<div style="text-align: center; font-weight: bold; font-size: 20pt;">1040EZ</div>
        <div style="text-align: right"><fieldset><legend align="top" style="font-weight: bold">
                    Personal Information
                </legend><table width="100%"><tr><td>&amp;nbsp;
                        </td><td>First name and initial</td><td>Last name</td><td>Social security number</td><td>Campaign fund($3)</td>
                    </tr><tr><td>You</td><td><input id="your-first-name" tabindex="1" type="text"/>
                        </td><td><input id="your-last-name" tabindex="2" type="text"/>
                        </td><td><input id="your-ssn" tabindex="3" type="text"/>
                        </td><td><input id="your-donation" tabindex="4" type="checkbox"/>
                        </td>
                    </tr><tr><td>Spouse</td><td><input id="spouse-first-name" tabindex="11" type="text"/>
                        </td><td><input id="spouse-last-name" tabindex="12" type="text"/>
                        </td><td><input id="spouse-ssn" tabindex="13" type="text"/>
                        </td><td><input id="spouse-donation" tabindex="14" type="checkbox"/>
                        </td>
                    </tr><tr><td colspan="2">Street Address</td><td colspan="3"><input id="street-address" tabindex="21" type="text"/>
                        </td>
                    </tr><tr><td colspan="2">City, State, Zip</td><td colspan="3"><input id="city-state-zip" tabindex="22" type="text"/>
                        </td>
                    </tr>
                </table>
            </fieldset><fieldset><legend align="top" style="font-weight: bold">Income</legend><table width="100%"><tr><td>1</td><td>Wages, salaries and tips</td><td align="right"><input id="wages" tabindex="31" type="text"/>
                        </td>
                    </tr><tr><td>2</td><td>Taxable interest, $1500 or less</td><td align="right"><input id="taxable-interest" tabindex="32" type="text"/>
                        </td>
                    </tr><tr><td>3</td><td>Unemployment compensation</td><td align="right"><input id="unemployment-compensation" tabindex="33" type="text"/>
                        </td>
                    </tr><tr><td>4</td><td>Adjusted gross income (Add lines 1,2 and 3)</td><td align="right"><input id="adjusted-gross-income" tabindex="34" type="text"/>
                        </td>
                    </tr><tr><td>5</td><td>
                            Standard deduction($8,450 if single, $16,900 if married)
                            <br/>
                            (See instructions before entering)
                        </td><td align="right"><input id="standard-deduction" tabindex="35" type="text"/>
                        </td>
                    </tr><tr><td>6</td><td>Taxable income (Subtract 5 from 4)</td><td align="right"><input id="taxable-income" tabindex="36" type="text"/>
                        </td>
                    </tr>
                </table>
            </fieldset><fieldset><legend align="top" style="font-weight: bold">Tax payments</legend><table width="100%"><tr><td>7</td><td>Federal income tax withheld</td><td align="right"><input id="federal-tax-withheld" tabindex="41" type="text"/>
                        </td>
                    </tr><tr><td>8a</td><td>Earned income credit</td><td align="right"><input id="earned-income-credit" tabindex="42" type="text"/>
                        </td>
                    </tr><tr><td>8b</td><td>Nontaxable combat pay</td><td align="right"><input id="nontaxable-combat-pay" tabindex="43" type="text"/>
                        </td>
                    </tr><tr><td>9</td><td>Federal telephone credit</td><td align="right"><input id="federal-telephone-credit" tabindex="44" type="text"/>
                        </td>
                    </tr><tr><td>10</td><td>Total payments (Add 7, 8a, 9)</td><td align="right"><input id="total-payments" tabindex="45" type="text"/>
                        </td>
                    </tr><tr><td>11</td><td>Tax (from tax tables using line 6)</td><td align="right"><input id="tax" tabindex="46" type="text"/>
                        </td>
                    </tr>
                </table>
            </fieldset><fieldset><legend align="top" style="font-weight: bold">Refund or Payment</legend><table width="100%"><tr><td>12a</td><td>Refund (if 10 is larger then 11, enter difference here)</td><td align="right"><input id="refund" tabindex="51" type="text"/>
                        </td>
                    </tr><tr><td>12b</td><td>Routing number</td><td align="right"><input id="routing-number" tabindex="52" type="text"/>
                        </td>
                    </tr><tr><td>12c</td><td align="center" colspan="2">
                            Checking:
                            <input id="routing-checking" tabindex="53" type="checkbox"/>
                            Savings:
                            <input id="routing-savings" tabindex="54" type="checkbox"/>
                        </td>
                    </tr><tr><td>12d</td><td>Account number</td><td align="right"><input id="account-number" tabindex="54" type="text"/>
                        </td>
                    </tr><tr><td>13</td><td>Owed (if 11 is larger then 10, enter difference here)</td><td align="right"><input id="owed" tabindex="55" type="text"/>
                        </td>
                    </tr>
                </table>
            </fieldset><fieldset><legend align="top" style="font-weight: bold">Signatures</legend><table align="right" width="100%"><tr><td>Designee's name</td><td colspan="2">PIN</td><td>Phone number</td>
                    </tr><tr><td><input id="designees-name" tabindex="61" type="text"/>
                        </td><td colspan="2"><input id="designees-pin" tabindex="62" type="text"/>
                        </td><td><input id="designees-phone" tabindex="63" type="text"/>
                        </td>
                    </tr><tr><td>Your signature</td><td>Date</td><td>Occupation</td><td>Phone number</td>
                    </tr><tr><td><input id="your-signature" tabindex="71" type="text"/>
                        </td><td><input id="your-date" tabindex="72" type="text"/>
                        </td><td><input id="your-occupation" tabindex="73" type="text"/>
                        </td><td><input id="your-phone" tabindex="74" type="text"/>
                        </td>
                    </tr><tr><td>Spouse signature</td><td>Date</td><td>Occupation</td><td>Phone number</td>
                    </tr><tr><td><input id="spouse-signature" tabindex="81" type="text"/>
                        </td><td><input id="spouse-date" tabindex="82" type="text"/>
                        </td><td><input id="spouse-occupation" tabindex="83" type="text"/>
                        </td><td><input id="spouse-phone" tabindex="84" type="text"/>
                        </td>
                    </tr><tr><td>Preparer's signature</td><td>Date</td><td>Self-employed?</td><td>Preparer's SSN or PTIN</td>
                    </tr><tr><td><input id="preparers-signature" tabindex="91" type="text"/>
                        </td><td><input id="preparers-date" tabindex="92" type="text"/>
                        </td><td><input id="preparers-self-employed" tabindex="93" type="checkbox"/>
                        </td><td><input id="preparers-ssn-ptin" tabindex="94" type="text"/>
                        </td>
                    </tr><tr><td>Firm or Preparer's name</td><td>Preparer's address</td><td>EIN</td><td>Phone number</td>
                    </tr><tr><td><input id="preparers-name" tabindex="101" type="text"/>
                        </td><td><input id="preparers-address" tabindex="102" type="text"/>
                        </td><td><input id="preparers-ein" tabindex="103" type="text"/>
                        </td><td><input id="preparers-phone" tabindex="104" type="text"/>
                        </td>
                    </tr>
                </table>
            </fieldset>
        </div>