Security Code

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Personal Information

Name		Social Sec. #	Date of Birth	Occupation	Work Phone
Taxpayer: (*)
Spouse:
Taxpayer Email Address (*):

	Taxpayer	Spouse	Marital Status
Blind	YesNo	YesNo	MariedSingleWidow(er)
Disabled	YesNo	YesNo	If Widow(er), Date of Spouse's Death
Pres. Campaign Fund	YesNo	YesNo	Filing Jointly? YesNo

Dependents (Children & Others)

Name First, Last)	Relationship	Date of Birth	Social Sec. #	Months Lived With You	Disabled	Full-time Student	Gross Income

Please remember to bring the following to your appointment:

- Last year's tax return (new clients only)
- Name and address label (from government booklet or card)
- All Statements (W-2s, 1099s, etc.)

Deductions

Please answer the following questions to help determine maximum deductions.

1. Are you self employed or do you receive hobby income? (*)	YesNo
2. Did you receive income from raising animals or crops? (*)	YesNo
3. Did you receive rent from real estate or other property? (*)	YesNo
4. Did you receive income from gravel, timber, minerals, oil, gas, copyrights or patents? (*)	YesNo
5. Did you withdraw or write checks from a mutual fund?	YesNo
6. Do you have a foreign bank account, trust or business?	YesNo
7. Do you provide a home for or help support anyone not listed as a dependent above?	YesNo
8. Did you receive any correspondence from the IRS or State Department of Taxation?	YesNo
9. Were there any births, deaths, marriages, divorces or adoptions in your immediate family?	YesNo
10. Did you give a gift of more than $11,000 to one or more people?	YesNo
11. Did you go through bankruptcy proceedings?	YesNo
12(A). If you paid rent, how much did you pay?
12(B). Was heat included?	YesNo
13. Did you pay interest on a student loan for yourself, your spouse, or your dependent during the year?	YesNo
14. Did you pay expenses for yourself, your spouse, or your dependent to attend classes beyond high school?	YesNo
* Contact us for further instructions if you answered "Yes" to any of the above 14 questions marked with an (*).

Wage, Salary Income

List all sources of wage/salary income below:

	TaxpayerSpouse
	TaxpayerSpouse
	TaxpayerSpouse
	TaxpayerSpouse
	TaxpayerSpouse
	TaxpayerSpouse
	TaxpayerSpouse

Interest Income

	TaxpayerSpouse
	TaxpayerSpouse
	TaxpayerSpouse
	TaxpayerSpouse
Tax Exempt:
	TaxpayerSpouse
	TaxpayerSpouse
	TaxpayerSpouse

Dividend Income

Payer	Ordinary	Capital Gains	Non-Taxable

Partnership, Trust, Estate Income

List payers of partnership, limited partnership, S-corporation, trust, or estate income - bring K-1 to appointment

Investments Sold

Stocks, Bonds, Mutual Funds, Gold, Silver, Partnership Interest - Bring 1099-B & Confirmation Slips to appointment

Investment	Date Acquired/Sold			Cost	Sale Price
		/
		/
		/
		/

Property Sold

Bring 1099-S and closing statemtents to appointment

Property	Date Acquired	Cost & Improvements
Personal Residence(*)
Vacation Home
Land
Other
(*)Provide information on improvements, prior sales of home, and cost of a new residence.

I.R.A. (Individual Retirement Account)

Contributions for tax year income

	Amount	Date	U for Roth
Taxpayer
Spouse

For amounts withdrawn, bring forms 1099-R & 5498 to appointment

Plan Trustee	Reason for Withdrawal	Reinvested?
		YesNo
		YesNo
		YesNo

Pension, Anuity Income

Bring form 1099-R to appointment

Payer*	Reason for Withdrawal	Reinvested?
		YesNo
		YesNo
		YesNo

Did you receive:

	Taxpayer	Spouse
Social Security Benefits:	YesNo	YesNo
Railroad Retirement	YesNo	YesNo

Bring forms SSA 1099 & RRB 1099 to your appointment

Other Income

List all other income, including non-taxable

Alimony Received:
Child Support:
Scholarship (Grants):
Unemployment Compensation (Repaid):
Prizes, Bonuses & Awards:
Gambling, Lottery:	(Expenses: )
Unreported Tips:
Director / Executor's Fee:
Commissions:
Jury Duty:
Worker's Compensation:
Disability Income:
Veteran's Pension:
Payments from Prior Installment Sale:
State Income Tax Refund:
Other:
Other:

Medical / Dental Expenses

Medical Insurance Premiums:
Medical Insurance Premiums Paid by You:
Prescription Drugs:
Insulin
Glasses, Contacts
Hearing Aids, Batteries
Braces
Medical Equipments, Supplies
Nursing Care
Medical Therapy
Hospital
Doctor/Dental/Orthodontist
Medical Mileage (# miles)

Taxes Paid

Real Property Tax (bring bills to appointment):
Personal Property Tax:
Other:

Interest Expense

Mortgage Interest Paid (Bring 1098 to appointment):
Interest paid to individual for your home (Bring amortization schedule to appointment.)
Paid to (Name):
Paid to (Address):
Paid to (Social):
Investment Interest:

Casualty/Theft Loss

For property damaged by storm, water, fire, accident, or stolen.

Location of Property:




Description of Property:

Amount of Damage:
Insurance Reimbursement:
Repair Costs:
Federal Grants Received:

Charitable Contributions

Church:
United Way:
Scouts:
Telethons:
University, Public TV/Radio:
Heart, Lung, Cancer, Etc.:
Wildlife Fund:
Salvation Army, Goodwill:
Other:
Non-Cash:
Volunteer (# Miles):

Job-Related Moving Expenses

Date of Move:
Move Household Goods:
Travel to New Home (# Miles):
Lodging During Move:

Employment Related Expenses You Paid (Not Self-Employed)

Dues - Union, Professional:
Books, Subscriptions, Supplies:
Licenses:
Tools, Equipment, Safety Equipment:
Uniforms (Include Cleaning):
Sales Expense, Gifts:
Tuition, Books (Work Related):
Entertainment:
In-Home Office: (In Square Feet)
A. Total Home:
B. Office:
C. Storage:
Rent:
Insurance:
Utilities:
Maintenance:

Child & Other Dependent Care Expenses

Name of Care Provider	Address	Soc. Sec. # or EID	Amount Paid

Business Mileage

Do you have written records?	YesNo
Did you sell or trade in a car used for business?	YesNo
If "Yes" bring a copy of the purchase agreement to your appointment.
Make/Year of Vehicle
Date Purchased:
Total Miles (Personal and Business)
Business Miles (Not to and from Work):
From First to Second Job:
Education (One way, work to school)
Job Seeking:
Other Business:
Round Trip Commuting Distance:
Gas, Oil, Lubrication:
Batteries, Tires, Etc.
Repairs:
Wash:
Insurance:
Interest:
Lease Payments:
Garage Rent:

Business Travel

If you are not reimbursed for exact amount, give total expenses.

Airfare, Train, Etc.:
Lodging:
Meals (# Days: )
Taxi, Car Rental:
Other:
Reimbursement Received:

Investment Related Expenses

Tax Preparation Fee:
Safe Deposit Box Rental
Mutual Fund Fee:
Investment Counselor:
Other:

Estimated Tax Paid

Due Date	Date Paid	Federal	State

Other Deductions

Alimony Paid To:
Social Security Number:
Total Alimony Paid:
Student Interest Paid:

Education Expenses

Student's Name	Type of Expense	Amount

Questions, Comments or Other Information

Residence:

Town:			County:
Village:			School District:
City:

By submitting this form, I agree that the included information is correct and includes all income, deductions, and other information necessary for the preparation of this year's income tax returns for which I have adequate records and to the best of my knowledge.