Tue-Fri 9AM-5:30PM, Sat 9AM-12Noon, Mon Closed

1. Rollover

2. Personal Information

Taxpayer
Spouse
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3. Dependents (Children & Others)

Please answer the following questions to determine maximum deductions:

4. Wage, Salary Income

Attach Form(s) W-2's
Employer name
TP
SP

5. Pensions, Annuities, Profit Sharing, IRA's, etc.

Attach Form(s) 1099-R
1099-R Payer Name
TP
SP

6. Social Security/Railroad Benefits.

Attach Form(s) SSA-1099
Taxpayer
Spouse

7. Interest Income

Attach Form(s) 1099-INT & Broker Statements
1099-INT Payer Name
Tax-exempt?
Amount

8. Partnership, Trust, Estate Income

Attach Form(s) K-1

9. Dividend Income

Attach Form(s) 1099-DIV

10. Property Sold

Attach Form(s) 1099-S & Closing Statements

11. Other Income

12. Adjustments to Income

13. Investments Sold

Attach Form(s) 1099-B & Confirmation Slips

14. Medical/Dental Expenses

15. Taxes Paid

16. Interest Expense

 
Paid to:
 
 
 

17. Casualty/Theft Loss

For property damaged by storm, water, fire, accident, or stolen.

18. Estimated Tax Payments

 
Federal Amount
 
State Amount

19. Charitable Contributions

 
 
 

20. Miscellanous/Unreimbursed Expenses

21. Day Care Expense

Expenses

Assets Purchased

Cost of Goods Sold

Rental Income