| Medical and Dental Expenses (not paid by insurance or otherwise) |
| 1. One-half (but not more than $150) of insurance premiums you paid for medical care |
$ 150.00 |
| 2. Medicine and drugs |
$ 450.00 |
| 3. Enter 1 % of Form 1040, line 31 (AGI) |
$ 250.00 |
| 4. Subtract line 3 from line 2 |
$ 200.00 |
| 5. Balance of insurance premiums for medical care not entered on line 1 |
$ 200.00 |
| 6. Other medical and dental expenses |
$ 1,187.50 |
| 7. Total (add lines 4 through 6) |
$ 1,587.50 |
| 8. Enter 3% of Form 1040, line 31 (AGI) |
$ 750.00 |
| 9. Subtract line 8 from line 7 |
$ 837.50 |
| 10. Total medical and dental expenses (add lines 1 and 9) |
$ 987.50 |
