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 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
Nadia Superville 740-58-5930
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
3102 Newkirk Ave 2G 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
Brooklyn NY 11210 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 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 Dylan N Solomon 659-37-1837 Son
dependents,
see instructions
and check
here . .

Income 1a Total amount from Form(s) W-2, box 1 (see instructions) . . . . . . . . . . . . . 1a 12,897.
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 0.
W-2, see
instructions.
i Nontaxable combat pay election (see instructions) . . . . . . . 1i
z Add lines 1a through 1h . . . . . . . . . . . . . . . . . . . . . . 1z 12,897.
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 b Taxable amount . . . . . . 5b
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
jointly or
Qualifying 9 Add lines 1z, 2b, 3b, 4b, 5b, 6b, 7, and 8. This is your total income . . . . . . . . . . 9 12,897.
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 12,897.
household,
$19,400 12 Standard deduction or itemized deductions (from Schedule A) . . . . . . . . . . 12 19,400.
• 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 19,400.
Deduction, 15 Subtract line 14 from line 11. If zero or less, enter -0-. This is your taxable income . . . . .
see instructions.
15 0.

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

Tax and 16 Tax (see instructions). Check if any from Form(s): 1 8814 2 4972 3 . . 16 0.
Credits 17 Amount from Schedule 2, line 3 . . . . . . . . . . . . . . . . . . . . 17
18 Add lines 16 and 17 . . . . . . . . . . . . . . . . . . . . . . . . 18 0.
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 0.
23 Other taxes, including self-employment tax, from Schedule 2, line 21 . . . . . . . . . 23 0.
24 Add lines 22 and 23. This is your total tax . . . . . . . . . . . . . . . . . 24 0.
Payments 25 Federal income tax withheld from:
a Form(s) W-2 . . . . . . . . . . . . . . . . . . 25a 1,363.
b Form(s) 1099 . . . . . . . . . . . . . . . . . . 25b
c Other forms (see instructions) . . . . . . . . . . . . . 25c
d Add lines 25a through 25c . . . . . . . . . . . . . . . . . . . . . . 25d 1,363.
26 2022 estimated tax payments and amount applied from 2021 return . . . . . . . . . . 26
If you have a
qualifying child, 27 Earned income credit (EIC) . . . . . . . . . . . . . . 27 3,733.
attach Sch. EIC.
28 Additional child tax credit from Schedule 8812 . . . . . . . . 28 1,500.
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 5,233.
33 Add lines 25d, 26, and 32. These are your total payments . . . . . . . . . . . . 33 6,596.
34 If line 33 is more than line 24, subtract line 24 from line 33. This is the amount you overpaid . . 34 6,596.
Refund
35a Amount of line 34 you want refunded to you. If Form 8888 is attached, check here . . . . 35a 6,596.
Direct deposit? b Routing number 0 2 1 0 0 0 0 2 1 c Type: Checking Savings
See instructions.
d Account number 5 0 7 7 5 2 0 3 5
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
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? PC Technician (see inst.)
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. (718)419-4492 Email address

Preparer’s name Preparer’s signature Date PTIN Check if:
Paid Self-employed
Preparer
Firm’s name Self-Prepared Phone no.
Use Only
Firm’s address Firm’s EIN
Go to www.irs.gov/Form1040 for instructions and the latest information. BAA REV 03/22/23 Intuit.cg.cfp.sp Form 1040 (2022)
SCHEDULE EIC Earned Income Credit OMB No. 1545-0074
(Form 1040) Qualifying Child Information
Complete and attach to Form 1040 or 1040-SR only if you have a qualifying child.
2022
Department of the Treasury Attachment
Go to www.irs.gov/ScheduleEIC for the latest information. Sequence No. 43
Internal Revenue Service
Name(s) shown on return Your social security number
Nadia Superville 740-58-5930
If you are separated from your spouse, filing a separate return, and meet the requirements to claim the EIC (see instructions), check here

Before you begin: • See the instructions for Form 1040, line 27, to make sure that (a) you can take the EIC, and (b) you have a
qualifying child.
• Be sure the child’s name on line 1 and social security number (SSN) on line 2 agree with the child’s social
security card. Otherwise, at the time we process your return, we may reduce your EIC. If the name or SSN on
the child’s social security card is not correct, call the Social Security Administration at 800-772-1213.
• If you have a child who meets the conditions to be your qualifying child for purposes of claiming the EIC, but that
child doesn’t have an SSN as defined in the instructions for Form 1040, line 27, see the instructions.
• You can’t claim the EIC for a child who didn’t live with you for more than half of the year.

F
!
CAUTION
• If your child doesn’t have an SSN as defined in the instructions for Form 1040, line 27, see the instructions.
• If you take the EIC even though you are not eligible, you may not be allowed to take the credit for up to 10 years. See the instructions for details.
• It will take us longer to process your return and issue your refund if you do not fill in all lines that apply for each qualifying child.

Qualifying Child Information Child 1 Child 2 Child 3

1 Child’s name First name Last name First name Last name First name Last name

If you have more than three qualifying

children, you have to list only three to get
the maximum credit. Dylan N Solomon
2 Child’s SSN
The child must have an SSN as defined in
the instructions for Form 1040, line 27,
unless the child was born and died in 2022
or you are claiming the self-only EIC (see
instructions). If your child was born and
died in 2022 and did not have an SSN,
enter “Died” on this line and attach a copy
of the child’s birth certificate, death
certificate, or hospital medical records
showing a live birth. 659-37-1837
3 Child’s year of birth Year 2 0 1 5 Year Year
If born after 2003 and the child is If born after 2003 and the child is If born after 2003 and the child is
younger than you (or your spouse, younger than you (or your spouse, younger than you (or your spouse,
if filing jointly), skip lines 4a and if filing jointly), skip lines 4a and if filing jointly), skip lines 4a and
4b; go to line 5. 4b; go to line 5. 4b; go to line 5.

4a Was the child under age 24 at the end of

2022, a student, and younger than you (or Yes. No. Yes. No. Yes. No.
your spouse, if filing jointly)?
Go to Go to line 4b. Go to Go to line 4b. Go to Go to line 4b.
line 5. line 5. line 5.
b Was the child permanently and totally
disabled during any part of 2022? Yes. No. Yes. No. Yes. No.
Go to The child is not a Go to The child is not a Go to The child is not a
line 5. qualifying child. line 5. qualifying child. line 5. qualifying child.
5 Child’s relationship to you
(for example, son, daughter, grandchild,
niece, nephew, eligible foster child, etc.)
Son
6 Number of months child lived
with you in the United States
during 2022
• If the child lived with you for more than
half of 2022 but less than 7 months,
enter “7.”
• If the child was born or died in 2022 and
your home was the child’s home for more 12 months months months
than half the time he or she was alive Do not enter more than 12 Do not enter more than 12 Do not enter more than 12
during 2022, enter “12.” months. months. months.
For Paperwork Reduction Act Notice, see your tax return instructions. BAA REV 03/22/23 Intuit.cg.cfp.sp Schedule EIC (Form 1040) 2022
SCHEDULE 8812 Credits for Qualifying Children OMB No. 1545-0074
(Form 1040) and Other Dependents
Attach to Form 1040, 1040-SR, or 1040-NR.
2022
Department of the Treasury Attachment
Internal Revenue Service Go to www.irs.gov/Schedule8812 for instructions and the latest information. Sequence No. 47
Name(s) shown on return Your social security number
Nadia Superville 740-58-5930
Part I Child Tax Credit and Credit for Other Dependents
1 Enter the amount from line 11 of your Form 1040, 1040-SR, or 1040-NR . . . . . . . . . . . . 1 12,897.
2a Enter income from Puerto Rico that you excluded . . . . . . . . . . . 2a
b Enter the amounts from lines 45 and 50 of your Form 2555 . . . . . . . . 2b 0.
c Enter the amount from line 15 of your Form 4563 . . . . . . . . . . . 2c
d Add lines 2a through 2c . . . . . . . . . . . . . . . . . . . . . . . . . . . 2d 0.
3 Add lines 1 and 2d . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 12,897.
4 Number of qualifying children under age 17 with the required social security number 4 1
5 Multiply line 4 by $2,000 . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2,000.
6 Number of other dependents, including any qualifying children who are not under age
17 or who do not have the required social security number . . . . . . . . 6 0
Caution: Do not include yourself, your spouse, or anyone who is not a U.S. citizen, U.S. national, or U.S. resident
alien. Also, do not include anyone you included on line 4.
7 Multiply line 6 by $500 . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
8 Add lines 5 and 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 2,000.
9 Enter the amount shown below for your filing status.
• Married filing jointly—$400,000
• All other filing statuses—$200,000 } . . . . . . . . . . . . . . . . . . . . . . 9 200,000.
10 Subtract line 9 from line 3.

}
• If zero or less, enter -0-.
• If more than zero and not a multiple of $1,000, enter the next multiple of $1,000. For
example, if the result is $425, enter $1,000; if the result is $1,025, enter $2,000, etc. . . . . . . . 10 0.
11 Multiply line 10 by 5% (0.05) . . . . . . . . . . . . . . . . . . . . . . . . . 11 0.
12 Is the amount on line 8 more than the amount on line 11? . . . . . . . . . . . . . . . . . 12 2,000.
No. STOP. You cannot take the child tax credit, credit for other dependents, or additional child tax credit.
Skip Parts II-A and II-B. Enter -0- on lines 14 and 27.
Yes. Subtract line 11 from line 8. Enter the result.
13 Enter the amount from the Credit Limit Worksheet A . . . . . . . . . . . . . . . . . 13 0.
14 Enter the smaller of line 12 or 13. This is your child tax credit and credit for other dependents . . . . . 14 0.
Enter this amount on Form 1040, 1040-SR, or 1040-NR, line 19.
If the amount on line 12 is more than the amount on line 14, you may be able to take the additional child tax credit
on Form 1040, 1040-SR, or 1040-NR, line 28. Complete your Form 1040, 1040-SR, or 1040-NR through line 27
(also complete Schedule 3, line 11) before completing Part II-A.
For Paperwork Reduction Act Notice, see your tax return instructions. BAA REV 03/22/23 Intuit.cg.cfp.sp Schedule 8812 (Form 1040) 2022
Schedule 8812 (Form 1040) 2022 Page 2
Part II-A Additional Child Tax Credit for All Filers
Caution: If you file Form 2555, you cannot claim the additional child tax credit.
15 Check this box if you do not want to claim the additional child tax credit. Skip Parts II-A and II-B. Enter -0- on line 27 . . . . .
16a Subtract line 14 from line 12. If zero, stop here; you cannot take the additional child tax credit. Skip Parts II-A
and II-B. Enter -0- on line 27 . . . . . . . . . . . . . . . . . . . . . . . . . 16a 2,000.
b Number of qualifying children under 17 with the required social security number: 1 x $1,500.
Enter the result. If zero, stop here; you cannot claim the additional child tax credit. Skip Parts II-A and II-B.
Enter -0- on line 27 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16b 1,500.
TIP: The number of children you use for this line is the same as the number of children you used for line 4.
17 Enter the smaller of line 16a or line 16b . . . . . . . . . . . . . . . . . . . . . . 17 1,500.
18a Earned income (see instructions) . . . . . . . . . . . . . . . . 18a 12,897.
b Nontaxable combat pay (see instructions) . . . . . . 18b
19 Is the amount on line 18a more than $2,500?
No. Leave line 19 blank and enter -0- on line 20.
Yes. Subtract $2,500 from the amount on line 18a. Enter the result . . . . 19 10,397.
20 Multiply the amount on line 19 by 15% (0.15) and enter the result . . . . . . . . . . . . . . 20 1,560.
Next. On line 16b, is the amount $4,500 or more?
No. If you are a bona fide resident of Puerto Rico, go to line 21. Otherwise, skip Part II-B and enter the
smaller of line 17 or line 20 on line 27.
Yes. If line 20 is equal to or more than line 17, skip Part II-B and enter the amount from line 17 on line 27.
Otherwise, go to line 21.
Part II-B Certain Filers Who Have Three or More Qualifying Children and Bona Fide Residents of Puerto Rico
21 Withheld social security, Medicare, and Additional Medicare taxes from Form(s) W-2,
boxes 4 and 6. If married filing jointly, include your spouse’s amounts with yours. If
your employer withheld or you paid Additional Medicare Tax or tier 1 RRTA taxes, see
instructions . . . . . . . . . . . . . . . . . . . . . . . 21
22 Enter the total of the amounts from Schedule 1 (Form 1040), line 15; Schedule 2 (Form
1040), line 5; Schedule 2 (Form 1040), line 6; and Schedule 2 (Form 1040), line 13 . 22
23 Add lines 21 and 22 . . . . . . . . . . . . . . . . . . . . 23
24 1040 and

}
1040-SR filers: Enter the total of the amounts from Form 1040 or 1040-SR, line 27,
and Schedule 3 (Form 1040), line 11.
1040-NR filers: Enter the amount from Schedule 3 (Form 1040), line 11. 24
25 Subtract line 24 from line 23. If zero or less, enter -0- . . . . . . . . . . . . . . . . . . 25
26 Enter the larger of line 20 or line 25 . . . . . . . . . . . . . . . . . . . . . . . 26
Next, enter the smaller of line 17 or line 26 on line 27.
Part II-C Additional Child Tax Credit
27 This is your additional child tax credit. Enter this amount on Form 1040, 1040-SR, or 1040-NR, line 28 . . 27 1,500.
REV 03/22/23 Intuit.cg.cfp.sp Schedule 8812 (Form 1040) 2022
BAA
 REV 01/27/23 INTUIT.CG.CFP.SP

IT-201
Department of Taxation and Finance

Resident Income Tax Return

New York State • New York City • Yonkers • MCTMT
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740585930
Federal income and adjustments
Whole dollars only

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25 7D[DEOHUHIXQGVFUHGLWVRURႇVHWVRIVWDWHDQGORFDOLQFRPHWD[HV(from line 4) 25 .

26 3HQVLRQVRI1<6DQGORFDOJRYHUQPHQWVDQGWKHIHGHUDOJRYHUQPHQW 26 .
27 7D[DEOHDPRXQWRI6RFLDO6HFXULW\EHQH¿WV(from line 15) ... 27 .
28 ,QWHUHVWLQFRPHRQ86JRYHUQPHQWERQGV ..................... 28 .
29 3HQVLRQDQGDQQXLW\LQFRPHH[FOXVLRQ ............................ 29 .
30 New York’sFROOHJHVDYLQJVSURJUDPGHGXFWLRQHDUQLQJV 30 .
31 Other (Form IT-225, line 18) ................................................. 31 .
32 $GGOLQHVWKURXJK ............................................................................................................. 32 .
33 New York adjusted gross income (subtract line 32 from line 24) ................................................. 33 12897 .

Standard deduction or itemized deduction

34 (QWHU\RXUstandard deduction or\RXUitemized deduction (from Form IT-196)

0DUNDQX LQWKHDSSURSULDWHER[ Standard - or - Itemized 34 11200 .
35 6XEWUDFWOLQHIURPOLQH(if line 34 is more than line 33, leave blank) ......................................... 35 1697 .
36 'HSHQGHQWH[HPSWLRQV(enter the number of dependents listed in item H) ........................................ 36 1 000.00
37 Taxable income (subtract line 36 from line 35) .............................................................................. 37 697 .
201002224555
1DPH V DVVKRZQRQSDJH <RXU6RFLDO6HFXULW\QXPEHU IT-201   Page 3RI
NADIA SUPERVILLE 740585930 REV 01/27/23 INTUIT.CG.CFP.SP

Tax computation, credits, and other taxes

38 Taxable income (from line 37 on page 2) ....................................................................................... 38 697 .
39 1<6WD[RQOLQHDPRXQW.......................................................................................................... 39 27 .
40 1<6KRXVHKROGFUHGLW ........................................................ 40 75 .
41 5HVLGHQWFUHGLW .................................................................. 41 .

NO HANDWRITTEN ENTRIES, OTHER THAN SIGNATURE, ON THIS FORM

42 2WKHU1<6QRQUHIXQGDEOHFUHGLWV(Form IT-201-ATT, line 7) ... 42 .
43 $GGOLQHVDQG.............................................................................................................. 43 75 .
44 6XEWUDFWOLQHIURPOLQH(if line 43 is more than line 39, leave blank) .......................................... 44 .
45 1HWRWKHU1<6WD[HV(Form IT-201-ATT, line 30) ............................................................................. 45 .
46 Total New York State taxes (add lines 44 and 45) ........................................................................ 46 .
New York City and Yonkers taxes, credits, and surcharges, and MCTMT

47 1<&WD[DEOHLQFRPH ......................................................... 47 697 .

47a 1<&UHVLGHQWWD[RQOLQHDPRXQW ................................ 47a 21 . See instructions to
compute New York City and
48 1<&KRXVHKROGFUHGLW ...................................................... 48 60 . Yonkers taxes, credits, and
49 6XEWUDFWOLQHIURPOLQHD(if line 48 is more than surcharges, and MCTMT.
line 47a, leave blank) ........................................................ 49 .
50 3DUW\HDU1<&UHVLGHQWWD[(Form IT-360.1) ....................... 50 .
51 2WKHU1<&WD[HV(Form IT-201-ATT, line 34) ........................ 51 .
52 $GGOLQHVDQG .................................................. 52 .
53 1<&QRQUHIXQGDEOHFUHGLWV(Form IT-201-ATT, line 10) ........ 53 .
54 6XEWUDFWOLQHIURPOLQH (if line 53 is more than
line 52, leave blank) ......................................................... 54 .
54a MCTMT net
   HDUQLQJVEDVH .... 54a .
54b MCTMT ............................................................................ 54b .
55 <RQNHUVUHVLGHQWLQFRPHWD[VXUFKDUJH .......................... 55 .
56 <RQNHUVQRQUHVLGHQWHDUQLQJVWD[(Form Y-203) ............... 56 .
57 3DUW\HDU<RQNHUVUHVLGHQWLQFRPHWD[VXUFKDUJH(Form IT-360.1) 57 .
58 Total New York City and Yonkers taxes / surcharges and MCTMT (add lines 54 and 54b through 57) .. 58 .

59 Sales or use tax (do not leave blank) ......................................................................................... 59 0 .

60 Voluntary contributions (Form IT-227, Part 2, line 1) ................................................................... 60 .

61 Total New York State, New York City, Yonkers, and sales or use taxes, MCTMT, and
voluntary contributions (add lines 46, 58, 59, and 60) ............................................................. 61 .

201003224555
Page 4RI IT-201  REV 01/27/23 INTUIT.CG.CFP.SP <RXU6RFLDO6HFXULW\QXPEHU
740585930
62 (QWHUDPRXQWIURPOLQH ........................................................................................................... 62 .
Payments and refundable credits
63 (PSLUH6WDWHFKLOGFUHGLW .................................................. 63 330 .
64 1<61<&FKLOGDQGGHSHQGHQWFDUHFUHGLW ...................... 64 .
65 1<6HDUQHGLQFRPHFUHGLW (,&  ............................... 65 1093 .
66 1<6QRQFXVWRGLDOSDUHQW(,& .......................................... 66 .
67 5HDOSURSHUW\WD[FUHGLW .................................................... 67 .

NO HANDWRITTEN ENTRIES, OTHER THAN SIGNATURE, ON THIS FORM

68 &ROOHJHWXLWLRQFUHGLW......................................................... 68 .
69 1<&VFKRROWD[FUHGLW ¿[HGDPRXQW (also complete F on page 1) 69 63 .
69a 1<&VFKRROWD[FUHGLW UDWHUHGXFWLRQDPRXQW ................. 69a 1 .
70 1<&HDUQHGLQFRPHFUHGLW ........................................ 70 933 .
70a 7KLVOLQHLQWHQWLRQDOO\OHIWEODQN ........................................ 70a
71 2WKHUUHIXQGDEOHFUHGLWV (Form IT-201-ATT, line 18) ............. 71 . ,IDSSOLFDEOHFRPSOHWH Form(s) IT-2
72 Total New York StateWD[ZLWKKHOG ................................... 72 608 . and/or IT-1099-RDQGVXEPLWWKHP
ZLWK\RXUUHWXUQ
73 Total New York CityWD[ZLWKKHOG ..................................... 73 431 .
Do not send federal Form W-2
74 Total YonkersWD[ZLWKKHOG............................................... 74 . with your return.
75 7RWDOHVWLPDWHGWD[SD\PHQWVandDPRXQWSDLGZLWK)RUP,7 75 .
76 Total payments (add lines 63 through 75) ..................................................................................... 76 3459 .

Your refund, amount you owe, and account information

77 Amount overpaid (if line 76 is more than line 62, subtract line 62 from line 76) ................................ 77 3459 .
78 $PRXQWRIOLQHavailable for refund (subtract line 79 from line 77) .......................................... 78 3459 .
TIP:8VHWKLVDPRXQWWRFKHFN\RXUUHIXQGVWDWXVRQOLQH
78a $PRXQWRIOLQHWKDW\RXZDQWWRGHSRVLWLQWRD1<6DFFRXQW(Form IT-195, line 4) (also submit Form IT-195) 78a .
78b 7RWDOUHIXQGDIWHU1<6DFFRXQWGHSRVLW(subtract line 78a from line 78) .................................. 78b 3459 .
direct depositWRFKHFNLQJRU paper
Mark one refund choice: VDYLQJVDFFRXQW ¿OOLQOLQH - or - check Refund?'LUHFWGHSRVLWLVWKH
HDVLHVWIDVWHVWZD\WRJHW\RXU
79 $PRXQWRIOLQHWKDW\RXZDQWDSSOLHGWR\RXU UHIXQG
   HVWLPDWHGWD[(see instructions) ....................................... 79 . See instructions for payment
80 $PRXQW\RXowe (if line 76 is less than line 62, subtract line 76 from line 62). 7RSD\E\HOHFWURQLF options.
   IXQGVZLWKGUDZDOPDUNDQXLQWKHER[ DQG ¿OOLQOLQHVDQG,I\RXSD\E\FKHFN
   RUPRQH\RUGHU\RXmustFRPSOHWH)RUP,79DQGPDLOLWZLWK\RXUUHWXUQ .................. 80 .
81 (VWLPDWHGWD[SHQDOW\(include this amount in line 80 or
reduce the overpayment on line 77) .................................... 81 . See instructions for the proper
82 2WKHUSHQDOWLHVDQGLQWHUHVW ............................................. 82 . assembly of your return.
83 $FFRXQWLQIRUPDWLRQIRUGLUHFWGHSRVLWRUHOHFWURQLFIXQGVZLWKGUDZDO.
  ,IWKHIXQGVIRU\RXUSD\PHQW RUUHIXQG ZRXOGFRPHIURP RUJRWR DQDFFRXQWRXWVLGHWKH86PDUNDQXLQWKLVER[ ............
83a $FFRXQWW\SH 3HUVRQDOFKHFNLQJ - or - 3HUVRQDOVDYLQJV - or - %XVLQHVVFKHFNLQJ - or - %XVLQHVVVDYLQJV

83b 5RXWLQJQXPEHU 021000021 83c $FFRXQWQXPEHU 507752035

84 (OHFWURQLFIXQGVZLWKGUDZDO..................................... 'DWH $PRXQW .

Third-party  3ULQWGHVLJQHH¶VQDPH 'HVLJQHH¶VSKRQHQXPEHU 3HUVRQDOLGHQWL¿FDWLRQ

QXPEHU 3,1
designee? (see instr.) ( )
Yes No  (PDLO

ź Paid preparer must complete ź 3UHSDUHU¶V1<735,1 1<735,1

ź Taxpayer(s) must sign here ź
(see instructions) excl. code
3UHSDUHU¶VVLJQDWXUH 3UHSDUHU¶VSULQWHGQDPH <RXUVLJQDWXUH
SELF-PREPARED
)LUP¶VQDPH(or yours, if self-employed)   3UHSDUHU¶V37,1RU661 <RXURFFXSDWLRQ
PC TECHNICIAN
$GGUHVV   (PSOR\HULGHQWL¿FDWLRQQXPEHU 6SRXVH¶VVLJQDWXUHDQGRFFXSDWLRQ(if joint return)

Date 'DWH 'D\WLPHSKRQHQXPEHU

(
718 ) 419 4492
(PDLO (PDLO [email protected]
201004224555
See instructions for where to mail your return.
 REV 01/27/23 INTUIT.CG.CFP.SP

'HSDUWPHQWRI7D[DWLRQDQG)LQDQFH

Claim for Empire State Child Credit IT-213

Tax Law – Section 606(c-1)

Submit this form with Form IT-201 or IT-203.

Enter identifying information
YourQDPHDVVKRZQRQUHWXUQ <RXU6RFLDO6HFXULW\QXPEHU 661

NADIA SUPERVILLE 740585930

Spouse’s name 6SRXVH¶V661

Determine eligibility

1 :HUH\RX DQG\RXUVSRXVHLI¿OLQJDMRLQW1HZ<RUN6WDWHUHWXUQ 1HZ<RUN6WDWHUHVLGHQWVIRUWKHIXOO\HDU" 1 <HV 1R

,I\RXPDUNHGDQXLQWKHNo box, stop; \RXGRQRWTXDOLI\IRUWKLVFUHGLW

NO HANDWRITTEN ENTRIES ON THIS FORM

2 'LG\RXFODLPWKHIHGHUDOFKLOGWD[FUHGLWDGGLWLRQDOFKLOGWD[FUHGLWRUFUHGLWIRURWKHUGHSHQGHQWV"  2 <HV 1R

3 ,V\RXU1<UHFRPSXWHGIHGHUDODGMXVWHGJURVVLQFRPHRQ)RUP,7OLQHD(see instructions)
– RUOHVVDQG\RXU¿OLQJVWDWXVLVdPDUULHG¿OLQJMRLQWUHWXUQ
– RUOHVVDQG\RXU¿OLQJVWDWXVLVcVLQJOHfKHDGRIKRXVHKROGRUgTXDOLI\LQJVXUYLYLQJVSRXVHor
– RUOHVVDQG\RXU¿OLQJVWDWXVLVePDUULHG¿OLQJVHSDUDWHUHWXUQ"  3 <HV 1R
  ,I\RXPDUNHGDQXLQWKHNoER[DWERWKOLQHVDQG stop;\RXGRQRWTXDOLI\IRUWKLVFUHGLW

4 (QWHUWKHQXPEHURIFKLOGUHQZKRTXDOLI\IRUWKHfederalFKLOGWD[FUHGLWDGGLWLRQDOFKLOGWD[FUHGLWRU
   FUHGLWIRURWKHUGHSHQGHQWV(see instructions)  4 1

5 (QWHUWKHQXPEHURIFKLOGUHQIURPOLQHWKDWZHUHat least four but less than 17\HDUVRIDJHRQ'HFHPEHU 5 1

,I\RXHQWHUHG 0RQOLQHstop\RXGRQRWTXDOLI\IRUWKLVFUHGLW

Enter child information

/LVWEHORZWKHQDPH661RULQGLYLGXDOWD[SD\HULGHQWL¿FDWLRQQXPEHU ,7,1 DQGGDWHRIELUWKIRUHDFKFKLOGLQFOXGHGRQOLQH

'DWHRIELUWK
)LUVWQDPH MI /DVWQDPH 6Xႈ[ 661RU,7,1
(mmddyyyy)

DYLAN N SOLOMON 659371837 08262015

Use Form IT-213-ATT if you have additional children to report.

213001224555
3DJH of 2 IT-213  REV 01/27/23 INTUIT.CG.CFP.SP

Compute credit
,I\RXDQVZHUHGYesWRTXHVWLRQ\RXPXVWFRPSOHWH:RUNVKHHW$or B and:RUNVKHHW&LQWKHLQVWUXFWLRQVEHIRUH\RXFRQWLQXHZLWK
OLQH

,I\RXDQVZHUHGNoWRTXHVWLRQVNLSOLQHVWKURXJKDQGHQWHU0RQOLQHFRQWLQXHZLWKOLQH
Whole dollars only

6 (QWHUWKHDPRXQWIURP:RUNVKHHW$OLQHRU:RUNVKHHW%OLQH(see instructions) 6 0 .

7 (QWHU\RXUDGGLWLRQDOFKLOGWD[FUHGLWDPRXQWIURP:RUNVKHHW&(see instructions) 7 1000 .

8 $GGOLQHVDQG 8 1000 .

  ,IWKHDPRXQWRQOLQHLV]HURVNLSOLQHVWKURXJKDQGHQWHU0RQOLQHFRQWLQXHZLWKOLQH
  ,IWKHDPRXQWRQOLQHLVPRUHWKDQ]HURFRQWLQXHZLWKOLQH

9 (QWHUWKHQXPEHURIFKLOGUHQIURPOLQH 9 1

NO HANDWRITTEN ENTRIES ON THIS FORM

10 'LYLGHOLQHE\OLQH 10 1000 .

11 (QWHUWKHQXPEHURIFKLOGUHQIURPOLQH 11 1

12 0XOWLSO\OLQHE\OLQH 12 1000 .

13 0XOWLSO\OLQHE\   13 330 .

,I\RXPDUNHGWKHNoER[RQOLQHVNLSOLQHVDQGDQGHQWHUWKHDPRXQWIURPOLQHRQOLQH
All others continue with line 14.

14 (QWHUWKHQXPEHURIFKLOGUHQIURPOLQH 14 1

15 0XOWLSO\OLQHE\ 15 100 .

16 (PSLUH6WDWHFKLOGFUHGLW(enter the amount from line 13 or line 15, whichever is greater) 16 330 .

,I\RX¿OHGDMRLQWIHGHUDOUHWXUQEXWDUHUHTXLUHGWR¿OHVHSDUDWH1HZ<RUN6WDWHUHWXUQVFRQWLQXHZLWK
OLQHVDQG$OORWKHUVHQWHUWKHOLQHDPRXQWRQ)RUP,7OLQH

6SRXVHVUHTXLUHGWR¿OHVHSDUDWH1HZ<RUN6WDWHUHWXUQV(see instructions)

17 (QWHUWKHIXOO\HDUUHVLGHQWVSRXVH¶VVKDUHRIWKHOLQHDPRXQWGRQRWOHDYHOLQHEODQN 17 .
(QWHUKHUHDQGRQ)RUP,7OLQH

18 (QWHUWKHSDUW\HDUUHVLGHQWRUQRQUHVLGHQWVSRXVH¶VVKDUHRIWKHOLQHDPRXQW
  GRQRWOHDYHOLQHEODQN  18 .
  (QWHUWKHOLQHDPRXQWDQGFRGH213 RQ)RUP,7$77OLQH

213002224555
 REV 01/27/23 INTUIT.CG.CFP.SP

Department of Taxation and Finance

Claim for Earned Income Credit IT-215

New York State • New York City
Tax Law - Section 606(d)

Submit this form with Form IT-201 or IT-203.

1DPH V DVVKRZQRQUHWXUQ <RXU6RFLDO6HFXULW\QXPEHU
NADIA SUPERVILLE 740585930

1 Did you claim the federal earned income credit? ......................................................................................................... 1 Yes No
1a 'LG\RX¿OHD1<6)RUP,7" ................................................................................................................................. 1a Yes No
If No, on lines 1 and 1a, stop; you do not qualify for these credits.
All others: See instructions.
2 Is your investment income (see instructions) greater than $10,300? If Yes, stop; you do not qualify for these credits. ..... 2 Yes No
3 +DYH\RXDOUHDG\¿OHG\RXU1HZ<RUN6WDWHLQFRPHWD[UHWXUQ",IYes\RXPXVW¿OHDQDPHQGHG1<6UHWXUQ........ 3 Yes No
4 'LG\RXFODLPTXDOLI\LQJFKLOGUHQRQ\RXUfederal Schedule EIC? If No, continue with line 5.
If YesLQWKHVSDFHVEHORZOLVWXSWRWKUHHRIWKHVDPHFKLOGUHQ\RXFODLPHGRQIHGHUDO6FKHGXOH(,&................ 4 Yes No
If you claimed more than three, see instructions.

NO HANDWRITTEN ENTRIES ON THIS FORM

)LUVWQDPH 0, /DVWQDPH 6Xႈ[ 5HODWLRQVKLS

1st DYLAN N SOLOMON SON

Child No. of months Full-time Person with
6RFLDO6HFXULW\QXPEHU 'DWHRIELUWK(mmddyyyy)
lived with you 12 student* GLVDELOLW\ 659371837 08262015
)LUVWQDPH 0, /DVWQDPH 6Xႈ[ 5HODWLRQVKLS

2nd
Child No. of months Full-time Person with
6RFLDO6HFXULW\QXPEHU 'DWHRIELUWK(mmddyyyy)
lived with you student* GLVDELOLW\
)LUVWQDPH 0, /DVWQDPH 6Xႈ[ 5HODWLRQVKLS

3rd
Child No. of months Full-time Person with
6RFLDO6HFXULW\QXPEHU 'DWHRIELUWK(mmddyyyy)
lived with you student* GLVDELOLW\

* Mark an XLQWKHVHER[HVonly if you checked YesLQWKHVDPHER[RQ\RXUIHGHUDO6FKHGXOH(,& ER[DRUE 

5 ,VWKH,56¿JXULQJ\RXUfederal earned income credit (EIC) for you? If Yes, complete lines 6 through 9 (also lines 21,
23, and 24 if you are a part-year New York State resident, and line 28 if you are a part-year New York City resident).
7KH7D['HSDUWPHQWZLOOFRPSXWH\RXU1HZ <RUN6WDWHDQGLIDSSOLFDEOH\RXU1HZ<RUN&LW\HDUQHGLQFRPHFUHGLW
for you. If No, complete lines 6 through 17 (and lines 18 through 26 if you are a part-year New York State resident).
New York City residents must complete Worksheet C, New York City earned income credit, in the instructions.
3DUW\HDU1HZ<RUN&LW\UHVLGHQWVPXVWDOVRFRPSOHWHOLQH RQWKHEDFNRIWKLVFODLPIRUP ....................................... 5 Yes No
Whole dollars only

6 Wages, salaries, tips, etc., from Worksheet A line 3, in the instructions. ..................................................................... 6 12897 .00
7 Earned income adjustments (see instructions) ................................................................................................................. 7 0 .00
8 Business income or loss (see instructions) ....................................................................................................................... 8 .00
(PSOR\HULGHQWL¿FDWLRQQXPEHU(see instructions)...
9 Enter your recomputed federal adjusted gross income (from Form IT-201, line 19a, or Form IT-203, line 19a, Federal amount column) 9 12897 .00
10 Amount of federal EIC claimed or recomputed federal EIC (see instructions) ........................................................... 10 3733 .00
11 New York State earned income credit (NYS EIC) rate 30% (.30) ................................................................................. 11 .30
12 Tentative NYS EIC (multiply line 10 by line 11; see instructions) ........................................................................................... 12 1120 .00
Complete Worksheet B on the back page before continuing.
13 Enter the amount from Worksheet B,OLQHRQWKHEDFNRIWKLVIRUP................... 13 27 .00
14 New York State household credit (from Form IT-201, line 40, or Form IT-203, line 39) .. 14 75 .00
15 Enter the smaller of line 13 or line 14 ........................................................................................................................... 15 27 .00
16 Allowable New York State earned income credit (subtract line 15 from line 12; see instructions) .................................... 16 1093 .00
17 &RPSOHWHRQO\LI\RX¿OHG\RXUIHGHUDOUHWXUQDV0DUULHG¿OLQJMRLQWEXWDUHUHTXLUHGWR¿OH\RXU1HZ<RUN6WDWH
return as 0DUULHG¿OLQJVHSDUDWH (see instructions). ..................................................................................................... 17 .00
Joint NY recomputed federal adjusted gross income ....................................... .00

215001224555
3DJH of 2 IT-215  REV 01/27/23 INTUIT.CG.CFP.SP

Part-year New York State resident earned income credit

Lines 18 through 26 apply only to part-year New York State

residents claiming the New York State earned income credit.
18 Enter your New York State earned income credit (from line 16 or line 17) ........................................................................ 18 .00
19 Enter the amount from Form IT-203, line 42 ................................................................................................................. 19 .00
 ± ,IOLQHLVHTXDOWRRUPRUHWKDQOLQHstop.
20 6XEWUDFWOLQHIURPOLQH ......................................................................................................................................... 20 .00
21
Enter the amount from Form IT-203-ATT, line 31 ,I\RXGRQRWKDYHWR¿OH)RUP,7$77OHDYHEODQNDQGFRQWLQXHRQOLQHEHORZ  21 .00
 ± ,I)RUP,7OLQHLVHTXDOWRRUPRUHWKDQ)RUP,7OLQHstop. Do not continue
with this computation. (QWHUWKHDPRXQWIURPOLQHDERYHRQ)RUP,7$77OLQH
   ± ,I)RUP,7OLQHLVOHVVWKDQ)RUP,7OLQHHQWHUWKHDPRXQWIURPOLQHDERYHRQ
    )RUP,7$77OLQHDQGFRQWLQXHRQOLQHEHORZ
22 6XEWUDFWOLQHIURPOLQH .......................................................................................................................................... 22 .00

NO HANDWRITTEN ENTRIES ON THIS FORM

23 Amount from line 19, Column D, of 3DUW\HDUUHVLGHQWLQFRPHDOORFDWLRQZRUNVKHHW, in Form IT-203-I.
   ± ,I\RXGLGQRW¿OH1<6)RUP,7HQWHUWKLVDPRXQW(see instructions)
– ,I\RX¿OHG1<6)RUP,7DGGWRRUVXEWUDFWIURPWKLVDPRXQWDQ\DPRXQWVRQOLQH
and line 4 of /LQHD1HZ<RUN6WDWHDPRXQWFROXPQZRUNVKHHW, in Form IT-203-I
(that is related to your NYS resident period), and enter the result (see instructions) ..... 23 .00

24 Enter the amount from Form IT-203, line 19a, Federal amount column ....................... 24 .00

25 'LYLGHOLQHE\OLQH(round the result to the fourth decimal place). This amount cannot exceed 100% (1.0000) (see instr.) 25
26 0XOWLSO\OLQHE\OLQH(QWHUWKHUHVXOWKHUHDQGRQ)RUP,7$77OLQH .................................................. 26 .00

New York City earned income credit IXOO\HDUDQGSDUW\HDU1HZ<RUN&LW\UHVLGHQWV

27 Enter the amount from Worksheet C, here and on Form IT-201, line 70,
or Form IT-203-ATT, line 11. ..................................................................................................................................... 27 933 .00
   3DUW\HDU1HZ<RUN&LW\UHVLGHQWVPXVWDOVRFRPSOHWHOLQHEHORZ
28 Part-year New York City adjusted gross income
Enter the amounts from Worksheet C, lines 6 and 7 ........................................ 28A .00 28B .00

Worksheet B

1 New York State tax (from Form IT-201, line 39, or Form IT-203, line 38) ................................................................................ 1 27 .00
2 Resident credit (see instructions) .................................................................................... 2 .00
3 $FFXPXODWLRQGLVWULEXWLRQFUHGLW(see instructions) .......................................................... 3 .00
4 Add lines 2 and 3 .......................................................................................................................................................... 4 .00
5 6XEWUDFWOLQHIURPOLQH(If line 4 is more than line 1, enter 0.) Enter here and on line 13 on the front of this form. ......... 5 27 .00

215002224555
 REV 01/27/23 INTUIT.CG.CFP.SP

IT-2
Department of Taxation and Finance

Summary of W-2 Statements

New York State • New York City • Yonkers
Do not detach or separateWKH:5HFRUGVEHORZ)LOH)RUP,7DVDQHQWLUHSDJHZLWK\RXUUHWXUQ6HHLQVWUXFWLRQVRQWKHEDFN
Box c Employer’s information
W-2 Record 1 Employer’s name

Box a Employee’s 6RFLDO6HFXULW\QXPEHU BROOKDALE HOSPITAL MEDICAL CENTER

for this W-2 Record Employer’s address (number and street)
740585930 10101 AVENUE D
Box b (PSOR\HULGHQWL¿FDWLRQQXPEHU (,1 &LW\ 6WDWH =,3FRGH &RXQWU\

111631746 BROOKLYN NY 11236-1902

Box 1 Wages, tips, other compensation Box 12a $PRXQW &RGH Box 14a $PRXQW 'HVFULSWLRQ
12897 .00 .00 .00
Box 8 Allocated tips Box 12b $PRXQW &RGH Box 14b $PRXQW 'HVFULSWLRQ
.00 .00 .00
Box 10 'HSHQGHQWFDUHEHQH¿WV Box 12c $PRXQW &RGH Box 14c $PRXQW 'HVFULSWLRQ
.00 .00 .00

NO HANDWRITTEN ENTRIES ON THIS FORM

Box 11 1RQTXDOL¿HGSODQV Box 12d $PRXQW &RGH Box 14d $PRXQW 'HVFULSWLRQ
.00 .00 .00

Box 13 6WDWXWRU\HPSOR\HH Retirement plan 7KLUGSDUW\VLFNSD\ &RUUHFWHG :F

Box 16a 1<6ZDJHVWLSVHWF Box 17a 1<6LQFRPHWD[ZLWKKHOG
NY6WDWHLQIRUPDWLRQ Box 15a
1<6WDWH N Y 12897 .00 608 .00
Box 16b 2WKHUVWDWHZDJHVWLSVHWF Box 17b 2WKHUVWDWHLQFRPHWD[ZLWKKHOG
OtherVWDWHLQIRUPDWLRQ Box 15b
other state .00 .00

NYC and Yonkers Box 18 /RFDOZDJHVWLSVHWF  Box 19 /RFDOLQFRPHWD[ZLWKKHOG  Box 20 Locality name
information (see instr.)
Locality a 12897 .00 Locality a 431 .00 Locality a NYC
/RFDOLW\E .00 /RFDOLW\E .00 /RFDOLW\E

Do not detach. Box c Employer’s information

W-2 Record 2 Employer’s name

Box a Employee’s 6RFLDO6HFXULW\QXPEHU

for this W-2 Record Employer’s address (number and street)

Box b (PSOR\HULGHQWL¿FDWLRQQXPEHU (,1 &LW\ 6WDWH =,3FRGH &RXQWU\

Box 1 Wages, tips, other compensation Box 12a $PRXQW &RGH Box 14a $PRXQW 'HVFULSWLRQ
.00 .00 .00
Box 8 Allocated tips Box 12b $PRXQW &RGH Box 14b $PRXQW 'HVFULSWLRQ
.00 .00 .00
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