TAXPAYER INFORMATION SPOUSE INFORMATION Name Initial Name Initial Last Name Last name SSN DOB SSN DOB Occupation Occupation T: Home Cell Home Cell Email Email Address City State ZIP FILING STATUS ESTIMATED TAX PAYMENTS Single Head of Household FEDERAL STATE Married Married Filing Separately Date Amount Date Amount Overpayment DEPENDENTS 1st Quarter Name 2nd Quarter DOB SSN 3rd Quarter Relationship Months Lived @ Home 4th Quarter Name DOB SSN REFUND Relationship Months @ Home Automatic Deposit Yes (attach a VOID check) No SALARIES & WAGES – Attach all W-2 forms INCOME FROM BUSINESS OR PROFESSION W-2 Employer Gross Wages GENERAL INFORMATION 1 Cash Basis Accrual Basis 1st Year 2 Principal Business/Profession 3 Business Name 4 Business Address City State ZIP OTHER INCOME INCOME INTEREST – Attach Forms 1099INT Total $ Gross Receipts or Sales DIVIDENDS – Attach Forms 1099DIV Total $ Returns & Allowances CAPITAL GAINS – Attach Forms 1099B, 1099S and year-end brokerage statements with purchase date and cost of each asset. Other Income COST OF GOODS SOLD (if applicable) Inventory @ Beginning of the year TAX REFUND – Attach Forms 1099G Purchases if you did NOT itemize last year Cost of Labor ALIMONY RECEIVED Materials & Supplies Payor Other Costs Payor’s SSN Amount Inventory @ End of the Year SOCIAL SECURITY BENEFITS RECEIVED – Attach Forms SSA-1099 EXPENSES Advertising UNEMPLOYMENT BENEFITS RECEIVED – Attach Forms 1099G Car & Expenses* Commissions PENSIONS/IRA/ANNUITY DISTRIBUTIONS – Attach Forms 1099R Employee Benefits Insurance (other than health) INCOME FROM PARTNERSHIPS, ESTATES, LLCS, TRUSTS AND S-CORPORATIONS – Attach Forms K-1 and list any not yet received. Health Insurance Premiums for Self* Interest & Professional Office Expenses
Pensions & Profit Sharing Rent – Vehicles, Machinery & Equipment Rent – Business Property OTHER INCOME – Attach detailed schedules Repairs & Maintenance Include royalties, jury duty fees, finder’s fees, director’s fees, gambling winnings, disability payments, unreported tip income and any other income (whether taxable or not). Supplies Taxes – Property Taxes – Other Travel & Entertainment* Utilities Wages Other Expenses* * Attach detailed schedules WE WELCOME NEW INTRODUCTIONS HOME OFFICE Please introduce us to your family, friends & business associates who may need help with their taxes or financial planning. Did you have a home office during the year? Yes No If yes, attach detailed schedule of expenses including mortgage interest (or rent), real estate taxes, utilities, property insurance, maintenance & cleaning. RENTAL INCOME & EXPENSES ITEMIZED DEDUCTIONS PROPERTY #1 #2 MEDICAL & DENTAL EXPENSES – Attach detailed schedules Location INCOME Prescriptions Rent Received Insurance Premiums EXPENSES Doctors & Dentists Advertising Eyeglasses/Contacts Association Dues Other: Auto & Travel Cleaning/Maintenance Insurance Labor Professional Fees Miscellaneous Mortgage Interest TAXES PAID Other Interest State & Local Income Taxes Supplies Real Estate Taxes – Residence Taxes Real Estate Taxes – Other Property Telephone Auto License: Number of cars Utilities Auto License: Fees Paid Repairs Personal Property Improvements: Other Taxes: Other: INTEREST PAID – Attach Forms 1098 Home Mortgage (1st) Home Mortgage (2nd) ADJUSTMENTS TO INCOME Home Mortgage (Equity Line) ALIMONY PAID Student Loan Interest