2017 Tax Organizer Personal and Dependent Information

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1 Tax Organizer Personal and Dependent Information Personal Information Name SSN Date of birth Healthcare coverage ALL year Taxpayer Spouse Street address, city, state, and ZIP Occupation Daytime phone Evening phone Cell phone Taxpayer Spouse Taxpayer Spouse Marital status at the end of 2017 Taxpayer Spouse Married Yes No Yes No Are you blind? Married filing separately Yes No Yes No Are you disabled? Single Yes No Yes No Are you a full-time student? Widow(er) If spouse passed away in 2017 enter the date of death Dependent Information Yes No Yes No Do you want $3 to go to the Presidential Election Campaign Fund? Months Full- First and last name SSN Relationship Date of birth Disabled time in home student Healthcare coverage ALL year List dependents required to file a return Estimates Overpayment applied from 2016 Federal Resident state Resident city Date paid Amount Date paid Amount Date paid Amount First quarter Second quarter Third quarter Fourth quarter Additional payments Appointment Information & Notes Your 2017 appointment is scheduled for Notes N_DEMO.LD

2 Healthcare Coverage Questionnaire Healthcare Information Member of household Covered Covered less No healthcare for healthcare purposes the entire year than 12 months coverage at all YES NO Did anyone other than you or your spouse pay for healthcare coverage for anyone listed above? Did you pay for healthcare coverage for anyone not listed above? If you had coverage for any part of the year: Where was the policy obtained? Employer / Medicare / Medicaid / Marketplace(Exchange) / Other If you didn't have coverage part or all of the year: Answer YES if the following applies to any member of the household Was your previous insurance policy cancelled in 2017? Was coverage offered by your employer or your spouse's employer? Are you a member of a federally recognized Indian tribe? Are you eligible for services through an Indian healthcare provider? Are you a member of a healthcare sharing ministry? Did you live in the United States the entire year? Are you enrolled in TRICARE? Did you apply for CHIP coverage? Do any of the following apply to you? Do NOT indicate which one. Became homeless Evicted in the past six months, or facing eviction or foreclosure Received a shut-off notice from a utility company Recently experienced domestic violence Recently experienced the death of a close family member Recently experienced a fire, flood, or other natural or human-caused disaster that resulted in substantial damage to your property Filed for bankruptcy in the last six months Incurred unreimbursed medical expenses in the last 24 months that resulted in substantial debt Experienced unexpected increases in essential expenses due to caring for an ill, disabled, or aging family member N_ACA.LD

3 Income Wages & Salaries Provide all copies of Form W-2 Employer name 2017 federal wages Retirement Provide all copies of Form 1099-R Payer name 2017 distribution Form 1099-Misc Income Provide all copies of Form 1099-MISC (* Also reported on Schedule C or E) Payer name 2017 amount N_INC.LD

4 Income Dividend Income Provide all copies of Form 1099-DIV & other statements that report dividend income ordinary qualified Payer name dividends dividends Interest Income Provide all copies of Form 1099-INT, Form 1099-OID and other statements that report interest income Payer name 2017 interest If any interest income listed above is from a seller-financed mortgage, provide the payer's ID number and address N_INC2.LD

5 Sale of Capital Assets Sale of Capital Assets (not reported on Form 1099-B) Provide all brok erage statements Des cription of property Date Date Sales purchas ed s old price C os t Installment Sale Income Description of property: Date acquired Selling price Mortgages assumed Cost of property sold Depreciation allowed Commissions and expense of sale Gross profit percentage Interest received Principal payments received Date sold Prior years Property was sold to a related party N_INC3.LD

6 Other Income and Adjustments Other Income Scholarships or grants not reported on form W-2 State income tax refund (attach Forms 1099-G) Alimony received Unemployment compensation (attach Forms 1099-G) Unemployment compensation repaid in 2017 Social Security Benefits (attach Forms 1099-SSA) Railroad Retirement Benefits (attach Forms 1099-RRB) Gambling winnings (attach Forms W2-G) Alaska Permanent Fund Taxpayer Spouse Other income: Adjustments Educator expenses (If you are an educator, enter the amount you paid for classroom supplies) Contributions made to a Health Savings Account (HSA) Contributions made to a Self-Employed Pension plan (SEP) Payments made for Self-Employed Health Insurance for you, your spouse, or dependents Alimony paid Taxpayer Spouse Contributions made to an Individual Retirement Account (IRA) Contributions made to a Roth IRA Contributions made to a myra Interest paid on a student loan Other adjustments: Job-related Moving Expenses Number of miles from old home to old workplace Number of miles from old home to new workplace Expenses to move household goods & personal effects and lodging expenses while traveling to your new home (Do not include cost of meals) This was a military move N_INC4.LD

7 Schedule C - Profit or Loss from Business General Business Information Business name Employer ID number Professional product or service Business address, city, state, ZIP Payments of $600 or more were paid to an individual who is This business started or was acquired during 2017 Yes No not your employee for services provided for this business This business was disposed of during 2017 Yes No You filed Form(s) 1099 for the individual(s) Income Gross receipts or sales Income from Form 1099-MISC Returns & allowances Expenses Advertising Car & truck expenses Commissions & fees Contract labor Depletion Employee benefit programs Insurance (other than health) Mortgage interest Other interest Legal & professional services Office expenses Pension & profit sharing plans Rent or lease (vehicles, machinery, & equipment) Rent (other business property) Repairs & maintenance Supplies Taxes & licenses Cost of Goods Sold.... Other income.. Inventory at beginning of year Materials & supplies.... Purchases... Other costs.. Cost of personal use items. Inventory at end of year.. Cost of labor Travel Total meals & entertainment..... Utilities Wages Other expenses (list) There was a change in inventory method N_C.LD

8 Schedule E - Income or Loss from Rental Real Estate & Royalties General Property Information Property description Address, city, state, ZIP Select the property type Single family residence Vacation / short-term rental Land Multi-family residence Commercial Royalties Self-rental Other Number of days property was rented Income Expenses Number of days property was used for personal use If the rental is a multi-dwelling unit and you occupied part of the unit, enter the percentage you occupied This property is your main home This property was disposed of during 2017 This property was owned as a qualified joint venture Yes Rental unit expenses No Payments of $600 or more were paid to an individual who is not your employee for services provided for this rental Yes No You filed Form(s) 1099 for the individual(s) Royalties from oil, gas, Rent income.... mineral, copyright or patent. Rental income from Form(s) 1099-MISC Royalties from Form 1099-MISC Advertising Auto & travel Cleaning & maintenance Commissions Depletion Insurance Legal & professional fees Management fees Interest - mortgage Interest - other Repairs Supplies Taxes Utilities Other expenses Rental and homeowner expenses If this Schedule E is for a a multi-unit dwelling and you lived in one unit and rented out the other units, use the "Rental and homeowner expenses" column to show expenses that apply to the entire property. Use the "Rental unit expenses" column to show expenses that pertain ONLY to the rental portion of the property. If the Schedule E is not for a multi-unit property in which you lived in one unit, complete just the "Rental unit expenses" column. N_E.LD

9 Schedule A - Itemized Deductions Medical and Dental Expenses Health insurance premiums (paid by you) Long-term care premiums (you) Long-term care premiums (your spouse) Long-term care premiums (dependents) Mileage driven for medical purposes Medical and dental expenses Doctor, dental, etc Prescription medicines Insulin Glasses and contacts Hearing aids Braces Medical equipment & supplies Hospital services Laboratory services Nursing services Other Taxes Paid State and local income taxes Sales tax Real estate taxes Personal property taxes Other taxes (list) Charitable Contributions Donations to charity Cash Noncash Amount Church Boy or Girl Scouts Goodwill Red Cross Salvation Army United Way Veterans Hospital University Other Miles driven for charitable purposes Job Expenses & Certain Miscellaneous Deductions Necessary job expenses you paid that were not reimbursed by your employer Safety equipment, tools, & supplies Uniforms Protective clothing (shoes, hardhats, glasses, etc.) Dues to professional organizations Books & subscriptions Other Tax preparation fees Other nonpersonal expenses related to taxable income Safe deposit box fees Investment expenses not entered elsewhere Other Interest Paid Other Miscellaneous Deductions Mortgage interest paid (attach Form 1098) Amortizable bond premiums. Mortgage interest paid to an individual Federal estate tax Paid to: Gambling losses. Name Impairment-related work expenses Address Claim repayments City, State, ZIP Unrecovered pension investments SSN or EIN Qualified mortgage insurance premiums Investment interest Loss from other activities from Schedule K-1 Ordinary loss debt instrument.... N_A.LD

10 Other Information Mortgage Interest Provide all copies of Form 1098 Mortgage Mortgage interest insurance Real estate Lender's name received premiums taxes paid Employee Business Expense Not Reimbursed by Your Employer Rural mail carrier expenses Parking fees, tolls, local transportation Meals & entertainment Overnight business travel expenses (Do not include meals & entertainment) Other business expenses NOT reimbursed Reimbursed by your employer by your employer not included on your W-2 You used your persional vehicle for your job during 2017 You are a reservist You are a qualified performing artist You are a fee-based state or local government official You are a disabled employee with impairment-related work expenses You are a member of the clergy Casualties and Thefts Property description Property location Date property was damaged or stolen Cost of property damaged or stolen Amount of damage Insurance reimbursement Property description Property location Date property was damaged or stolen Cost of property damaged or stolen Amount of damage Insurance reimbursement N_OTHER.LD

11 Other Information Child and Other Dependent Care Expenses SSN Name of care provider Address or EIN Amount paid Education Expenses Provide all copies of Form 1098-T Student name Student name Type of expense Amount Type of expense Amount Student name Student name Type of expense Amount Type of expense Amount N_OTHER2.LD

2018 Tax Organizer Personal and Dependent Information

2018 Tax Organizer Personal and Dependent Information Tax Organizer Personal and Dependent Information Personal Information Name SSN Date of birth Healthcare coverage ALL year Taxpayer Spouse Street address, city, state, and ZIP Occupation Daytime phone Evening