Form

1040 Department of the Treasury—Internal Revenue Service

U.S. Individual Income Tax Return

(99)
2017 OMB No. 1545-0074 IRS Use Only—Do not write or staple in this space.

For the year Jan. 1–Dec. 31, 2017, or other tax year beginning , 2017, ending , 20 See separate instructions.
Your first name and initial Last name Your social security number

Louella E Daughtrey 490-60-8554

If a joint return, spouse’s first name and initial Last name Spouse’s social security number

Home address (number and street). If you have a P.O. box, see instructions. Apt. no. Make sure the SSN(s) above
c
and on line 6c are correct.
190 E LAWRENCE D
City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions). Presidential Election Campaign
SPRING HILL KS 66083 Check here if you, or your spouse if filing
jointly, want $3 to go to this fund. Checking
Foreign country name Foreign province/state/county Foreign postal code
a box below will not change your tax or
refund. You Spouse

1 Single 4 Head of household (with qualifying person). (See instructions.)

Filing Status
2 Married filing jointly (even if only one had income) If the qualifying person is a child but not your dependent, enter this
Check only one 3 Married filing separately. Enter spouse’s SSN above child’s name here. a
box. and full name here. a 5 Qualifying widow(er) (see instructions)

Exemptions 6a
b
Yourself. If someone can claim you as a dependent, do not check box 6a .
Spouse . . . . . . . . . . . . . . . . . . . .
.
.
.
.
.
.
.
.
} Boxes checked
on 6a and 6b
No. of children
1
c Dependents: (2) Dependent’s (3) Dependent’s (4) if child under age 17 on 6c who:
social security number relationship to you qualifying for child tax credit • lived with you
(1) First name Last name (see instructions) • did not live with
you due to divorce
or separation
If more than four (see instructions)
dependents, see Dependents on 6c
instructions and not entered above
check here a Add numbers on
d Total number of exemptions claimed . . . . . . . . . . . . . . . . . lines above a 1
7 Wages, salaries, tips, etc. Attach Form(s) W-2 . . . . . . . . . . . . 7 19,875.
Income
8a Taxable interest. Attach Schedule B if required . . . . . . . . . . . . 8a
b Tax-exempt interest. Do not include on line 8a . . . 8b
Attach Form(s)
9a Ordinary dividends. Attach Schedule B if required . . . . . . . . . . . 9a
W-2 here. Also
attach Forms b Qualified dividends . . . . . . . . . . . 9b
W-2G and 10 Taxable refunds, credits, or offsets of state and local income taxes . . . . . . 10
1099-R if tax 11 Alimony received . . . . . . . . . . . . . . . . . . . . . 11
was withheld.
12 Business income or (loss). Attach Schedule C or C-EZ . . . . . . . . . . 12
13 Capital gain or (loss). Attach Schedule D if required. If not required, check here a 13
If you did not 14 Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . . . 14
get a W-2,
see instructions. 15a IRA distributions . 15a b Taxable amount . . . 15b
16a Pensions and annuities 16a b Taxable amount . . . 16b
17 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E 17
18 Farm income or (loss). Attach Schedule F . . . . . . . . . . . . . . 18
19 Unemployment compensation . . . . . . . . . . . . . . . . . 19
20a Social security benefits 20a b Taxable amount . . . 20b
21 Other income. List type and amount 21
22 Combine the amounts in the far right column for lines 7 through 21. This is your total income a 22 19,875.
23 Educator expenses . . . . . . . . . . . 23
Adjusted 24 Certain business expenses of reservists, performing artists, and
Gross fee-basis government officials. Attach Form 2106 or 2106-EZ 24
Income 25 Health savings account deduction. Attach Form 8889 . 25
26 Moving expenses. Attach Form 3903 . . . . . . 26
27 Deductible part of self-employment tax. Attach Schedule SE . 27
28 Self-employed SEP, SIMPLE, and qualified plans . . 28
29 Self-employed health insurance deduction . . . . 29
30 Penalty on early withdrawal of savings . . . . . . 30
31a Alimony paid b Recipient’s SSN a 31a
32 IRA deduction . . . . . . . . . . . . . 32
33 Student loan interest deduction . . . . . . . . 33
34 Reserved for future use . . . . . . . . . . 34
35 Domestic production activities deduction. Attach Form 8903 35
36 Add lines 23 through 35 . . . . . . . . . . . . . . . . . . . 36
37 Subtract line 36 from line 22. This is your adjusted gross income . . . . . a 37 19,875.
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. BAA REV 01/09/18 Intuit.cg.cfp.sp Form 1040 (2017)
Form 1040 (2017) Page 2
38 Amount from line 37 (adjusted gross income) . . . . . . . . . . . . . . 38 19,875.
Tax and
Credits
39a Check
if:
{ You were born before January 2, 1953,
Spouse was born before January 2, 1953,
Blind.
Blind.
} Total boxes
checked a 39a
b If your spouse itemizes on a separate return or you were a dual-status alien, check here a 39b
Standard 40 Itemized deductions (from Schedule A) or your standard deduction (see left margin) . . 40 6,350.
Deduction 13,525.
for— 41 Subtract line 40 from line 38 . . . . . . . . . . . . . . . . . . . 41
• People who 42 Exemptions. If line 38 is $156,900 or less, multiply $4,050 by the number on line 6d. Otherwise, see instructions 42 4,050.
check any
box on line 43 Taxable income. Subtract line 42 from line 41. If line 42 is more than line 41, enter -0- . . 43 9,475.
39a or 39b or 44 Tax (see instructions). Check if any from: a Form(s) 8814 b Form 4972 c 44 955.
who can be
claimed as a 45 Alternative minimum tax (see instructions). Attach Form 6251 . . . . . . . . . 45
dependent,
see 46 Excess advance premium tax credit repayment. Attach Form 8962 . . . . . . . . 46
instructions. 47 Add lines 44, 45, and 46 . . . . . . . . . . . . . . . . . . . a 47 955.
• All others:
48 Foreign tax credit. Attach Form 1116 if required . . . . 48
Single or
Married filing 49 Credit for child and dependent care expenses. Attach Form 2441 49
separately,
$6,350 50 Education credits from Form 8863, line 19 . . . . . 50
Married filing 51 Retirement savings contributions credit. Attach Form 8880 51 400.
jointly or
Qualifying 52 Child tax credit. Attach Schedule 8812, if required . . . 52
widow(er), 53 Residential energy credit. Attach Form 5695 . . . . . 53
$12,700
Head of 54 Other credits from Form: a 3800 b 8801 c 54
household, 55 Add lines 48 through 54. These are your total credits . . . . . . . . . . . . 55 400.
$9,350
56 Subtract line 55 from line 47. If line 55 is more than line 47, enter -0- . . . . . . a 56 555.
57 Self-employment tax. Attach Schedule SE . . . . . . . . . . . . . . . 57
Other 58 Unreported social security and Medicare tax from Form: a 4137 b 8919 . . 58
59 Additional tax on IRAs, other qualified retirement plans, etc. Attach Form 5329 if required . . 59
Taxes 60a Household employment taxes from Schedule H . . . . . . . . . . . . . . 60a
b First-time homebuyer credit repayment. Attach Form 5405 if required . . . . . . . . 60b
61 Health care: individual responsibility (see instructions) Full-year coverage . . . . . 61 0.
62 Taxes from: a Form 8959 b Form 8960 c Instructions; enter code(s) 62
63 Add lines 56 through 62. This is your total tax . . . . . . . . . . . . . a 63 555.
Payments 64 Federal income tax withheld from Forms W-2 and 1099 . . 64 1,002.
65 2017 estimated tax payments and amount applied from 2016 return 65
If you have a
66a Earned income credit (EIC) . . . . . . .No. . . 66a
qualifying
child, attach b Nontaxable combat pay election 66b
Schedule EIC. 67 Additional child tax credit. Attach Schedule 8812 . . . . . 67
68 American opportunity credit from Form 8863, line 8 . . . 68
69 Net premium tax credit. Attach Form 8962 . . . . . . 69
70 Amount paid with request for extension to file . . . . . 70
71 Excess social security and tier 1 RRTA tax withheld 71 . . . .
72 Credit for federal tax on fuels. Attach Form 4136 72 . . . .
73 Credits from Form: a 2439 b Reserved c 8885 d 73
74 Add lines 64, 65, 66a, and 67 through 73. These are your total payments . . . . . a 74 1,002.
Refund 75 If line 74 is more than line 63, subtract line 63 from line 74. This is the amount you overpaid 75 447.
76a Amount of line 75 you want refunded to you. If Form 8888 is attached, check here . a 76a 447.
a bRouting number 3 2 2 0 7 7 7 9 5 a c Type: Checking Savings
Direct deposit?
See a dAccount number 3 0 0 0 0 5 0 0 5
instructions.
77 Amount of line 75 you want applied to your 2018 estimated tax a 77
Amount 78 Amount you owe. Subtract line 74 from line 63. For details on how to pay, see instructions a 78
You Owe 79 Estimated tax penalty (see instructions) . . . . . . . 79
Third Party Do you want to allow another person to discuss this return with the IRS (see instructions)? Yes. Complete below. No
Designee’s Phone Personal identification
Designee name a no. a number (PIN) a
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 belief, they are true, correct, and
Sign accurately list all amounts and sources of income I received during the tax year. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Here Your signature Date Your occupation Daytime phone number
F

Joint return? See

instructions. property manager (913)256-8997
Keep a copy for Spouse’s signature. If a joint return, both must sign. Date Spouse’s occupation If the IRS sent you an Identity Protection
your records. PIN, enter it
here (see inst.)
Print/Type preparer’s name Preparer’s signature Date PTIN
Paid Check if
self-employed
Preparer
Use Only Firm’s name a Self-Prepared Firm’s EIN a

Firm’s address a Phone no.

Go to www.irs.gov/Form1040 for instructions and the latest information. REV 01/09/18 Intuit.cg.cfp.sp Form 1040 (2017)
Form 8889 Health Savings Accounts (HSAs)
OMB No. 1545-0074

2017
a Attach to Form 1040 or Form 1040NR.
Department of the Treasury Attachment
Internal Revenue Service a Go to www.irs.gov/Form8889 for instructions and the latest information. Sequence No. 52
Name(s) shown on Form 1040 or Form 1040NR Social security number of HSA
beneficiary. If both spouses have
Louella E Daughtrey HSAs, see instructions a 490-60-8554
Before you begin: Complete Form 8853, Archer MSAs and Long-Term Care Insurance Contracts, if required.
Part I HSA Contributions and Deduction. See the instructions before completing this part. If you are filing jointly
and both you and your spouse each have separate HSAs, complete a separate Part I for each spouse.
1 Check the box to indicate your coverage under a high-deductible health plan (HDHP) during
2017 (see instructions) . . . . . . . . . . . . . . . . . . . . . . . a Self-only Family
2 HSA contributions you made for 2017 (or those made on your behalf), including those made
from January 1, 2018, through April 17, 2018, that were for 2017. Do not include employer
contributions, contributions through a cafeteria plan, or rollovers (see instructions) . . . . . 2 0.
3 If you were under age 55 at the end of 2017, and on the first day of every month during 2017,
you were, or were considered, an eligible individual with the same coverage, enter $3,400
($6,750 for family coverage). All others, see the instructions for the amount to enter . . . . 3 4,400.
4 Enter the amount you and your employer contributed to your Archer MSAs for 2017 from Form
8853, lines 1 and 2. If you or your spouse had family coverage under an HDHP at any time
during 2017, also include any amount contributed to your spouse’s Archer MSAs . . . . . 4 0.
5 Subtract line 4 from line 3. If zero or less, enter -0- . . . . . . . . . . . . . . . 5 4,400.
6 Enter the amount from line 5. But if you and your spouse each have separate HSAs and had
family coverage under an HDHP at any time during 2017, see the instructions for the amount to
enter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 4,400.
7 If you were age 55 or older at the end of 2017, married, and you or your spouse had family
coverage under an HDHP at any time during 2017, enter your additional contribution amount
(see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . 7 0.
8 Add lines 6 and 7 . . . . . . . . . . . . . . . . . . . . . . . . . . 8 4,400.
9 Employer contributions made to your HSAs for 2017 . . . . 9 923.
10 Qualified HSA funding distributions . . . . . . . . . . 10
11 Add lines 9 and 10 . . . . . . . . . . . . . . . . . . . . . . . . . . 11 923.
12 Subtract line 11 from line 8. If zero or less, enter -0- . . . . . . . . . . . . . . . 12 3,477.
13 HSA deduction. Enter the smaller of line 2 or line 12 here and on Form 1040, line 25, or Form
1040NR, line 25 . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 0.
Caution: If line 2 is more than line 13, you may have to pay an additional tax (see instructions).
Part II HSA Distributions. If you are filing jointly and both you and your spouse each have separate HSAs, complete
a separate Part II for each spouse.
14a Total distributions you received in 2017 from all HSAs (see instructions) . . . . . . . . 14a 2,582.
b Distributions included on line 14a that you rolled over to another HSA. Also include any excess
contributions (and the earnings on those excess contributions) included on line 14a that were
withdrawn by the due date of your return (see instructions) . . . . . . . . . . . . 14b
c Subtract line 14b from line 14a . . . . . . . . . . . . . . . . . . . . . . 14c 2,582.
15 Qualified medical expenses paid using HSA distributions (see instructions) . . . . . . . 15 2,582.
16 Taxable HSA distributions. Subtract line 15 from line 14c. If zero or less, enter -0-. Also,
include this amount in the total on Form 1040, line 21, or Form 1040NR, line 21. On the dotted
line next to line 21, enter “HSA” and the amount . . . . . . . . . . . . . . . . 16 0.
17a If any of the distributions included on line 16 meet any of the Exceptions to the Additional
20% Tax (see instructions), check here . . . . . . . . . . . . . . . . . a
b Additional 20% tax (see instructions). Enter 20% (0.20) of the distributions included on line 16
that are subject to the additional 20% tax. Also include this amount in the total on Form 1040,
line 62, or Form 1040NR, line 60. Check box c on Form 1040, line 62, or box b on Form 1040NR,
line 60. Enter “HSA” and the amount on the line next to the box . . . . . . . . . . . 17b
For Paperwork Reduction Act Notice, see your tax return instructions. REV 11/27/17 Intuit.cg.cfp.sp Form 8889 (2017)
BAA
Form 8889 (2017) Page 2
Part III Income and Additional Tax for Failure To Maintain HDHP Coverage. See the instructions before
completing this part. If you are filing jointly and both you and your spouse each have separate HSAs,
complete a separate Part III for each spouse.

18 Last-month rule . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

19 Qualified HSA funding distribution . . . . . . . . . . . . . . . . . . . . . 19

20 Total income. Add lines 18 and 19. Include this amount on Form 1040, line 21, or Form
1040NR, line 21. On the dotted line next to Form 1040, line 21, or Form 1040NR, line 21, enter
“HSA” and the amount . . . . . . . . . . . . . . . . . . . . . . . . 20
21 Additional tax. Multiply line 20 by 10% (0.10). Include this amount in the total on Form 1040,
line 62, or Form 1040NR, line 60. Check box c on Form 1040, line 62, or box b on Form 1040NR,
line 60. Enter “HDHP” and the amount on the line next to the box . . . . . . . . . . 21
REV 11/27/17 Intuit.cg.cfp.sp Form 8889 (2017)
8880
OMB No. 1545-0074
Credit for Qualified Retirement Savings Contributions
Form

Department of the Treasury

a
Attach to Form 1040, Form 1040A, or Form 1040NR.
2017
Attachment
Internal Revenue Service a Go to www.irs.gov/Form8880 for instructions and the latest information. Sequence No. 54
Name(s) shown on return Your social security number

Louella E Daughtrey 490-60-8554

You cannot take this credit if either of the following applies.

F
!
CAUTION
• The amount on Form 1040, line 38; Form 1040A, line 22; or Form 1040NR, line 37 is more than $31,000 ($46,500 if head of
household; $62,000 if married filing jointly).
• The person(s) who made the qualified contribution or elective deferral (a) was born after January 1, 2000, (b) is claimed as a
dependent on someone else’s 2017 tax return, or (c) was a student (see instructions).
(a) You (b) Your spouse
1 Traditional and Roth IRA (including myRA) contributions for 2017. Do
not include rollover contributions . . . . . . . . . . . . . 1
2 Elective deferrals to a 401(k) or other qualified employer plan, voluntary
employee contributions, and 501(c)(18)(D) plan contributions for 2017
(see instructions) . . . . . . . . . . . . . . . . . . 2 2,457.
3 Add lines 1 and 2 . . . . . . . . . . . . . . . . . . 3 2,457.
4 Certain distributions received after 2014 and before the due date
(including extensions) of your 2017 tax return (see instructions). If
married filing jointly, include both spouses’ amounts in both columns.
See instructions for an exception . . . . . . . . . . . . . 4
5 Subtract line 4 from line 3. If zero or less, enter -0- . . . . . . . 5 2,457.
6 In each column, enter the smaller of line 5 or $2,000 . . . . . . 6 2,000.
7 Add the amounts on line 6. If zero, stop; you cannot take this credit . . . . . . . . . . 7 2,000.
8 Enter the amount from Form 1040, line 38*; Form 1040A, line 22; or
Form 1040NR, line 37 . . . . . . . . . . . . . . . . . 8 19,875.
9 Enter the applicable decimal amount shown below.

If line 8 is— And your filing status is—

Married Head of Single, Married filing
But not filing jointly household
Over— separately, or
over—
Enter on line 9— Qualifying widow(er)
--- $18,500 .5 .5 .5
$18,500 $20,000 .5 .5 .2
$20,000 $27,750 .5 .5 .1 9 X .2
$27,750 $30,000 .5 .2 .1
$30,000 $31,000 .5 .1 .1
$31,000 $37,000 .5 .1 .0
$37,000 $40,000 .2 .1 .0
$40,000 $46,500 .1 .1 .0
$46,500 $62,000 .1 .0 .0
$62,000 --- .0 .0 .0
Note: If line 9 is zero, stop; you cannot take this credit.
10 Multiply line 7 by line 9 . . . . . . . . . . . . . . . . . . . . . . . . . 10 400.
11 Limitation based on tax liability. Enter the amount from the Credit Limit Worksheet in the
instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 955.
12 Credit for qualified retirement savings contributions. Enter the smaller of line 10 or line 11 here
and on Form 1040, line 51; Form 1040A, line 34; or Form 1040NR, line 48 . . . . . . . . 12 400.

*See Pub. 590-A for the amount to enter if you are filing Form 2555, 2555-EZ, or 4563 or you are excluding income from Puerto Rico.
For Paperwork Reduction Act Notice, see your tax return instructions. BAA REV 11/27/17 Intuit.cg.cfp.sp Form 8880 (2017)
K-40 Page 1 of 2
2017 KANSAS INDIVIDUAL INCOME TAX 005 122817
(Rev. 7-17)

LOUELLA E DAUGHTREY 9132568997 DAUG 490608554

190 E LAWRENCE APT D JO 230

SPRING HILL KS 66083
Name or address has changed? Taxpayer or (spouse if filing joint) died during this tax year Taxpayer was engaged in commercial farming/fishing in 2017

Amended Return: Amended affects Kansas only Amended Federal tax return Adjustment by the IRS

Head of Household (Do not

Filing Status: X Single Married Filing Joint (Even if only one had income) Married Filing Separate check if filing joint return)

Residency Status: X Resident NonResident (Complete Sch S, Part B) State of Legal Residence

Part-Year Resident (Complete Sch S, Part B) From To

Exemptions: Enter number of exemptions you claimed on your 2017 federal return. If filing status above is Head of Total Kansas exemptions
1 If no federal return is required, enter total exemptions for you, your Household, add one exemption.
1
spouse (if applicable), and each person you claim as a dependent.

In the following spaces, provide the requested information for all persons you claimed as dependents. DO NOT include you or your spouse. If additional space is needed,
enclose a separate sheet, only after completing all nine lines below.
Dependent Name - First, Middle and Last Date of Birth - MMDDYYYY Relationship SSN

Food Sales Tax Credit: You must have been a Kansas resident for ALL of 2017. Complete this section to determine your qualifications and credit.
If you did not mark A, B, and C, STOP HERE; you do not qualify for this credit.

A. Had a dependent child who lived with you all year and was E. Number of exemptions claimed on your federal income
under the age of 18 all of 2017? tax return. 1
B. Were you (or spouse) 55 years of age or older all of 2017 F. Number of dependents that are 18 years of age or older
(born prior to January 1, 1962)? X (born on or before January 1, 2000) 0
C. Were you (or spouse) totally and permanently disabled or
blind all of 2017, regardless of age? G. Total qualifying exemptions (subtract line F from line E) 1
D. If you answered YES to A, B, or C, enter your FAGI
from line 1 of this return. If it is more than $30,615 H. Food Sales Tax Credit (multiply line G by $125).
STOP HERE, you do not qualify for this credit. 19875 Enter result here and on line 17 of this form. 125

IMPORTANT: 1) Form K-40 is a 2 PAGE FORM. BOTH PAGES REQUIRED WHEN FILING; 2) Make sure your NAME, 1st 4-letters of last
name, and SSN print to the top of page 2 of 2; 3) DO NOT USE RED or SHADES of RED INK on tax returns filed with Kansas
REV 11/13/17 INTUIT.CG.CFP.SP

Page
1 of 2 F o r O f f i c e U s e O n l y
K-40
(Rev. 7-17) Page 2 of 2
2017 KANSAS INDIVIDUAL INCOME TAX 005 122917

LOUELLA E DAUGHTREY 490608554

23. Amount paid with Kansas
1. Federal adjusted gross income 19875 extension 0
24. Refundable portion of earned
2. Modifications 0 income tax credit 0
3. Kansas adjusted gross income 19875 25. Refundable portion of tax credits 0
26. Payments remitted with original
4. Standard or itemized deductions 3000 return 0
5. Exemption allowance 2250 27. Overpayment from original return 0
6. Total deductions 5250 28. Total refundable credits 319
7. Taxable income 14625 29. Underpayment 0
8. Tax 424 30. Interest 0
9. Nonresident percentage 0.0000 31. Penalty 0
10. Nonresident tax 0 32. Estimated tax penalty 0
11. KS tax on lump sum distributions 0 33. AMOUNT YOU OWE 0
12. TOTAL INCOME TAX 424 34. Overpayment 20
13. Credit for taxes paid to other
states 0 35. CREDIT FORWARD 0
14. Other credits 0 36. Chickadee Checkoff 0
37. Senior Citizens Meals On Wheels
15. Subtotal 424 Contribution Program 0
16. Earned Income Credit 0 38. Breast Cancer Research Fund 0
17. Food Sales Tax Credit 125 39. Military Emergency Relief Fund 0
18. Tax balance after credits 299 40. Kansas Hometown Heroes Fund 0
19. Use Tax Due (Out-of-State and 41. Kansas Creative Arts Industry
Internet Purchases) 0 Fund 0
42. Local School District Contribution
20. Total Tax Balance 299 Fund 0
21. KS income tax withheld from W-2,
319 School District Number
1099 or K-19

22. Estimated tax paid 43. REFUND 20

0
I authorize the Director of Taxation or the Director’s designee to discuss my K-40 and any enclosures with my preparer.
I declare under the penalties of perjury that to the best of my knowledge and belief this is a true, correct, and complete return.
Taxpayer
Signature Preparer Preparer PTIN,
(Required) Date Signature SELF-PREPARED EIN or SSN

Taxpayer
Signature Preparer
(Required) Date Phone Number

IMPORTANT: 1) Form K-40 is a 2 PAGE FORM. BOTH PAGES REQUIRED WHEN FILING; 2) Make sure your NAME, 1st
4-letters last name, and SSN are printed at the top of page 2 of 2; 3) Refunds are not issued for any unsigned
returns. Signature(s) are required; 4) DO NOT USE RED or SHADES of RED INK on tax returns filed with Kansas
INDIVIDUAL INCOME TAX

Page 2 of 2 PO Box 750260

TOPEKA KS 66675-0260 REV 11/13/17 INTUIT.CG.CFP.SP