Form 1040-SS                                                                                          U.S. Self-Employment Tax Return                                                                OMB No. 1545-0090 
                                                           (Including the Refundable Child Tax Credit for Bona Fide Residents of Puerto Rico)
Department of the Treasury                                 U.S. Virgin Islands, Guam, American Samoa, the Commonwealth of the Northern Mariana Islands, or Puerto Rico                               2021
Internal Revenue Service                                   For the year Jan. 1–Dec. 31, 2021, or other tax year beginning            , 2021, and ending          , 20
                                          Your first name and initial                                           Last name                                               Your social security number 

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

                                          Present home address (number, street, and apt. no., or rural route) 

                                          City, town or post office, commonwealth or territory, and ZIP code 
                     Please type or print.
                                          Foreign country name                                                                   Foreign province/state/county                                       Foreign postal code   

At any time during 2021, did you receive, sell, exchange, or otherwise dispose of any financial interest in any virtual currency?                                                                        Yes  No
Part I                                      Total Tax and Credits 
1                                           Filing status. Check the box for your filing status. See instructions. 
                                            Single         Married filing jointly                     Married filing separately (MFS)       Head of household                   Qualifying Widow(er)
                                            If you checked the MFS box, enter spouse’s social security no. above and full name here ▶
2                                           Qualifying children.        Complete only if you are a bona fide resident of Puerto Rico and you are claiming the refundable child tax 
                                            credit. See instructions. If more than four qualifying children, see instructions and check here  .                  .      .     . .                    . . . . .
                                              (a) First name                    Last name                            (b) Child’s social security number       (c) Child’s relationship to you 

3                                           Self-employment tax from Part V, line 12                  . .     . .    .    . .    . . .  . . . .         . . . .  .      .       3 
4                                           Household employment taxes (see instructions). Attach Schedule H (Form 1040)  .                             . . . .  .      .       4 
5 a                                         Additional Medicare Tax. Attach Form 8959                   .     . .    .    . .    . . .  . . . .         . . . .  .      .       5a
                                          b Repayment of advance child tax credit (see instructions)  .                     .    . . .  . . . .         . . . .  .      .       5b
6                                           Total tax. Add lines 3 through 5b. See instructions  .                   .    . .    . . .  . . . .         . . . .  .      .       6
7                                           2021 estimated tax payments (see instructions)  .                   .    .    . .    . . .  . .   7
8                                           Excess social security tax withheld (see instructions)   .                    . .    . . .  . .   8
9                                           Refundable child tax credit from Part II, line 3  .               . .    .    . .    . . .  . .   9
10                                          Health coverage tax credit. Attach Form 8885 .                    . .    .    . .    . . .  . .   10
11a                                         Credit for qualified sick and family leave wages for leave taken before April 1, 2021             11a
                                          b Credit for qualified sick and family leave wages for leave taken after March 31, 2021             11b
12                                          Total payments and credits (see instructions)                     . .    .    . .    . . .  . . . .         . . . .  .      .       12 
13                                          If line 12 is more than line 6, subtract line 6 from line 12. This is the amount you overpaid                   . .  .      .       13
14a                                         Amount of line 13 you want refunded to you. If Form 8888 is attached, check here  .                           . . .  ▶              14a 
                                          b Routing number                                                             ▶  Type:c        Checking          Savings
                                          d Account number
15                                          Amount of line 13 you want applied to 2022 estimated tax                        .    . . .  . ▶   15
16                                          Amount you owe. If line 6 is more than line 12, subtract line 12 from line 6. See instructions                    .  .  ▶           16
                                                    Do you want to allow another person to discuss this return with the IRS? See instructions.                Yes. Complete the following.                    No
Third Party 
Designee                                            Designee’s                                                              Phone                           Personal Identification 
                                                    name      ▶                                                             no.  ▶                          Number (PIN)           ▶
                                                    Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge 
Sign                                                and belief, they are true, correct, and complete. Declaration of preparer (other than the taxpayer) is based on all information of which the preparer has 
                                                    any knowledge.
Here                                        ▲       Your signature                                              Date               Daytime phone number   If the IRS sent you an Identity Protection PIN, 
Joint return?                                                                                                                                             enter it here 
See instructions.                                                                                                                                         (see instructions) ▶
Keep a copy                                         Spouse’s signature. If a joint return, both must sign.                         Date                   If the IRS sent your spouse an Identity Protection 
for your records.                                                                                                                                         PIN, enter it here 
                                                                                                                                                          (see instructions) ▶
                                              Print/Type preparer’s name                              Preparer’s signature                    Date               Check          if                   PTIN
Paid                                                                                                                                                             self-employed
Preparer                                                              ▶                                                                                       Firm’s EIN ▶
                                              Firm’s name     
                                              Firm’s address 
Use Only                                                              ▶                                                                                       Phone no.
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice,                                                            www.irs.gov/Form1040SS        Cat. No. 17184B          Form 1040-SS (2021)
see instructions. 

Form 1040-SS (2021)                                                                                                                 Page  2 
Part II  Bona Fide Residents of Puerto Rico Claiming Refundable Child Tax Credit—See instructions.
Tip: Bona fide residents of Puerto Rico may claim the refundable child tax credit for one or more qualifying children.
1     Modified adjusted gross income  .         .  . .  . .  . .  . .   . .  .   .  .    . .    . . .   . .  .         1 
2     Reserved for future use  .       . . .    .  . .  . .  . .  . .   . .  .   .  .    . .    . . .   . .  .         2 
3     Refundable child tax credit. Use the Refundable Child Tax Credit Worksheet in the instructions. Enter 
      the amount from line 20 of the worksheet here and on Part I, line 9 .  .   .  .    . .    . . .   . .  .         3 
Part III Profit or Loss From Farming—See the Instructions for Schedule F (Form 1040).
Name of proprietor                                                                                          Social security number 

Note: If you are filing a joint return and both you and your spouse had a profit or loss from a farming business, see Joint returns and  
      Business Owned and Operated by Spouses in the instructions for more information. 
                                                Section A—Farm Income—Cash Method
             Complete Sections A and B. (Accrual method taxpayers, complete Sections B and C, and Section A, line 11.) 
                    Don’t include sales of livestock held for draft, breeding, sport, or dairy purposes. See instructions. 
1     Sales of livestock and other items you bought for resale    . .   . .  .   .  .      1 
2     Cost or other basis of livestock and other items reported on line 1  . .   .  .      2 
3     Subtract line 2 from line 1      . . .    .  . .  . .  . .  . .   . .  .   .  .    . .    . . .   . .  .         3 
4     Sales of livestock, produce, grains, and other products you raised  .  .   .  .    . .    . . .   . .  .         4 
5a    Total cooperative distributions (Form(s) 1099-PATR)      5a                          5b   Taxable amount         5b 
6     Agricultural program payments received         .  . .  . .  . .   . .  .   .  .    . .    . . .   . .  .         6 
7     Commodity Credit Corporation (CCC) loans reported under election (or forfeited)  .        . . .   . .  .         7 
8     Crop insurance proceeds          . . .    .  . .  . .  . .  . .   . .  .   .  .    . .    . . .   . .  .         8 
9     Custom hire (machine work) income  .         . .  . .  . .  . .   . .  .   .  .    . .    . . .   . .  .         9 
10    Other income        . .   . .    . . .    .  . .  . .  . .  . .   . .  .   .  .    . .    . . .   . .  .         10 
11    Gross  farm  income.      Add  amounts  in  the  right  column  for  lines  3  through  10.  If  accrual  method 
      taxpayer, enter the amount from Section C, line 50  .    .  . .   . .  .   .  .    . .    . . .   . .  ▶         11 
                                         Section B—Farm Expenses—Cash and Accrual Method
    Don’t include personal or living expenses (such as taxes, insurance, or repairs on your home) that didn’t produce farm income.  
             Reduce the amount of your farm expenses by any reimbursements before entering the expenses below. 
12    Car and truck expenses                                        24    Labor hired      .    . . .   . .  .         24 
      (see instructions)   .    . .    . .      12                  25    Pension and profit-sharing plans             25
13    Chemicals   .       . .   . .    . .      13                  26    Rent or lease: 
14    Conservation expenses .          . .      14                      a Vehicles, machinery, and 
15    Custom hire (machine work) .       .      15                        equipment .      .    . . .   . .  .         26a 
16    Depreciation  and  section  179                                   b Other (land, animals, etc.) .   .  .         26b 
      expense  deduction  not  claimed                              27    Repairs and maintenance .       .  .         27 
      elsewhere  (attach    Form  4562  if                          28    Seeds and plants purchased .       .         28 
      required) .     .   . .   . .    . .      16                  29    Storage and warehousing         .  .         29 
17    Employee benefit programs other                               30    Supplies purchased        .   . .  .         30 
      than on line 25  .    .   . .    . .      17                  31    Taxes     .    . .    . . .   . .  .         31 
18    Feed purchased .      .   . .    . .      18                  32    Utilities .    . .    . . .   . .  .         32 
19    Fertilizers and lime .    . .    . .      19                  33    Veterinary, breeding, and medicine           33 
20    Freight and trucking   .    .    . .      20                  34    Other expenses (specify): 
21    Gasoline, fuel, and oil .   .    . .      21                      a                                              34a 
22    Insurance (other than health)   .         22                      b                                              34b 
23    Interest (see instructions):                                      c                                              34c 
a     Mortgage (paid to banks, etc.)  .      23a                        d                                              34d 
b     Other .       . .   . .   . .    . .   23b                        e                                              34e 
35    Total expenses. Add lines 12 through 34e  .       . .  . .  . .   . .  .   .  .    . .    . . .   . .  ▶         35 
36    Net farm profit or (loss). Subtract line 35 from line 11. Enter the result here and on Part V, line 1a  .        36 
                                                                                                                       Form 1040-SS (2021)

Form 1040-SS (2021)                                                                                                                            Page  3 
                                                   Section C—Farm Income—Accrual Method
      Don’t include sales of livestock held for draft, breeding, sport, or dairy purposes on any of the lines below. See instructions. 
 37     Sales of livestock, produce, grains, and other products during the year           .   .   . .  . .  .    .  .   .             37 
 38 a   Total cooperative distributions (Form(s) 1099-PATR)          38a                            38b Taxable amount                38b 
 39     Agricultural program payments received          .     . . .  .  . .     . . .     .   .   . .  . .  .    .  .   .             39 
 40     Commodity Credit Corporation (CCC) loans reported under election (or forfeited)  .             . .  .    .  .   .             40 
 41     Crop insurance proceeds        .    .  .   .  . .     . . .  .  . .     . . .     .   .   . .  . .  .    .  .   .             41 
 42     Custom hire (machine work) income  .          . .     . . .  .  . .     . . .     .   .   . .  . .  .    .  .   .             42 
 43     Other farm income (specify)                                                                                                   43 
 44     Add lines 37, 38b, and 39 through 43          . .     . . .  .  . .     . . .     .   .   . .  . .  .    .  .   .             44 
 45     Inventory of livestock, produce, grains, and other products at the beginning of
        the year  .  . .    . .      . .    .  .   .  . .     . . .  .  . .     . . .     .   .     45 
 46     Cost of livestock, produce, grains, and other products purchased during the year            46 
 47     Add lines 45 and 46  .       . .    .  .   .  . .     . . .  .  . .     . . .     .   .     47 
 48     Inventory of livestock, produce, grains, and other products at the end of the year          48 
 49     Cost of livestock, produce, grains, and other products sold. Subtract line 48 from line 47*  .           .  .   .             49 
 50     Gross farm income. Subtract line 49 from line 44. Enter the result here and on Part III, line 11 .          .  ▶              50 
*If you use the unit-livestock-price method or the farm-price method of valuing inventory and the amount on line 48 is larger than the amount on line 47, 
subtract line 47 from line 48. Enter the result on line 49. Add lines 44 and 49. Enter the total on line 50 and on Part III, line 11. 
Part IV     Profit or Loss From Business (Sole Proprietorship)—See the Instructions for Schedule C (Form 1040)                                .
Name of proprietor                                                                                                     Social security number 

Note: If you are filing a joint return and both you and your spouse had a profit or loss from a business, see Joint returns and Business 
        Owned and Operated by Spouses in the instructions for more information. 
                                                                Section A—Income 
 1      Gross receipts $                           Less returns and allowances $                            Balance  ▶                1 
 2 a    Inventory at beginning of year  .      .   .  . .     . . .  .  . .     . . .     .   .     2a 
    b   Purchases less cost of items withdrawn for personal use  .        .     . . .     .   .     2b 
    c   Cost of labor. Don’t include any amounts paid to yourself  .      .     . . .     .   .     2c 
    d   Materials and supplies       . .    .  .   .  . .     . . .  .  . .     . . .     .   .     2d 
    e   Other costs (attach statement)  .      .   .  . .     . . .  .  . .     . . .     .   .     2e 
    f   Add lines 2a through 2e  .     .    .  .   .  . .     . . .  .  . .     . . .     .   .     2f 
    g   Inventory at end of year  .    .    .  .   .  . .     . . .  .  . .     . . .     .   .     2g 
    h   Cost of goods sold. Subtract line 2g from line 2f  .      .  .  . .     . . .     .   .   . .  . .  .    .  .   .             2h 
 3      Gross profit. Subtract line 2h from line 1  .         . . .  .  . .     . . .     .   .   . .  . .  .    .  .   .             3 
 4      Other income   .    . .      . .    .  .   .  . .     . . .  .  . .     . . .     .   .   . .  . .  .    .  .   .             4 
 5      Gross income. Add lines 3 and 4  .         .  . .     . . .  .  . .     . . .     .   .   . .  . .  .    .  .  ▶              5 
                                                                Section B—Expenses 
 6      Advertising  . .    . .      . .    .      6                      18      Rent or lease: 
 7      Car and truck expenses                                                  a Vehicles, machinery, and equipment                  18a 
        (see instructions)  . .      . .    .      7                            b Other business property  .        .   .             18b 
 8      Commissions and fees         . .    .      8                      19      Repairs and maintenance .         .   .             19 
 9      Contract labor  .   . .      . .    .      9                      20      Supplies (not included in Section A)                20 
 10     Depletion  . . .    . .      . .    .      10                     21      Taxes and licenses  .     .    .  .   .             21 
 11     Depreciation  and  section  179                                   22      Travel and meals: 
        expense  deduction  not  claimed                                        a Travel  .       . .  . .  .    .  .   .             22a 
        elsewhere  (attach  Form  4562  if                                      b Deductible meals       .  .    .  .   .             22b 
        required)  . . .    . .      . .    .      11                     23      Utilities  .    . .  . .  .    .  .   .             23 
 12     Employee benefit programs (other                                  24      Wages not included on line 2c  .                    24 
        than on line 17)  . . .      . .    .      12                     25 a    Other expenses (list type and 
 13     Insurance (other than health)       .      13                             amount): 
 14     Interest on business indebtedness 
        (see instructions)  . .      . .    .      14 
 15     Legal and professional services  .         15 
 16     Office expense  .   . .      . .    .      16 
 17     Pension and profit-sharing plans           17                           b Total other expenses  .        .  .   .             25b 
 26     Total expenses. Add lines 6 through 25b         .     . . .  .  . .     . . .     .   .   . .  . .  .    .  .   ▶             26 
 27     Net profit or (loss). Subtract line 26 from line 5. Enter the result here and on Part V, line 2 .        .  .   .             27 
                                                                                                                                      Form 1040-SS (2021)

Form 1040-SS (2021)                                                                                                                      Page  4 
Part V     Self-Employment Tax—If you had church employee income, see instructions before you begin. 
Name of person with self-employment income                                   Social security number of person 
                                                                             with self-employment income ▶
Note: If you are filing a joint return and both you and your spouse had self-employment income, you must each complete a separate 
      Part V. 
A     If you are a minister, member of a religious order, or Christian Science practitioner       and you filed Form 4361, but you had 
      $400 or more of other net earnings from self-employment, check here and continue with Part V  .              .        . .  . . . . ▶
1 a   Net  farm  profit  or  (loss)  from  Part  III,  line  36,  and  your  distributive  share  from  farm  partnerships. 
      Note: Skip lines 1a and 1b if you use the farm optional method. See instructions  .          . . . .   .     .          1a 
   b  If  you  received  social  security  retirement  or  disability  benefits,  enter  the  amount  of  Conservation
      Reserve Program payments included on Part III, line 6, plus your distributive share of these payments 
      from farm partnerships  .     . .      .   .  . .   . . .   .   . .  .   .  . .   .  .    .  . . . .   .    .           1b (                             ) 
2     Net  nonfarm  profit  or  (loss)  from  Part  IV,  line  27,  and  your  distributive  share  from  nonfarm 
      partnerships. Ministers and members of religious orders, see instructions for amounts to report on
      this  line.  See  instructions  for  other  income  to  report. Note:  Skip  this  line  if  you  use  the  nonfarm
      optional method. See instructions .        .  . .   . . .   .   . .  .   .  . .   .  .    .  . . . .   .    .           2 
3     Combine lines 1a, 1b, and 2     .      .   .  . .   . . .   .   . .  .   .  . .   .  .    .  . . . .   .    .           3 
4 a   If line 3 is more than zero, multiply line 3 by 92.35% (0.9235). Otherwise, enter the amount from line 3                4a 
      Note: If line 4a is less than $400 due to Conservation Reserve Program payments on line 1b, see 
      instructions. 
   b  If you elect one or both of the optional methods, enter the total of lines 2 and 4 of Part VI here .   .     .          4b 
   c  Combine lines 4a and 4b. If less than $400, stop; you don’t owe self-employment tax. Exception. If 
      less than $400 and you had church employee income, enter -0- and continue .               .  . . . .   .     ▶          4c 
5 a   Enter  your   church  employee  income  from  Form(s)  W-2,  W-2AS,  W-2CM, 
      W-2GU, W-2VI, or 499R-2/W-2PR. See instructions for the definition of church
      employee income  .        . . . .      .   .  . .   . . .   .   . .  .   .  . .   .       5a 
   b  Multiply line 5a by 92.35% (0.9235). If less than $100, enter -0-  .     .  . .   .  .    .  . . . .   .     .          5b 
6     Add lines 4c and 5b  .      . . .      .   .  . .   . . .   .   . .  .   .  . .   .  .    .  . . . .   .  ▶             6 
7     Maximum amount of combined wages and self-employment earnings subject to social security tax for 
      2021  .       . . .   .   . . . .      .   .  . .   . . .   .   . .  .   .  . .   .  .    .  . . . .   .    .           7        142,800
8 a   Total  social  security  wages  and  tips  from  Form(s)  W-2,  W-2AS,  W-2CM, 
      W-2GU, W-2VI, or 499R-2/W-2PR. If $142,800 or more, skip lines 8b through
      10, and go to line 11  .    . . .      .   .  . .   . . .   .   . .  .   .  . .   .       8a 
   b  Unreported  tips  subject  to  social  security  tax  from  Form  4137,  line  10  (see 
      instructions)  .  .   .   . . . .      .   .  . .   . . .   .   . .  .   .  . .   .       8b 
   c  Wages subject to social security tax from Form 8919, line 10 (see instructions)           8c 
   d  Add lines 8a, 8b, and 8c  .   . .      .   .  . .   . . .   .   . .  .   .  . .   .  .    .  . . . .   .    .           8d 
9     Subtract line 8d from line 7. If zero or less, enter -0- here and on line 10 and go to line 11  .  .   .  ▶             9 
10    Multiply the smaller of line 6 or line 9 by 12.4% (0.124) .     . .  .   .  . .   .  .    .  . . . .   .     .          10 
11    Multiply line 6 by 2.9% (0.029)  .     .   .  . .   . . .   .   . .  .   .  . .   .  .    .  . . . .   .    .           11 
12    Self-employment tax. Add lines 10 and 11. Enter here and on Part I, line 3  .        .    .  . . . .   .     .          12 
Part VI    Optional Methods To Figure Net Earnings—See instructions for limitations. 
Note: If you are filing a joint return and both you and your spouse choose to use an optional method to figure net earnings, you must 
      each complete and attach a separate Part VI. 
      Farm Optional Method 
1     Maximum income for optional methods  .          .   . . .   .   . .  .   .  . .   .  .    .  . . . .   .     .          1          5,880
2     Enter the smaller of: two-thirds (2/3) of gross farm income (Part III, line 11, plus your distributive share 
      from farm partnerships), but not less than zero;      or $5,880. Also, include this amount on Part V, line
      4b, above .     . .   .   . . . .      .   .  . .   . . .   .   . .  .   .  . .   .  .    .  . . . .   .     .          2 
      Nonfarm Optional Method 
3     Subtract line 2 from line 1   . .      .   .  . .   . . .   .   . .  .   .  . .   .  .    .  . . . .   .    .           3 
4     Enter the     smaller of: two-thirds ( /2)3of gross nonfarm income (Part IV, line 5, plus your distributive 
      share from nonfarm partnerships), but not less than zero;         or the amount on Part VI, line 3, above. 
      Also, include this amount on Part V, line 4b, above .       .   . .  .   .  . .   .  .    .  . . . .   .    .           4 
                                                                                                                              Form 1040-SS (2021)