4. Income If you have any of the following income sources, please mark and include forms. Form Name # of each you have W-2s (wage, salary income) W-2G’s (unemployment) 1099-INT (interest statements) Brokerage Statements 1099-DIV (dividend statements) 1099-C (cancellation of debt) K-1 (partnership, S-Corp, Estate, or trust income) SSA-1099 (social security) RRB-1099 (railroad retirement) 1099-R (pension/annuity income) Others: 5. I.R.A. (Individual Retirement Acct.) Contributions made for this tax year: Amount Date Roth? Taxpayer: Spouse: Withdrawals (Attach 1099-R or 5498): Amount Reason Rolled Over? Taxpayer: Spouse: 6. Investments Sold (Attach Documentation (1099-B, etc.)) Stocks, Mutual Funds, Gold, Silver, and Partnership Interest Investment Date Acquired Cost Date Sold Price 7. Real Estate Sold (Attach 1099-S and Closing Statements) Property Was this your principal residence? Date Acquired Cost Improvements Date Sold Price 8. Other Income Lawsuit settlements: Describe: Scholarships (Grants) Alimony Received Prizes, Bonuses, Awards Gambling, Lottery, Winnings - Gambling, Lottery Expenses ( ) Unreported Tips Director, Executor Fee Received Commissions Jury Duty Payment from Prior Installment State Income Tax Refund Other: 9. Charitable Contributions You MUST keep the receipts, but we do not need to see them. Contributions greater than $250 must have “no goods or services were received” on the receipt in order to fully qualify. Church United Way Colleges, Universities Other Cash Contributions: Non-Cash Contributions: (Bring in details) Volunteer Miles Driven: Jan.-Dec. 2016 miles
Student Name Year in School School Campus location Type of Expense Amount Student Loan Interest Paid: (attach statements) Contribution(s) to Indiana College 529 Plan: (attach statements) 17. Investment Related Expenses Tax Preparation Fee Safe Deposit Box Rental Mutual Fund Fees Investment Counselor Investment Interest Other: 18. Job-Related Mileage/Travel (Not Do you have written records? Make & Year of vehicle: Total Miles (personal & business) Business Miles: January – December 2016 From 1st Job to 2nd Job: From Job to School (Job Related): Job Seeking: Other Business Miles: Other Job Seeking Expenses: Business Travel: Airfare, etc: Lodging: Meals (NO. of Days ): Taxi, Car Rental: Reimbursement Received: ( ) 19. Deductions Alimony Paid to: Soc. Security No: 20. Casualty, Theft Loss For property stolen or damaged by storm, water, fire, accident Location of property: Date of Purchase Cost & Improvements: Description of property: Amt. of Damage: Ins. Reimburs.: Repair Cost: Fed. Grants Received: 21. Energy Credit/Insulation (attach receipts) Alternative Fuel Vehicle Purchased: Date: Make: Price: Install insulation or energy efficient items in your home: Item: Date: Price: 22. Other Information Did any of the following apply to you in 2016? Marriage Births Divorce Adoption Bankruptcy Job-Related Move Home Foreclosure Income from Animals Self-employment Income from Crops Hobby Income Rental Income Give a gift of more than $14,000 to anyone Provide home or help support to someone not listed as a dependent on Page 1 23. Foreign Bank Accounts & Foreign Income (please circle “do” or “do not” for the following statements) I(we) do / do not have any foreign bank accounts. I(we) do / do not have any foreign income. __________________________________________________________ Taxpayers signature