INDIVIDUAL INCOME TAX QUESTIONNAIRE
INDIVIDUAL INCOME TAX QUESTIONNAIRE
WORKSHEET
CALENDAR YEAR:
Your Name____________________________ Birth Date______________
Social Security No. _________________ Occupation _____________
Spouse's Name________________________ Birth Date _____________
Social Security No. ________________ Occupation _____________
Address __________________________________________ Apt. #______
County _____________ City _________________ Zip Code_________
Telephone: Home _____________________ Office__________________
Check if you were single with dependents living in your home.____
Check if you were widowed or divorced during the year. _________
DEPENDENTS
Names of children under 19 years of age:_________________________
_________________________________________________________________
Children over 19 having taxable gross income over $l,000.00 must
be full time students to qualify as dependents. Identify with
an asterisk those dependents listed below who are filing a
return of their own or who did not live at your principal
resident at the end of the year.
Approx. Taxable % of Your
Other Dependents Relationship Gross Income Support
__________________ ____________ _______________ _________
__________________ ____________ _______________ _________
__________________ ____________ _______________ _________
To qualify, the dependent, other than children, must have less
than $l,000.00 gross income and you must have furnished more
than half of that dependent's support or same must have been
furnished according to a multiple support agreement.
Is any member of your household legally blind? _________
Were there any births or deaths in your household
during this calendar year? _________
Did you pay more than half the cost of supporting
a parent in a rest home or home for the aged or
in furnishing them a home? _________
Did you maintain a household for a child who was
either a student or under 19, or did you maintain
a household for a disabled adult? _________
If you are under 19 or a full time student and
can be claimed as a dependent on your parents'
return, did you have any unearned income such
as dividends, interest, etc.? __________
Do you wish to designate $l of your income tax
liability to the Presidential Election Campaign
Fund? __________
Social Security payments received? Taxpayer _____ Spouse_______
Amount of Medicare Premiums paid: Taxpayer _____ Spouse_______
Were Social Security payments received before
or after deduction for Medicare premiums? Before _____After_____
Did you make any gift totaling $10,000 per donee? __________
Did you purchase any bonds at a discount or premium? __________
Did you sell a residence during the year? __________
If yes, please provide documents pertaining to the
sale, purchase and any improvements.
Did you change residences because of a change in
location of your job during the year? If "yes"
and your new job location is at least 35 miles
further from your former residence than your
old job location was, complete the appropriate
schedule. __________
Did you purchase any significant amount of
gasoline, lubricating oil, or special fuels for
non-highway business use such as for farm vehicles
or airplanes during the year? __________
If "yes", please furnish the following information
for each type of use:
Use Type of Fuel Gallons Used
______________________ ____________ ____________
______________________ ____________ ____________
______________________ ____________ ____________
Did you receive any payments from a pension or
profit sharing plan? __________
During the year did you have an interest in or
a signature authority over a bank account,
securities or other financial account in a
foreign country? __________
Were you the grantor of, or transferor to, a
foreign trust during any taxable year, which
existed during the current year, whether or not
the taxpayer has any beneficial interest in the
trust? __________
Did you make any alimony or separate maintenance
payments? If "yes", how much? $_________
Was your home constructed prior to April 19, 1977,
and did you purchase insulation or other energy
saving devices for your home during the year,
such as storm windows and doors, weather stripping,
etc.? __________
During the current year, did you receive any
disability income? If "yes", please furnish
the following information: (a) physician's
statement of permanent and total disability;
and (b) detail of income received. __________
Will you file a Tangible or Intangible Tax
Return for the State of ____________ for the
current year? If yes, please enclose copies. __________
Did you receive unemployment compensation during
the year? __________
If you and your spouse worked during the year,
did you pay for any child care or dependent
care? If "yes", complete the schedule attached. __________
Do you have a current will? __________
If "yes", has it been revised in the last three
years? __________
Please provide your tax returns for the last
four (4) calendar years.
Were you notified by the Internal Revenue Service
during the year of any changes in any prior year's
returns? If "yes", please provide correspondence. _________
Did you have any casualty or theft losses during
the year? If "yes", please complete the schedule
attached. ____________
Did you exercise stock options during the year? __________
WAGES
Enclose all Federal withholding statements, Forms W-2, received
by you and your spouse during the year. If more than one
employer per taxpayer, please list employers in the spaces
provided.
Federal Wages State
Employer/Address Who W/H Salaries FICA W/H
________________ ___ _______ ________ ____ _____
________________ ___ _______ ________ ____ _____
________________ ___ _______ ________ ____ _____
________________ ___ _______ ________ ____ _____
________________ ___ _______ ________ ____ _____
DIVIDEND INCOME
Please attach Forms 1099 and list dividends received.
Husband/Wife/Joint Name of Payor Amount
__________________ __________________________ _______________
__________________ __________________________ _______________
__________________ __________________________ _______________
__________________ __________________________ _______________
__________________ __________________________ _______________
__________________ __________________________ _______________
INTEREST INCOME
Please attach Forms 1099 and list interest received.
Husband/Wife/Joint Name of Payor Amount
__________________ __________________________ _______________
__________________ __________________________ _______________
__________________ __________________________ _______________
__________________ __________________________ _______________
__________________ __________________________ _______________
__________________ __________________________ _______________
__________________ __________________________ _______________
__________________ Interest/Fed. Sav. Bonds _______________
Forfeited Interest/
__________________ Premature Withdrawals _______________
__________________ All savers Interest _______________
OTHER INCOME
Husband/Wife/Joint Name of Payor Amount
__________________ St./City Inc. Tx. Refunds _______________
__________________ Group Life Ins. Premiums _______________
__________________ Alimony _______________
__________________ Jury Fees _______________
__________________ Commissions _______________
__________________ Unemployment Comp. _______________
__________________ Other:___________________ _______________
Include Federal and State bond interest. The non-taxable
interest will be eliminated.
If your employer paid for group term life insurance coverage for
you in excess of $50,000.00, the premium on the excess is
includible in gross income. If it is not reported on Form 1099
or included on your W-2 enclosed herewith, enter the excess
premium above. If such coverage is provided by more than one
employer, please give all pertinent details.
If your employer provides you with a company automobile, the
non-business portion is includible in gross income. If it is
not reported on Form 1099 or included on your W-2 enclosed
herewith, enter the value of the non-business portion of use.
Please provide the following for income received from pension,
profit-sharing, annuities and individual retirement plans and
attach Forms 1099.
Husband/Wife/Joint Name of Payor Nature/Distribution Amount
__________________ _____________ ___________________ _______
__________________ _____________ ___________________ _______
__________________ _____________ ___________________ _______
__________________ _____________ ___________________ _______
__________________ _____________ ___________________ _______
Please attach Forms K-l for income or loss from partnerships,
trusts and small business corporations.
PROFIT OR LOSS FROM BUSINESS/PROFESSION
Please provide complete details, including income and expenses
for each business/profession.
RENTAL PROPERTIES
Please provide details, per property, as follows:
A B C
Purchase Price:
Land: __________ ___________ __________
Improvements: __________ ___________ __________
Total Purchase Price:__________ ___________ __________
Date Purchased __________ ___________ __________
Rents Received __________ ___________ __________
Rental Expenses:
Advertising ___________ ___________ ___________
Auto/Travel ___________ ___________ ___________
Cleaning/Maintenance ___________ ___________ ___________
Commissions ___________ ___________ ___________
Insurance ___________ ____________ ___________
Interest ___________ ____________ ___________
Professional Fees ___________ ____________ ___________
Repairs ___________ ____________ ___________
Supplies ___________ ____________ ____________
Taxes ___________ ____________ ____________
Utilities ___________ ____________ ____________
Wages/Salaries ___________ ____________ ____________
Other (list):
________________ ___________ ____________ ____________
________________ ___________ ____________ ____________
________________ ___________ ____________ ____________
________________ ___________ ____________ ____________
________________ ___________ ____________ ____________
________________ ___________ ____________ ____________
________________ ___________ ____________ ____________
________________ ___________ ____________ ____________
Total Expenses: ___________ ____________ ____________
Description/Location
of Property: A ___________________________________
___________________________________
B ___________________________________
___________________________________
C ___________________________________
___________________________________
If property was purchased in the current year or if improvements
were made, please submit complete details.
GAINS AND LOSSES FROM SALE OR EXCHANGE OF PROPERTY
No. of (H)
Shares (W)
Date How Date of or Sales
Acqd. (*) Sold Bonds (J) Description Cost Price
_____ ___ ____ ______ ___ ________________ _____ _____
_____ ___ ____ ______ ___ ________________ _____ _____
_____ ___ ____ ______ ___ ________________ _____ _____
_____ ___ ____ ______ ___ ________________ _____ _____
_____ ___ ____ ______ ___ ________________ _____ _____
_____ ___ ____ ______ ___ ________________ _____ _____
_____ ___ ____ ______ ___ ________________ _____ _____
_____ ___ ____ ______ ___ ________________ _____ _____
_____ ___ ____ ______ ___ ________________ _____ _____
_____ ___ ____ ______ ___ ________________ _____ _____
_____ ___ ____ ______ ___ ________________ _____ _____
_____ ___ ____ ______ ___ ________________ _____ _____
_____ ___ ____ ______ ___ ________________ _____ _____
_____ ___ ____ ______ ___ ________________ _____ _____
_____ ___ ____ ______ ___ ________________ _____ _____
_____ ___ ____ ______ ___ ________________ _____ _____
If you have sold properties, other than marketable securities,
please attach all purchase, sale and improvement information.
This includes the sale of any real property, including your
personal residence.
Attach slips provided by Broker for all purchases and sales of
securities, if possible.
(*) A - Purchase on open market.
B - Exercise of stock option or via employee stock plan.
C - Inheritance or gift.
D - Exchange involving carryover of basis.
E - Other: _________________________________________________
_________________________________________________
If a sale or a distribution was pursuant to a contract,
installment sale or plan of liquidation entered into before
October 10, 1969, please so indicate and give full details,
including copies of all pertinent documents.
MEDICAL & DENTAL EXPENSES PAID
Medical insurance premiums $__________
Drugs and medications ___________
Medical supplies (purchase/rental) ___________
Eyeglasses ___________
Doctors and Dentists ___________
Laboratories and X-rays ___________
Hospitals ___________
Mileage driven for medical attention
______ miles x $.09 per mile = ___________
Reimbursements by Insurance ___________
TAXES PAID
State and local income taxes paid exclusive
of those taxes shown as having been withheld
on Form W-2 ___________
Real estate taxes paid ___________
Sales tax - IRS tables will be used if omitted ___________
Sales tax on major purchases (auto, boat, etc.) ___________
Other (list) ______________________________ ___________
______________________________ ___________
INTEREST PAID
Home Mortgage ___________
Credit & charge cards ___________
Auto loan ___________
Bank loan ___________
Installment purchases ___________
Credit Union loan ___________
Points paid on personal residence ___________
Internal Revenue Service ___________
Other (list) _______________________________ ___________
_______________________________ ___________
CONTRIBUTIONS
Total cash contributions for which you have
receipts or cancelled checks ___________
Other cash contributions (list)
_____________________________________________ ___________
_____________________________________________ ___________
_____________________________________________ ___________
_____________________________________________ ___________
_____________________________________________ ___________
_____________________________________________ ___________
Contributions of property - Show date and to whom contributed,
description of property, method of valuation, any conditions
attached to the gift, manner of acquisition, cost or other basis
and a signed copy of an appraisal report, if possible.
_____________________________________________ ___________
_____________________________________________ ___________
_____________________________________________ ___________
_____________________________________________ ___________
_____________________________________________ ___________
_____________________________________________ ___________
Mileage driven for charitable purposes
_____ miles x $.09 per mile = ___________
CASUALTY & THEFT LOSSES
(Auto, storm, fire damage, theft, etc.)
Give full details, including a description of each item damaged
or stolen, date acquired, date damaged or stolen, value at time
of acquisition, value at time of damage or theft, value after
damage or theft and amount of any insurance payment received.
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
OTHER DEDUCTIONS
Attorney or Accountant fees (Specify matter for which fees were
incurred, i.e. tax preparation, tax advice, etc.) __________
__________
Safe deposit box rental __________
Investment publications __________
Other investment expenses (list)
_______________________________________ __________
_______________________________________ __________
Employment agency fees __________
Education expenses __________
Professional dues __________
Uniforms __________
Union dues __________
Other (list)
_______________________________________ __________
_______________________________________ __________
_______________________________________ __________
EMPLOYEE BUSINESS EXPENSES
Did you receive an expense allowance or
reimbursement from your employer? If yes,
for what? __________________________________ __________
_____________________________________________ __________
_____________________________________________ __________
Deductions for business travel, entertainment and gift expenses
must be substantiated by documentary evidence as prescribed by
IRS. The following records are required: (l) A daily diary or
similar record which indicates who was entertained, the business
relationship, where and when, the cost of entertainment and the
business reason; (2) Supporting receipts, cancelled checks,
etc. Each expenditure in excess of $25.00 must be supported by
a receipt. Cancelled checks alone are not sufficient to
substantiate such expenditures. Deductions for business gifts
are allowable only to the extent of $25.00 for each individual.
Deductions for club dues are not allowable unless it can be
shown that more than 50% of the use of the club was for business
purposes. The deductible portion of the dues is then limited to
a percentage of certain business use.
TOTAL REIMB. UNREIMB.
Transportation, other
than your automobile __________ __________ __________
Meals and lodging __________ __________ __________
Entertainment __________ __________ __________
Gifts __________ __________ __________
Dues __________ __________ __________
Other (list)__________ __________ __________ __________
______________________ __________ __________ __________
______________________ __________ __________ __________
______________________ __________ __________ __________
If you use your automobile for business purposes other than
commuting to and from your full time employer's place of
business, please provide the following information:
Number of months you used your car in business __________
Total mileage driven for months above __________
Business portion of mileage driven __________
In lieu of actual auto expenses, the standard mileage allowance
is $.20 per mile for the first 15,000 business miles drive plus
$.ll per mile over the first 15,000. Parking and tolls are
allowed. Please indicate parking and toll expenses: __________
Enter the actual expenses incurred for your automobile for the
months indicated above.
Gas, oil, lubrication, etc. __________
Repairs __________
Tires, supplies, etc. __________
Insurance __________
Taxes __________
Tags and licenses __________
Interest __________
Other (list) ____________________________________ __________
_________________________________________________ __________
_________________________________________________ __________
_________________________________________________ __________
Year and type of automobile __________________________________
Cost of automobile __________________________________
Date automobile purchased __________________________________
Amount of reimbursement from your employer ______________________
CONTRIBUTIONS TO RETIREMENT ACCOUNTS
Payments to Keogh (H.R.10) retirement plan __________
Payments to an Individual Retirement Account (H) __________
(W) __________
MOVING EXPENSES
Indicate number of miles between your former
residence and your new job. __________
Indicate number of miles between your former
residence and your former job. __________
TOTAL REIMB UNREIMB
Transportation of
personal effects/
household goods __________ ___________ __________
Personal travel,
meals & lodging expense __________ ___________ __________
Premove travel,meals
& lodging expense __________ ___________ __________
Temporary (up to 30
days) living expense __________ ___________ __________
Other: sale/exchange
of former residence;
settling or obtaining
new lease,
(list)________________ __________ ___________ __________
______________________ __________ ___________ __________
______________________ __________ ___________ __________
______________________ __________ ___________ __________
Either calculate actual expenses for gasoline, oil, etc. or use
standard $.09 per mile rate.
ENERGY CREDIT
Summarize your expenditures in the following categories:
Insulation __________
Storm or thermal windows/doors __________
Caulking/weather stripping __________
Solar water heater __________
Other (list) _____________________________ __________
Did you install energy saving devices in your home
in previous years? __________
CHILD AND DEPENDENT CARE EXPENSES
If you and your spouse worked and incurred costs in the care of
your dependents while you and your spouse were working, please
provide the following:
Name of child/dependent receiving care__________________________
Date of birth___________________________________________________
Period of time the child/dependent has lived with you during the
tax year________________________________________________________
Person or organization caring for the individual________________
________________________________________________________________
If an individual, note social security number and relationship,
if any__________________________________________________________
________________________________________________________________
Period of care was from (month) ________ (day) ________ to
(month) ________ (day) ________.
Amount of child care expenses paid _________
Amount of child care expenses incurred _________
ESTIMATED TAX PAYMENTS
Please note payments made for current year's taxes:
Date Paid Amount
Overpayment from previous year
to be credited to this year _____________ __________
Payments made this year:
First _____________ __________
Second _____________ __________
Third _____________ __________
Fourth _____________ __________
Payments made on deficiencies
from prior years, if applicable _____________ __________
DECLARATION OF ESTIMATED INCOME TAX FOR CURRENT YEAR
Unless instructed otherwise, your estimated tax declaration for
the forthcoming calendar year will be based on your current
year's tax return and your current year's withheld taxes. If
your estimated taxable income for the forthcoming calendar year
will be less or materially greater than in the current year,
please advise.___________________________________________________
_________________________________________________________________
_________________________________________________________________
If you have overpaid your income tax liability for the current
year, please indicate whether you wish to receive a refund, have
any such overpayment applied to your estimated payments for the
forthcoming calendar year, or have part applied and part
refunded.
Refunded _________________ Applied ___________________
WORKSHEET
CALENDAR YEAR:
Your Name____________________________ Birth Date______________
Social Security No. _________________ Occupation _____________
Spouse's Name________________________ Birth Date _____________
Social Security No. ________________ Occupation _____________
Address __________________________________________ Apt. #______
County _____________ City _________________ Zip Code_________
Telephone: Home _____________________ Office__________________
Check if you were single with dependents living in your home.____
Check if you were widowed or divorced during the year. _________
DEPENDENTS
Names of children under 19 years of age:_________________________
_________________________________________________________________
Children over 19 having taxable gross income over $l,000.00 must
be full time students to qualify as dependents. Identify with
an asterisk those dependents listed below who are filing a
return of their own or who did not live at your principal
resident at the end of the year.
Approx. Taxable % of Your
Other Dependents Relationship Gross Income Support
__________________ ____________ _______________ _________
__________________ ____________ _______________ _________
__________________ ____________ _______________ _________
To qualify, the dependent, other than children, must have less
than $l,000.00 gross income and you must have furnished more
than half of that dependent's support or same must have been
furnished according to a multiple support agreement.
Is any member of your household legally blind? _________
Were there any births or deaths in your household
during this calendar year? _________
Did you pay more than half the cost of supporting
a parent in a rest home or home for the aged or
in furnishing them a home? _________
Did you maintain a household for a child who was
either a student or under 19, or did you maintain
a household for a disabled adult? _________
If you are under 19 or a full time student and
can be claimed as a dependent on your parents'
return, did you have any unearned income such
as dividends, interest, etc.? __________
Do you wish to designate $l of your income tax
liability to the Presidential Election Campaign
Fund? __________
Social Security payments received? Taxpayer _____ Spouse_______
Amount of Medicare Premiums paid: Taxpayer _____ Spouse_______
Were Social Security payments received before
or after deduction for Medicare premiums? Before _____After_____
Did you make any gift totaling $10,000 per donee? __________
Did you purchase any bonds at a discount or premium? __________
Did you sell a residence during the year? __________
If yes, please provide documents pertaining to the
sale, purchase and any improvements.
Did you change residences because of a change in
location of your job during the year? If "yes"
and your new job location is at least 35 miles
further from your former residence than your
old job location was, complete the appropriate
schedule. __________
Did you purchase any significant amount of
gasoline, lubricating oil, or special fuels for
non-highway business use such as for farm vehicles
or airplanes during the year? __________
If "yes", please furnish the following information
for each type of use:
Use Type of Fuel Gallons Used
______________________ ____________ ____________
______________________ ____________ ____________
______________________ ____________ ____________
Did you receive any payments from a pension or
profit sharing plan? __________
During the year did you have an interest in or
a signature authority over a bank account,
securities or other financial account in a
foreign country? __________
Were you the grantor of, or transferor to, a
foreign trust during any taxable year, which
existed during the current year, whether or not
the taxpayer has any beneficial interest in the
trust? __________
Did you make any alimony or separate maintenance
payments? If "yes", how much? $_________
Was your home constructed prior to April 19, 1977,
and did you purchase insulation or other energy
saving devices for your home during the year,
such as storm windows and doors, weather stripping,
etc.? __________
During the current year, did you receive any
disability income? If "yes", please furnish
the following information: (a) physician's
statement of permanent and total disability;
and (b) detail of income received. __________
Will you file a Tangible or Intangible Tax
Return for the State of ____________ for the
current year? If yes, please enclose copies. __________
Did you receive unemployment compensation during
the year? __________
If you and your spouse worked during the year,
did you pay for any child care or dependent
care? If "yes", complete the schedule attached. __________
Do you have a current will? __________
If "yes", has it been revised in the last three
years? __________
Please provide your tax returns for the last
four (4) calendar years.
Were you notified by the Internal Revenue Service
during the year of any changes in any prior year's
returns? If "yes", please provide correspondence. _________
Did you have any casualty or theft losses during
the year? If "yes", please complete the schedule
attached. ____________
Did you exercise stock options during the year? __________
WAGES
Enclose all Federal withholding statements, Forms W-2, received
by you and your spouse during the year. If more than one
employer per taxpayer, please list employers in the spaces
provided.
Federal Wages State
Employer/Address Who W/H Salaries FICA W/H
________________ ___ _______ ________ ____ _____
________________ ___ _______ ________ ____ _____
________________ ___ _______ ________ ____ _____
________________ ___ _______ ________ ____ _____
________________ ___ _______ ________ ____ _____
DIVIDEND INCOME
Please attach Forms 1099 and list dividends received.
Husband/Wife/Joint Name of Payor Amount
__________________ __________________________ _______________
__________________ __________________________ _______________
__________________ __________________________ _______________
__________________ __________________________ _______________
__________________ __________________________ _______________
__________________ __________________________ _______________
INTEREST INCOME
Please attach Forms 1099 and list interest received.
Husband/Wife/Joint Name of Payor Amount
__________________ __________________________ _______________
__________________ __________________________ _______________
__________________ __________________________ _______________
__________________ __________________________ _______________
__________________ __________________________ _______________
__________________ __________________________ _______________
__________________ __________________________ _______________
__________________ Interest/Fed. Sav. Bonds _______________
Forfeited Interest/
__________________ Premature Withdrawals _______________
__________________ All savers Interest _______________
OTHER INCOME
Husband/Wife/Joint Name of Payor Amount
__________________ St./City Inc. Tx. Refunds _______________
__________________ Group Life Ins. Premiums _______________
__________________ Alimony _______________
__________________ Jury Fees _______________
__________________ Commissions _______________
__________________ Unemployment Comp. _______________
__________________ Other:___________________ _______________
Include Federal and State bond interest. The non-taxable
interest will be eliminated.
If your employer paid for group term life insurance coverage for
you in excess of $50,000.00, the premium on the excess is
includible in gross income. If it is not reported on Form 1099
or included on your W-2 enclosed herewith, enter the excess
premium above. If such coverage is provided by more than one
employer, please give all pertinent details.
If your employer provides you with a company automobile, the
non-business portion is includible in gross income. If it is
not reported on Form 1099 or included on your W-2 enclosed
herewith, enter the value of the non-business portion of use.
Please provide the following for income received from pension,
profit-sharing, annuities and individual retirement plans and
attach Forms 1099.
Husband/Wife/Joint Name of Payor Nature/Distribution Amount
__________________ _____________ ___________________ _______
__________________ _____________ ___________________ _______
__________________ _____________ ___________________ _______
__________________ _____________ ___________________ _______
__________________ _____________ ___________________ _______
Please attach Forms K-l for income or loss from partnerships,
trusts and small business corporations.
PROFIT OR LOSS FROM BUSINESS/PROFESSION
Please provide complete details, including income and expenses
for each business/profession.
RENTAL PROPERTIES
Please provide details, per property, as follows:
A B C
Purchase Price:
Land: __________ ___________ __________
Improvements: __________ ___________ __________
Total Purchase Price:__________ ___________ __________
Date Purchased __________ ___________ __________
Rents Received __________ ___________ __________
Rental Expenses:
Advertising ___________ ___________ ___________
Auto/Travel ___________ ___________ ___________
Cleaning/Maintenance ___________ ___________ ___________
Commissions ___________ ___________ ___________
Insurance ___________ ____________ ___________
Interest ___________ ____________ ___________
Professional Fees ___________ ____________ ___________
Repairs ___________ ____________ ___________
Supplies ___________ ____________ ____________
Taxes ___________ ____________ ____________
Utilities ___________ ____________ ____________
Wages/Salaries ___________ ____________ ____________
Other (list):
________________ ___________ ____________ ____________
________________ ___________ ____________ ____________
________________ ___________ ____________ ____________
________________ ___________ ____________ ____________
________________ ___________ ____________ ____________
________________ ___________ ____________ ____________
________________ ___________ ____________ ____________
________________ ___________ ____________ ____________
Total Expenses: ___________ ____________ ____________
Description/Location
of Property: A ___________________________________
___________________________________
B ___________________________________
___________________________________
C ___________________________________
___________________________________
If property was purchased in the current year or if improvements
were made, please submit complete details.
GAINS AND LOSSES FROM SALE OR EXCHANGE OF PROPERTY
No. of (H)
Shares (W)
Date How Date of or Sales
Acqd. (*) Sold Bonds (J) Description Cost Price
_____ ___ ____ ______ ___ ________________ _____ _____
_____ ___ ____ ______ ___ ________________ _____ _____
_____ ___ ____ ______ ___ ________________ _____ _____
_____ ___ ____ ______ ___ ________________ _____ _____
_____ ___ ____ ______ ___ ________________ _____ _____
_____ ___ ____ ______ ___ ________________ _____ _____
_____ ___ ____ ______ ___ ________________ _____ _____
_____ ___ ____ ______ ___ ________________ _____ _____
_____ ___ ____ ______ ___ ________________ _____ _____
_____ ___ ____ ______ ___ ________________ _____ _____
_____ ___ ____ ______ ___ ________________ _____ _____
_____ ___ ____ ______ ___ ________________ _____ _____
_____ ___ ____ ______ ___ ________________ _____ _____
_____ ___ ____ ______ ___ ________________ _____ _____
_____ ___ ____ ______ ___ ________________ _____ _____
_____ ___ ____ ______ ___ ________________ _____ _____
If you have sold properties, other than marketable securities,
please attach all purchase, sale and improvement information.
This includes the sale of any real property, including your
personal residence.
Attach slips provided by Broker for all purchases and sales of
securities, if possible.
(*) A - Purchase on open market.
B - Exercise of stock option or via employee stock plan.
C - Inheritance or gift.
D - Exchange involving carryover of basis.
E - Other: _________________________________________________
_________________________________________________
If a sale or a distribution was pursuant to a contract,
installment sale or plan of liquidation entered into before
October 10, 1969, please so indicate and give full details,
including copies of all pertinent documents.
MEDICAL & DENTAL EXPENSES PAID
Medical insurance premiums $__________
Drugs and medications ___________
Medical supplies (purchase/rental) ___________
Eyeglasses ___________
Doctors and Dentists ___________
Laboratories and X-rays ___________
Hospitals ___________
Mileage driven for medical attention
______ miles x $.09 per mile = ___________
Reimbursements by Insurance ___________
TAXES PAID
State and local income taxes paid exclusive
of those taxes shown as having been withheld
on Form W-2 ___________
Real estate taxes paid ___________
Sales tax - IRS tables will be used if omitted ___________
Sales tax on major purchases (auto, boat, etc.) ___________
Other (list) ______________________________ ___________
______________________________ ___________
INTEREST PAID
Home Mortgage ___________
Credit & charge cards ___________
Auto loan ___________
Bank loan ___________
Installment purchases ___________
Credit Union loan ___________
Points paid on personal residence ___________
Internal Revenue Service ___________
Other (list) _______________________________ ___________
_______________________________ ___________
CONTRIBUTIONS
Total cash contributions for which you have
receipts or cancelled checks ___________
Other cash contributions (list)
_____________________________________________ ___________
_____________________________________________ ___________
_____________________________________________ ___________
_____________________________________________ ___________
_____________________________________________ ___________
_____________________________________________ ___________
Contributions of property - Show date and to whom contributed,
description of property, method of valuation, any conditions
attached to the gift, manner of acquisition, cost or other basis
and a signed copy of an appraisal report, if possible.
_____________________________________________ ___________
_____________________________________________ ___________
_____________________________________________ ___________
_____________________________________________ ___________
_____________________________________________ ___________
_____________________________________________ ___________
Mileage driven for charitable purposes
_____ miles x $.09 per mile = ___________
CASUALTY & THEFT LOSSES
(Auto, storm, fire damage, theft, etc.)
Give full details, including a description of each item damaged
or stolen, date acquired, date damaged or stolen, value at time
of acquisition, value at time of damage or theft, value after
damage or theft and amount of any insurance payment received.
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
OTHER DEDUCTIONS
Attorney or Accountant fees (Specify matter for which fees were
incurred, i.e. tax preparation, tax advice, etc.) __________
__________
Safe deposit box rental __________
Investment publications __________
Other investment expenses (list)
_______________________________________ __________
_______________________________________ __________
Employment agency fees __________
Education expenses __________
Professional dues __________
Uniforms __________
Union dues __________
Other (list)
_______________________________________ __________
_______________________________________ __________
_______________________________________ __________
EMPLOYEE BUSINESS EXPENSES
Did you receive an expense allowance or
reimbursement from your employer? If yes,
for what? __________________________________ __________
_____________________________________________ __________
_____________________________________________ __________
Deductions for business travel, entertainment and gift expenses
must be substantiated by documentary evidence as prescribed by
IRS. The following records are required: (l) A daily diary or
similar record which indicates who was entertained, the business
relationship, where and when, the cost of entertainment and the
business reason; (2) Supporting receipts, cancelled checks,
etc. Each expenditure in excess of $25.00 must be supported by
a receipt. Cancelled checks alone are not sufficient to
substantiate such expenditures. Deductions for business gifts
are allowable only to the extent of $25.00 for each individual.
Deductions for club dues are not allowable unless it can be
shown that more than 50% of the use of the club was for business
purposes. The deductible portion of the dues is then limited to
a percentage of certain business use.
TOTAL REIMB. UNREIMB.
Transportation, other
than your automobile __________ __________ __________
Meals and lodging __________ __________ __________
Entertainment __________ __________ __________
Gifts __________ __________ __________
Dues __________ __________ __________
Other (list)__________ __________ __________ __________
______________________ __________ __________ __________
______________________ __________ __________ __________
______________________ __________ __________ __________
If you use your automobile for business purposes other than
commuting to and from your full time employer's place of
business, please provide the following information:
Number of months you used your car in business __________
Total mileage driven for months above __________
Business portion of mileage driven __________
In lieu of actual auto expenses, the standard mileage allowance
is $.20 per mile for the first 15,000 business miles drive plus
$.ll per mile over the first 15,000. Parking and tolls are
allowed. Please indicate parking and toll expenses: __________
Enter the actual expenses incurred for your automobile for the
months indicated above.
Gas, oil, lubrication, etc. __________
Repairs __________
Tires, supplies, etc. __________
Insurance __________
Taxes __________
Tags and licenses __________
Interest __________
Other (list) ____________________________________ __________
_________________________________________________ __________
_________________________________________________ __________
_________________________________________________ __________
Year and type of automobile __________________________________
Cost of automobile __________________________________
Date automobile purchased __________________________________
Amount of reimbursement from your employer ______________________
CONTRIBUTIONS TO RETIREMENT ACCOUNTS
Payments to Keogh (H.R.10) retirement plan __________
Payments to an Individual Retirement Account (H) __________
(W) __________
MOVING EXPENSES
Indicate number of miles between your former
residence and your new job. __________
Indicate number of miles between your former
residence and your former job. __________
TOTAL REIMB UNREIMB
Transportation of
personal effects/
household goods __________ ___________ __________
Personal travel,
meals & lodging expense __________ ___________ __________
Premove travel,meals
& lodging expense __________ ___________ __________
Temporary (up to 30
days) living expense __________ ___________ __________
Other: sale/exchange
of former residence;
settling or obtaining
new lease,
(list)________________ __________ ___________ __________
______________________ __________ ___________ __________
______________________ __________ ___________ __________
______________________ __________ ___________ __________
Either calculate actual expenses for gasoline, oil, etc. or use
standard $.09 per mile rate.
ENERGY CREDIT
Summarize your expenditures in the following categories:
Insulation __________
Storm or thermal windows/doors __________
Caulking/weather stripping __________
Solar water heater __________
Other (list) _____________________________ __________
Did you install energy saving devices in your home
in previous years? __________
CHILD AND DEPENDENT CARE EXPENSES
If you and your spouse worked and incurred costs in the care of
your dependents while you and your spouse were working, please
provide the following:
Name of child/dependent receiving care__________________________
Date of birth___________________________________________________
Period of time the child/dependent has lived with you during the
tax year________________________________________________________
Person or organization caring for the individual________________
________________________________________________________________
If an individual, note social security number and relationship,
if any__________________________________________________________
________________________________________________________________
Period of care was from (month) ________ (day) ________ to
(month) ________ (day) ________.
Amount of child care expenses paid _________
Amount of child care expenses incurred _________
ESTIMATED TAX PAYMENTS
Please note payments made for current year's taxes:
Date Paid Amount
Overpayment from previous year
to be credited to this year _____________ __________
Payments made this year:
First _____________ __________
Second _____________ __________
Third _____________ __________
Fourth _____________ __________
Payments made on deficiencies
from prior years, if applicable _____________ __________
DECLARATION OF ESTIMATED INCOME TAX FOR CURRENT YEAR
Unless instructed otherwise, your estimated tax declaration for
the forthcoming calendar year will be based on your current
year's tax return and your current year's withheld taxes. If
your estimated taxable income for the forthcoming calendar year
will be less or materially greater than in the current year,
please advise.___________________________________________________
_________________________________________________________________
_________________________________________________________________
If you have overpaid your income tax liability for the current
year, please indicate whether you wish to receive a refund, have
any such overpayment applied to your estimated payments for the
forthcoming calendar year, or have part applied and part
refunded.
Refunded _________________ Applied ___________________
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