount from line 14.
17a Add lines 13 and 16c . . . . . . . . . . . . . . . . . . . . . . . . . . . 17a
b Enter the amount from line 13 of your 2020 Form 7202. If you didn’t file a 2020 Form 7202, enter -0- . . 17b
c Add lines 17a and 17b . . . . . . . . . . . . . . . . . . . . . . . . . . . 17c
18 Enter the smaller of line 17c or $2,000 . . . . . . . . . . . . . . . . . . . . . . 18
19 Subtract line 18 from line 17c . . . . . . . . . . . . . . . . . . . . . . . . . 19
20a Add lines 10, 15c, and 18 . . . . . . . . . . . . . . . . . . . . . . . . . . 20a
b Enter the amount from line 10 of your 2020 Form 7202. If you didn’t file a 2020 Form 7202, enter -0- . . 20b
c Add lines 20a and 20b . . . . . . . . . . . . . . . . . . . . . . . . . . . 20c
21 Enter the smaller of line 20c or $5,110 . . . . . . . . . . . . . . . . . . . . . . 21
22 Subtract line 21 from line 20c . . . . . . . . . . . . . . . . . . . . . . . . . 22
23 Add lines 19 and 22 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
24 Subtract line 23 from line 14. If zero or less, enter -0-. Enter here and include on Schedule 3 (Form 1040),
line 13b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 720.
For Privacy Act and Paperwork Reduction Act Notice, see your tax return instructions. Cat. No. 56395K Form 7202 (2021)

CDA
Form 7202 (2021) Page 2
Part II Credit for Family Leave for Certain Self-Employed Individuals (January 1, 2021, through March 31, 2021, only)
25a Number of days after December 31, 2020, and before April 1, 2021, you were unable to perform services as
a self-employed individual because of certain coronavirus-related care you provided to a son or daughter.
(Don’t enter more than 50 days. Don’t include any day you listed on either line 4b or line 6b.) See instructions 25a
b Enter the amount from line 25 of your 2020 Form 7202. If you didn’t file a 2020 Form 7202, enter -0- . . 25b
c Subtract line 25b from the number 50 . . . . . . . . . . . . . . . . . . . . . . 25c
d Enter the smaller of line 25a or line 25c . . . . . . . . . . . . . . . . . . . . . . 25d
26a Net earnings from self-employment (see instructions) . . . . . . . . . . . . . . . . . 26a
b Check this box if you are electing to use prior year net earnings from self-employment on line 26a . . a
27 Divide line 26a by 260 (round to nearest whole number) . . . . . . . . . . . . . . . . . 27
28 Multiply line 27 by 67% (0.67) . . . . . . . . . . . . . . . . . . . . . . . . . 28
29 Enter the smaller of line 28 or $200 . . . . . . . . . . . . . . . . . . . . . . . 29
30 Multiply line 25d by line 29 . . . . . . . . . . . . . . . . . . . . . . . . . 30
31a Amount of qualified family leave wages you received from an employer for periods of leave taken after
December 31, 2020, and before April 1, 2021 (see instructions) . . . . . . . . . . . . . . 31a
b Enter the amount from line 31 of your 2020 Form 7202. If you didn’t file a 2020 Form 7202, see instructions
for amount to enter . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31b
c Add lines 31a and 31b . . . . . . . . . . . . . . . . . . . . . . . . . . . 31c
If line 31c is zero, skip to line 35 and enter the amount from line 30.
32a Add lines 30 and 31c . . . . . . . . . . . . . . . . . . . . . . . . . . . 32a
b Enter the amount from line 30 of your 2020 Form 7202. If you didn’t file a 2020 Form 7202, enter -0- . . 32b
c Add lines 32a and 32b . . . . . . . . . . . . . . . . . . . . . . . . . . . 32c
33 Enter the smaller of line 32c or $10,000 . . . . . . . . . . . . . . . . . . . . . . 33
34 Subtract line 33 from line 32c . . . . . . . . . . . . . . . . . . . . . . . . . 34
35 Subtract line 34 from line 30. If zero or less, enter -0-. Enter here and include on Schedule 3 (Form 1040), line 13b 35
Part III Credit for Sick Leave for Certain Self-Employed Individuals (April 1, 2021, through September 30, 2021, only)
36 Number of days after March 31, 2021, and before October 1, 2021, you were unable to perform services as
a self-employed individual because of certain coronavirus-related care you required. See instructions . . 36 150
37 Number of days after March 31, 2021, and before October 1, 2021, you were unable to perform services as
a self-employed individual because of certain coronavirus-related care you provided to another. (Don’t
include days you included on line 36.) See instructions . . . . . . . . . . . . . . . . . 37 150
38a Enter the smaller of 10 days or the number of days entered on line 36 . . . . . . . . . . . . 38a 10
b List each day included on line 38a (MM/DD): 04/01 04/02 04/03 04/05 04/06 04/07 04/08 04/09 04/10 04/
39 Subtract line 38a from the number 10 . . . . . . . . . . . . . . . . . . . . . . 39
40a Enter the smaller of line 37 or line 39 . . . . . . . . . . . . . . . . . . . . . . . 40a
b List each day included on line 40a (MM/DD):
Caution: The total of line 38a plus line 40a cannot exceed 10 days.
41a Net earnings from self-employment (see instructions) . . . . . . . . . . . . . . . . . 41a 18,678.
b Check this box if you are electing to use prior year net earnings from self-employment on line 41a . . a X
42 Divide line 41a by 260 (round to nearest whole number) . . . . . . . . . . . . . . . . 42 72.
43 Enter the smaller of line 42 or $511 . . . . . . . . . . . . . . . . . . . . . . . 43 72.
44 Multiply line 38a by line 43 . . . . . . . . . . . . . . . . . . . . . . . . . . 44 720.
45 Multiply line 42 by 67% (0.67) . . . . . . . . . . . . . . . . . . . . . . . . . 45 48.
46 Enter the smaller of line 45 or $200 . . . . . . . . . . . . . . . . . . . . . . . 46 48.
47 Multiply line 40a by line 46 . . . . . . . . . . . . . . . . . . . . . . . . . . 47
48 Add lines 44 and 47 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 720.
49 Amount of qualified sick leave wages subject to the $511 per day limit you received from an employer for
periods of leave taken after March 31, 2021, and before October 1, 2021 (see instructions) . . . . . 49
50 Amount of qualified sick leave wages subject to the $200 per day limit you received from an employer for
periods of leave taken after March 31, 2021, and before October 1, 2021 (see instructions) . . . . . 50
If line 49 and line 50 are both zero, skip to line 58 and enter the amount from line 48.
51 Add lines 47 and 50 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
52 Enter the smaller of line 51 or $2,000 . . . . . . . . . . . . . . . . . . . . . . 52
53 Subtract line 52 from line 51 . . . . . . . . . . . . . . . . . . . . . . . . . 53
54 Add lines 44, 49, and 52 . . . . . . . . . . . . . . . . . . . . . . . . . . 54
55 Enter the smaller of line 54 or $5,110 . . . . . . . . . . . . . . . . . . . . . . 55
56 Subtract line 55 from line 54 . . . . . . . . . . . . . . . . . . . . . . . . . 56
57 Add lines 53 and 56 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
58 Subtract line 57 from line 48. If zero or less, enter -0-. Enter here and include on Schedule 3 (Form 1040), line 13h 58 720.
Form 7202 (2021)
CDA
Form 7202 (2021) Page 3
Part IV Credit for Family Leave for Certain Self-Employed Individuals (April 1, 2021, through September 30, 2021, only)
59 Number of days after March 31, 2021, and before October 1, 2021, you were unable to perform services as a
self-employed individual because of certain coronavirus-related care you required or provided to another.
(Don’t enter more than 60 days. Don’t include any day you listed on either line 38b or line 40b.) See instructions 59 60
60a Net earnings from self-employment (see instructions) . . . . . . . . . . . . . . . . . 60a 18,678.
b Check this box if you are electing to use prior year net earnings from self-employment on line 60a . . a X
61 Divide line 60a by 260 (round to nearest whole number) . . . . . . . . . . . . . . . . . 61 72.
62 Multiply line 61 by 67% (0.67) . . . . . . . . . . . . . . . . . . . . . . . . . 62 48.
63 Enter the smaller of line 62 or $200 . . . . . . . . . . . . . . . . . . . . . . . 63 48.
64 Multiply line 59 by line 63 . . . . . . . . . . . . . . . . . . . . . . . . . . 64 2,880.
65 Amount of qualified family leave wages you received from an employer for periods of leave taken after
March 31, 2021, and before October 1, 2021 (see instructions) . . . . . . . . . . . . . . 65
If line 65 is zero, skip to line 69 and enter the amount from line 64.
66 Add lines 64 and 65 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
67 Enter the smaller of line 66 or $12,000 . . . . . . . . . . . . . . . . . . . . . . 67
68 Subtract line 67 from line 66 . . . . . . . . . . . . . . . . . . . . . . . . . 68
69 Subtract line 68 from line 64. If zero or less, enter -0-. Enter here and include on Schedule 3 (Form 1040),
line 13h . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 2,880.
Form 7202 (2021)

CDA