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									                                          Personal Information
                                   If anything changed from prior year, check this box.
                                              Taxpayer                                       Spouse
First Name & Initial
Last Name
Social Security No
Date of Birth
Home Phone
Work Phone
Other Phone
E-Mail Address
Street Address                                                                      Apt No
City                                                                     State                  Zip

                                                    Date of                          Living     Student     Gross
  Name                         Relationship          Birth    Social Security Number with you   Disabled    Income
                                                                                                   Yes      No
Did you receive unemployment or Disability Income?
Did you purchase, sell or refinance any of your homes or take an equity loan?
Did you convert a traditional/SEP/SIMPLE IRA to a Roth IRA?
Can you be claimed as a dependant on another persons tax return?
Did you foreclose, file bankruptcy, or have repossession procedures?
Do you have any income from foreign country?
Did you make any purchases from catalog or internet and not pay sales tax?

          Wages and Salary Income                                    Pensions, Annuities, IRA's, etc
                           W-2's                                                     1099-R
          Employer Name              Taxpayer       Spouse           1099-R Payer Name           Taxpayer Spouse

     Social Security/ Railroad Benefits                                          Interest Income
                         SSA-1099                                                   1099-INT
                                      Taxpayer      Spouse          1099-INT Payer Name          Taxpayer    Spouse
Social Security Benefits
Railroad Retirement Benefits
Medicare B premiums paid
Medicare D premiums paid

                                                   Basic Information
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     Partnership, Trust, Estate Income                                             Property Sold
                           K-1                                                          1099-S
                                                             Property                            Pur Date   Basis

                  Dividend Income                                                  Other Income
                    1099-DIV                                 Alimony Received
Form 1099-DIV Payer Ordinary Cap Gain           Tax Exempt   Gambling/Lottery Winnings
                                                             Jury Duty
                                                             Disability Income
                                                             State Income Tax Refund

                Adjustments to Income                                   Estimated Tax Payments
Alimony Paid                                                                         Federal                State
    Name ____________               SSN ____________         Prior Year - Jan 15
IRA/SEP Cont Taxpayer                                        1st Qtr - Apr 15
IRA/SEP Cont Spouse                                          2nd Qtr - Jun 15
Student Loan Interest                                        3rd Qtr - Sep 15
Health Savings Account                                       4th Qtr - Jan 15
Other                                                        Total

                                               Investments Sold
                                           1099-B and Confirmation slips
                              Investment                            Acquired         Date Sold Basis        Sale Price

                                              State Information
If rent paid:           Amount                  No Months                W / Heat Y/N

Health/Long Term Care Insurance

Amount Paid for health insurance - employer paid a portion

Amount Paid for health insurance - employer did not contribute

Note: If health insurance premiums are deducted pre-tax, disregard.

                                                   Basic Information
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                                             Itemized Deductions
Medical Dental Expenses                                    Charitable Contributions (Receipts Required)
Medical Ins Prem (pd by you)                               Church Cash Contributions
Long Term Care Insurance                                                You must have receipts for cash contributions
Prescription Drugs                                         Other Cash Contributions
Glasses, Contacts                                          Donated Goods
Hearing Aids, Batteries                                                 Must have receipts from organization
Medical Equipment, Supplies                                Organization donated to _____________________
Hospital                                                     Address ______________________________
Doctor, Dentist, Specialist                                            ______________________________
Medical Miles                                              Volunteer mileage
                                                           Unreimbursed Miscellaneous Expenses
Real Estate Taxes Paid                                     Union/Professional Dues
Real Estate Taxes -Prin Residence                          Professional Subscriptions
Other Real Estate Taxes                                    Licenses
Personal Property Tax                                      Tools, Safety Equipment
Other                                                      Uniforms
                                                           Sales Expenses
Mortgage Interest Expense                                  Tax Prep Fee
Mort Int Paid - 1099                                       Safe Deposit Box
Interest pd to others - no 1099                            IRA Custodial Fees
   Paid to: Name __________________________                Investment expenses
              Address ________________________             Job Search Expenses
                         ________________________          Other
             Soc Sec No/EIN ___________________            Other
Investment Interest                                        Other

                                                  Casualty Theft Loss
Property damaged or lost by weather, accident, loss
Location of property
Description of property
Value before loss                                           Value after loss
Insurance Reimbursement                                     Replacement/Repair costs
Federal grants received                                     Date of Loss

                                                Day Care Expenses
Children cared for
Provider 1                                                 Provider 2
Address                                                    Address

Soc Sec No/EIN                      Amt Pd                 Soc Sec No/EIN                          Amt Pd
Questions for your tax preparer?

                                                   Basic Information
C:\Docstoc\Working\pdf\13d9261c-1575-4bf9-adbf-ac07256ab1d8.xls                                                         Page 3
         Schedule C Business Income and Expenses                   Business Name
Total Sales                                            Owner      Taxpayer          Spouse
Advertising                                            Supplies
Bank Charges                                           Taxes
Commissions                                            Telephone
Dues & Subscriptions                                   Tools & Equipment
Insurance                                              Travel Expenses
Interest - Mortgage                                    Uniforms
Interest - Other                                       Utilities
Legal & Professional Fees                              Vehicle Expense
Meals & Entertainment                                  Vehicle Mileage
Office Expense
Postage                                                 Wages
Rent - Building                                         Other
Rent - Equipment                                        Other
Repairs & Maintenance                                   Other
                                               Assets Purchased
Date          Amount   Description                                                  Business Percentage

                                              Cost of Goods Sold
                       Beginning Inventory
                       Less Personal Use
                       Direct Labor
                       Ending Inventory
Schedule E Rental Income and Expenses
Rental Income               Property 1            Property 2           Property 3        Property 4
City, State
Rent Received
Cleaning & Maint
Commissions Paid
Interest - Mortgage
Interest - Other
Legal & Prof Fees
Management Fees
Vehicle Mileage


                                                   Basic Information
C:\Docstoc\Working\pdf\13d9261c-1575-4bf9-adbf-ac07256ab1d8.xls                                           Page 4
                                     Moving Expense Worksheet
Distance Test and Job Information

Date of Move                                    Employment Start Date

Number of miles from Old Home to New Workplace

Number of miles from Old Home to Old Workplace

Transportation and Storage of Household Goods and Personal Effects

Cost to pack, crate and move your household goods

Cost to store and insure household goods and personal effects
Within any period of 30 days in a row after the items were moved
From your old home and before they were delivered to your new

Travel and Lodging Expense of Moving From Your Old Home to Your New Home

Lodging costs on the way, including the day you arrive

Actual out-of-pocket expenses for gas and oil
Mileage rate at 16.5 cents a mile
Parking fees and tolls

                                    No Meals are Deductible

Employer Reimbursements

Amount your employer paid for your move that is not included in your W-2.
This amount should be identified with code P in box 13 of your W-2 form.

13d9261c-1575-4bf9-adbf-ac07256ab1d8.xlsMoving Expense Expense
                          FARM INCOME & EXPENSE WORKSHEET

               Name                                                 A: Principal Product
     Employer ID #                                                       B: Activity Code

  1 Sale of livestock purchased for resale                 3 Expenses:
     (purchased feeder stock)                                                 Item                  Amount
                                                          12 Vehicle miles
        Item          Amt Recv'd            Cost
                                                          13   Chemicals
                                                          14   Conservation Expenses
                                                          15   Machine Hire
                                                          17   Employee Benefit Plans
   2 Sale of livestock, produce, grains, and              18   Feed Purchase
     other raised products                                19   Fertilizers & Lime
                  Item                      Amount        20   Freight & Trucking
Raised feeder cattle                                      21   Gasoline, Fuel, & Oil
(not cull cows see #4)                                    22   Insurance (f/s)
Calves                                                   23a   Mortgage Interest paid
Sheep                                                    23b   Other Interest
Swine                                                     24   Labor Hired
Poultry                                                  26a   Rent - Machinery & Equipment
Dairy Products                                           26b   Other - Land, Animals
Eggs                                                      27   Repair & Maintenance of Bldg/ Mach
Wool                                                      28   Seed & Plants
Tobacco                                                   29   Storage & Warehouse
Vegetables                                                30   Supplies
Soybeans                                                  31   Taxes (f/s)
Corn                                                      32   Utilities (f/s)
Other Grains                                              33   Vet Fees
Hay                                                            Testing
Straw                                                          Breeding
Fruit & Nuts                                                   Medicine
Total to Schedule F, Line 4
                                                         Various Expenses:
5a Patronage dividend                                    Dues & Subscriptions
6a Total agriculture prog. Pymts                         Meals for Labor
7a Commodity CR Loans                                    Employee Health Insurance
7b CCC Loan Forfeited or                                 Owner's Health Insurance
   Repaid w/ Certificates
8a Crop Insurance
9a Custom Work

10a Other Income:
    Federal Gas Tax Credit
    State Gas Tax Credit
Total to Schedule F, Line 10                             Total Various Expenses

                                                  Income & Expense
     13d9261c-1575-4bf9-adbf-ac07256ab1d8.xlsFarmFarm Income & Expense                                 Page 6 of 7
4. Sale of livestock used for dairy or breeding purposes
                 (Both RAISED AND PURCHASED cull cows)
   Item          Date Sold     Sale Price  Date Acquired               Cost

5. Equipment Sold
   Item                          Date Sold       Sales Price           Date Acquired Cost

6. Machinery, Equipment & Livestock Bought
   Item                          New / Used      Date          Cost    Item Traded          Cash Pd "Boot"

                                                Income & Expense
   13d9261c-1575-4bf9-adbf-ac07256ab1d8.xlsFarmFarm Income & Expense                            Page 7 of 7

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