Document Sample
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 transferror 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 __________________ __________________________ __________________ __________________________ __________________ __________________________ __________________ __________________________ __________________ __________________________ __________________ __________________________ __________________ __________________________ INTEREST INCOME Please attach Forms 1099 and list interest received. Husband/Wife/Joint Name of Payor __________________ __________________________ __________________ __________________________ __________________ __________________________ __________________ __________________________ __________________ __________________________ __________________ __________________________ __________________ __________________________ __________________ Interest/Fed. Sav. Bonds __________________ Forfeited Interest/ __________________ Premature Withdrawals __________________ All savers Interest OTHER INCOME Husband/Wife/Joint Name of Payor __________________ St./City
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