PRIMARY
NAME SPOUSE NAME
SSN Birthdate
SSN Birthdate
ADDRESS(CITY, STATE, ZIP)
PHONE
(DAY)
PHONE (EVE)
Did
you and your spouse live apart during the year? YES
NO
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Dependents:
( List youngest first) Name
(first, initial and last name) |
Month,
Day & Year
of birth |
Dependent’s
SSN |
Relationship |
Months
lived in your home |
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If your child didn’t live with you but is claimed
as your dependent under a pre- 1985 agreement, check here
If
someone else can claim you as a dependent, check here
IRA
Contribution ………. $ Alimony Paid ………. $
Keogh
Retirement / SEP… $ Recipient’s SSN
Did
you pay estimated Federal (1040ES)/State taxes?
How much? $ Which state?
Do
you itemize? Yes / No (
If yes, see reverse.) If yes, REFUND / BALANCE DUE from State…
How
much? $
CHECK THE INCOME ITEMS WHICH PERTAIN TO YOU
(Attach Documentation)
Wage Statement – W-2’s
Pension, Retirement Income Installment Sale
(How
many) Income From Rentals Social Security / Railroad Retirement
Interest $ (to include Partnership/S Corporation (K-1)
Municipal Bonds
Savings
bonds) Estates/Trusts Tips/Other Income
Dividends Farm Income Moving Expense
Alimony Received
Unemployment $
*BAS/BAQ $
Self-Employed Business Income
Lottery or Gambling Winnings (Military
Housing Allowance)
Commissions – 1099’s
Stock Sales Did you buy or sell a personal
residence?
Child Care Information (
Note: This information is required for each provider. More spaces on reverse.)
Provider’s Name ………. Provider’s SSN/EIN ……….
Provider’s Address ……. Amount Paid to Provider ….
Provider’s Name ………. Provider’s SSN/EIN ……….
Provider’s Address ……. Amount Paid to Provider ….
¸ Are you interested in receiving a RAL? ¸ Are you interested in having your return
Electronically Filed?
*
BAS/BAQ Amounts are included on YTD Leave & Earnings Statement (LES)
Did
You Sell:
Any
Real-estate Yes No Business
Equipment Yes No
A
Business Yes No Business
Vehicles Yes No
(List amounts for items you have – keep
receipts for your deductions)
Medical
& Dental: Contributions:
DR $ Church $
DR $
Church $
DR $
College $
DR $
United Way $
Prescription Drugs $ March of Dimes $
Hospital Insurance $ Heart
Fund $
Hospital & Emergency $ Seals -
Christmas & Easter $
Lab & Ex-Ray $ Cancer Society $
Nurses $
Red
Cross $
Dental $ Muscular
Dystrophy $
Dentures $
CARE $
Glasses & Contact Lenses $ Mental
Retardation $
Hearing Aids & Batteries $ Salvation
Army $
Orthopedic Shoes $ YMCA,
YWCA $
Therapy Treatments $
Multiple
Sclerosis $
Canes/Crutches/Braces $ Crippled
Children $
Wheelchairs $
Cerebral Palsy $
On
Doctor’s Advice: Fair
Market Value of
Air Conditioning $ furniture or clothing: $
Vaporizers $
Volunteer work expenses: $
Thermometers & Bandages $ Church, scouts, etc. $
Other $ Auto miles driven: $
Medical Miles Driven $
Other $
Other Med. Transportation $ Interest
Paid:
Taxes: Points Paid at Closing $
Real Estate $
Home Mortgage to Individual $
Personal Property $
Name
State Income Taxes $ SSN
$
Address
Home Mortgage $
Casualty Losses: 2nd
Mortgage/Home Equity $
Accident, Fire, & Theft $ 2nd
Home/Boat/Mobile/Vacation $
Investment $
Miscellaneous and Employee Business
Expenses:
Uniform Cleaning $ Employment/Job
Seeking Fees $
Work Tools $ Sales/Entertainment $
Union Dues $ Office-in-Home
Expense $
Safety Shoes $ Tax Return
Preparation $
Safe Deposit Box $ Investment
Expenses $
Education Expenses $
Vehicle Expenses:
Did you use your personal vehicle for work?
(Not commute) Yes No
Total miles driven for year Commuting
miles (one way)
Total business miles Days worked during the year
Business Travel:
Out of Town/Temporary(Lodging) $ Vehicle Use (Auto/Truck)
Miles
Meals $
Moving Expenses:
Miles $
Household Moving Expenses $
Lodging Expense During
Move $
Child Care Information (Continued from
front.)
Provider’s Name Provider’s
SSN/EIN
Provider’s Address Amount Paid to
Provider