PERSONAL QUESTIONNAIRE

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PERSONAL QUESTIONNAIRE Powered By Docstoc
					                                                   Noel Baldwin, CPA
                                                     454 W. Jackson St.
                                                    Woodstock, IL 60098
                                                      (815) 206-2929
                                                    www.baldwincpa.net
                                                                              _____________________________________
                                                                                          REFERRAL NAME

                                     PERSONAL QUESTIONNAIRE
       The information requested on this simple form is necessary to assist us in preparing your State and Federal Income
Tax Return at the greatest legal saving to you.

          Read the ENTIRE form carefully. If anything puzzles you, call us. Return the completed form as soon as possible to
                                                                          th
enable us to properly prepare your tax returns by the due date of April 15 . If you wish to come in for a personal interview, we
will be pleased to make an appointment. Please bring this completed sheet with you.

                                                             Check if:
Name: _______________________________________                Age 65 or over      _____ Yourself        _____ Spouse
                                                             Blind               _____ Yourself        _____ Spouse
Address: _____________________________________               Disabled            _____ Yourself        _____ Spouse

                                                             Telephone: __________________________________________
Date of Birth: Yourself __________________________           In what county do you live? _____________________________
              Spouse __________________________              In what township do you live? ___________________________
Your Social Security No. _________________________           Spouse’s Social Security No. ____________________________
Occupation ___________________________________               Occupation __________________________________________

 I. Your Dependents
   Note all children over one year must have a Social Security number.

        Name (First & Last Name)        Date of Birth     Social Security No.     Relationship     No. of Months in Home




 II. IF YOU, OR YOUR SPOUSE WORKED ATTACH W-2 FORMS TO THIS FORM.                             Did both work? ____________
     Do you or your spouse collect social security? ____________ If so, how much? _______________________________
     Do you or your spouse belong to any IRA Plan or Keogh Plan? ___ If yes, enclose statement from bank or insurance co.
     Did you or your spouse rollover traditional IRA to a Roth IRA? ______ If so, attach statement.
     Did you or your spouse collect unemployment compensation? _______ If so, how much? __________

    Indicate Federal Est. Taxes Paid:    April 15 _____             Indicate State Est. Taxes Paid:    April 15 _____
                                         June 15 _____                                                 June 15 _____
                                         Sept. 15 _____                                                Sept. 15 _____
                                         Jan. 15 _____                                                  Jan. 15 _____
 III. Other sources of income:
      Example: Rental Income, Dividends, Pensions, Interest, or Alimony. ATTACH STATEMENTS.
                 Amount                    Source                        Amount                          Source




                                                                                                      IV. Additional Information
    Do you pay alimony? _________ If so, how much a year? __________________________________________
    Do you or your dependents attend college? ______________________________________________________
    If yes, indicate the number of dependents attending: _______________________________________________
    Do you pay student loan interest? __________ College loan interest? ________________________________
    Need for State Lot # __________ Block # __________ Rent Paid ________________________________

                                           PERSONAL DEDUCTIONS
   MEDICAL AND DENTAL
                                                                             TAXES
   Medicines and Drugs                                      Property Tax on Home
   Ambulance                                                State Income Tax
   Dental-Artificial Teeth                                  State Tax
   Eyeglasses                                               City Tax
   Hearing Aids
   Hospital
   Medical Insurance
   Laboratory & Fees
   Nurse & Nursing                                          INTEREST (PAID)
   Orthopedic Shoes-Braces                                  Home Mortgage
   Therapy Treatments                                       Home Equity Loans
   Transportation Expense
   X-Ray
   Dr.
   Dr.
   Dr.




         CONTRIBUTIONS                                         OTHER DEDUCTIONS
                                       Church               Casualty Loss:
                                       Church
   American Cancer
   American Red Cross                                       Loss Sustained
   Boy Scouts $            Boy’s Town $                     Less: Insurance Reimbursed
   Camp Fire Girls $       Girl Scouts $                    Net Casualty Loss
   CARE                                                     Less: $100.00 Limitation
   Diabetes Association                                     Casualty Loss Allowable
   Heart Association                                        Alimony
   Multiple Sclerosis Society
   Muscular Dystrophy Association                           Educational Expense (for job advance)
   Salvation Army                                           Employment Fees
   Tuberculosis Society                                     Preparation of Tax Returns
   United Fund                                              Safe Deposit Box
   Y.M.C.A $             Y.W.C.A $                          Tools $               Safety Shoes $
                                                            Uniform & Uniform Expense
                                                            Union Dues



I. CHILD CARE:      Total Amount Paid _______________       To Whom ____________                Fed. El No.
___________

                                                                  Address
_______________________________________
Burglary, theft, bad debts, damage caused by storm (not covered by insurance) reimbursed travel expenses, etc., list below.
List any other items you are not certain and would like to inquire about.
                  NAME                                    AMOUNT                         NAME
AMOUNT

_________________________________                   $_______________           ______________________________
$__________
_________________________________                   $_______________           ______________________________
$__________

II. CAPITAL GAINS AND LOSSES
    The sale of a business or a real estate, securities, machinery, and other property must be included on your tax return. List
below:
DESCRIPTION OF PROPERTY                      DATE ACQUIRED                   SOLD                  ORG. COST
SALE PRICE
__________________________                   _______________                 _____                 __________
___________
__________________________                   _______________                 _____                 __________
___________
__________________________                   _______________                 _____                 __________
___________
Attach itemized list of improvements and expenses of selling, and settlement sheet.