2017 Income Tax Data-Itemizer

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1 Documents Used to Verify Primary Taxpayer Identity: (select one) Driver's License (complete detail below) State issued identification card (complete detail below) Passport IDENTITY VERIFICATION WORKSHEET In an effort to protect your identity, the IRS now requires verification of your identity and, if married, the identity of your spouse. The documents you provide to verify your identity will be used by the IRS and verified to other third party information at the time your tax return is filed and prior to the processing of your income tax return. Account statement from financial institution Utility billing statement Credit card billing statement Taxpayer - No Driver's License or State ID Documents Used to Verify Primary Spouse Identity (if you file joint return): (select one) Driver's License (complete detail below) State issued identification card (complete detail below) Spouse - No Driver's License or State ID Driver's License Detail Taxpayer: License number Spouse: License number State Identification Card Detail Taxpayer: Identification number Does not expire Spouse: Identification number Does not expire

2 HOW THE AFFORDABLE CARE ACT IMPACTS YOUR TAXES You may notice some changes in your tax return related to the Affordable Care Act (ACA). All Americans must have qualified health insurance or face a "Shared Responsibility Payment" more commonly known as the Health Care Penalty. Please check the appropriate box to indicate your health insurance status for I enrolled in a health plan through my employer, private insurance, Medicare or Medicaid. You are all set if you have minimum essential coverage that includes individual market policies, job-based coverage, Medicare, Medicaid, CHIP, TRICARE and certain other coverage. I purchased a health plan through a Health Insurance Marketplace also known as a health exchange. Did you receive a government subsidy in the form of a tax credit to purchase health insurance through the online Health Insurance Marketplace? ( Yes ) ( No ) ( Circle One ) Please provide Form 1095-A if you purchased health insurance through the Health Insurance Marketplace. I don't have health insurance. Under the ACA, individuals who do not have health insurance for more than two consecutive months in 2017, must pay a tax penalty. If you are getting an exemption through the Health Insurance Marketplace, please provide the exemption certificate number. # If you don't have health insurance and don't qualify for an exemption, you will have to pay a penalty when your tax return is filed. For tax year 2017, the annual one-time penalty will be $695 per adult, $ per child under 18, with a family maximum of $2,085 for the year OR 2.5% of your total income, whichever is Greater. The tax penalty is assessed on your 2017 tax return. ( Yes ) ( No ) ( Circle One ) For the entire year, did you, your spouse and your dependents have health care coverage provided by either an employer or the government (Medicare, Medicaid or VA) or purchased through the Health Insurance Marketplace (Exchange) or directly from an insurance company? Please indicate the months of health insurance coverage for each family member listed on your 2017 tax return: C = Covered Signature Print Name Date

3 Client Code Tax Year Taxpayer's Name Spouse's Name Social Security # Social Security # Date of Birth / / Date of Birth / / Occupation Occupation Cell Cell Blind / Disabled? ( Yes ) ( No ) Blind / Disabled? ( Yes ) ( No ) Contribute $3 to Presidential Election Campaign Fund? Taxpayer ( Yes ) ( No ) Spouse ( Yes ) ( No ) Address Home Phone City State Work Phone Zip Code Fax Preferred Contact ( Circle One ) ( Home ) ( Work ) ( Cell ) ( ) ( Fax ) Check Here if you wish to continue to receive this Income Tax Data-Itemizer each year. Please note that this form is available on our website: ("Resources" tab). DOCUMENTS YOU NEED TO BRING TO YOUR TAX APPOINTMENT W2 Forms 1098 Mortgage Interest Statements 1099-INT Forms Real Estate Tax Bills 1099-DIV Forms Last Payroll Stub of the Year 1099-MISC Forms Last Year's Tax Returns ( if new client ) 1099 Forms Voided Blank Check ( for direct deposit ) 1095 Forms (A, B, and/or C) Items You Have Questions About Closing Statements on Sale or Purchase of Real Estate ( including refinancing ) Schedule K-1 Forms ( Income/Loss from Partnerships, Estates, Trusts, or S-Corps ) Copies of Compensation, Moving Expense Reimbursement or Pension Income Single Married Filing Joint Return Married Filing Separate Returns FILING STATUS Head of Household Qualifying Widow(er) Year Spouse Died DEPENDENT CHILDREN Name Social Security # Date of Birth Relationship / / / / / / OTHER DEPENDENTS Name Name Social Security # Social Security # Date of Birth / / Date of Birth / / Relationship Relationship Income Income Support by You Support by You Support by s Support by s Months in Your Home Months in Your Home INTEREST & DIVIDEND INCOME Please indicate (T)axpayer, (S)pouse or (J)oint for each item. T/S/J Payer $ T/S/J Payer $ Page 1 of 4

4 OTHER INCOME If you have Income, Examples: Child Care Farming Jury Duty Self Employment Strike Benefits Partnerships & S-Corps Social Security Scholarships/Fellowships Alimony Received Pensions & Annuities Unreported Tip Income Estates & Trusts Non-Taxable Interest Royalties State Income Tax Refunds Gambling Income & Prizes Unemployment Benefits Cancellation of Debt Workers' Compensation SALE OF STOCK OR OTHER PROPERTY Stock or Property Purchase Purchase Sale Sale Description Date Price Date Price / / / / / / / / / / / / RENTAL PROPERTY INCOME & EXPENSE Property #1 Property #2 Address Address Date Became Rental / / Date Became Rental / / Property Cost Basis Property Cost Basis Total Rents Received Total Rents Received Expenses: Expenses: Taxes Taxes Utilities Utilities Mortgage Interest Mortgage Interest Insurance Insurance Auto Mileage Auto Mileage Repairs Repairs Supplies Supplies CHILD & DEPENDENT CARE EXPENSES Number of children/dependents cared for during the year Total expenses paid for child/dependent care Provider Provider Provider Amount Name Address Tax ID# Paid If the payments above were to an individual and you paid $50 or more in a calendar quarter, were the services performed in your home? ( Yes ) ( No ) Total amount of employer-provided dependent care benefits Qualified expenses paid during the year Page 2 of 4

5 IRAs Traditional - Roth - Education CONTRIBUTIONS TO A RETIREMENT PLAN Taxpayer Spouse Date Amount SEPs or SIMPLEs Distributions DISTRIBUTIONS FROM A RETIREMENT PLAN Taxpayer Spouse Date Amount EDUCATION CREDITS / EXPENSE DEDUCTION Student Name Full Time Part Time Student's Grade Year in College Books, Supplies & Equipment Date Paid Qualified Expenses: Tuition Date Paid Required Fees Date Paid MEDICAL EXPENSES TAXES PAID Insurance Pay Deduction (after tax) Federal Estimate Taxes: Insurance & Medicare Applied from Prior Year Return $ Doctors 1st Qtr Date Paid / / $ Dentists 2nd Qtr Date Paid / / $ Hospitals 3rd Qtr Date Paid / / $ Ambulance 4th Qtr Date Paid / / $ Laboratory Fees Prescriptions State of Estimate Taxes: Eyeglasses, Contacts Applied from Prior Year Return $ Hearing Aids & Batteries 1st Qtr Date Paid / / $ Nursing/Long Term Care Facility 2nd Qtr Date Paid / / $ Medical Auto Mileage 3rd Qtr Date Paid / / $ Medical Travel Expenses 4th Qtr Date Paid / / $ Self Employed Health Insurance State Taxes Paid for Previous Year Medical Reimbursement Real Estate Taxes Health Savings Acct Contributions Vehicle Registration(s) Health Savings Acct Distributions Sales Taxes Paid on Medical Expenses Motor Vehicle, Boat, RV, etc. ( please detail ) ( major purchases ) INTEREST EXPENSES CONTRIBUTIONS Home Mortgage Interest Paid Churches* Additional Mortgage Interest Paid Cash Contributions* Mortgage Interest Paid to an Individual *( If greater than $250, provide written record ) Name Address Charitable Auto Mileage SS# Property Donated** Investment Interest Non-Cash Contributions** ALL Student Loan Interest Paid **( If more than $500, please itemize ) CASUALTY & THEFT LOSSES ARIZONA PUBLIC / PRIVATE SCHOOL TAX CREDIT Description of Property Date Loss Occurred / / Would you like to hear more about this? Yes No Cost of Property Lost MOVING EXPENSES Fair Market Value of Property Travel & Lodging - ( Not Meals ) Insurance Reimbursement Rec'd Moving Household Goods/Items If Applicable, Please Bring Police Report Reimbursement ( if any ) Page 3 of 4

6 AUTOMOBILE EXPENSES (BUSINESS USE ONLY) UNREIMBURSED EMPLOYEE EXPENSES Vehicle Description Work Uniforms & Laundry Date Placed in Service / / Work Supplies Total Miles Professional Licenses Business Miles Books & Journals Gas, Oil & Insurance Continuing Education Interest on Loan Union Dues Lease Payments Equipment/Tools Req'd for Work Tolls & Local Transportation Unreimbursed Teaching Expenses Unreimbursed Expenses for Armed Forces Guard/Reservists Traveling More Than 100 Miles for Overnight Duty ( travel, meals, lodging ) MISCELLANEOUS GENERAL QUESTIONS Job Seeking Expenses Did Your Marital Status Change Last Year? Accounting Fees ( incl. tax prep fees ) ( Yes ) ( No ) Investment & Tax Advice Are You Being Claimed as a Dependent of Another Safe Deposit Box Rental Person? ( Yes ) ( No ) Gambling Losses ( not to exceed winnings ) May the IRS discuss your return with Source One Impairment Related Work Expenses Accounting & Tax Services, P.C.? ( Yes ) ( No ) Alimony Paid Purchase of Hybrid/Electric Vehicle All of the information contained on this Income Tax Qualified Solar Home Improvements Data-Itemizer is true and complete. ( Please Sign Below ) Repayment of First-Time Homebuyer Credit ( taxpayer ) ( spouse ) OTHER INFORMATION Please Provide Any Information Related to Your Taxes Not Reported Elsewhere on This Income Tax Data-Itemizer ELECTRONIC FILING INFORMATION All Tax Returns will be Filed Electronically Unless wise Requested. Free Free E-File Do You Wish to Opt Out of Electronic Filing? ( Yes ) ( No ) E-File ( No additional fees will be charged ) FINAL PREPARATION NOTES If a Refund is Expected, Please Indicate How You Would Like to Receive Your Refund: Apply to Estimate Taxes for Next Year's Return Paper Check to be Received by Mail Direct Deposit ( Up to 3 different accounts. Please provide a blank "voided check(s)" ) If Additional Taxes are Due with Your Return, Would You Like to Receive: Estimate Tax Calculations and Vouchers for Next Year's Return Installment Agreement Request(s) ( IRS imposes a setup fee ) Please Rate this Income Tax Data-Itemizer and its Usefulness to You in Gathering Your Tax Information BEST WORST Thank You! Your Opinions Mean a Great Deal to Us! Page 4 of 4

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