Client Tax Organizer 2012 2 by Sm12aD7


									         In order to help us prepare your returns, please complete these forms prior to bringing in your 2012 tax information

                                                    Lehman, Hershberger & Company P.C.
                                                        Client Tax Organizer

1. Personal Information

                        Name                                          Soc. Sec. No.           Date of Birth         Occupation             Work Phone
Street Address:                                               City:                           State:              ZIP                      Home Phone:

Email Address(es):                                                                            Cell (Taxpayer):    Cell (Spouse):        Fax:

                                              Taxpayer                              Spouse                                    Marital Status
Blind……………………………….                            Yes      No                          Yes     No                              Single
Disabled………………………….                           Yes      No                          Yes     No                              Married filing jointly
Wish to donate $3 to the                                                                                                   Married but filing separately
Pres. Campaign fund?                          Yes             No                   Yes          No                         Widow(er)
                                                                                                                             -Date of Spouse’s Death:
School District:

2. Dependents (Children & Others you supported)
                                                                                             Months       Can anyone
                                                                                                                                         Full    Dependent’s
           Name                                     Date of             Soc. Security      Lived with      else ever
                               Relationship                                                                                Disabled     Time        Gross
        (First, Last)                                Birth                Number           you during      claim this
                                                                                                                                       Student     Income
                                                                                              year          person?

3. Estimated Taxes You Paid for 2012
                                Federal                                                                                 State
                                              Amount               Check                                                              Amount       Check
Quarter       Due Date     Date Paid                                                    Quarter        Due Date     Date Paid
                                                $                    #                                                                  $            #
    1          4/17/12                                                                    1            4/17/12
    2          6/15/12                                                                    2            6/15/12
    3          9/17/12                                                                    3            9/17/12
    4          1/15/13                                                                    4            1/15/13

To the best of my knowledge, this information is correct and complete.

        Signature:                                                                                                       Date:
4. Wage, Salary Income                                                 10. Social Security or Railroad Retirement
Attach W-2’s                                                           Attach SSA-1099/RRB-1099:
                                                                                         Soc. Security or RRB Amount
Employer:                                Taxpayer       Spouse

                                                                       11. Pension, Annuity Income
                                                                       Attach 1099-R’s

5. Unemployment Compensation
Attach W2-G’s                                                                                               Taxpayer       Spouse


6. Interest Income
Attach 1099-INT’s & any broker statement                               12. I.R.A. (Individual Retirement Acct.)

                                                                                  Contributions made for this tax year:

                                                                                           Amount         Date            Roth?
7. Dividend Income
From Mutual Funds/Stocks – Attach 1099-Div’s:                          Spouse:

                                                                       Withdrawals (Attach 1099-R or 5498):

                                                                                           Amount        Reason        Rolled Over?
8. Cancellation of Debt (attach 1099-C’s)
Were you bankrupt/insolvent at date of debt cancellation?


9. Income from Partnerships, S-Corps.,
Estates, Trusts, Etc. (attach K-1’s)

13. Investments Sold
Stocks, Bonds, Mutual Funds, Gold, Silver, Partnership Interest - Attach Documentation (1099-B, etc.)
                           Investment                                   Date Acquired       Cost        Date Sold       Sale Price

14. Real Estate Sold
Attach 1099-S and Closing Statements
                             Was this your principal
        Property                  residence?
                                                       Date Acquired       Cost         Improvements    Date Sold       Sale Price
15. Other Income                                         19. Medical/Dental Expenses

Lawsuit settlements:                                     Med. Insurance Premiums (NOT on W-2)
            Describe:                                    Long-Term Care Insurance Premiums
Scholarships (Grants)                                    Name of Insurance
Alimony Received                                         Co.:
Prizes, Bonuses, Awards                                  Prescription Drugs
Gambling, Lottery, Winnings                              Eye, Glasses, Contacts
            - Gambling, Lottery                          Hearing Aids, Batteries
                                             (       )
Expenses                                                 Medical Equipment, Supplies
Unreported Tips                                          Nursing Care, Medical Therapy
Director, Executor Fee Received                          Hospital
Commissions                                              Doctor, Dental, Orthodontist
Jury Duty                                                Other
Payment from Prior Installment Sale                      Health Savings Account (HSA):   Distributions
State Income Tax Refund                                    Contributions by                  Employer
Other:                                                                  You             Contributions
                                                         Medical Savings Account (MSA):   Distributions
                                                           Contributions by                  Employer
16. Taxes Paid in 2012 (attach receipts)
                                                                        You             Contributions
                                                         Medical Miles Driven:
Real Estate:
                                                                 January – June 2012                 miles
                                                                 July – December 2012                miles
Personal Property Tax:
Auto Excise & Wheel Tax: (not reg. fees)
Sales Tax on Purchase of New Vehicle:
                     Date Purchased:                     20. Mortgage Interest Paid
Sales Tax on other Big Ticket Items:
                                                         Mortgage Interest Paid (Attach 1098)
17. Rent Paid
                                                         Interest Paid to an individual for your
                        Rent Paid in 2012:               home (attach amortization schedule)
Rent Paid To:                                            Paid to: Name
Address:                                                 Address:

Address where rented:

                                                         Soc. Sec.#
Number of months rented:

18. Charitable Contributions                             21. Job-Related Expenses (Not self-employed)
You MUST have the receipts!                              Dues – Union, Professional
Church                                                   Teacher/Educator Expenses
United Way                                               Tools, Equipment, Safety Equipment
Colleges, Universities                                   Uniforms (including cleaning)
Other Cash Contributions:                                Tuition, Books (work related)

                                                         Office in Home (Job-Related):
Non-Cash Contributions:                                                      Total Home Sq. Footage:
                                                                          Office/Storage Sq. Footage:
                                                           Rent Paid:                       Utilities:
Volunteer Miles Driven: Jan.-Dec. 2012           miles     Insurance:                  Maintenance:
22. Child & Dependent Care Expenses

   Child or                                                                                    Soc. Sec. No. or         Amount
                        Name of Care Provider                     Address
  Dependent                                                                                      Fed. ID No.             Paid

Did you receive dependant care benefits from your employer?

23. Education Expenses (including home school and private school in Indiana)
 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)

24. Investment Related Expenses                                  27. Casualty, Theft Loss
                                                                 For property stolen or damaged by storm, water, fire, accident
Tax Preparation Fee
Safe Deposit Box Rental                                            Location of property:
Mutual Fund Fees
Investment Counselor                                             Date of Purchase
Investment Interest                                              Cost & Improvements:
Other:                                                           Description of
                                                                      Amt. of                               Ins.
                                                                    Damage:                          Reimburs.:
25. Job-Related Mileage/Travel (Not self-employed)
                                                                                                    Fed. Grants
                                                                 Repair Cost:                         Received:
Do you have written records?
Make & Year of vehicle:
Total Miles (personal & business)                                28. Energy Credit/Insulation (attach receipts)
Business Miles:                                January –
                                             December 2012       Alternative Fuel Vehicle Purchased:             Date:
                 From 1st Job to 2nd Job:                          Make:                Model:                Price:
        From Job to School (Job Related):                         Install insulation or energy efficient items in your home:
                            Job Seeking:                           Item:                 Date:                Price:
                   Other Business Miles:
Other Job Seeking Expenses:
Business Travel:      Airfare, Train, etc:
            Meals (NO. of Days          ):
                        Taxi, Car Rental:                        29. Other Information
Reimbursement Received:                            (         )   Did any of the following apply to you in 2012?
                                                                         Marriage                    Births
                                                                         Divorce                     Adoption
26. Other Deductions                                                     Bankruptcy                  Job-Related Move
Alimony Paid to:                                                         Home Foreclosure            Foreign bank account
    Soc. Security No:                                                    Self-employment             Foreign income
                                                                         Hobby Income                Income from Animals
Other:                                                                   Rental Income               Income from Crops
                                                                         Give a gift of more than $13,000 to anyone
                                                                         Provide home or help support to someone not
                                                                         listed as a dependent on Page 1

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