Please answer the questions below as completely as possible, as they apply to you. If there is a question in your mind, write in on a separate sheet and return to
me. This is just for your convenience. You do not have to fill this out. Please remember to bring your W2’s, 1099’s etc.
Ask Yourself These Questions
Did you buy or sell a home? ________ Did you pay Estimated Income Tax? ________ Did you move to get a new job during the year?
COVERED by Health Insurance? _______ All year? _____ Did you purchase Health Ins. through the Marketplace?
Did you receive a form 1095? Beginning in 2015, the preparer will need to have health insurance information for every family member.
Do you have a home based business? ________
Do you use your car in any charitable work? ________
Did you purchase Energy Efficient Home Improvements?
Phone No. ( )__________ Hours to call __________
Family Information
Name _________________________________________
Address _______________________________________
City __________________________________________
Social Security No. ____/___/____ Date of Birth __/__/__
Occupation _____________________________________
Spouse’s Name __________________________________
Social Security No. ____/___/____ Date of Birth __/__/__
Occupation _____________________________________
Were either of you 65 by December 31st of last year?
Husband ________ Wife ________
Are either of you blind?
Husband ________ Wife ________
Dependents Full Name Date of Birth Social Security No. Relationship No. of Months in
your home
2. Income
No. of employers for whom you worked
(including spouse) ___________________________________
Enclose W‐2’s for each
Dividends . . . . . . . . . . . . . . . . . . . . . . . . . $ ________________
Enclose 1099’s received
Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . $ ________________
Enclose 1099’s received
Other Income Received Amount
Commissions . . . . . . . . . . . . . . . . . . . . . . . $_______________
Alimony . . . . . . . . . . . . . . . . . . . . . . . . . . . $ _______________
*Business . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ________________________________
(I will need a full list of income and expenses)
Did you file 1099’s on Contract Labor? Yes No
*Rent or Royalties . . . . . . . . . . . . . . . . . . . $ ______________
(I will need expenses)
Unemployment . . . . . . . . . . . . . . . . . . . . . $ ______________
*Farm Income . . . . . . . . . . . . . . . . . . . . . . . $ _______________
(I will need a full list of income and expenses)
Pension Rec’d . . . . . . . . . . . . . . . . . . . . . . . $ _______________
Social Security Rec’d . . . . . . . . . . . . . . . . . .$ _______________
Other Income (Prizes, etc.) . . . . . . . . . . . . .$ _______________
*If I did not prepare last year’s return I would appreciate a copy of last year’s return & depreciation schedule if depreciation is applicable and
you had any!
3. Medical Bills You Paid
Prescriptions . . . . . . . . . . . . . . . . . . $ _______________
Ambulance . . . . . . . . . . . . . . . . . . . $ _______________
Dentist . . . . . . . . . . . . . . . . . . . . . . . $ _______________
Eyeglasses . . . . . . . . . . . . . . . . . . . . $ _______________
Hearing Aids . . . . . . . . . . . . . . . . . . $ _______________
Hospital . . . . . . . . . . . . . . . . . . . . . . $ _______________
Laboratory Fees . . . . . . . . . . . . . . . $ _______________
X‐Rays . . . . . . . . . . . . . . . . . . . . . . . $ _______________
Nurses . . . . . . . . . . . . . . . . . . . . . . . $ _______________
Orthopedic Shoes/Braces . . . . . . . . $ _______________
Therapy . . . . . . . . . . . . . . . . . . . . . . $ _______________
Hospitalization Insurance . . . . . . . $ _______________
Dr. __________________________$ _______________
Dr. __________________________$ _______________
Dr. __________________________$ _______________
Dr. __________________________$ _______________
Dr. __________________________$ _______________
Total miles to & from Doctors
and for medicine .. . . . . . . . . . . . . . $ _______________ Did you receive payment for any of the above from your insurance . . .
4. Taxes Paid
Real Estate Taxes . . . . . . . . . . . . . . . $ _______________
Personal Property Taxes . . . . . . . . . $ _______________
This does not need to be filled out but it is a useful tool when deciding what to bring to get your taxes prepared.