CYNTAX, LLC 908 Merchants Walk, Huntsville, AL Phone: FAX:

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1 CYNTAX, LLC 908 Merchants Walk, Huntsville, AL Phone: FAX: INCOME TAX INFORMATION Taxpayer s Full Name Spouse s Full Name Soc. Sec. No. Date of Birth Soc. Sec. No. Date of Birth Occupation Driver s License No. Occupation Driver s License No. Driver s License Issue Date: Expiration Date: Driver s License Issue Date: Expiration Date: Home Address Home Phone Cell Phone Cell Phone (Spouse) address address (Spouse) DEPENDENTS Full Name Social Security Number* Date of Birth Relationship *Please bring Social Security cards for verification if we do not have a copy. IMPORTANT ITEMS TO BRING W-2s from all employers Mortgage Interest Statement (If you bought/sold/refinanced a Social Security Benefits Statement (SSA-1099) home in 2016, please provide a copy of the settlement statement) Unemployment Compensation (1099-G) Real estate/property taxes paid Form 1095 Proof of Health Insurance Car Tag Receipts Forms 1099: 1099-MISC (Miscellaneous Income); 1099-INT (Interest); Proof of charitable contributions 1099-DIV (Dividends); 1099-B (Sale of stocks/securities); Form 1098-T for tuition + statement showing dates paid 1099-R (Pensions & Annuities/Retirement Plan Withdrawals); Student loan interest information 1099-C or 1099-A (Debt Forgiveness); 1099-K (Credit card/3 rd party payments) Stock or property sold? Bring historical cost basis Form K-1 from Estates/Trusts, Partnerships or S Corporations Purchase price/cost basis for any stock declared worthless Form W-2G for Gambling Winnings Medical Savings Account/Health Savings Account info If you are a new client, please bring a copy of last year s tax return.

2 During 2016, did you: QUICK QUESTIONNAIRE (Check any which apply and bring all data) Have a change in marital status due to marriage/divorce? Any change in number of dependents? Have qualifying health insurance for everyone in your household? Was it purchased online through the Marketplace? (Bring Form 1095) Receive Social Security benefits or Unemployment Compensation? (Bring SSA-1099 for Social Security; 1099-G for Unemployment) Make any estimated tax payments? Please provide payment details on the next page. Transfer or rollover any 401(k) or IRA accounts? If so, bring 1099-R. Contribute (or do you plan to contribute) to an IRA or Roth IRA? Provide details. Make a donation to charity from a traditional IRA? Incur any education expenses for yourself, your spouse, or dependent? Receive education benefits through a prepaid tuition program (PACT or Alabama 529 Plan)? Pay student loan interest? Contribute to the Alabama College Counts 529 Plan? Pay for child/dependent care? If so, we need the name, address, social security number/ein of your child care provider, plus the total amount you paid during Did you receive any employer-provided dependent care assistance benefits? Have unreimbursed work-related expenses? (Union dues, professional association dues, uniforms, job search, etc.) Receive any income from a pension, profit-sharing, 401(k), Retirement, Keogh, IRA, Roth, or tax sheltered annuity plan? (Bring 1099-R) Have any out-of-pocket expenses incurred as a volunteer? (This includes mileage, uniforms, and supplies). Pay (or receive) alimony? (If you paid alimony, please provide the name, SSN, and address of the person receiving payments). Purchase a new home? Sell or refinance an existing home? Please provide a copy of the settlement statement. Have a casualty or theft loss? If so, attach an itemized list, insurance information and police report. Make qualified energy improvements such as solar water heaters, energy efficient windows, doors, insulation or metal roof? Have you claimed energy improvements before? Did you purchase a hybrid/electric vehicle in 2016? Sell or cash in stocks, bonds, U.S. savings bonds, or property? If so, bring form 1099-B. Any stocks declared worthless? Need basis. Earn any Municipal Bond interest? Start a business or purchase a rental property? Have income (or loss) on K-1 from any Partnership, LLC, S Corp, Estate or Trust? (Bring K-1) Have foreign income or pay foreign taxes? Have foreign investment/bank accounts valued at over $10,000 at any time during 2016? Make any internet purchases from out-of-state retailers on which no sales tax was paid? If so, what was the total amount of those purchases?

3 2016 ESTIMATED TAX PAYMENTS Federal Payments State Payments Date Due Amount Paid Date Sent Date Due Amount Paid Date Sent 4/18/16 4/18/16 6/15/16 6/15/16 9/15/16 9/15/16 1/17/17 1/17/17 SCHEDULE A ITEMIZED DEDUCTIONS UNREIMBURSED MEDICAL EXPENSES Prescription Drugs $ Medical Insurance Premiums $ Long-Term Care Ins. Premiums $ Medicare Premiums $ Doctors $ Dentists $ Clinic/Lab Tests $ Eyeglasses/Contact Lenses $ Hearing Aids/Batteries $ Orthopedic Shoes/Braces $ Medical Lodging $ Miles for Medical Treatment: per mile $ INTEREST EXPENSE Home Mortgage Interest Paid to Financial Institutions $ Home Equity Interest $ Home Mortgage Interest Paid to Individual $ Name/Address Social Security No. Deductible Points Paid $ Investment Interest $ TAXES PAID Real Estate Taxes $ Personal Property Taxes $ State/Local Income Taxes $ Sales Tax paid on Car/Boat/RV $ Car Tag (Ad Valorem Tax) $ CHARITABLE CONTRIBUTIONS Cash/Check Contributions $ Non-Cash Contributions $ Miles for Charity: per mile $ MISCELLANEOUS DEDUCTIONS Unreimbursed Business Expenses $ Union/Professional Dues $ Safe Deposit Box $ Tax Return Preparation Fee $ Business Publications $ Business Phone Calls $ Tools, Supplies, Equipment $ Job Search Expenses $ Gambling Losses $

4 SCHEDULE C BUSINESS INCOME Business Name ID Number Gross Income: Gross Income Less: Returns & Allowances Cost of Sales: Beginning Inventory $ Purchases $ Cost of Labor $ Materials & Supplies $ Freight In $ Other $ Ending Inventory $ Deductions/Expenses: Advertising $ Car & Truck Expenses $ Business Miles: per mile $ Bank Fees $ Collection Expenses $ Contract Labor $ Deductions/Expenses (continued) Employee Benefit Plan $ Insurance $ Interest (Mortgage) $ Interest (Other) $ Janitorial/Cleaning $ Legal/Accounting Fees $ Meals & Entertainment $ Office Expenses $ Postage $ Professional Development $ Professional Dues/Subscriptions $ Rent or Lease $ Repairs/Maintenance $ Salaries $ Supplies $ Taxes & Licenses $ Telephone $ Travel (Hotel/Airfare) $ Utilities $ Home Office (100% Business Use): House Sq. Ft. Office Area Sq. Ft. MAJOR PURCHASES SCHEDULE C DESCRIPTION DATE PURCHASED COST TRADE-IN (IF ANY)

5 SCHEDULE E RENTAL PROPERTY/ROYALTIES Property Description: Gross Rental Income: $ Number of days rented in 2016: Number of days used personally: Expenses: Advertising $ Auto/Travel Expense $ Mileage: per mile $ Cleaning/Maintenance $ Commissions $ Insurance $ Management Fees $ Mortgage Interest $ Other Interest $ Professional Fees $ Repairs $ Supplies $ Taxes $ Utilities $ MAJOR PURCHASES SCHEDULE E DESCRIPTION DATE PURCHASED COST TRADE-IN (IF ANY)