Advanced Scenario 9: Joe Lopez

Interview Notes

? Joe is age 41 and was widowed in July, 2023. He has a daughter, Josie, age 9, who lived with him the entire year.

? Joe provided the entire cost of maintaining the household and over half of the support for Josie. In order to work, he pays childcare expenses to Southside Daycare.

? Joe purchased health insurance for himself and his daughter through the Marketplace. He received a Form 1095-A.

? Joe and Josie are U.S. citizens and lived in the United States all year in 2024.

Advanced Scenario 9: Retest Questions

1. Joe's net premium tax credit on his Form 1040 Schedule 3, line 9 is $_______. (Note: whole number only, do not use special characters.

Form 1095-A Health Insurance Marketplace Statement VOID OMB No. 1545-2232 Department of the Treasury Do not attach to your tax retum. Keep for your records. CORRECTED 2024 Do to www.bagew/For10854 for instructions and the latest information Part | Recipient Information 1 Marketplace denahe 2 Marketplace-nasigned policy number 3 Policy issuer's name 12-3456789 987654 4 Recipient's name AS 5 Recipient's SEN 8 Focipient's date of birth JOE LOPEZ 328-00-XXXX 4/12/1983 YAscipioit's spouse's mama 8 Recipient's spouse's 8BN 9 Recipient's spouse's date of birth 10 Policy start date 11 Policy termination date 13 Street address Including apartment noj 01/01/2024 12/31/2024 13 City of town 14 Stine or province 15 Country and ZIP or foreign postal code YOUR CITY YOUR STATE ZIP Part II Covered Individuals A. Covered individual name Coward individual 98N C. Covered individual D. Courage start date E. Cownaga termination dots corta of birth 328-00-XXXX 04/12/1983 01/01/2024 12/31/2024 16 JOE LOPEZ SIE LOPEZ 125-00-XXXX 07/24/2015 01/01/2024 12/31/2024 18 JU 20 Part Ill Coverage Information Month A. Monthly enrollment premiums] B. Monthly second lowest cost alive C. Monthly advance payment of plan (SLC-SP) premium premium tax credit $602 21 January $446 $446 $602 $388 22 February $446 $602 23 March $446 $602 $385 24 April $446 $388 25 May $602 28 Jun SA46 $388 27 July $602 $446 $602 $388 28 August $446 $602 $385 29 September $602 $368 30 October $446 $446 $602 31 November SA4 $602 $388 32 December $5,352 $7.224 $4,656 23_Annual Totals For Privacy Act and Paperwork Reduction Act Notice, see separate instructions Fat. No. 607030 Form 1095-A 2024)22222 Employee's social security number 328-00-XXXX OMB No. 1545-0008 b Employer identification number (EINI 1 Wages, tips, other compensation 2 Federal income tax withheld 34-800XXXX $42 000 00 $1,700.00 Employer's name, address, and ZIP code 3 Social security wages 4 Social security tax withheld ROSEWOOD SCHOOL DISTRICT $45,500 00 $2,697.00 1452 ROOSEVELT CIRCLE YOUR CITY, YOUR STATE, ZIP 5 Medicare wages and tips Medicare bak withhold REASU $43,500 00 $630.75 7 Social security lips d Control number 10 Dependent care benefits . Employee's first name and initial Last name Suff. 11 Nonqualified plans JOE ND $1,500.00 200 SKY WAY YOUR CITY, YOUR STATE, ZIP ND OM x] 14 Other ! Employee's address and ZIP code DA 15 State Employer's site D number 18 State wages, tips, sie. 17 State income tax 18 Local wages, ups, ate. 19 Local income tax 20 Locality more 34 200XXXX $42,000.00 $600 00 W-2 Wage and Tax Statement 2024 Copy 1-For State, City. or Local Tax Department VOID CORRECTED PAYER S name. street oddross. city of town. state of province, country. ZIP Pow's ATN optional DE NO 1945-91 12 F or forsign portal coda, and telephone no. NEW BANK AND TRUST Form 1099-INT Interest 6020 YONKERS BLVD YOUR CITY, YOUR STATE, ZIP There. January 306-4) Income or calendar your 140.00 2 Early withdrawal paraly Copy 1 PAYER'S TN RECIPIENT'S TIN S 71,00 For State Tax 27-700XXXX 324-00-XXXX Intersat on UUS. Savings bonds and Tamery Department RECIPIENT8 name 4 Federal income tax withhold $ lawssim tooperiod JOE LOPEZ AND O Fondlye tan paid S 200 SKY WAY City or town stain or province, country, and ZIP or forsign portal code YOUR CITY, YOUR STATE , ZIP 11 Band premium FATCA Ving$ Account number isss lastsections Lantomb bond CUSP ne. Department at the Trawary . Interri Irwin.s Service