FORM 6 FULL AND PUBLIC DISCLOSURE OF 2009

Please print or typo your name, mailing

address, agency name, and position below ; FINANCIAL INTEREST

LAST NAME — FIRST NAME — MIDDLE NAME.

Green Jr., Dennis David

MAILING ADDRESS

PO Box 11777

CITY: ZIP

Pensacola, FL 32524 Escambia

COUNTY

NAME OF AGENCY :

Escambia County Board of County Commissioners

NAME OF OFFICE OR POSITION HELD OR SOUGHT

County Commissioner Dist 4

CHECK IF THIS IS A FILING BY A CANDIDATE

FOR OFFICE

USE ONLY:

ID Code

ID No

Conf. Code

P. Req. Code

c_

ut

en

co rri

o m

-n a

CO

o

PART A- NET WORTH

Please enler the value of your net worth as of December 31, 2009, or a more current date [Nole. Net worth is not calculated by subtracting your reported

liabilities from your reported assets, so please see the instructions on page 3.]

My net worth as of June 1st , 20 10 was$ 19,000.00

PART B-ASSETS

HOUSEHOLD GOODS AND PERSONAL EFFECTS:

Household goods and personal effects may be reported in a lump sum if their aggregate value exceeds S1,000 This category includes any of the following,

if not held for investment purposes: jewelry; collections of stamps, guns, and numismatic items; art objects; household equipment and furnishings; clothing;

other household items; and vehicles for personal use.

The aggregate value of my household goods and personal effects (described above) is S _

ASSETS INDIVIDUALLY VALUED AT OVER 51,000:

DESCRIPTION OF ASSET (specific description is required - see instructions p.4) VALUE OF ASSET

Foreign Currency- Iraqi Dinar 4120.00

PART C-LIABILITIES

LIABILITIES IN EXCESS OF $1,000:

NAME AND ADDRESS OF CREDITOR AMOUNT OF LIABILITY

GMAC P. O. Box 380901 Bloomington, MN 55438 14,000.00

JOINT AND SEVERAL LIABILITIES NOT REPORTED ABOVE:

NAME AND ADDRESS OF CREDITOR AMOUNT OF LIABILITY

CEFORM6-Eff. 1/2010 (Continued on reverse side) PAGE 1

PART D-INCOME

You may EITHER (1) file a complete copy of your 2009 federal income tax return, including all attachments, OR (2) file a sworn statement identifying each

separate source and amount of income which exceeds $1,000, including secondary sources of income, by completing the remainder of Part D, below.

I /I I elect to file a copy of my 2009 federal income tax return. [If you check this box and attach a copy of your 2009 tax return, you need not completethe remainder of Part D ]

PRIMARY SOURCES OF INCOME:

NAME OF SOURCE OF INCOME EXCEEDING S1 000 AHDRFSS OF SOURCE OF INCOME AMOUNT

SECONDARY SOURCES OF INCOME [Major customers, clients, etc., of businesses owned by reporting person-see instructions]:

NAME OF NAME OF MAJOR SOURCES ADDRESS PRINCIPAL BUSINESS

BUSINESS ENTITY OF BUSINESS' INCOME OF SOURCE ACTIVITY OF SOURCE

PART E - INTERESTS IN SPECIFIED BUSINESSES

BUSINESS ENTITY # 1 BUSINESS ENTITY # 2 BUSINESS ENTITY # 3

NAME OFRDSINFSSFNTITY

({Q\ ti^c** &(C£ADDRESS OFRHSINFSR FNTITY

PRINCIPAL BUSINESSACTIVITY

POSITION HELDWITH FNTITY

I OWN MORE THAN A 5%INTFRFRT IN THF RUSINESS too

NATURE OF MYOWNERSHIP INTEREST

m m

IF ANY OF PARTS A THROUGH E ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE

OATH STATE OF FLORIDACOUNTY OF

I, the person whose name appears at the

beginning of this form, do depose on oath or affirmation

and say that the information disclosed on this form

and any attachments hereto is true, accurate,

and complete.

Sworn to (or affirmed) and subscribed before me this 81 . day of

20 by

SIGNATJ

(Signature of Notary Public-State of FloridaDridaV

TAMELAR.McGOWIN

(Print, Type, or Stamp Commissioned Narffl

REPORTING OFFICIAL t)R CANDIDATE Personally Known OR :p

O DOO070751

4/1/2013

tdentdmttfVlataiyAsaiMM

Type of Identification Produced

FILING INSTRUCTIONS for when and where to file this form are located at the top of page 3.

INSTRUCTIONS on who must file this form and how to fill it out begin on page 3.

OTHER FORMS you may need to file are described on page 6.

CE FORM 6-Eff. 1/2010 PAGE 2

1040Department of the Treasury—Inle

U.S. individuT"

LabelFor the year Jan. 1-Dec. 31, 2009,.ir ether tax yeai beginning

(Sea

insiru chons

on paga 1-1 J

Use the IRS

label.

Otherwise,

please pnnl

or type.

Presidential

Election Campaign

I Service

Return

Ml.

M.I.

Last name -

Green

IRS Use Only—Do net w.'iie or staple m Iliia

OMB Nu 1545-0074

,-Suffix

Last n

ft JUN 1H PH 12Set). If you have a P.O. bos. see page 1>1.

town or post office, state, and ZIP code. If you have a foreign address, seepage 14.

Apt no.

Jfrnirsocia^jfciiril^ijiml, u,

Spouse's social security number

"ek- '' V° ^

_

f niirio jointly, vtanl S3 to go to this

1 [Xj Single

Fifing Status 2 L J Married filing jointly (even if only one had income)|_J Married filing separately. Enter spouse's SSN above

and full name here.

Check only one

box. First name Last name

Exemptions

If more than lour

dependents, see

page 17 and

check here ►■ [_ .

You must enter

your SSN(s| above.

Checking a box below will not

change your tax or refund.

EJ You [~~l Spouse4 {_} Head of household (with qualifying person). (See page 15 )

If the qualifying person is a child but not your dependententer this child's name here.

First name Last name; ~~SSN

5 I I Quaking widow(er) with dependent child (see page 16)6a |_Xj Yourself. If someone can claim you as a dependent, do not check box 6ab I I Spouse

c Dependents:

(1) First name Last name

(2) Dependent's

social security number

d Total number ol exemptions claimed

(3) Dependent's

relalionstiip lo you

(4)

cJfts(ad*ftai

D

P

D

D

Boies charted

on 5a and 6b

No ol children

ondc who;

■ lived with yen

• did not live with

you due lo divorce

or separation

(see page 18)

Dependents on 6c

not entered above

Add numbers on

linos above *■

Income

Attach Form(s)

W-2 hero. Also

attach Forms

W-2G and

1099-Riftax

was withheld.

If you did not

get a W-2,

see page 22.

Enclose, but do

not attach, any

payment Also,

please use

Form1040-V.

7 Wages, salaries, tips, etc. Attach Form(s) W-2 .

8a Taxable interest. Attach Schedule B if required

b Tax-exempt interest. Do not include on line 8a .

9a Ordinary dividends. Attach Schedule B if required

b Qualified dividends (see page 22)

Sb

10

11

12

13

14

15a

16a

17

18

19

20a

21

22

9b

Taxable refunds, credits, or offsets of state and local income taxes (see page 23)

Alimony received

Business income or (loss). Attach Schedule C or C-EZ . .

Capilal gain or (loss). Attach Schedule D if required. If not required, check here

Other gains or (losses). Attach Form 4797

IRA distributions . .

Pensions and annuities

16a

16a

b Taxable amount (see page 2

Form 1040 (2009) Dennis Green. Jr

Tax and

Credits

for—

• People who

check any

box on line

39a, 39b, or

40b or who

can be

claimed as a

dependent,

see page 35.

• All others:

Single or

Married filing

separately,

$5,700

Married filing

jointly or

Qualifying

widow(er),

$11,400

Head of

household,

$8,350

38 Amount from line 37 (adjusted gross income)

39a Check r\_J You were bo™ before January 2,1945. Fl Blind i:». II 1 Total boxes>f «-|—| Spouse was born before January 2.1945. □ Blind. J checked

ir spouse itemizes on a separate return or you were a dual-status alien, see page 35 and check here.

40a Itemized deductions (from Schedule A) or your standard deduction (see left margin)

b If you are increasing your standard deduction by certain real estate taxes new,

39a

38

39b) I

41

42

43

44

45

46

47

48

49

50

51

52

53

54

55

vehicle taxes, or a net disaster loss, attach Schedule L and check here (see pagSubtract line 40a from line 38 ....

Exemptions. Ifjne38 is $125,100 or less and you did not provide housing to a Midwesternd.splaced individfafemuftipi?^3,650 by the number on line 6d. Otherwise, see page 37Taxable income. Subtract line 42 from line 41. If line 42 is more than line 41. enter -0-

Tax (see page 37). Check if any tax is from: a [_| Form(s) 8814 b |_J Form 4972Alternative minimum tax (see page 40). Attach Form 6251

Add lines 44 and 45

41

42

43

44

Foreign tax credit. Attach Form 1116 if requiredCredit for child and dependent care expenses. Attach Form 2441Education credits from Form 8863, line 29

Retirement savings contributions credit. Attach Form 8880

Child tax credit (see page 42)

Credits from Form: a □ 8396 bQ8839 QOther credits from Form: a □ 3800 b Q 8801 c

Add lines 47 through 53. These are your total credits.

47

48

49

50

51

52

53

45

46

Subtract line 54 from line 46. If line 54 is more than line 46, enter -0-

Other

Taxes

Self-employment tax. Attach Schedule SEUnreported social security and Medicare tax from Form:

56

57 Unreported social security and Medicare tax from Form: a Q 4137 D Q 8919

58 Additional tax on IRAsjather qualified retirement plans, etc. Attach Form 5329 if required

59 Additional taxes: a LJ AEIC payments b □ Household employment taxes. Attach Schedule H

54

Payments60 Add lines 55 through 59. This is your total tax .

57

58

If you have a

qualifying

child, attach

Schedule EIC.

61 Federal income tax withheld from Forms W-2 and 1099

62 2009 estimated tax payments and amount applied from 2008 return

. 63 Making work pay and government retiree credits. Attach Schedule M .,64a Earned income credit (EIC)

b Nontaxable combat pay election | 64b I

65 Additional child tax credit. Attach Form 8812

Refundable education credit from Form 8863, line 16First-time homebuyer credit. Attach Form 5405

Amount paid with request for extension to file (see page 72)

Excess social securityand tier 1 RRTA tax withheld (see page 72) .

Credits from Form: a [_| 2439 b Q 4136 c □ 8801 d [_] 8885Add lines 61, 62. 63. 64a. and 65 through 70. These are your total payments

61

62

63

64a

65

66

67

68

69

70

11,033

400

59

60

63.!

58.271

3,650

54,621

9,844

9.844

9,844

102

9,946

Refund

Direct deposit?

See page 73

and nil in 73b.

73c, and 73d,

or Form 8888.

If line 71 is more than line 60, subtract line 60 from line 71. This is the amount you overpaid

73a Amount of line 72 you want refunded to you. If Form 8888 is attached check here ► f~^► b Routing number XXXXXXXXX ► c Type: Q Checking ' ' Q Savings

►• d Account number XXXXXXXXXXXXXXXXX

74 Amount of line 72 you want applied to your 2010 estimated tax

72

73a

74

Amount 75 Amount you owe. Subtract line 71 from line 60. For details on how to pay, see page 74You Owe 76 Estimated tax penalty (see page 74) | 76 |

75

1,487

1,487

0

Third Party

Designee

Do you want to allow another person to discuss this return with the IRS (see page 75)? □ Yes. Complete the following. □No

Designers Phone Personal identificationname * "Q- » number (PIN) ► ' ~l

Sign

Here

Joint return?

See page 15.

Keep a copy

for your

records.

Under penalties of perjury. I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge andbehef. they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledgeYour sianature naia v«..,~. .:

Spouse's signature. If a joint return, both must sign. Date

Your occupation

securitv/l nvestiqation

Spouse's occupation

Daytime phone number

Paid

Preparer's

Use Only

Prepared

signalure ►Firm's name (or

yours if self-employed),

address, and ZIP code ►Scotts Bookkeeping Service

Date

2/26/2010Check if

self-employed

804 N 75th Ave

Pensacola

EIN

Preparer's SSN or PTIN

59-1563620

Phone no. 850 4565465

State FL ZIP code 32506

Form 1040 f>ftna\

SCHEDULE C

(Form 1040?

Department of the Treasury

Internal Revenue Service (99)

Name of proprietor

Dennis Green. Jr

Profit or Loss From Business(Sole Proprietorship)

► Partnerships, joint ventures, etc., generally must file Form 1065 or 1065-B► Attach to Form 1040,1040NR, or 1041. » See Instructions for Schedule C IFnrm

A Principal business or profession, including product or service (seepage C-2 of the instructions)security

C Business name. If no separate business name, leave blank.Dennis

F

G

H

2

3

4

5

6

8

9

10

11

12

13

14

15

16

17

28

29

30

31

32

OMB No. 1545-0074

Social security number (SSN)

Enter code from pages c-9,10, & 11

561600

D Employer ID number (EIN), if any

Business address (including suite or room no.)

City, town or post office, state, and ZIP code

Accounting method: (DlXjCash (2) □ Accrual (3) □ Other (specify)D.d you "materially participate" in the operation of this business during 2009? If "No." see page C-3 for limit on lossesIf you started or acquired this business during 2009, check here

Income

Gross receipts or sales. Caution. See page C-4 and check the box if:

• This income was reported to you on Form W-2 and the "Statutory employee" boxon that form was checked, or

• You are a member of a qualified joint venture reporting only rental real estateincome not subject to self-employment tax. Also see page C-3 for limit on losses.

Returns and allowances

Subtract line 2 from line 1

Cost of goods sold (from line 42 on page 2)

Gross profit. Subtract line 4 from line 3

Other income, including federal and state gasoline or fuel tax credit or refund (see page C-4)Gross income. Add lines 5 and 6

Expenses. Enter expenses for business use of your home only on line 30.Advertising

Car and truck expenses (see

page C-4)

Commissions and fees .

Contract labor (see page C-4)

Depletion

Depreciation and section 179

expense deduction (not

included in Part III) (see

page C-5)

Employee benefit programs

(other than on line 19) . .

Insurance (other than health)

Interest:

Mortgage (paid to banks, etc.)

Other

Legal and professional

services

10

11

12

13

14

15

16a

16b

17

330

192

554

18

19

20

a

b

21

22

23

24

a

b

25

26

27

Office expense .

Pension and profit-sharing plans

Rent or lease (see page C-6):

Vehicles, machinery, and equipment.

Other business property

Repairs and maintenance .

Supplies (not included in Part III)

Taxes and licenses

Travel, meals, and entertainment:

Travel

Deductible meals and

entertainment (see page C-6).

Utilities

Wages (less employment credits). .

Other expenses (from line 48 on

page 2)

Total expenses before expenses for business use of home. Add lines 8 through 27 .

Tentative profit or (loss). Subtract line 28 from line 7

Expenses for business use of your home. Attach Form 8829

Net profit or (loss). Subtract line 30 from line 29.

• If a profit, enter on both Form 1040, line 12, and Schedule SE, line 2, or on Form 1040NR line13 (if you checked the box on line 1, see page C-7). Estates and trusts, enter on Form 1041, iine 3.

• If a loss, you must go to line 32.

If you have a loss, check the box that describes your investment in this activity (see page C-7)

• If you checked 32a, enter the loss on both Form 1040, line 12, and Schedule SE, line 2 or onForm 1040NR, line 13 (if you checked the box on line 1. see the line 31 instructions on page C-7)Estates and trusts, enter on Form 1041, line 3.

■ If you checked 32b, you must attach Form 6198. Your loss may be limited.

20a

20b

21

22

23

24a

24b

25

26

27

28

29

30

31

41

342

1,570

3.402

723

723

32a [_J All investment is at risk.

32b (_) Some investment isnot at risk.

For Paperwork Reduction Act Notice, see page C-9 of the instructions.(HTA) Schedule C (Form 1040) 2009

Schedule C (Form 1040) 2009 Dennis Green. Jr

Cost of Goods Sold (see page C-8 Page 2

33 Method(s) used to

value closing inventory:

34

i explanation

Cost b LJ Lower of cost or market c □ Other (attach explanation)

M !!!!?rj?^elefminin9 qUantities> costs' or valua«ons between opening and closing inventory?.■ QYes [Ino

35 Inventory at beginning of year. If different from last year's closing inventory, attach explanation

36 Purchases less cost of items withdrawn for personal use

37 Cost of labor. Do not include any amounts paid to yourself

38 Materials and supplies

39 Other costs

40 Add lines 35 through 39

41 Inventory at end of year

42 Cost of goods sold. Subtract line 41 from line 40. Enter the result here and on pan* 1 line 4

35

36

37

38

39

40

41

n

■- " ■■..— .. ..w w ->w. uiubi mo icauu licit? gnu ufi page i line h 42 fV

Information on Your Vehicle. Complete this part only if you are claiming ca or t uck expenses onhne 9 ana" are not required to file Form 4562 for this business. See the instructions for line 13 on pageC-5 to find out if you must file Form 4562 M 9

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

44 Of the total number of miles you drove your vehicle during 2009. 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? I I Yes I—I N

46 Do you (or your spouse) have another vehicle available for personal use? I I Yes I—I

47 a Do you have evidence to support your deduction? I ] Yes I—I

□ Yes □ Nob If "Yes," is the evidence written?.

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

Communication

_Un|f_&_upkeep_

Range

68J

54

341

48 Total other expenses. Enter here and on page 1. line 27 48 1.570

Schedule C (Form 1040) 2009

Form 4562Department of the Treasury

Internal Revenue Sorvica(99)

hown on return

Depreciation and Amortization

(Including Information on Listed Property)

* See separate Instructions. ► Attach to your tax returnBusiness or activity to which this form relatesSch C: 01 - security

OMB No 15450172

Identifying number

Election To Expense Certain Property Under Section 179Note: If you have any listed property, complete Part V befom yn,, ™»w»to Part,

Maximum amount. See the instructions for a higher limit for certain businesses 'Total cost of section 179 t l

1

2 Total cost of section 179 property placed in service (see instructions)"3 Threshold cost of section 179 property before reduction in limitation (see instructions) '4 Reduction in limitation. Subtract line 3 from line 2. If zero or less enter -0- '

b) Cost (business use onl

7 Listed property. Enter the amount from line 29

8 Total elected cost of section 179 property. Add amounts'in column (c). lines 6 and 79 Tentative deduction. Enter the smaller of line 5 or line 8

10 Carryover of disallowed deduction from line 13 of your 2008 Form 456211 Business income limitation. Enter the smaller of business income (not less than zero) or line 5(see instructions)'12 Section 179 expense deduction. Add lines 9 and 10, but do not enter more than line 11 '"^ructions).13 Carryover of disallowed deduction to 2010. Add lines 9 and 10, less line 12""a-Ponor use Part HorPartIIIbelow forlisted property. Instead. use~pTri~v

1d q . . Special Depreciation Allowance and Other Deprecation,Do not in14 Spec.adeprec.at.on allowance for qualified property (other than listed property) placed in service

during the tax year (see instructions) service

15 Property subject to section 168(f)(1) election16 Other depreciation (including ACRS) '.*.''

MACRS Depreciation (Do not include'listed propertv.WSee irWrnrHnnc ')Section A

8

9

10

11

0

0

17 MACRS deductions for assets placed in service in tax years beginning before 200918 If you are electing to group any assets placed in service during the tax year into one or more

general asset accounts, check here

19 a 3-year property

(b) Month and

year placed

in service

Sec«°n B - Assets Placed in Service During 2009 Tax Year Uslr^ the General(b) Month and ■ '

(a) Classification of property

b 5-year property

c 7-year property

d 10-year property

e 15-year property

f 20-year property

g 25-year property

h Residential rental

property

i Nonresidential real

property

(c) Basis for

depreciation

(buainess/invoalfnaru

1.280

(d) Recovery

period

27.5 yrs.

27.5 vrs.

39 yrs.

Convention

HY

MM

MM

MM

(0

Method

150DB

S/L

S/L

S/L

S/L

20 a7= Section C - Assets Placed In Service During 2009 Tax Year Using the Alternative DepreciationLrldSS III 6 -

(9)

Depreciation deduction

192

b 12-year

40-year

Summary (See instructions.)

12 yrs.

40 yrs. MM

S/L

S/L

S/L

21 Listed property. Enter amount from line 28 ■——

22 Total. Add amounts from line 12. lines 14 through 17, lines 19 and 20 in column (g) and line 21Enter here and on the appropriate lines of your return. Partnerships and S corporations - see instructions

23 For assets shown above and placed in service during the current year, enter the portionof the basis attributable to section 263A costs ....

For Paperwork Reduction Act Notice, see separate instructions.(HIA)

23

21

22 192

Form 4562 (2009)

SCHEDULE SE

(Form 1040)

Oopartmant of !ho Treasury

Inlernal Ravanue Service (99)

Name of person wilh self-employment income (as shown on Form 1040)

Dennis Green. Jr

Self-Employment Tax

►Attach to Form 1040. ►See Instructions for Schedule SE (Form 1040)

OMB No 15450074

Who M

You must fi

ule SE

Social security number of person

with self-employment income

chedule SE if:

*om other *" *"*employee lnc°me *•4 - Sh°« **-*

May I Use Short Schedule SE or Must I Use Long Schedule SE?Note. Use this flowchart only if you must file Schedule SE. If unsure, see Who Must File Schedule SE, above.

| Did you receive wages or tips in 2009?

No , .

Are you a minister, member of a religious order, or ChristianScience practitioner who received IRS approval not lo be taxed

on earnings from these sources, but you owe self-employmenttax on other earnings?

r- }No

r

Are you using one of (he optional methods lo figure your netearnings (see page SE-4)?

Nor

Did you receive church employee income reported on FormW-2 of $108.28 or more?

You may use Short Schedule SE below

Yes ^

Yes_^

Yes fc^ No

Yesr

Was the total of your wages and lips subject lo socialsecurity or railroad retirement (tier 1) lax plus your net

earnings from self-employment more than $106,800?

Nof

-^ *

Did you receive lips subject to social security or Medicaretax that you did not report to your employer?

No

r

Did you report any wages on Form 8919. Uncollected SocialSecurity and Medicare Tax on Wages?

You must use Long Schedule SE on page 2

Yes ,

Yes

Yes

Section A-Short Schedule SE. Caution. Read above to see if you can use Short Schedule SE.

1 a Net farm profit or (loss) from Schedule F. line 36, and farm partnerships. Schedule K-1 (Form1065), box 14, code A

b If you received social security retirement or disability benefits, enter the amount of Conservation ReserveProgram payments included on Schedule F, line 6b. or listed on Schedule K-1 (Form 1065), box 20. code Y

2 Net profit or (loss) from Schedule C, line 31; Schedule C-EZ, line 3; Schedule K-1 (Form 1065)box 14. code A (other than farming); and Schedule K-1 (Form 1065-B). box 9 code J1 Ministersand members of religious orders, see page SE-1 for types of income to report on this line Seepage SE-3 for other income to report

3 Combine lines 1a, 1b. and 2

4 Net earnings from self-employment. Multiply line 3 by 92.35% (.9235). If less than $400do not file this schedule; you do not owe self-employment tax ' ►

5 Self-employment tax. If the amount on line 4 is:

• $106,800 or less, multiply line 4 by 15.3% (.153). Enter the result here and on Form 1040, line 56.• More than $106,800, multiply line 4 by 2.9% (.029). Then, add $13,243 20 to the resultEnter the total here and on Form 1040, line 56

6 Deduction for one-half of self-employment tax. Multiply line 5 by50% (.50). Enter the result here and on Form 1040, line 27 ■ . . . | 6 I 51I

For Paperwork Reduction Act Notice, see Form 1040 instructions(HTA)

1a

1b

2

3

4

5

(

723

723

668

102

)

Schodule SE (Form 1040) 2009

Form 8917

Department of the Treasury

Internal Revenue Service

Tuition and Fees Deduction

*■ See Instructions.

Attach to Form 1040 or Form 1040A.

OMB No 154S-0074

Attachment

Sequence No. 163

!our social security number

Before you begin: V 11 o see if you qualify tor Ms deduction, see who Can Take me Deduct*, ,n (he instructions

1 (a) Student's name (as shown on page 1 of your tax return)

First name Last name

Dennis

for line 36.

(b) Student's social securityynumber (as shown on page

1f

2 Add the amounts on line 1, column (c). and enter the total

3 Enter the amount from Form 1040. line 22, or Form 1040A. line 15

4 Enter the total from either:

• Form 1040. lines 23 through 33, plus any write-in adjustmentsentered on the dotted line next to Form 1040, line 36. or

• Form 1040A. lines 16 through 18

66,022

51

5 Subtract line 4 from line 3.* If the result is more than $80,000 ($160,000 if married filing jointly)stop; you cannot take the deduction for tuition and fees

^HS f7m 25,55; v555^' °r 4563' or you are exdudin9 income from Puerto RicoEffect of the Amount of Your Income on the Amount of Your Deduction in Pub 970ter 7. to figure the amount to enter on line 5.

see

chapter 7

6 Tuition and fees deduction. Is the amount on line 5 more than $65,000 ($130 000 if marriedfiling jointly)? '

I"x1 Yes. Enter the smaller of line 2, or $2,000. "\

□ No. Enter the smaller of line 2, or $4,000. J

Also enter this amount on Form 1040, line 34, or Form 1040A, line 19.

(c) Qualified

expenses(see

4.16C

65.971

2.000

For Paperwork Reduction Act Notice, see page 3.(HTA) Form 8917 (2009)

SCHEDULE M

(Form 1040A or 1040)

Dopartmonl of tha Treasury

Internal Revenue Service (99)

Making Work Pay and Government

Retiree Credits

► Attach to Form 1040'A, 1040, or 1040NR. ► See separate Instructions.

OMB No. 1545-0074

09Altachmenl

Sequence No. 166

Name(s) shown on return

lalmpoTOm^^TfWTOlructions if you can be claimed as someone else's dependent or are filing Form 1040NR.Check the 'No' box below and see the instructions if (a) you have a net loss from a business, (b) you received

a taxable scholarship or fellowship grant not reported on a Form W-2, (c) your wages include pay for work

performed while an inmate in a penal institution, (d) you received a pension or annuity from a nonqualified

deferred compensation plan or a nongovernmental section 457 plan, or (e) you are filing Form 2555 or 2555-EZ

Do you (and your spouse if filing jointly) have 2009 wages of more than $6,451 ($12,903 if married filing jointly)?

[x] Yes. Skip lines 1a through 3. Enter $400 ($800 if married filing jointly) on line 4 and go to line 5.

| | No. Enter your earned income (see instructions)

b Nontaxable combat pay incW^Sff^f^^^line 1a (see instructions) I 1b I

2 Multiply line 1a by 6.2% (.062). . . .

3 Enter $400 ($800 if married filing jointly)

1a

4 Enter the smaller of line 2 or line 3 (unless you checked "Yes" on line 1a)

5 Enter the amount from Form 1040, line 38*. or Form 1040A, line 22 .

6 Enter $75,000 ($150,000 if married filing jointly)

7 Is the amount on line 5 more than the amount on line 6?

[x] No. Skip line 8. Enter the amount from line 4 on line 9 below.

Q Yes. Subtract line 6 from line 5

63,971

75.000

8 Multiply line 7 by 2% (.02)

9 Subtract line 8 from line 4. If zero or less, enter -0-

10 Did you (or your spouse, if filing jointly) receive an economic recovery payment in 2009? You

may have received this payment if you received social security benefits, supplemental security

income, railroad retirement benefits, or veterans disability compensation or pension benefits (see

instructions).

[x] No. Enter -0- on line 10 and go to line 11. "|

□ Yes. Enter the total of the payments received by you (and your spouse, if filing r . . .

jointly). Do not enter more than $250 ($500 if married filing jointly) J

11 Did you (or your spouse, if filing jointly) receive a pension or annuity in 2009 for services performed

as an employee of the U.S. Government or any U.S. state or local government from work not

covered by social security? Do not include any pension or annuity reported on Form W-2.

[x] No. Enter -0- on line 11 and go to line 12.

□ Yes. • If you checked "No" on line 10, enter $250 ($500 if married filing jointly

and the answer on line 11 is "Yes" for both spouses)

• If you checked "Yes" on line 10, enter -0- (exception: enter $250 if filing

jointly and the spouse who received the pension or annuity did not receive

an economic recovery payment described on line 10)

12 Add lines 10 and 11

13 Subtract line 12 from line 9. If zero or less, enter-0

14 Making work pay and government retiree credits. Add lines 11 and 13. Enter the result here

and on Form 1040, line 63; Form 1040A, line 40; or Form 1040NR, line 60

Your social security number

10

11

12

13

14

400

400

400

400

•|f you are filing Form 2555. 2555-EZ. or 4563 or you are excluding income from Puerto Rico, see instructions.

Schedule M (Form 1040A or 1040) 2009For Paperwork Reduction Act Notice, see Form 1040A, 1040, or

1040NR instructions.

(HTA)