1040 U.S.

Individual Income Tax Return 2020 (99)

Form Department of the Treasury—Internal Revenue Service

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

Filing Status Single Married filing jointly Married filing separately (MFS) Head of household (HOH) Qualifying widow(er) (QW)
Check only If you checked the MFS box, enter the name of your spouse. If you checked the HOH or QW box, enter the child’s name if the qualifying
one box.
person is a child but not your dependent a
Your first name and middle initial Last name Your social security number
Nube Balarezo 054-86-9334
If joint return, spouse’s first name and middle initial Last name Spouse’s social security number

Home address (number and street). If you have a P.O. box, see instructions. Apt. no. Presidential Election Campaign
256 Lincoln Ave Check here if you, or your
spouse if filing jointly, want $3
City, town, or post office. If you have a foreign address, also complete spaces below. State ZIP code
to go to this fund. Checking a
Elizabeth NJ 072081611 box below will not change
Foreign country name Foreign province/state/county Foreign postal code your tax or refund.
You Spouse

At any time during 2020, did you receive, sell, send, exchange, or otherwise acquire any financial interest in any virtual currency? Yes No

Standard Someone can claim: You as a dependent Your spouse as a dependent

Deduction Spouse itemizes on a separate return or you were a dual-status alien

Age/Blindness You: Were born before January 2, 1956 Are blind Spouse: Was born before January 2, 1956 Is blind
Dependents (see instructions): (2) Social security (3) Relationship (4)  if qualifies for (see instructions):
(1) First name Last name number to you Child tax credit Credit for other dependents
If more
than four
dependents,
see instructions
and check
here a
1 Wages, salaries, tips, etc. Attach Form(s) W-2 . . . . . . . . . . . . . . . . 1 37,522.
Attach 2a Tax-exempt interest . . . 2a 2b
b Taxable interest . . . . .
Sch. B if
3a Qualified dividends . . . 3a b Ordinary dividends . . . . . 3b
required.
4a IRA distributions . . . . 4a b Taxable amount . . . . . . 4b
5a Pensions and annuities . . 5a b Taxable amount . . . . . . 5b
Standard 6a Social security benefits . . 6a b Taxable amount . . . . . . 6b
Deduction for— a
7 Capital gain or (loss). Attach Schedule D if required. If not required, check here . . . . 7
• Single or
Married filing 8 Other income from Schedule 1, line 9 . . . . . . . . . . . . . . . . . . . 8
separately,
$12,400 9 Add lines 1, 2b, 3b, 4b, 5b, 6b, 7, and 8. This is your total income . . . . . . . . . a 9 37,522.
• Married filing 10 Adjustments to income:
jointly or
Qualifying a From Schedule 1, line 22 . . . . . . . . . . . . . . 10a
widow(er),
$24,800
b Charitable contributions if you take the standard deduction. See instructions 10b 300.
• Head of c Add lines 10a and 10b. These are your total adjustments to income . . . . . . . . a 10c 300.
household,
$18,650 11 Subtract line 10c from line 9. This is your adjusted gross income . . . . . . . . . a 11 37,222.
• If you checked 12 Standard deduction or itemized deductions (from Schedule A) . . . . . . . . . . 12 12,400.
any box under
Standard 13 Qualified business income deduction. Attach Form 8995 or Form 8995-A . . . . . . . . 13
Deduction,
see instructions.
14 Add lines 12 and 13 . . . . . . . . . . . . . . . . . . . . . . . . 14 12,400.
15 Taxable income. Subtract line 14 from line 11. If zero or less, enter -0- . . . . . . . . . 15 24,822.
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Form 1040 (2020)
Form 1040 (2020) Page 2
16 Tax (see instructions). Check if any from Form(s): 1 8814 2 4972 3 . . 16 2,782.
17 Amount from Schedule 2, line 3 . . . . . . . . . . . . . . . . . . . . 17
18 Add lines 16 and 17 . . . . . . . . . . . . . . . . . . . . . . . . 18 2,782.
19 Child tax credit or credit for other dependents . . . . . . . . . . . . . . . . 19
20 Amount from Schedule 3, line 7 . . . . . . . . . . . . . . . . . . . . 20
21 Add lines 19 and 20 . . . . . . . . . . . . . . . . . . . . . . . . 21
22 Subtract line 21 from line 18. If zero or less, enter -0- . . . . . . . . . . . . . . 22 2,782.
23 Other taxes, including self-employment tax, from Schedule 2, line 10 . . . . . . . . . 23 0.
24 Add lines 22 and 23. This is your total tax . . . . . . . . . . . . . . . . a 24 2,782.
25 Federal income tax withheld from:
a Form(s) W-2 . . . . . . . . . . . . . . . . . . 25a 2,719.
b Form(s) 1099 . . . . . . . . . . . . . . . . . . 25b
c Other forms (see instructions) . . . . . . . . . . . . . 25c
d Add lines 25a through 25c . . . . . . . . . . . . . . . . . . . . . . 25d 2,719.
• If you have a 26 2020 estimated tax payments and amount applied from 2019 return . . . . . . . . . . 26
qualifying child, 27 Earned income credit (EIC) . . . . . . . . . . . . No. . 27
attach Sch. EIC.
• If you have 28 Additional child tax credit. Attach Schedule 8812 . . . . . . . 28
nontaxable 29 American opportunity credit from Form 8863, line 8 . . . . . . . 29
combat pay,
see instructions. 30 Recovery rebate credit. See instructions . . . . . . . . . . 30
31 Amount from Schedule 3, line 13 . . . . . . . . . . . . 31
32 Add lines 27 through 31. These are your total other payments and refundable credits . . . a 32
33 Add lines 25d, 26, and 32. These are your total payments . . . . . . . . . . . a 33 2,719.
34 If line 33 is more than line 24, subtract line 24 from line 33. This is the amount you overpaid . . 34
Refund
35a Amount of line 34 you want refunded to you. If Form 8888 is attached, check here . . . a 35a
Direct deposit? ab Routing number X X X X X X X X X a c Type: Checking Savings
See instructions. ad Account number X X X X X X X X X X X X X X X X X
36 Amount of line 34 you want applied to your 2021 estimated tax . . a 36
Amount 37 Subtract line 33 from line 24. This is the amount you owe now . . . . . . . . . . a 37 63.
You Owe Note: Schedule H and Schedule SE filers, line 37 may not represent all of the taxes you owe for
For details on 2020. See Schedule 3, line 12e, and its instructions for details.
how to pay, see
instructions. 38 Estimated tax penalty (see instructions) . . . . . . . . . a 38
Third Party Do you want to allow another person to discuss this return with the IRS? See
Designee instructions . . . . . . . . . . . . . . . . . . . . a Yes. Complete below. No
Designee’s Phone Personal identification
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
Sign belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Here Your signature Date Your occupation If the IRS sent you an Identity
Protection PIN, enter it here
F

Joint return? Medical Assistant (see inst.) a

See instructions. Spouse’s signature. If a joint return, both must sign. Date Spouse’s occupation If the IRS sent your spouse an
Keep a copy for Identity Protection PIN, enter it here
your records. (see inst.) a
Phone no. Email address
Preparer’s name Preparer’s signature Date PTIN Check if:
Paid Self-employed
Preparer Firm’s name a Self-Prepared Phone no.
Use Only Firm’s address a Firm’s EIN a

Go to www.irs.gov/Form1040 for instructions and the latest information. BAA REV 03/25/21 Intuit.cg.cfp.sp Form 1040 (2020)
Form 8962 Premium Tax Credit (PTC)
OMB No. 1545-0074

2020
a Attach to Form 1040, 1040-SR, or 1040-NR.
Department of the Treasury Attachment
Internal Revenue Service a Go to www.irs.gov/Form8962 for instructions and the latest information. Sequence No. 73
Name shown on your return Your social security number
Nube Balarezo 054-86-9334
You cannot take the PTC if your filing status is married filing separately unless you qualify for an exception. See instructions. If you qualify, check the box . . a

Part I Annual and Monthly Contribution Amount

1 Tax family size. Enter your tax family size. See instructions . . . . . . . . . . . . . . . . . 1 1
2a Modified AGI. Enter your modified AGI. See instructions . . . . . . . . . 2a 37,222.
b Enter the total of your dependents’ modified AGI. See instructions . . . . . . 2b
3 Household income. Add the amounts on lines 2a and 2b. See instructions . . . . . . . . . . . . 3 37,222.
4 Federal poverty line. Enter the federal poverty line amount from Table 1-1, 1-2, or 1-3. See instructions. Check the
appropriate box for the federal poverty table used. a Alaska b Hawaii c Other 48 states and DC 4 12,490.
5 Household income as a percentage of federal poverty line (see instructions) . . . . . . . . . . . . 5 298 %
6 Did you enter 401% on line 5? (See instructions if you entered less than 100%.)
No. Continue to line 7.
Yes. You are not eligible to take the PTC. If advance payment of the PTC was made, see the instructions for
how to report your excess advance PTC repayment amount.
7 Applicable figure. Using your line 5 percentage, locate your “applicable figure” on the table in the instructions . . 7 0.0972
8a Annual contribution amount. Multiply line 3 by b Monthly contribution amount. Divide line 8a
8a 3,618.
line 7. Round to nearest whole dollar amount by 12. Round to nearest whole dollar amount
8b 302.
Part II Premium Tax Credit Claim and Reconciliation of Advance Payment of Premium Tax Credit
9 Are you allocating policy amounts with another taxpayer or do you want to use the alternative calculation for year of marriage? See instructions.
Yes. Skip to Part IV, Allocation of Policy Amounts, or Part V, Alternative Calculation for Year of Marriage. No. Continue to line 10.
10 See the instructions to determine if you can use line 11 or must complete lines 12 through 23.
Yes. Continue to line 11. Compute your annual PTC. Then skip lines 12–23 No. Continue to lines 12–23. Compute
and continue to line 24. your monthly PTC and continue to line 24.
(a) Annual enrollment (b) Annual applicable (c) Annual (d) Annual maximum (e) Annual premium tax (f) Annual advance
Annual SLCSP premium premium assistance
premiums (Form(s) contribution amount credit allowed payment of PTC (Form(s)
Calculation (Form(s) 1095-A, (subtract (c) from (b); if
1095-A, line 33A) (line 8a) (smaller of (a) or (d)) 1095-A, line 33C)
line 33B) zero or less, enter -0-)

11 Annual Totals
(c) Monthly
(a) Monthly enrollment (b) Monthly applicable (d) Monthly maximum (f) Monthly advance
contribution amount (e) Monthly premium tax
Monthly premiums (Form(s) SLCSP premium premium assistance payment of PTC (Form(s)
(amount from line 8b credit allowed
Calculation 1095-A, lines 21–32, (Form(s) 1095-A, lines (subtract (c) from (b); if 1095-A, lines 21–32,
or alternative marriage (smaller of (a) or (d))
column A) 21–32, column B) zero or less, enter -0-) column C)
monthly calculation)

12 January 1. 100. 302. 0. 0.

13 February
14 March
15 April
16 May
17 June
18 July
19 August
20 September
21 October
22 November
23 December
24 Total premium tax credit. Enter the amount from line 11(e) or add lines 12(e) through 23(e) and enter the total here 24 0.
25 Advance payment of PTC. Enter the amount from line 11(f) or add lines 12(f) through 23(f) and enter the total here 25

26 Net premium tax credit. If line 24 is greater than line 25, subtract line 25 from line 24. Enter the difference here and
on Schedule 3 (Form 1040), line 8. If line 24 equals line 25, enter -0-. Stop here. If line 25 is greater than line 24,
leave this line blank and continue to line 27 . . . . . . . . . . . . . . . . . . . . . 26 0.
Part III Repayment of Excess Advance Payment of the Premium Tax Credit
27 Excess advance payment of PTC. If line 25 is greater than line 24, subtract line 24 from line 25. Enter the difference here 27
28 Repayment limitation (see instructions) . . . . . . . . . . . . . . . . . . . . . . 28
29 Excess advance premium tax credit repayment. Enter the smaller of line 27 or line 28 here and on Schedule 2
(Form 1040), line 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
For Paperwork Reduction Act Notice, see your tax return instructions. BA REV 03/25/21 Intui Form 8962 (2020)
Form 8962 (2020) Page 2
Part IV Allocation of Policy Amounts
Complete the following information for up to four policy amount allocations. See instructions for allocation details.
Allocation 1
30 (a) Policy Number (Form 1095-A, line 2) (b) SSN of other taxpayer (c) Allocation start month (d) Allocation stop month

Allocation percentage (g) Advance Payment of the PTC

(e) Premium Percentage (f) SLCSP Percentage
applied to monthly Percentage
amounts

Allocation 2
31 (a) Policy Number (Form 1095-A, line 2) (b) SSN of other taxpayer (c) Allocation start month (d) Allocation stop month

Allocation percentage (g) Advance Payment of the PTC

(e) Premium Percentage (f) SLCSP Percentage
applied to monthly Percentage
amounts

Allocation 3
32 (a) Policy Number (Form 1095-A, line 2) (b) SSN of other taxpayer (c) Allocation start month (d) Allocation stop month

Allocation percentage (g) Advance Payment of the PTC

(e) Premium Percentage (f) SLCSP Percentage
applied to monthly Percentage
amounts

Allocation 4
33 (a) Policy Number (Form 1095-A, line 2) (b) SSN of other taxpayer (c) Allocation start month (d) Allocation stop month

Allocation percentage (g) Advance Payment of the PTC

(e) Premium Percentage (f) SLCSP Percentage
applied to monthly Percentage
amounts

34 Have you completed all policy amount allocations?

Yes. Multiply the amounts on Form 1095-A by the allocation percentages entered by policy. Add all allocated policy amounts and non-
allocated policy amounts from Forms 1095-A, if any, to compute a combined total for each month. Enter the combined total for each month on
lines 12–23, columns (a), (b), and (f). Compute the amounts for lines 12–23, columns (c)–(e), and continue to line 24.
No. See the instructions to report additional policy amount allocations.

Part V Alternative Calculation for Year of Marriage

Complete line(s) 35 and/or 36 to elect the alternative calculation for year of marriage. For eligibility to make the election, see the instructions for line 9.
To complete line(s) 35 and/or 36 and compute the amounts for lines 12–23, see the instructions for this Part V.
(a) Alternative family size (b) Alternative monthly (c) Alternative start month (d) Alternative stop month
35 Alternative entries contribution amount
for your SSN

(a) Alternative family size (b) Alternative monthly (c) Alternative start month (d) Alternative stop month
36 Alternative entries contribution amount
for your spouse’s
SSN
REV 03/25/21 Intui Form 8962 (2020)
 2020 NJ-1040
New Jersey Resident Income Tax Return

For Privacy Act Notification, See Instructions

NJ-1040
2020
Page 1
1555

040MP01200
Your Social Security Number (required) Last Name, First Name, Initial (Joint Filers enter first name and middle initial of each. Enter spouse’s/CU partner’s last name ONLY if different.)

054869334 BALAREZO NUBE

Spouse’s/CU Partner’s SSN (if filing jointly)

Home Address (Number and Street, including apartment number)

County/Municipality Code (See Table page 50) 256 LINCOLN AVE
2004
City, Town, Post Office State ZIP Code
ELIZABETH NJ 072081611
Driver’s License Number (Voluntary) (See instructions)
B02366000059832

Federal extension filed.

The address above is a foreign address.
Your address has changed.
Death certificate is enclosed.
Do not want a paper form next year.
I authorize the Division of Taxation to discuss my return and enclosures with my preparer.
NJ-1040-O is enclosed.

Gubernatorial Elections Fund Note: This does not reduce your refund or increase your balance due.
Do you want to designate $1 to the Gubernatorial Elections Fund? You Yes No
If joint return, does your spouse want to designate $1? Spouse/CU Partner Yes No

Direct Deposit Information

dd1. Direct deposit indicator (1 for direct deposit, 4 for no direct deposit) dd1. 1
dd2. Account type (C for checking, S for savings) dd2. C
dd3. Fill in the checkbox if the direct deposit is going to an account outside the United States dd3.
dd4. Routing number dd4. 021200025
dd5. Account number dd5. 1010140889374

REV 03/17/21 Intuit.cg.cfp.sp

 Name(s) as shown on Form NJ-1040
BALAREZO NUBE
NJ-1040 Your Social Security Number
2020
Page 2
054869334 1555

040MP02200
Part-year residents, provide months/days you were a New Jersey resident during 2020: Fiscal year filers only:
From: To: Enter month of your year end 2 02 1

Filing Status
Fill in only one.

1. Single
2. Married/CU Couple, filing joint return
3. Married/CU Partner, filing separate return
4. Head of Household Enter spouse’s/CU partner’s SSN
5. Qualifying Widow(er)/Surviving CU Partner
Indicate the year of your spouse’s/CU partner’s death: 2018 2019

Exemptions
Fill in the ovals that apply. You must enter a total in the boxes to the right and complete the calculation.

6. Regular Self Spouse/CU Partner Domestic Partner 1 1000

x $1,000 = _________
7. Senior 65+ (Born in 1955 or earlier) Self Spouse/CU Partner x $1,000 = _________
8. Blind/Disabled Self Spouse/CU Partner x $1,000 = _________
9. Veteran Self Spouse/CU Partner x $6,000 = _________
10. Qualified Dependent Children x $1,500 = _________
11. Other Dependents x $1,500 = _________
12. Dependents Attending Colleges (See instructions) x $1,000 = _________
13. Total Exemption Amount (Add totals from the lines at 6 through 12) 13. 1000 .

14. Dependent Information. Provide the following information for each dependent.
Last Name, First Name, Middle Initial Social Security Number Birth Year No Health Insurance
a. _________________________________________________________________
b. _________________________________________________________________
c. _________________________________________________________________
d. _________________________________________________________________

REV 03/17/21 Intuit.cg.cfp.sp

 Name(s) as shown on Form NJ-1040
BALAREZO NUBE
NJ-1040 Your Social Security Number
2020
Page 3 054869334 1555

040MP03200

15. Wages, salaries, tips, and other employee compensation (State wages from Box 16 of enclosed W-2(s)) (See instructions) 15. 41791 .
16a. Taxable interest income (Enclose federal Schedule B if over $1,500) (See instructions) 16a. .
16b. Tax-exempt interest income (Enclose Schedule) (See instructions) Do not include on line 16a 16b. .
17. Dividends 17. .
18. Net profits from business (Schedule NJ-BUS-1, Part I, line 4) (Enclose federal Schedule C) 18. .
19. Net gains or income from disposition of property (Schedule NJ-DOP, line 4) 19. .
20a. Pensions, Annuities, and IRA Withdrawals (See instructions) 20a. .
20b. Excludable Pensions, Annuities, and IRA Withdrawals 20b. .
21. Distributive Share of Partnership Income (Schedule NJ-BUS-1, Part II, line 4) (Enclose Schedule NJK-1 or federal Schedule K-1) 21. .
22. Net pro rata share of S Corporation Income (Schedule NJ-BUS-1, Part III, line 4) (Enclose Schedule NJ-K-1 or federal Schedule K-1) 22. .
23. Net gains or income from rents, royalties, patents, and copyrights (Schedule NJ-BUS-1, Part IV, line 4) 23. .
24. Net Gambling Winnings (See instructions) 24. .
25. Alimony and Separate Maintenance Payments received 25. .
26. Other (Enclose documents) (See instructions) 26. .
27. Total Income (Add lines 15, 16a, 17 through 20a, and 21 through 26) 27. 41791 .
28a. Retirement/Pension Exclusion (See instructions) 28a. .
28b. Other Retirement Income Exclusion (See Worksheet D and instructions page 19) 28b. .
28c. Total Exclusion Amount (Add lines 28a and 28b) 28c. .
29. New Jersey Gross Income (Subtract line 28c from line 27) (See instructions) 29. 41791 .
30. Exemption Amount (Enter amount from line 13. Part-year residents see instr.) 30. 1000 .
31. Medical Expenses (See Worksheet F and instructions) 31. 265 .
32. Alimony and Separate Maintenance Payments (See instructions) 32. .
33. Qualified Conservation Contribution 33. .
34. Health Enterprise Zone Deduction 34. .
35. Alternative Business Calculation Adjustment (Schedule NJ-BUS-2, line 11) 35. 0 .
36. Organ/Bone Marrow Donation Deduction (See instructions) 36. .
37. Total Exemptions and Deductions (Add lines 30 through 36) 37. 1265 .
38. Taxable Income (Subtract line 37 from line 29) 38. 40526 .
39a. Total Property Taxes (18% of Rent) Paid (See instructions page 23) 39a. .
39b. Block .
39b. Lot .
39b. Qualifier Fill in if you completed Worksheet G
39c. County/Municipality Code
39d. Indicate your residency status during 2020 (fill in only one) Homeowner Tenant Both
40. Property Tax Deduction (From Worksheet H) (See instructions) 40. .
41. New Jersey Taxable Income (Subtract line 40 from line 38) 41. 40526 .
42. Tax on Amount on line 41 (Tax Table page 52) 42. 747 .
43. Credit For Income Taxes Paid to Other Jurisdictions (Enclose Schedule NJ-COJ) (See instructions) 43. .
Enter Code
44. Balance of Tax (Subtract line 43 from line 42) 44. 747 .
45. Child and Dependent Care Credit (See instructions) 45. .
Fill in if you are a CU couple claiming the Child and Dependent Care Credit
46. Sheltered Workshop Tax Credit 46. .
47. Gold Star Family Counseling Credit (See instructions) 47. .
48. Credit for Employer of Organ/Bone Marrow Donor (See instructions) 48. .
49. Total credits (Add lines 45 through 48) 49. .
50. Balance of Tax After Credits (Subtract line 49 from line 44) If zero or less, make no entry 50. 747 .
51. Use Tax Due on Internet, Mail-Order, or Other Out-of-State Purchases (See instructions) If no Use Tax, enter 0 51. 0 .
52. Interest on Underpayment of Estimated Tax 52. .
Fill in if Form NJ-2210 is enclosed

REV 03/17/21 Intuit.cg.cfp.sp

 Name(s) as shown on Form NJ-1040
BALAREZO NUBE
NJ-1040 Your Social Security Number
2020
Page 4
054869334 1555

040MP04200

53. Shared Responsibility Payment (See instructions) REQUIRED Enclose Schedule HCC and fill in 53. 0 .
54. Total Tax Due (Add lines 50 through 53) 54. 747 .
55. Total New Jersey Income Tax Withheld (Enclose Forms W-2 and 1099) 55. 859 .
56. Property Tax Credit (See instructions page 23) 56. .
57. New Jersey Estimated Tax Payments/Credit from 2019 tax return 57. .
58. New Jersey Earned Income Tax Credit (See instructions) 58. .
Fill in if you had the IRS calculate your federal earned income credit
Fill in if you are a CU couple claiming the NJ Earned Income Tax Credit
59. Excess New Jersey UI/WF/SWF Withheld (Enclose Form NJ-2450) (See instructions) 59. .
60. Excess New Jersey Disability Insurance Withheld (Enclose Form NJ-2450) (See instructions) 60. .
61. Excess New Jersey Family Leave Insurance Withheld (Enclose Form NJ-2450) (See instructions) 61. .
62. Wounded Warrior Caregivers Credit (See instructions) 62. .
63. Pass-Through Business Alternative Income Tax Credit (See instructions) 63. .
64. Total Withholdings, Credits, and Payments (Add lines 55 through 63) 64. 859 .
65. If line 64 is less than line 54, you have tax due. Subtract line 64 from line 54 and enter the amount you owe 65. .
If you owe tax, you can still make a donation on lines 68 through 75.
66. If the total on line 64 is more than line 54, you have an overpayment. Subtract line 54 from line 64 and enter the overpayment 66. 112 .
67. Amount from line 66 you want to credit to your 2021 tax 67. .
68. Contribution to N.J. Endangered Wildlife Fund $10 $20 Other 68. .
69. Contribution to N.J. Children’s Trust Fund to Prevent Child Abuse $10 $20 Other 69. .
70. Contribution to N.J. Vietnam Veterans’ Memorial Fund $10 $20 Other 70. .
71. Contribution to N.J. Breast Cancer Research Fund $10 $20 Other 71. .
72. Contribution to U.S.S. New Jersey Educational Museum Fund $10 $20 Other 72. .
73. Other Designated Contribution (See instructions) $10 $20 Other Enter Code 73. .
74. Other Designated Contribution (See instructions) $10 $20 Other Enter Code 74. .
75. Other Designated Contribution (See instructions) $10 $20 Other Enter Code 75. .
76. Total Adjustments to Tax Due/Overpayment amount (Add lines 67 through 75) 76. .
77. Balance due (If line 65 is more than zero, add line 65 and line 76) 77. .
78. Refund amount (If line 66 is more than zero, subtract line 76 from line 66) 78. 112 .

Under penalties of perjury, I declare that I have examined this Income Tax return, including accompanying schedules and statements, and to Tax Due Address
the best of my knowledge and belief, it is true, correct, and complete. If prepared by a person other than the taxpayer, this declaration is Enclose payment along with the NJ-1040-V payment
based on all information of which the preparer has any knowledge. voucher and tax return. Use the labels provided with the
envelope and mail to:
State of New Jersey
Division of Taxation
Revenue Processing Center - Payment
PO Box 111
Your Signature Date Spouse’s/CU Partner’s Signature (required if filing jointly) Date Trenton, NJ 08645-0111
Include Social Security number and make check or
Paid Preparer's Signature Federal Identification Number money order payable to:
State of New Jersey – TGI
You can also make a payment on our website:
www.njtaxation.org
Refund or No Tax Due Address
Use the labels provided with the envelope and mail to:
Firm's Name Firm’s Federal Employer Identification Number
New Jersey Division of Taxation
Revenue Processing Center - Refunds
PO Box 555
SELF PREPARED Trenton, NJ 08647-0555

Division Use: 1 _______________ 2 _______________ 3 _______________ 4 _______________ 5 _______________ 6 _______________ 7 _______________

REV 03/17/21 Intuit.cg.cfp.sp

 REQUIRED If your income on line 29 is above the filing threshold, you
must submit this schedule with your return.

Name(s) as shown on Form NJ-1040 Social Security Number

Balarezo, Nube 054-86-9334

Schedule NJ-HCC Health Care Coverage 2020

If your income on line 29 is at or below the filing threshold, do not complete this schedule.
PART I

Did you and, if applicable, all members of your tax household, have minimum essential health coverage for every month in
2020? (See instructions for line 53, NJ-1040.) Part-year residents include only months as a New Jersey resident.
Yes. You do not owe a shared responsibility payment. Fill in the oval at line 53, NJ-1040, and enclose this
schedule with your return.
No. Continue to Part II.

PART II
Enter the name and Social Security number for each member of your tax household. Check the box for every month each
person had minimum essential health coverage or qualified for an exemption (part-year residents include only months as a New
Jersey resident). If an individual qualified for an exemption, enter the exemption number. (See instructions for line 53, NJ-1040.)
If an individual has more than one exemption number, check the box. If you need more space, enclose a statement listing any
additional individuals.
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Name Social Security Number

Exemption number: Check box if this individual has more than one exemption number

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Name Social Security Number

Exemption number: Check box if this individual has more than one exemption number

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Name Social Security Number

Exemption number: Check box if this individual has more than one exemption number

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Name Social Security Number

Exemption number: Check box if this individual has more than one exemption number

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Name Social Security Number

Exemption number: Check box if this individual has more than one exemption number

Keep a copy of this schedule for your records REV 03/17/21 Intuit.cg.cfp.sp 1555