Form 1040

Form 1040 Line 21 Other Income Statement 2017 Statement Name(s) Shown on Return Social Security Number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 a b c a b c d e f a b c a b a b a b c d e f a b a a b c d a b Child's investment income, Gambling winnings: From Form W-2G Winnings (prizes, etc ) Not reported on Form Taxable income from Substitute payments in Other income from box Alaska Permanent Fund Tribal Gaming Non-Employee Compensation Rent from personal property Taxable income from Qualified tuition program Coverdell ESA distributions ABLE account distributions Taxable income from Grants RTAA payments Foreign earned income Net operating loss carryover Other income, from Schedule(s) Taxable distribution from: Form 8853: 1 Taxable Archer MSA 2 Taxable Medicare 3 Taxable long term 4 Total Form 8853 Form 8889, Health Savings Refunds or reimbursements in a prior year: Reimbursement for deducted Refunds of deducted taxes Recapture of deducte Reimbursement for deducted Reimbursement for deducted Other refunds or reimbursements Recoveries of bad debts Jury duty pay Bartering income not reported Income from the rental Income from the Cancellation From Form 1099-C: 1 Amount of debt canceled 2 Amount of canceled 3 Taxable amount of From Schedule(s) K-1 Taxable income from Payment Card/Third Party Income from *not for profit* Other taxable income: Union unemployment Private fund unemployment State employee unemployment from Form 8814 from Form 1099-MISC, box W-2G or Form 1099-MISC Form 1099-MISC: lieu of interest or dividends 3 from Form 1099 MISC from Form 1099-MISC Form 1099-O or 1099-QA: distributions Form 1099-G: and housing exclusion, from from a prior year K-1 distributions Advantage distributions care distributions Accounts of deductions claimed medical expenses (not state or local income Type of Tax 3 box 7 box 1 Form 2555 MSA Med MSA LTC taxes) State or Local ID (a) Taxpayer (b) Spouse moving expenses casualty or theft loss employee business expenses. . deducted in a prior year elsewhere of personal property of Debt: from box 2 debt excluded from income canceled debt Form 1099-K: Network Transactions activities (hobbies) - benefits benefits benefits Income from Community Property: Positive community property adjustment Negative community property adjustment (enter as positive) . . Total. Add lines 1 through 14,15a(3), 15b, 16 through 19. Enter here and on Form 1040 or Form 1040NR, line 21 EFTA01222047