2018 Tax Organizer Personal and Dependent Information

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Esther Bates
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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 end of Taxpayer Spouse Married Are you blind? Yes No Yes No Married filing separately Are you disabled? Yes No Yes No Single Are you a full-time student? Yes No Yes No Widow(er) If spouse died in enter the date of death Dependent Information Do you want $3 to go to the Presidential Election Campaign Fund? Yes No Yes No Months Full- First and last name SSN Relationship in Date of birth Disabled time home student Healthcare coverage ALL year List dependents required to file a return Estimates Overpayment applied from 2017 Federal Resident state Resident city Date paid Amount Date paid Amount Date paid Amount First quarter Second quarter Third quarter Fourth quarter Additional payments Account Information for Deposits or Withdrawals Type of account Use this account for Bank Bank Name of bank routing number account number Checking Savings Deposits Withdrawals Appointment Information Your appointment is scheduled for 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 canceled in? 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 federal wages Retirement Provide all copies of Form 1099-R Payer name distribution Form 1099-Misc Income Provide all copies of Form 1099-MISC Payer name 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 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 brokerage statements Date Date Sales Description of property purchased sold price Cost Installment Sale Income Description of property: Date acquired Date sold Selling price... Mortgages assumed Cost of property sold Depreciation allowed... Commissions and expense of sale... Gross profit percentage... Interest received... Principal payments received... Prior years Property was sold to a related party N_INC3.LD

6 Other Income and Adjustments Other Income Taxpayer Spouse Scholarships or grants not reported on Form W-2... State income tax refund (attach Forms 1099-G)... Social Security Benefits (attach Forms 1099-SSA)... Railroad Retirement Benefits (attach Forms 1099-RRB)... Alimony received... Unemployment compensation (attach Forms 1099-G)... Unemployment compensation repaid in... Gambling winnings (attach Forms W2-G)... Alaska Permanent Fund... ABLE distributions... 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 Select this box and complete the fields below if you are member of the Armed Forces on active duty, and moved due to a military order for a permanent change of station. Number of miles from old home to old workplace... Number of miles from old home to new workplace... Expense to move household goods & personal effects and lodging expenses while traveling to your new home... (Do not include cost of meals) 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 Yes No not your employee for services provided for this business This business was disposed of during Yes No You filed Form(s) 1099 for the individual(s) Income Gross receipts or sales... Other income... Income from Form 1099-MISC... Returns & allowances... Expenses Advertising... Travel... Car & truck expenses Commissions & fees... Total meals Utilities... Contract labor... Wages... Depletion... Other expenses (list)... Employee benefit programs... Insurance (other than health)... Interest - mortgage... Interest - other... 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 Inventory at beginning of year... Materials & supplies... Purchases... Other costs... Cost of personal use items... Inventory at end of year... Cost of labor... 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 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 Payments of $600 or more were paid to an individual who is This property is your main home Yes No not your employee for services provided for this rental This property was disposed of during This property was owned as a qualified joint venture Yes No You filed Form(s) 1099 for the individual(s) Income Rent income... Royalties from oil, gas, mineral, copyright or patent... Rental income from Form(s) 1099-MISC... Royalties from Form 1099-MISC... Expenses Advertising... Auto & travel... Cleaning & maintenance... Commissions... Depletion... Insurance... Legal & professional fees... Management fees Mortgage interest Other interest... Repairs... Supplies... Taxes... Utilities... Other expenses Rental unit 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 Income or Loss from Partnerships, S corporations, and Fiduciaries Partnerships, S corporations, Estates and Trusts Provide all copies of Schedule K-1 and attachments Entity Name EIN N_E2.LD

10 Expenses Related to Business Auto Expense Name of business vehicle is used for Description of vehicle Another vehicle is available for personal use This vehicle is available for use during off-duty hours Date vehicle was placed in service There is evidence to support your deduction The evidence is written Number of miles the vehicle was driven during Business Commuting Total Garage rent... Property tax... Gas... Repairs... Insurance... Tires... Licenses... Tolls... Oil... Other expenses Parking fees... Lease payments... Interest... Business Use of Home Name of business home is used for What is the total square footage of your home that was used regularly and exclusively for business? What is the total square footage of your home? For daycare facilities not used exclusively for business, complete the following questions How many days during the year was the area used? How many hours per day was the area used? The daycare facility was in operation for the entire year Expenses Office expenses Home expenses Mortgage interest... Real estate taxes... Excess mortgage interest... Insurance... Rent... Repairs & maintenance... Utilities... Other expenses... In the "Office expenses" column, enter those expenses that pertain exclusively to your office; in the "Home expenses" column, enter those expenses that pertain to the entire dwelling. N_EXP.LD

11 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) Interest Paid Mortgage interest paid (attach Form 1098)... Some of your home mortgage loan was not used to buy, build, or improve your home Mortgage interest paid to an individual... Paid to: Name Address City, State, ZIP SSN or EIN Qualified mortgage insurance premiums... Investment interest... 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 Other Miscellaneous Deductions Amortizable bond premiums... Federal estate tax... Gambling losses... Impairment-related work expenses... Claim repayments... Unrecovered pension investments... Loss from other activities from Schedule K-1 Ordinary loss debt instrument 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 N_A.LD

12 Other Information Child and Other Dependent Care Expenses Name of care provider Address SSN 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 Student name Student name Type of expense Amount Type of expense Amount N_OTHER2.LD

2017 Tax Organizer Personal and Dependent Information

2017 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