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fiRS e.,file Si:gniltiure Authorization OMB No, 1:545-0074

'~ l3.on"tsend 'to theiRS. This isn't atax r.eturn.

!Depar:tmem '@tthe'1T'rceasury: '~Ke.ep this itaim faryal!lr ~eGOr.ds.
,Internal Revenue,Seniice : ~jn'onnatiQn abollt :F,orm 8879 and ,its Jnstruetlons Is at :www.irs.govltor:m8879.

Submission :ldlntiiicaHorJNumber ,(SID) ~

:ra>\payer'sname :SO:Cial.secur,ity 'number

WALTER ERALLSJR 563-72-9021

lM,I1",RY RALL:S 4 38- '] 4- 3834

Tax Return lnfor.mation - Tax Year Endi~ <December :31,,20~t6lWnole dollars on:I,)
1 ,Aqjnsted :gr{']ss 'income {Fo~m iMB, llne '38; 'Form i Iil4UA,line22; 'Form 1:o40EZ, Iine 4; Forrn 104UNR,
Itine:37~_ 28'635
:2 Totat tax ((F1llm1 ~;{M(()l,:lime i63; iEorrnJHll4:l1lA, line '39.; iEon ililil4({)lEZ" dime iL2;; iFolif:IiI 11({)l4flNR., ilirne '0 ~~ _ _ ,;2 503
3 Feder-al income tax withheld from Forms W-2 and 10'99 JFor.m i1D4:O,line 64,; Form i,MDA, line 40~
Form 11lJ40EZ, ~it"le 7; !Form 1 '04:(')NH, ;fine (02a) . 3 4243
4 iRfiftmrndfflFornn ~Mm" :Hme 7lBa; !FtGtm !l4!il!\, Uime4Ba; tFllltl'rn 1410EZ, ilime 113a; :FGrnn i1{!)4'{!HSS, !Hartt ~. !Ikre ~-aa;
For,m1fJ4DNH,,liRe4(39) ,4 3740
.5 Amount you owe -(For.m 1040, ,line 78; Fotml040A, line So.; Form 104(jJEZ,line14; Form l04Q'NR, line 75) 1--'5'-1------
Taxpayer Oeclar:atiolil ana Signature ,Authorizati'on {Be sure you get and !keep aco.py -ofyour 'l'eturn1
\Ul.fi10eriJlreI'Ialties <of :perjuIW, illdeclare ff!tat 1III1aMe'elGl!1l'1ined'" copy <Of my -'cl.edtr,on1G in-dividcral iinC0me it:aJ( :relltlm and accm:npan:;jiAg schedules and -statements
for thetax ,year ,endirJ,9 December 31, .201,&, .and to fhe best ,of my knowledqe .and belief, ,it is true, .correct, .and accurately lists.all .arnounts and .sousces .o.f.income
'I :receilfed .Qcrdng t-he 'tax year, ~ fl!lrtber deClare 'that the amounts in Part 'I above are 'the amocnts irom 'my <elewlnic ,jncome'tax ifEiklrFI.. " consent +e allow 'my
imternnediate SBl'I.iioe :prDvkier;, xrcanstmlitter.1.1Ireleclronl.c ""frtum ,or.iginawr,tffiQ) t-o seAd mil' ,retutfil to the 'IRS -amd to ,rece;~e fmm tme U'lS ~ajan ,ackmowledger.rnerit
;oh.eceipt orreason ifor r.ejedioo 01 the iJ<Insniisliioll, !{b) 'the 'reasuo for 'any delay in :processing the returnor refund, and '(C) Ifhe cate 'of -an,o/'r.eflmd. lfapplicaljle, :1
al!ltmlllr,iz,e lbe (U.s, r~,ea;surlli' and Jts ~esi9nate<!l ,Fiinaouial Agent to iimitiate an AGH ilemr.Gnic fl:lods ~JitAdrawal i{dir.ect deI!Jit) :errtty iI:m ~h:eifir.ar.rdial linstitution
accountlndicates in 1me 'tax preparation saJitware :for payment (of my ~Bderal taxes 'Owed on this rsturn and/or .a 'pa)lR'1ent 'of 'estlmat-ed lax, anCiithe 'financial
Hmstitcrfiom tl:'G ilebit ;Ihe e1'llry ~a this acceunt. 1lihlis.awthor.iz.ati0m iisito iY<elmlim4mi!!fll ~:ar-ceand -effeot \Umtil il !tlotify th.e iilI.S. Tir-eastlry iFiililalildai #\.:eJilj1:0:temjimcite ~me
authorization. To r.evoke '(cancel) a ,payment, ,I must contact the U.S, Treasury 'Financial Agent at 1-888-353-4537, Payment cancellation requests must be
rec.eiMe.d !fiIG!later ~ham 21bJ!lSIrness~ays IprLor ~o !the lP~YlJiler;rt i(se11lemeJJ\) ,date, II,also ,authlonize 1me financial 'jnstitl!lfklms ,involved iim'tbe Ipnoces,$ing <of ~hle elEclrlllnh::
,payment 'of 'taxes to receive :confidential :information necessary to answer inquiries and 'resolve :issues related to the payment. 'I further acknewledge that the
'Personal f!;'leliltfficafLon immrlber!(RIN) ibel<:lw ~s imy:Sigmatl!lr.eiformy",leo1ronicinaoJNeitax'~et!]rn and, iif applicaele, 'my IBleotr.omic !F,uncls"Witf.Idrawal tG'Onsent,

T,a*p~yer"'SPIN: cheok 'one box IOrll,Y

f~ ~ 'aurthl;0rii~ RACHAELJJ-ENSEM
:ERO firm name ,Enter five ,digits, :but
as ,my .signatl!Jr.eon my tax year:2'OlB electronically filed income tax 'return. ._ ,dnri't'enterall'2er,as

[0 ~Wl11[1<.emilierItmly iPlM .as Itmly slgliratuJl1. :0:mItmlr' .:ear :2Iilll elredl;fi0.r:ii:r;all.~ilillieril iifiJDmnme 'tifi;{ re':tilllr.tlJ. Ohedk iJitriisIOOx olilly iif WD11I
;are
YourSi9:'~:'~;W!ll11Irrr;irm: [tN!. ,:iii,;', If!/' ',". ,- !fiile: I!.l[ "m~1IiIileiRr.at:i1iiilii:liIfi1erp,LNltmle~:_:trJerp,R~i:;p~~;a7m!bM:i];{i):W,'

~ I
~pouse~s IPJN: check lone !box 1Or;i1y
{~ J aurnoor.ize RACHAEL JENSEN
'EROiirmname

10

Spou:se"s signature'~ 'Dale'~

( /
lilione' PIN Method Returns :only--,continuebel.ow
t:mm 'Certification and Authentication - Practitioner PIN Method Only

~.certify -Thatthe .aoove lil\;lmer.iGemry 'is my PIN, 'which :is my signatur-efDr the tax -year :201:6electronically 'flied ijflG0me taxretum tot
'it'ge~~p:a.weli{S)iiraaica'ted :a:b:e13e. !I ;c lil:liYlIi!iIItrnat lIali!il s\!lhlilliiittil1\g \trnis !l'<etutll1 ilm acc0rdfaFlcewiitlil ,nme lI'eqJ.uiiremernt:s '0.f iIlhe iP>d'.acti~i,{mer IRIN
method andPlib. ~345~ Handbook for Authorized IRS :e-.file Providers of 'Indiv.iducil lnccme Tax Returns.
ERO'ssignatut-e'..- RACHAEL JENSEN Dale'''' 02/02/2017
----~--~------------------------
RACHAEL 'E JENSEN
ERD Must Retain T:tiisF:OTm ,- See mstf'tlclions
Don't Submit This Form to the IRS Unless Requested To Do So
For Paperwork Reduction Act Notice, see your tax return instructions. QNA Form 8879 (2016)