Docstoc

Personal

Document Sample
Personal Powered By Docstoc
					PERSONAL INFORMATION
If you are sure I already have this data, you do not need to provide it again here.

Personal Information                          Complete Name                  SSN / ITIN           Date of Birth            Occupation
Primary Taxpayer
Spouse
Dependent 1
Dependent 2
Dependent 3
Dependent 4

Mailing address                                                        <==Street and street number (in the order generally used in your country)
(The address you want to appear                                        <==Zip/postal code, city and US State (in the order generally used in your country)
at the top of your tax return)                                         <==Country

DIRECT REFUND DEPOSIT & TAX PAYMENT TO/FROM BANK ACCOUNT

If you are owed a refund, do you want IRS to direct-deposit it to your account?
If you owe tax, do you want IRS to deduct it from your bank account? (only if e-filing)

If either answer above is YES, provide your U.S. bank account details:
9-digit ABA routing #                                                Bank name
Account #                                                            Type of account

OTHER INFORMATION NOT COVERED ELSEWHERE
Please use this area to provide any additional information you believe may be relevant, or to ask any questions you have.
GENERAL QUESTIONS
ALL CLIENTS: PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS, PROVIDING ADDITIONAL DETAIL WHERE APPROPRIATE
All questions pertain to the calendar year 2009. All references to "you" refer to you, your spouse, and your dependents.

INCOME ITEMS                                                                                     ANSWER   If YES, then…

Did you receive wages from employment?                                                                    If US employer, provide copies of W-2's. If foreign employer, fill out "Wages" sheet.

Did you receive interest income?                                                                          If from US bank, provide 1099's. If from foreign bank, fill out "Int&Div" sheet.

Did you receive dividend income?                                                                          If from US company, provide 1099's. If from foreign company, fill out "Int&Div" sheet.

Did you have any transactions related to stock/equity based compensation?                                 Provide details/amounts

Did you receive a refund of any US State/local income tax?                                                Provide details and copy of Form 1099-G, if available

Did you receive any alimony?                                                                              Provide details/amounts

Did you earn income from self-employment, independent contracting or sole-proprietorship?                 Fill out the "SelfEmp" sheet.

Did you sell any investments (stocks, funds, real estate, foreign currency, gold, art, etc)?              If so, provide detailed brokerage reports and/or descriptions of asset(s) sold, purchase date/cost, and sale date/proceeds.

Did you receive a distribution from an IRA account?                                                       Provide copies of Form 1099-R and, if applicable, Form 5498.

Did you receive a distribution from a pension or annuity?                                                 Provide copies of Form 1099-R and, if applicable, Form 5498.

Did you receive any rental income?                                                                        Fill out the "Rental" sheet

Do you have income from any partnership, S-corporation, estate or trust?                                  Provide details and copies of all K-1 forms.

Did you receive any farm income?                                                                          Provide details/amounts

Did you receive any unemployment compensation?                                                            Provide details and copy of Form 1099-G, if available

Did you receive any US social security benefits?                                                          Provide copy of your Form(s) SSA-1099 or SSA-1042

Did you receive any foreign social security benefits?                                                     Provide details (description, amounts, and dates received)

Did you receive any other income, gain or profit of any sort not listed elsewhere?                        Provide details/amounts




EXPENSE ITEMS                                                                                    ANSWER   If YES, then…

If you are an educator, did you pay any "educator expenses"?                                              Provide details/amounts

Did you pay any business expenses related to status as a
 reservist, performing artist, or fee-basis government official?                                          Provide details/amounts

Did you contribute to a health savings account (HSA)?                                                     Provide details/amounts

Did you pay any moving expenses?                                                                          Provide details/amounts

Did you (or do you plan or wish to) contribute to a self-employed SEP, SIMPLE,
  or a qualified retirement plan such as an individual/solo 401(k)?                                       Provide details/amounts

If you are self-employed, did you pay premiums for health insurance?                                      Provide details/amounts

Did you incur a penalty for early withdrawal of savings?                                                  Provide details/amounts

Did you pay any alimony?                                                                                  Provide details/amounts and name/SSN of recipient

Did you (or do you plan or wish to) contribute to a traditional IRA account?                              Provide details/amounts

Did you (or do you plan or wish to) contribute to a Roth IRA account?                                     Provide details/amounts

Did you pay any student loan interest?                                                                    Provide details/amounts

Did you pay any tuition for post-secondary education for yourself, spouse or dependents?                  Provide details/amounts

Did you pay any other amount during the year that you feel may be relevant?                               Provide details/amounts




OTHER IMPORTANT QUESTIONS                                                                        ANSWER   If YES, then…

Did you or your spouse own or otherwise control a non-US bank or other financial account?                 Review & answer questions on the FBAR sheet; complete FBAR-TP and/or FBAR-SP sheet if applicable

Did you have an investment in any foreign-based investment fund or investment trust?                      Provide details/amounts

Did you have an ownership interest in any non-US-based company or business entity?                        Provide details/amounts

Did you enter into any significant transactions in foreign currency?                                      Provide details/amounts

Did you make or receive any gifts during the year (from US or foreign donors)?                            Provide details/amounts/sources

Did you have any relationship to, or did you receive a distribution from, any estate or trust?            Provide details/amounts

Did you purchase a principal residence in the United States during 2009 or 2010?                          Provide details/amounts

Did you pay state or local property tax on a property in the United States?                               Provide details/amounts

Did you purchase a new vehicle during 2009?                                                               Provide description and cost of the vehicle, and the amount of state/local taxes and fees paid

Do you want $3 of your tax diverted to the Presidential Election Campaign Fund?                           N/A
Same question for your spouse (if applicable)?                                                            N/A
ADVANCE/ESTIMATED TAX PAYMENTS
Provide on this sheet information regarding Federal and US State tax payments already made for 2009
Please provide W-2's and/or 1099's to show taxes withheld by US payers of income.

FEDERAL                                              Date       $ Amount
2008 overpayment applied to 2009 year                N/A
Estimated payment for 2009 Q1
Estimated payment for 2009 Q2
Estimated payment for 2009 Q3
Estimated payment for 2009 Q4
Payment made with Federal extension request
Any other Federal tax payment for 2009


US STATE(S)
                                                  State Name:                State Name:
                                                      Date      $ Amount         Date
2008 overpayment applied to 2009 year                 N/A                        N/A
Estimated payment for 2009 Q1
Estimated payment for 2009 Q2
Estimated payment for 2009 Q3
Estimated payment for 2009 Q4
Payment made with State extension request
Any other State tax payment for 2009
<><><><><><><><><><><><>
2008 State tax paid in 2009 - 2008Q4 estimate
2008 State tax paid in 2009 - extension request
2008 State tax paid in 2009 - final balance
eady made for 2009




                        State Name:
             $ Amount       Date      $ Amount
                            N/A
WAGES                For wages from US employers, provide copies of all your W-2 form(s).
                     For wages from foreign employers, provide data below.
                                                                                                                 Preparer use    Preparer use    In case of part-year employment
Employee Name          Employer Name       Income Description          Date        FX Code        Amount             Rate            USD            From Date         Until Date
                                                                                                                                    #DIV/0!
                                                                                                                                    #DIV/0!
                                                                                                                                    #DIV/0!
                                                                                                                                    #DIV/0!
                                                                                                                                    #DIV/0!
                                                                                                                                    #DIV/0!
                                                                                                                                    #DIV/0!
                                                                                                                                    #DIV/0!
                                                                                                                                    #DIV/0!
                                                                                                                                    #DIV/0!
                                                                                                                                    #DIV/0!




Notes:
1. Contributions you make to a foreign pension scheme/plan out of your salary are NOT deductible for US purposes (if a rare exception applies, I will inform you).
2. Contributions made by your employer to a foreign pension scheme/plan for your benefit/account are treated as income (if a rare exception applies, I will inform you).
3. As a "cash basis" taxpayer, you must report all income received during the calendar year. Thus, if you received Dec '08 salary in 2009, this would be reportable on
   your 2009 tax return.
ITEMIZED DEDUCTIONS (SCHEDULE A)
If you are sure you will not itemize deductions, do not fill out this sheet; the standard deduction will be claimed.
IRS instructions re itemized deductions:     http://www.irs.gov/pub/irs-pdf/i1040sca.pdf
INSERT MORE ROWS AS NEEDED.

                                                   Detailed Description             Date
Medical and Dental Expenses



US State Sales Tax on Major Purchases



Real Estate Taxes



Personal Property Taxes



Other Taxes



Home Mortgage Interest & Points
Provide copy of Form(s) 1098 if available



Qualified Mortgage Insurance Premiums



Investment Interest



Charitable Contributions
Provide name(s) of charity/ies


Casualty/Theft Losses



Unreimbursed employee expenses



Tax Preparation Fees



Other Expenses
t; the standard deduction will be claimed.


                                              Preparer use   Preparer use
                      FX Code        Amount       Rate           USD
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
                                                               #DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
INTEREST, DIVIDENDS & FOREIGN BANK ACCOUNT REPORT (SCHEDULE B)

FOREIGN BANK ACCOUNT REPORT
First, review the online "FBAR" page to determine if you and/or your spouse is required to file this form:         www.edelmantax.com/FBAR.htm

Question 1: Are either you or your spouse required to file an FBAR?                                                Answer:
Question 2: If you are required to file an FBAR, do you request Edelman Tax Services to prepare it?                Answer:

If you answered YES to both questions, please complete the FBAR-TP (taxpayer) and/or FBAR-SP (spouse) sheets, as applicable.
If you are self-preparing your FBAR, please list here all the countries in which your and/or your spouse's foreign accounts are located:



INTEREST
For US-source interest, please send copies of your Forms 1099-INT.
For foreign-source interest (or if you have no 1099 for US-source), enter your interest income below.              Preparer use    Preparer use   Preparer use
Recipient Name        Payer of Interest       Country        Date       FX Code Gross Amount          Tax W/held       Rate       Income (USD)     Tax (USD)     Relation to ForeignTax Sheet
                                                                                                                                      #DIV/0!        #DIV/0!
                                                                                                                                      #DIV/0!        #DIV/0!
                                                                                                                                      #DIV/0!        #DIV/0!
                                                                                                                                      #DIV/0!        #DIV/0!
                                                                                                                                      #DIV/0!        #DIV/0!
                                                                                                                                      #DIV/0!        #DIV/0!

DIVIDENDS
For US-source dividends, please send copies of your Forms 1099-DIV.
For foreign-source interest (or if you have no 1099 for US-source), enter your dividend income below.              Preparer use    Preparer use   Preparer use
Recipient Name       Payer of Dividend        Country        Date       FX Code Gross Amount        Tax W/held         Rate       Income (USD)     Tax (USD)     Relation to ForeignTax Sheet
                                                                                                                                      #DIV/0!        #DIV/0!
                                                                                                                                      #DIV/0!        #DIV/0!
                                                                                                                                      #DIV/0!        #DIV/0!
                                                                                                                                      #DIV/0!        #DIV/0!
                                                                                                                                      #DIV/0!        #DIV/0!
                                                                                                                                      #DIV/0!        #DIV/0!
SELF-EMPLOYMENT (SCHEDULE C)                                                                                                         Suggested expense categories (not comprehensive):
If you are not sure whether you are employed or self-employed, contact me to discuss.                                                Advertising
See at right for a list of common expense categories.                                                                                Commissions and fees
Contact me for special instructions if you want to deduct vehicle-related or home-office expenses.                                   Contract labor/consultants
If you are a new client, and have depreciable assets placed in service in a prior year, provide details.                             Cost of goods sold
For meal/entertainment expenses, provide the 100% amount, but note that only 50% will be deductible.                                 Employee benefit programs
                                                                                                                                     Insurance (other than health)
Self-Employed Business #1                                                                                                            Interest (mortgage)
Name of Self-Employed Person                                                                                                         Interest (non-mortgage)
Name of business, if different                                                                                                       Legal and professional services
Address of business                                                                                                                  Meals & entertainment
Description of business                                                                                                              Office expense
Employer ID (EIN), if any                                                                                                            Pension and profit-sharing plans
                                                                                                       Preparer use   Preparer use   Rent for vehicles, machinery & equipment
                                 Description/Notes/Category       Date      FX Code       Amount           Rate           USD        Rent for other business property/real estate
Revenues                                                                                                                 #DIV/0!     Repairs and maintenance
                                                                                                                         #DIV/0!     Supplies
                                                                                                                         #DIV/0!     Taxes and licenses
                                                                                                                         #DIV/0!     Travel
                                                                                                                         #DIV/0!     Utilities
                                                                                                                         #DIV/0!     Wages
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
Expenses                                                                                                                 #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
Capital Items                                                                                                            #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!


Self-Employed Business #2
Name of Self-Employed Person
Name of business, if different
Address of business
Description of business
Employer ID (EIN), if any
                                                                                                       Preparer use   Preparer use
                                 Description/Notes/Category       Date      FX Code       Amount           Rate           USD
Revenues                                                                                                                 #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
Expenses                                                                                                                 #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
Capital Items                                                                                                            #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
                                                                                                                         #DIV/0!
RENTAL PROPERTY (SCHEDULE E)
Fill out this sheet if you or your spouse has a rental real estate property.
Provide all income/expense data on a 100% basis. I will allocate your portion based on your ownership percentage.
If you are a new client, or if the property is new for 2009, contact me to discuss information I need to compute depreciation.

Property #1
% Owned by Primary Taxpayer
% Owned by Spouse
Is a dependent a co-owner?
Complete address of property:
Description of property (e.g., house, condo):
# of days used by you/your family during 2009:
# of days property rented at fair value in 2009:
                                                                                                                     Preparer use   Preparer use
                                                   Description/Notes        Date        FX Code         Amount           Rate           USD
Rental Income                                                                                                                          #DIV/0!
                                                                                                                                       #DIV/0!
                                                                                                                                       #DIV/0!
                                                                                                                                       #DIV/0!
                                                                                                                                       #DIV/0!
Expenses                                                                                                                               #DIV/0!
Advertising                                                                                                                            #DIV/0!
Auto and travel                                                                                                                        #DIV/0!
Cleaning and maintenance                                                                                                               #DIV/0!
Commissions                                                                                                                            #DIV/0!
Homeowner association (HOA) dues                                                                                                       #DIV/0!
Insurance                                                                                                                              #DIV/0!
Legal and professional                                                                                                                 #DIV/0!
Management fees                                                                                                                        #DIV/0!
Mortgage interest paid to banks                                                                                                        #DIV/0!
Other interest paid                                                                                                                    #DIV/0!
Repairs                                                                                                                                #DIV/0!
Supplies                                                                                                                               #DIV/0!
Taxes (other than foreign income taxes)                                                                                                #DIV/0!
Taxes - foreign income tax                                                                                                             #DIV/0!
Utilities                                                                                                                              #DIV/0!
Other (enter description here)                                                                                                         #DIV/0!
Other (enter description here)                                                                                                         #DIV/0!
Other (enter description here)                                                                                                         #DIV/0!
                                                                                                                                       #DIV/0!
                                                                                                                                       #DIV/0!
Capital Items                                                                                                                          #DIV/0!
                                                                                                                                       #DIV/0!
                                                                                                                                       #DIV/0!
                                                                                                                                       #DIV/0!
                                                                                                                                       #DIV/0!
                                                                                                                                       #DIV/0!


Property #2
% Owned by Primary Taxpayer
% Owned by Spouse
Is a dependent a co-owner?
Complete address of property:
Description of property (e.g., house, condo):
# of days used by you/your family during 2009:
# of days property rented at fair value in 2009:
                                                                                                                     Preparer use   Preparer use
                                                   Description/Notes        Date        FX Code         Amount           Rate           USD
Rental Income                                                                                                                          #DIV/0!
                                                                                                                                       #DIV/0!
                                                                                                                                       #DIV/0!
                                                                                                                                       #DIV/0!
                                                                                                                                       #DIV/0!
Expenses                                                                                                                               #DIV/0!
Advertising                                                                                                                            #DIV/0!
Auto and travel                                                                                                                        #DIV/0!
Cleaning and maintenance                                                                                                               #DIV/0!
Commissions                                                                                                                            #DIV/0!
Homeowner association (HOA) dues                                                                                                       #DIV/0!
Insurance                                                                                                                              #DIV/0!
Legal and professional                                                                                                                 #DIV/0!
Management fees                                                                                                                        #DIV/0!
Mortgage interest paid to banks                                                                                                        #DIV/0!
Other interest paid                                                                                                                    #DIV/0!
Repairs                                                                                                                                #DIV/0!
Supplies                                                                                                                               #DIV/0!
Taxes (other than foreign income taxes)                                                                                                #DIV/0!
Taxes - foreign income tax                                                                                                             #DIV/0!
Utilities                                                                                                                              #DIV/0!
Other (enter description here)                                                                                                         #DIV/0!
Other (enter description here)                                                                                                         #DIV/0!
Other (enter description here)                                                                                                         #DIV/0!
                                                                                                                                       #DIV/0!
                                                                                                                                       #DIV/0!
Capital Items                                                                                                                          #DIV/0!
                                                                                                                                       #DIV/0!
                                                                                                                                       #DIV/0!
                                                                                                                                       #DIV/0!
                                                                                                                                       #DIV/0!
                                                                                                                                       #DIV/0!




Property #3
% Owned by Primary Taxpayer
% Owned by Spouse
Is a dependent a co-owner?
Complete address of property:
Description of property (e.g., house, condo):
# of days used by you/your family during 2009:
# of days property rented at fair value in 2009:
                                                                                                                     Preparer use   Preparer use
                                                   Description/Notes        Date        FX Code         Amount           Rate           USD
Rental Income                                                                                                                          #DIV/0!
                                                                                                                                       #DIV/0!
                                                                                                                                       #DIV/0!
                                                                                                                                       #DIV/0!
                                                                                                                                       #DIV/0!
Expenses                                                                                                                               #DIV/0!
Advertising                                                                                                                            #DIV/0!
Auto and travel                                                                                                                        #DIV/0!
Cleaning and maintenance                                                                                                               #DIV/0!
Commissions                                                                                                                            #DIV/0!
Homeowner association (HOA) dues                                                                                                       #DIV/0!
Insurance                                                                                                                              #DIV/0!
Legal and professional                                                                                                                 #DIV/0!
Management fees                                                                                                                        #DIV/0!
Mortgage interest paid to banks                                                                                                        #DIV/0!
Other interest paid                                                                                                                    #DIV/0!
Repairs                                                                                                                                #DIV/0!
Supplies                                                                                                                               #DIV/0!
Taxes (other than foreign income taxes)                                                                                                #DIV/0!
Taxes - foreign income tax                                                                                                             #DIV/0!
Utilities                                                                                                                              #DIV/0!
Other (enter description here)                                                                                                         #DIV/0!
Other (enter description here)                                                                                                         #DIV/0!
Other (enter description here)                                                                                                         #DIV/0!
                                                                                                                                       #DIV/0!
                                                                                                                                       #DIV/0!
Capital Items                                                                                                                          #DIV/0!
                                                                                                                                       #DIV/0!
                                                                                                                                       #DIV/0!
                                                                                                                                       #DIV/0!
                                                                                                                                       #DIV/0!
                                                                                                                                       #DIV/0!
FOREIGN INCOME TAXES (FORM 1116)
Important: Before entering data, please read instructions below the yellow line!
Note re US workdays: If you are claiming a foreign tax credit and you worked some days in the US, fill out the
                    the US trip dates section of the FEI sheet (whether or not you are using the FEI exclusion).

Your foreign tax credit method (if known):
If "Accrued", what is your exchange rate method?
                                                                                                                    Preparer use     Preparer use        Preparer use     Preparer use   Preparer use   Preparer use
Taxpayer/Spouse/Joint        Description of Tax             Country         Date       FX Code        Amount            Rate             USD             General - FX     Passive - FX   General - USD Passive - USD
                                                                                                                                        #DIV/0!                                             #DIV/0!        #DIV/0!
                                                                                                                                        #DIV/0!                                             #DIV/0!        #DIV/0!
                                                                                                                                        #DIV/0!                                             #DIV/0!        #DIV/0!
                                                                                                                                        #DIV/0!                                             #DIV/0!        #DIV/0!
                                                                                                                                        #DIV/0!                                             #DIV/0!        #DIV/0!
                                                                                                                                        #DIV/0!                                             #DIV/0!        #DIV/0!
                                                                                                                                        #DIV/0!                                             #DIV/0!        #DIV/0!
                                                                                                                                        #DIV/0!                                             #DIV/0!        #DIV/0!
                                                                                                                                        #DIV/0!                                             #DIV/0!        #DIV/0!
                                                                                                                                        #DIV/0!                                             #DIV/0!        #DIV/0!
                                                                                                                                        #DIV/0!                                             #DIV/0!        #DIV/0!
                             TOTAL                                                                             -                        #DIV/0!                   -                -        #DIV/0!        #DIV/0!



INSTRUCTIONS:
1. In order to enter appropriate foreign income tax data, you need to know your foreign tax credit method which is either "Paid" or "Accrued".

2. Look at your most recent US tax return which included a foreign tax credit form (Form 1116), and look near the bottom left corner of Page 1.
   There are two small checkboxes there, and the box checked will indicate the method you are using (Paid or Accrued).

3. If you have never used the foreign tax credit before, and believe you have reason to claim it this year, contact me to discuss which method to use.

4. Once you are sure of your method, then enter the tax data above as follows:
  (a) PAID: Enter the date and amount of each tax payment paid (or withheld) during the calendar year 2009, regardless to which tax year the payment relates.
            If you made (or will make) a 2009 year tax payment after the end of 2009, this will be claimed on your 2009 return.

 (b) ACCRUED: Enter the amounts of your foreign tax liability that relate to the tax year 2009, regardless when you paid or will pay them (as long as paid by 12/31/10)

5. Non-Calendar (Fiscal) Tax Year: If you live in a country that has a fiscal tax year (tax year ending on a date other than December 31), and you use the
   accrued method, then enter the taxes that accrued during the year 2009. Example: if your tax year ends 3/31/09, then enter the taxes for the year 4/1/08 to 3/31/09.

6. Which foreign taxes count? All foreign taxes that are based on your INCOME, and for which you obtain no specific (quid-pro-quo) economic benefit.
   Employee-paid social security and similar contributions count as long as they do not depend on the payer's age, life expectancy, or similar characteristics.
   However, social security contributions paid to the following countries do NOT count:
                             Australia                   Italy
                             Austria                     Japan
                             Belgium                     Luxembourg
                             Canada                      Netherlands
                             Chile                       Norway
                             Denmark                     Portugal
                             Finland                     South Korea
                             France                      Spain
                             Germany                     Sweden
                             Greece                      Switzerland
                             Ireland                     UK
FOREIGN EARNED INCOME EXCLUSION (FORM 2555) -- PRIMARY TAXPAYER

Your country of citizenship                                    Which family members lived with you?
Foreign home address as of 12/31/09                            Type of foreign visa, if any
 Address 2nd line                                              Terms of your foreign employment
Date on which you moved to above city                          Do you maintain a home in the US?
Date you originally moved overseas                             Have you ever revoked this election?
Date of move back to US (if applicable)

Employer Data                                 Employer #1         Employer #2         Employer #3         Employer #4
Employer's name
Employment began (mm/dd/yy)
Employment ended (mm/dd/yy)
Total paid workdays for employer in 2009
Employer's US address, if applicable
 Address 2nd line
Employer's foreign address, if applicable
 Address 2nd line

                                             From Foreign Country (FC) to US           Return Trip from US to FC
US trip dates during 2009                    Depart from FC    Arrive in US         Depart from US     Arrive in FC          US Workdays




Foreign Housing Expenses                      Do not fill this out if your joint housing expenses were reported on the other spouse's FEI sheet.
If your foreign housing expenses exceeded $14,624 for the 2009 year, you may be entitled to an additional housing exclusion.
If you would like to use this exclusion, provide your housing expense details below.
Mortgage payments (both principal and interest) and pay TV, telephone and internet do not count.
                                                                                                           Preparer use        Preparer use        In case of part-year residence:
Income Description                                  Date                 FX Code            Amount              Rate               USD               From:                 Until:
Rent                                                                                                                              #DIV/0!
Utilities (not pay TV, internet or telephone)                                                                                     #DIV/0!
Furniture rental                                                                                                                  #DIV/0!
Insurance on home or its contents                                                                                                 #DIV/0!
Nonrefundable deposits or other fees                                                                                              #DIV/0!
Occupancy taxes                                                                                                                   #DIV/0!
Repairs                                                                                                                           #DIV/0!
Residential parking fees                                                                                                          #DIV/0!
Security                                                                                                                          #DIV/0!
Other: provide description                                                                                                        #DIV/0!
FOREIGN EARNED INCOME EXCLUSION (FORM 2555) -- SPOUSE

Your country of citizenship                                    Which family members lived with you?
Foreign home address as of 12/31/09                            Type of foreign visa, if any
 Address 2nd line                                              Terms of your foreign employment
Date on which you moved to above city                          Do you maintain a home in the US?
Date you originally moved overseas                             Have you ever revoked this election?
Date of move back to US (if applicable)

Employer Data                                 Employer #1         Employer #2         Employer #3         Employer #4
Employer's name
Employment began (mm/dd/yy)
Employment ended (mm/dd/yy)
Total paid workdays for employer in 2009
Employer's US address, if applicable
 Address 2nd line
Employer's foreign address, if applicable
 Address 2nd line

                                             From Foreign Country (FC) to US           Return Trip from US to FC
US trip dates during 2009                    Depart from FC    Arrive in US         Depart from US     Arrive in FC          US Workdays




Foreign Housing Expenses                      Do not fill this out if your joint housing expenses were reported on the other spouse's FEI sheet.
If your foreign housing expenses exceeded $14,624 for the 2009 year, you may be entitled to an additional housing exclusion.
If you would like to use this exclusion, provide your housing expense details below.
Mortgage payments (both principal and interest) and pay TV, telephone and internet do not count.
                                                                                                           Preparer use        Preparer use        In case of part-year residence:
Income Description                                  Date                 FX Code            Amount              Rate               USD               From:                 Until:
Rent                                                                                                                              #DIV/0!
Utilities (not pay TV, internet or telephone)                                                                                     #DIV/0!
Furniture rental                                                                                                                  #DIV/0!
Insurance on home or its contents                                                                                                 #DIV/0!
Nonrefundable deposits or other fees                                                                                              #DIV/0!
Occupancy taxes                                                                                                                   #DIV/0!
Repairs                                                                                                                           #DIV/0!
Residential parking fees                                                                                                          #DIV/0!
Security                                                                                                                          #DIV/0!
Other: provide description                                                                                                        #DIV/0!
FOREIGN BANK ACCOUNT REPORT DATA -- PRIMARY TAXPAYER
Before completing this form, please first review the "FBAR" webpage at:             www.edelmantax.com/FBAR.htm

Name of Financial Inst       Address of Financial Inst         Account Number        Type of Acct
Financial Account(s) Owned Separately, Whether Directly or Indirectly Through More-Than-50%-Owned Entities




Financial Account(s) Owned Jointly:




Financial Account(s) in Which Filer has Signature or Other Authority but No Direct/Indirect Financial Interest in the Ac
w.edelmantax.com/FBAR.htm
                                         Preparer use   Preparer use
             FX Code       Max Value         Rate           USD
Than-50%-Owned Entities
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!


                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
irect Financial Interest in the Account(s):
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
Name/Address and SSN/ITIN (if any) of the Joint Owner




Name/Address and SSN/ITIN/EIN (if any) of the Account Owner
FOREIGN BANK ACCOUNT REPORT DATA -- SPOUSE
Before completing this form, please first review the "FBAR" webpage at:             www.edelmantax.com/FBAR.htm

Name of Financial Inst       Address of Financial Inst         Account Number        Type of Acct
Financial Account(s) Owned Separately, Whether Directly or Indirectly Through More-Than-50%-Owned Entities




Financial Account(s) Owned Jointly:




Financial Account(s) in Which Filer has Signature or Other Authority but No Direct/Indirect Financial Interest in the Ac
w.edelmantax.com/FBAR.htm
                                         Preparer use   Preparer use
             FX Code       Max Value         Rate           USD
Than-50%-Owned Entities
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!


                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
irect Financial Interest in the Account(s):
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
                                                          #DIV/0!
Name/Address and SSN/ITIN (if any) of the Joint Owner




Name/Address and SSN/ITIN/EIN (if any) of the Account Owner

				
DOCUMENT INFO