PLEASE PROVIDE THE FOLLOWING: [ ] LAST YEAR'S TAX RETURN (Only if you are a new client) [ ] ALL WAGE AND INCOME STATEMENTS (W-2's and 1099's) [ ] NAME &ADDRESS LABELS PROVIDED BY FEDERAL & STATE (included with your government forms booklet or postcard) THE CHECKLIST BELOW COULD LEAD TO HELPFUL DEDUCTIONS. PLEASE CHECK AND PROVIDE SUPPORTING INFORMATION REQUESTED. Yes No [ ] [ ] Any births adoptions, marriages, divorces or deaths in your IMMEDIATE family during the past year? [ ] [ ] Did you live apart from a spouse during the year? if yes, give dates: Lived apart from __________ to _________ [ ] [ ] Did you help support anyone? It so, list In Section 13. [ ] [ ] Did you use your car for business purposes other than commuting to and from work? Did you travel between a first and second job? See Sections P & T. [ ] [ ] Were you provided a company car for business and/or personal use? If so, please provide documentation to show how it was treated by your employer for tax purpose. If any use, other than your personal use of the company vehicle was Included In your W-2, see instructions In Section P. [ ] [ ] Did you forfeit any interest from closing a time deposit account? [ ] [ ] Did you move because of a job change? If so, have employer's statement available and list expenses in Section W. [ ] [ ] Have you contributed to your IRA or SW-employed retirement plan for this year? If so, enter the amounts: FILER SPOUSE IRA ......................... $_____________ $__________ Keogh (HR-10)....... $_____________ $__________ [ ] [ ] Do you or your spouse have, ANY KIND of pension, profit sharing, 401 K, retirement KEOGH, IRA, or tax sheltered annuity plan? if so, circle which ones. if yes, were you or your spouse at West 701/2 yam of age on Dec. 31 at? [ ] Yes [ ] No [ ] [ ] Did you withdraw IRA or Keogh funds from one financial Institution and redeposit the funds to another Institution during the year? it so, please Indicate the amount of funds Withdrawn $___________ Re-deposited: $ [ ] [ ] Do you have rented property? if so, please complete Section V. [ ] [ ] Do you have a business? if so, please complete Section V. [ ] [ ] Did you sell any stock, land, securities, partnership interests, or other property, or have any become worthless? if so, please complete Section 0. [ ] [ ] Does anyone owe you money for which you have EXHAUSTED all reasonable effort to collect? (Bad debts of RELATIVES usually are not deductible.) [ ] [ ] Did you have income or loss from partnerships or trusts? See Section F. [ ] [ ] Did you pay alimony? Paid to: ___________ Social Security #: ___________ Amount paid____________ [ ] [ ] Did you pay estimated tax? See Section C. [ ] [ ] Did you pay additional federal or state taxes last year as a result of an audit or filing of a late return? if so, please have all government notices available. List all payments In Section W. [ ] [ ] Did you receive a distribution from a pension plan, profit sharing plan, tax shelter annuity, deferred compensation plan, IRA, or KEOGFT? If yes have Form 1099-R and all other Information provided by your plan administrator or your employer available. [ ] [ ] Do you have a foreign bank account? [ ] [ ] Did you buy or sell real estate last year? if so, have the FINAL settlement statement for the purchase and/or sale available and complete Section 0. If a resident was sold, a list of Improvements will be required. PLEASE CALL THIS OFFICE, IN ADVANCE OF YOUR APPOINTMENT for additional information required to report a sale on your tax return. [ ] [ ] Do you wish to designate $1 of your taxes to the Presidential Campaign Fund? This neither Increases nor decrease your tax. [ ] [ ] Are you or your spouse legally blind or disabled? [ ] [ ] Did you have a casualty or thief loss? (Generally, it must exceed 10% of your income.) if so, bring itemized list (including original cost and the value on the date of loss), insurance Information regarding coverage and reimbursement, and police report |
[ ] [ ] Did you have child or dependent care or household expenses to enable you to work or attend school full time? if yes and the care is for a child under 13 or for an individual who is physically or mentally Incapable of self care, complete Section K [ ] [ ] Did you PURCHASE a diesel powered vehicle AND are you the original owner? THE FOLLOWING INFORMATION IS FOR STATE TAX PURPOSES AND MAY OR MAY NOT APPLY TO YOUR PARTICULAR STATE. [ ] [ ] Were you or your amuse living in rented property year? if so, list name, address and phone number of each landlord, amount of rent, plus the inclusive date you rented in Section W. [ ] [ ] Enter the school district name & number if applicable: [ ] [ ] Did you make a political contribution? $ _______ [ ] [ ] Did you participate in a ride sharing or vanpool program? A. PERSONAL DATA Last Name:_________________________________ First Name & Initial: You ______ Spouse _________ Address:___________________________________ City: ________________ State: _____ Zip: ________ Phone: Res. _____ Wk: ____You _____Spouse _____ SS No. Occupation DOB You ____________ __________________ ________ Spouse _________ __________________ ________ B. DEPENDENT CHILDREN & OTHER DEPENDENTS Name Social Security #DOB Income Mo. In Home 1. ___________ __________ ______ ______ ______ 2. ___________ __________ ______ ______ ______ 3. ___________ __________ ______ ______ ______ 4. ___________ __________ ______ ______ ______ C. ESTIMATED TAXES PAID Please Provide Cancelled Checks Date Due Date Paid Fed State Applied From Prior Year's Refund $ ______ $ ______ First QuarterAPRIL _______ $ ________ $ _______ Second QuarterJUNE _______ $ ________ $ ______ Third QuarterSEP _________ $ ________ $ _______ Fourth Quarter THIS JAN______ $ ______ $ ______ D. INTEREST INCOME Please Provide All Forms 1099-INT Source Amount Source Amount Nontaxable ___________ ___________ _________ U.S. Government _________ __________ _________ Seller Financed Mortgage _______ ______ ________ E. DIVIDEND INCOME Please Provide All forms 1099-DIV Source Amount Source Amount Nontaxable _______ ___________ ______ __________ ___________ ___________ _________ __________ ___________ ___________ _________ __________ ___________ ___________ _________ F. OTHER INCOME List ALL Sources Including Those That Are Nontaxable # Of Forms Amount Alimony Receive ____________ Gambling, Lottery, Prize Winnings and Award ______ IRA or Keogh Withdrawals ___________ Lump Sum Distributions (Provide 1094)-R) [ ] ______ Municipal Bond Interest Income _________________ Nontaxable Inheritance Gifts, and Loans ___________ Partnership/Trusts (Provide Form K-1 and Instructions)[ ] _ Pension or Annuity (Provide 1099-R's) [ ] __________ Railroad Retirement (Forms RRB-1099 & RRB-W-2P)[ _______________________________ Salaries (Provide W-2's) [ ] _____________________ Scholarships [ ] ______________________________ Social Security (Provide Form SSA-1 099) [ ] _______ State Income Tax Refunds ______________________ Tips Received _______________________________ Unemployment Compensation ___________________ Workers Compensation or State Disability Insurance __________________________________________ Other: _________________________ ___________ Other : _________________________ ___________ |
