Form
Department of the Treasury -- American Samoa Tax Division
Income Tax Return for Single and Joint Filers With No Dependents
Your first name and initial Last name Last name Your Social Security number Spouse's Social Security number Home phone no. Business phone no.
Please Print or Type
If a joint return, spouse's first name and initial Home address (P.O. number and village). City, town or post office, state and ZIP code.
Do you live in a rental home
Yes
No
Income
Attach Forms W-2AS here
Also attach Form(s) 1099 if Samoa tax was withheld
1
Wages, salaries, tips, etc, attach form W-2AS
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2 3
Taxable interest. If the total is over $400, you cannot use Form 390EZ. Other income (List type and amount)
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4
Add line 1, 2, and 3. This is your adjusted gross income Can your parents (or someone else) claim you on their return? Yes. Enter amount from worksheet on back. No. If single, enter $7,200.00, If Married, enter $12,950.00. See back for explanation.
4
Note. You must check Yes or No
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5
6
Subtract line 5 from line 4. If line 5 is larger than line 4, enter -0- This is your taxable income. Tax. Use the amount on line 6 above to find your tax in the tax table (use tax year 2000 tax table). table). Then, enter the tax from the table on this line.
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Payments and Tax
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American Samoa Minimum Tax (4% of the adjusted gross income, line 4) This is your total tax, line 7 or 8 whichever is larger Samoa income tax withheld from Form W-2AS or Form(s) 1099 If line 10 is larger than line 9, subtract line 9 from line 10. This is your refund. If line 9 is larger than line 10, subtract line 10 from line 9. This is the Amount you owe. For details on how to pay, (Call the ASG Tax Office, refer to the Collection Section)
Refund Amount you owe Sign here
Joint return? Both spouses must sign
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Under penalties of perjury, I declare that I have examined this return, and to the best of my knowledge and belief, it is true, correct, and accurately lists all amounts and sources of income I received during the tax year. Declaration of preparer (other Your signature Spouse's signature. If a joint return, both must sign. Preparer's signature Firm's name (or yours if self employed), address and zip code Date Date Date Your Occupation Your Occupation Check if selfemployed EIN Phone no. Daytime phone number Work phone number Preparer's SSN or PTIN
Keep a copy for your records. Paid preparer's use only
Form 390EZ (2008)