INCOME TAX PREPARATION. Rose M. Le Flore. CLIENT PROFILE (Please fill out completely & print clearly) Are you a new client? Yes No

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1 INCOME TAX PREPARATION Rose M. Le Flore CLIENT PROFILE (Please fill out completely & print clearly) Are you a new client? *If you received a Refund last year, please indicate the amount: Federal $ State: $ Address: First Name: MI: Last Name: Address: Complete Street Address (include Apt #), City, State, Zip Code Social Security #: - - Date of Birth: / / Occupation: Day Phone ( ) - Eve. Phone ( ) - Spouse s Name: MI: Last Name: Social Security #: - - Date of Birth: / / Address: * Complete only if different from Spouse s Occupation: Day Phone ( ) - Eve. Phone ( ) - Please List All Dependents First Name Last Name Social Security # Date of Birth Relationship Child Care Provider s Name: Tax I.D. # Address: Ph No: ( Complete address City, State, Zip Code ) - Name of nearest relative not residing with you: Ph No: ( ) - Taxpayer s Signature: Date: Spouse s Signature: Date: 1 of 3

2 TAXPAYER S DECLARATION Please complete before you have your income taxes prepared: Have you provided correct I.D. numbers (photocopies if possible)? Do the names on the return match your and your dependents Social Security records? Are you legally married according to the legal definition via the State? Can someone else claim you and/ or your spouse as a dependent? Did you and/or your spouse receive any kind of housing allowance? Including any Government assistance, or live with someone with a higher income? If yes, by renting a room was there a rental agreement? If you are a NONE Resident/ Alien is your filing status married filing joint? Is all of your dependent information up to date? Did your spouse provide 50% of the dependent s support? Did your Earned Income Credit qualifying children meet anyone of the following? Under age 19 and lived in the taxpayers home more than 6 months Under age 19 and foster child of tax payers and lived in taxpayers home for the full year Full-time student under age 24 Totally disabled and can provide proof Did your qualifying child of another person with a higher modified AGI, include another Household member? I DECLARE THAT I UNDERSTAND THE ABOVE QUESTIONS AND HAVE ANSWERED THEM TRUTHFULLY TO THE BEST OF MY ABILITY Signature: Date: 2 of 3

3 INCOME TAX PREPARATION CHECKLIST Please utilize this checklist to make any notations for most of the following items that you will be claiming on your tax return: 1. A copy of your last years Federal & State Tax returns, if you are a new client (all others may be in our files) 2. All W-2 s, 1099 s (Earning Statements) and Social Security year end statements. 3. Record of other insurance and income expenses: (i.e...) Sale of property Investment Interest Escrow Statements & Moving Costs List of Improvement costs for Rental Property List of Stock s (buy or sale) Dividends Brokers statements or Farm Income 4. Records of any employment related expenses: (i.e...) Union Dues, Safety/ Protective Equipment (shoes, gloves, etc.) 5. Uniforms and Protective Clothing, Small Tools & Supplies, Travel. Automobile Expenses Etc 6. Contributions to Churches and Charities 7. Savings or Checking account number for direct deposit refund s or (Electronic Filing or Instant Refunds) 8. Your Mortgage interest statement(s) 9. Property Tax Statements or Records 10. Fees for Car Registration & Tags License $ 11. Record of medical expenses including doctor, dentist, x-ray fees, lab fees, prescriptions, and Travel. 12. Record of major losses sustained, accident, fire, theft, etc (Over 10% of your income) 13. Records of childcare expenses i.e.. Name, address, phone number, Tax I.D. or Social Security of provider 14. Tax Payers, your child & any other dependents that you are claiming, social security cards 15. Records for College or Vocational Education, including spouse and dependents 16. Any questions that you would like to ask your Tax Preparer you may make notation below and continue on the back of this sheet: Questions or Concerns: 3 of 3

4 DEDUCTIONS: MEDICAL EXPENSES Health, Accident, Insurance Premium Medicare Premium (W/H from Soc. Sec.) Drugs and Medicines Long Term Care INS Prem Dr. Dentist Hospital Laboratory/X Rays Travel Necessary To Get Medical Care Parking/Taxi/Bus/Air Fare Ambulance Glasses/Eye Exams Hearing Aid/Batteries Prosthetic Appliance Sick Room Supplies & Appliances In Home Attendant or Nursing Service Lodging for Medical Care Insurance Reimbursements (For ammount listed above) Deductions Claimed CONTRIBUTIONS to whome paid Churches Community Chest/United Crusade Red Cross Xmas and Easter Seals Heart Fund/Cancer Fund Payroll Deductions Scouts Contributions, Non-receipted - Church Other Non Cash Contributions Salvation Army/Goodwill Industries Other Miles Driven for Charity CASUALTY Total Casualty Loss (attach documentation TAXES -Examples: Theft, earthquake, fire, flood) State Income Tax-Prior Year Returns State Current Year Estimate (pg 1) State From W-2's Real Estate Tax Personal Property Tax Auto License (Less Reg. Fee) New Vehicle Sales Tax MISCELLANEOUS Auto Expenses Business Miles Communiting Miles Other Miles Business Meals and Entertainment Employment Agency Fees Income Tax Preparation IRA ok Keogh Plan Fees Job Education Expenses

5 INTEREST to whom paid Home Mortgage Interest and Points Home Mortgage Interest. Not on Form 1098 Mortage Int. Paid to Individual Refinance? Bring Settlement Sheet Points Paid on Mortage Loan Other Mortage Interest Investment Interest Safety Equipment Small Tools (Estimated life 1 Yr. or l ess). Subscriptions /Memberships Business Phone, Fax and Pager Expenses Business Travel Uniforms (Not General wear) Cost Uniforms, Laundry & Cleaning Union Dues & Professional Dues Others ADJUSTMENT TO INCOME Alimony (Paid To) Social Security Number Moving Expenses (Work Related) Employee Business Expenses that werereimbursed and are included on W 2 or Student loan Interest Paid Qualified Teaching Expenses TAX CREDITS Child Care (# of Children) Other Credits