This form is to assist you in gathering your income tax information. Use it as a guide for the information you need to provide.
Please call or e-mail us with any questions.
□ First, middle initial, and last names of taxpayers and dependents as written on the Social Security cards, and dates of birth for taxpayers and all dependents, especially new dependents.
□ Address (city, state, ZIP), telephone number, and e-mail address.
□ Marital Status: Single ___ Married ___ Head of Household ___ Separated ___
□ Did you get married to a same-sex spouse in a state that legally recognizes same-sex marriage?
□ Number of Dependents: ___ Did any dependents have any income? Yes ___ No ___
□ Do all dependents live with you? Yes ___ No ___
TYPES OF INCOME AND TAX REPORTING FORMS:
□ Wages: All Forms W-2
□ Pensions/Retirements: 1099-R
□ Social Security: SSA-1099
□ Bank Interest: 1099-INT
□ Dividends: 1099-DIV
□ Commissions: 1099-MISC
□ Tips and Gratuities
□ Sales of Stock, Mutual Funds: 1099-B
□ Income from Rentals: All 1099-MISC
□ Business Income: All 1099-MISC & 1099-K
□ Farm Income
□ Alimony Received: Total amount
□ Unemployment: 1099-G
□ State Tax Refund: 1099-G
□ Miscellaneous: Jury Duty, Gambling, Other
FOREIGN INCOME MATTERS:
Did you receive a distribution from, or were you a grantor or transferor for a foreign trust?
Did you have a financial interest in or signature authority over a financial account located in a foreign country?
Did you have any foreign financial accounts, foreign financial assets, or hold interest in a foreign entity?
BUSINESS INCOME & EXPENSE ITEMS:
This list is not all-encompassing. If you don’t see an expense listed below, ask.
Total (Gross) IncomeBusiness Phone ExpenseCommissions Paid
General Office Expense
Bank/Credit Card Fees
Business Miles & Total Miles (A Mileage log is required)
Asset Purchases (Date, amount and item)
Cell Phone Expense
Rent/Lease Fees Paid
Auto: Parking &Tolls
Legal or Professional Fees
Dues & Publications
License Fees/Taxes Paid
ADDITIONAL ITEMS FOR RENTAL PROPERTIES:
Termite Treatment Expense
DEDUCTIONS/CREDITS TO INCOME:
Self-employed Health Insurance
Retirement Saver’s Credit
Medical Savings Account
Penalty on Early Withdrawal of Savings
Copy of Tuition Statement from Accredited College or University
Student Loan Interest Provide Lender Letter showing amount(s) paid
* Total Alimony Paid: Must have name and Social Security number of recipient, and amount paid.
* Child Care/Day Care Credit: Must have name, address, Social Security number or EIN of provider, and amount paid per child.
ESTIMATED TAXES PAID:
Date of payment and amount paid for each Federal and State quarterly tax estimate.
HEALTH CARE INFORMATION:
Did you have qualifying health care coverage (employer group plan coverage or government-sponsored coverage) for every month of 2019 for you, your spouse and all members of your family as claimed on your tax return? If yes, provide Form(s) 1095-A or B
Did you or anyone in your family qualify for an exemption from the health care coverage mandate? If yes, provide Form(s) 1095-A or B
Did you acquire health care coverage through the Marketplace under the Affordable Care Act? If yes, provide Form(s) 1095-A or B.
Did you make any contributions to or receive distributions from a Health Savings Account, Archer MSA, or Medicare Advantage MSA?
ITEMIZED DEDUCTIONS: If you can still itemize you can gather the following:
Medical & Dental bills
Prescribed Medical Equipment
Travel Expenses for out-of-town care (lodging)
Medical/dental/long term care insurance (list separately)
TAXES Limited to $10,000 total
Prior year state tax paid
Other such as state withholding or state estimated payments paid within the calendar year
Real estate tax
Personal property tax
MORTGAGE INTEREST PAID FOR PRIMARY RESIDENCE
MORTGAGE INTEREST PAID FOR SECONDARY (VACATION) RESIDENCE
March of Dimes
Out-of-pocket Volunteer Expenses
THE STANDARD DEDUCTION FOR 2021 IS AS FOLLOWS:
- SINGLE AND MARRIED FILING SEPARATELY $12,550
- MARRIED FILING JOINTLY $25,100
- HEAD OF HOUSEHOLD $18,800
For donations, please provide evidence such as a receipt from the done organization, a canceled check, or record of payment to substantiate all contributions made. An itemized listing of all non-cash donations must be maintained with the receipts. List must include the Fair Market Value for each donation of non-cash items.
Did you receive an Identity Protection PIN from the Internal Revenue Service or have you been a victim of identity theft? If so, please provide the IRS letter.