PERSONAL INCOME TAX RETURN DATA by n1185

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									                                                  Tami R. Benus, CPA, 1808 Monroe St., Columbia, MO 65201. P: 573-499-1990 — F: 573-499-4650

                                                  PERSONAL INCOME TAX RETURN DATA
                             The Information required on this form is pertinent to the preparation of your INCOME TAX RETURN and
                             relates to you and your family personally, and not to your business operations. All records used in the
                             preparation of your tax return must be retained for three years. The prompt completion of this form will
insure that your return is prepared without delay. If we may be of assistance to you in preparing this form, kindly contact us.
                         PLEASE SIGN AND RETURN THIS FORM AS SOON AS POSSIBLE TO GUARANTEE TIMELY FILING.

                                                                                           Social                                            Age                      Date
NAMES: Self                                                                                Security                                          as of                    of
                                                                                           No.
                                                                                           Social                                            12/31/02
                                                                                                                                             Age                      Birth
                                                                                                                                                                      Date
                 Spouse                                                                    Security                                          as of
                                                                                                                                                                      of
                                                                                           No.                                               12/31/02
                                                                                                                                                                      Birth
OCCUPATION: Self                                                                           Spouse

ADDRESS: List your current mailing address

                                                    Street                                                          City                                  State                 Zip



                                                    County                                                 Township/School District                               Home Phone
                                                                                                               (If applicable)

                                   Office Phone                                      Cell Phone                                                      E-mail Address



                                                                                                                            Yes         No                            Yes      No
Will you be claimed as a dependent on someone else’s return?                                                   Self         1           1            Spouse 1                  1
                                                                                                                            Yes         No                            Yes      No
Do you wish to designate $3 of your taxes to the Presidential                                                  Self         1           1            Spouse 1                  1
Campaign Fund? (This will not affect the amount of taxes.)
                                                                                                                            Yes         No                            Yes      No
Are you legally blind?                                                                                         Self         1           1            Spouse                1 1
                                                                                                                            Yes         No                            Yes      No
Were you audited for the past three years?                                                                     Self         1           1            Spouse                1 1
If so, supply information.
                                                                                                                                                                        No. of Months
                                                                  Date of Birth      Social Security Number                           Relationship                      Live In Your
DEPENDENT
Name (first, initial, last name)                                                                                                                                       Home This Year




  If your child didn’t live with you but is claimed as your dependent under a pre-1985 agreement, check here 1

ESTIMATED TAX PAYMENTS YOU HAVE MADE                                                                (Important – Needed for Verification)
                                   APRIL 15                       JUNE 17                           SEPT. 16                            JAN. 15
                                   1ST QUARTER                    2ND QUARTER                       3RD QUARTER                         4TH QUARTER
                               Date               Amount         Date       Amount                  Date       Amount                   Date         Amount                    TOTAL

FEDERAL

STATE

LOCAL
SALARIES        List all employers and indicate husband or wife – Attach your W-2 Form from your employer.
 H/W                         Employer’s Name                      H/W                 Employer’s Name
_____          ____________________________________             _____ ____________________________________
_____          ____________________________________             _____ ____________________________________
_____          ____________________________________             _____ ____________________________________
_____          ____________________________________             _____ ____________________________________
CHECK HERE IF YOU ARE AN ACTIVE PARTICIPANT IN A PROFIT SHARING PLAN                                                         1 SELF              1SPOUSE

                                          Attach your 1099 Forms or copy                                                        Attach your 1099 Forms or copy
INTEREST YOU EARNED                        of year-end broker statement               DIVIDENDS YOU EARNED                       of year-end broker statement

HWJ         FROM WHOM RECEIVED                          AMOUNT                        HWJ        FROM WHOM RECEIVED                 AMOUNT                # Of Shares Held

                                                                                                                                                            on 12/31/02
                                                        $                                                                           $
                                                        $                                                                           $
Tax Exempt Interest                                     $                                                                           $
Interest Income from Seller-Financed Mortgage           $                                                                           $
List Name of Payer                                                                                                                  $
Address                                                                                                                             $
Social Security Number                                                                                                              $
      ATTACH ADDITIONAL SHEETS IF NECESSARY (If children under 14 had income for more than $700, provide details.)


                                      ITEM SOLD                  DATE                 DATE           SELLING          COST                   GAIN (LOSS)
CAPITAL                                                          SOLD                 ACQ’D           PRICE
GAINS/
LOSSES
Sales of Real
Estate, Personal
Property, Stocks
Bonds, etc.

                        FOR REAL ESTATE AND PERSONAL PURCHASES AND SALES, ENCLOSE CLOSING PAPERS

                                      Property #1         Property #2              Property #3
RENT INCOME                                                                                                                     OTHER
Description and                                                                                        Pensions (Attach W-2P or 1099R)       $     __________________
Address of Property               $                      $                     $
                                                                                                       IRA Distributions (Attach 1099R)      $     __________________
Gross Rents…
EXPENSES
                                                                                                       Partnerships (Attach K-1)                 $   __________________
Advertising                                                                                            Do you actively participate in this activity? 1 Yes 1 No
Cleaning & Maintenance                                                                                 S. Corp (Attach K-1)                      $   __________________
                                                                                                       Do you actively participate in this activity? 1 Yes 1 No
Commissions                                                                                            Estates or Trusts (Attach K-1)            $   __________________

Insurance                                                                                              Proceeds of Installment Sales         $     __________________
Mortgage Interest
                                                                                                       Alimony Received                      $     __________________
Repairs
                                                                                                       Social Security (Attach SSA 1099)     $     __________________
Supplies
                                                                                                       State Income Tax Refund               $     __________________
Taxes
                                                                                                       Tips (not included on W-2)            $     __________________
Utilities
                                                                                                       Lottery or Other Winnings             $     __________________
Other*
                                                                                                       (Attach W-2G)
Improvements*                                                                                          Unemployment Compensation             $     __________________
What percent of the property
Did you occupy during 2002?                         %                   %                        %     Farm Income (Attach Detail)           $     __________________
 Check here if you actively
participated in the operation            1                      1                      1
                                                                                                       Other                                 $     __________________
If a vacation home or condo, how
many days occupied by you?                        days                  days                 days
If property acquired in current year attach closing statement                                          If self-employed attach schedule of income and expenses.

IRA Payments for Self $                                      Spouse $                            Roth IRA for Self $                    Spouse $
NOTE: If you or your spouse are an active participate in a pension or profit sharing plan, your deduction for payment to an IRA may be limited.

Payments to a Keogh (H.R. 10) Retirement Plan $                                                      (Note: if Keogh Plan, 5500 must be filed.)

Penalty for Early Withdrawal of Savings $

Alimony: Paid to                                                                            Social Security #                                  Amount $

Job-Related Educational Expenses: Books: $                               Tuition: $                          Miles Driven (Work to school)

Business Use of Personal Auto: Date Purchased                                                       Total Miles Driven

 Business Miles Driven                                  Personal Miles Driven                                    Commuter Miles Driven

 Expenses Paid Personally:                 Gas $                      Repairs $                         Insurance $                           Other $

 Do you have another vehicle available for personal use?                                                                     1 Yes        1 No

 If your employer provided you with a vehicle, is personal use during off-duty hours permitted?                              1 Yes        1 No      1 Not Applicable

 Do you have evidence to support your deduction?                   1 Yes      1 No        If yes, is evidence written?       1 Yes        1 No

Reimbursement Received $

Other Non-reimbursed Business Expenses: Travel Expenses (Not including meals and entertainment)

Meals and Entertainment $                                       Other $                                (Proper substantiation is necessary for these deductions)

Student Loan (Attach Form 1098E) $

Did you move more than 50 miles? If so, furnish details of expenses.


                                                             ITEMIZED DEDUCTIONS
MEDICAL EXPENSE

M edical Insurance Premiums                         $                                     Hearing Aids ------------------------------           $

Long-term Care Premiums                                                                   Eye Glasses -------------------------------

Prescription Medicine & Drugs & Insulin                                                   Lab Fees -----------------------------------

Miles Driven for Medical Care                                                             Ambulance ---------------------------------

Other Medical Transportation & Lodging                                                    Hospitals (List) ----------------------------

                                 TO WHOM PAID                                             Hospitals (List) ----------------------------

Dr.                                                                                       Other (List other medical expense – specify)

Dr.

Dr.

Dr.                                                                                       Long Term Care Reimbursement (attach 1099 LTC)

                                                                                          Insurance Reimbursement on above exp.                         (              )
NOTE: Medical Expenses are deductible to the extent they exceed 7.5% of your adjusted gross income.

TAXES
         State and Local Taxes (Include payment made for last year)------------------------------------------------------------- $

         Real Estate Tax-------------------------------------------------------------------------------------------------------------------

         Personal Property Tax (Including intangible) --------------------------------------------------------------------------------
            CONTRIBUTIONS                                                             INTEREST PAID
            PAID TO                                 AMOUNT                          Home mortgage paid to financial institution: $
                                                                                    (Attach 1098)
Church /Temple ----------------------               $
                                                                                    Home Mortgage Paid to Individuals:           $
Other (please list) --------------------                                            (Attach name, address and social security number of mortgage holder)

                                                                                    Closing Points on New Home:

                                                                                    Closing Points on Refinancing:

Miles Driven for Charitable Purposes:                           Mi.                 Investment Interest:                         $

Do you have any non-cash contributions?             1 Yes     1 No                  (Do not include rental property and student loan interest reported
If so, attach receipts and indicate value                                           separately)
And how value determined.


            For non-cash donations in excess of $500, attach receipt.                          Personal Interest Is No Longer Deductible


MISCELLANEOUS: (Paid personally)                        NOTE: These expenses are deductible only to the extent they exceed 2% of adjusted gross income.

Tax Preparation ----------------------------------- $                               Safety Deposit Box -----------------------       $

Uniforms ------------------------------------------                                 Union and Professional Dues -----------

Tools -----------------------------------------------                               Telephone Used for Business -----------

Investment Expenses -----------------------------                                   Professional Books & Magazines ------

Casualty losses through fire, storm, theft or casualty not reimbursed – attach sheet with detailed explanation for each separate loss.

HOPE AND LIFETIME LEARING CREDIT:

Tuition and fees paid: $
(Do not include books, room and board and other expenses)

Were payments for first two years of post-secondary school education?               1 Yes                  1 No

CHILD AND DEPENDENT CARE EXPENSES (Children must be under 13 years old)
Who provided care?

Name:                                                                               Address:

SS# I.D.#                                                                           Amount Paid:

If you had more than one, attach schedule.
Note: If you paid cash wages of $1300 or more in the year, or $1000 or more in any calendar quarter, to an individual for services preformed in your
home, you must file an employer tax return. Ask your accountant for information. Number of qualifying persons cared for in 2002. New Jersey,
Massachusetts and California residents: Supply necessary information for renter’s credit.


Did you give or receive gifts in excess of $11,000 from any on individual? If so, please provide name, address and social security number of recipient.

NOTES:




DECLARATION: I HAVE REVIEWED THE INFORMATION GIVEN TO YOU ON THIS FORM AND TO THE BEST OF MY
KNOWLEDGE IT IS TRUE, CORRECT, COMPLETE AND READY FOR YOUR PREPARATION OF MY INCOME TAX RETURN. I
ACKNOWLEDGE THAT I HAVE MAINTAINED ADEQUATE DOCUMENTATION TO SUBSTANTIATE ALL DEDUCTIONS THAT
I HAVE CLAIMED.

Signature                                                                                              Date

                                                  (Must be signed)
                                       Tax Appointment Checklist
Client Name:                                               Social Security #:

Spouse Name:                                               Email Address:

Client Address:

Client Phone #:                                            Alt Phone #:

Please answer the questions below.                                                     YES   NO   ?
1. Did you purchase a Traditional IRA in 2005? Are you intending to do so?
2. Did you purchase a Roth IRA in 2005? Are you intending to do so?
3. Did you convert a Traditional IRA to a Roth IRA in 2005?
4. Have you contributed to a Roth IRA?
5. Did you have any non-deductible IRAs previously?
6. Did you lease a car for business purposes?
7. Did you pay interest on a student loan?
8. Did you pay tuition for post- high school education?
9. Are you interested in filing your federal return electronically?
10. Do you have dependent care benefits paid by your employer?
11. Do you live in one state and have at least one job in another state?
12. Are you over 69 years old and have IRA type investments?
13. Do you have any income from partnerships, S-corps, trusts, etc.?
14. Do you have capital loss carry- forward from last year or previous returns?
15. Did you withdraw from an IRA during 2005?
16. Did you sell a home in past 3 years?
17. Is the name on your Social Security card the same name that is on your tax
return? If not, the IRS will not process your refund.
18. Are you or your spouse a member of a pension or profit-sharing plan at work?
19. If you itemize deductions, did you give more than $500 (resale value) in non-
cash contributions?
20. Did you spend any money at your job for impairment-related expenses that were
necessary to allow yo u to work?
21. In addition to providing income tax services, we can assist you in the following
areas:
                Financial Planning – including IRAs, investments, retirement
                planning, college savings and annuities.
                Life Insurance – review and planning.
                Long-term care insurance
Would you be interested in a free consultation in any of these areas?

Client Signature:                                                         Date:

Office #:                    Associate #:                  Associate Name:

								
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