2017 Individual Worksheet Questionnaire:

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Hugh James
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1 Individual Worksheet Questionnaire: Client Name: address: Mobile Telephone#: ATTENTION: Business Owners: (which includes Sole Proprietors; Rental Property Owners; Farms; Corporations and Partnerships) There are new 1099 questions and requirements by the IRS. Please answer BOTH of the 1099 questions on the worksheets for Businesses (C); Rental Property (E) and Farms (F). New IRS / State laws: These are initiated to help prevent your IDENTITY THEFT. A. The IRS and States now require proof of your identification. (Both taxpayer & spouse if applicable) We MUST have on file a copy of (1) your current State issued drivers license or (2) other State issued ID. B. Home owners are now required to prove deductible mortgage interest, including origination date & type of debt (1) original mortgage debt, (2) refinancing of original mortgage debt, (3) Home Equity Debt YOU are now required to maintain proof of the debt. Please provide us with a copy of your 2017 mortgage form Please answer the following questions and complete / review all attached worksheets. They have been designed to assist you in organizing your income and deductible expenses. Please supply any supporting documents that may be beneficial to accurately completing your tax forms. Circle Yes or No 1. Did you have a change in filing / marital status? If yes please advise: YES / NO 2. Any change in dependents claimed? ie: births / adoptions / graduation of children. YES / NO 3. Did you pay child care expenses for child under age 13? Provide information - Page 6 YES / NO 4. Did you have educational (post high school) expenses for yourself, spouse or dependent child? YES / NO Provide information - Page 6 You MUST have form 1098-T from the qualified institution. 5. During 2017, did you have financial interest in or signature authority over a financial account located in a foreign country? (Bank / brokerage account, including joint accounts & co-signer accounts) YES / NO 6. Did you purchase a vehicle, boat, motor home, or have other large purchases subject to sales tax? YES / NO If yes, you MAY be able to deduct the sales tax. Provide documentation of sales tax. 7. Did you buy / sell / refinance a home? If yes, please provide the settlement documents (HUD-1). YES / NO Address Change?: 8. Did you pay real estate taxes? See page 4 (bring mortgage statement form 1098 if applicable) YES / NO 9. Did you contribute $ 250. (or more) to any qualified charitable organization? YES / NO Provide copies of receipt from Qualified Charitable Organizations. Not all non-profits qualify. 10. Did you have any cancellation of debt or enter into a mortgage modification. YES / NO Please bring copies of forms 1099-C or 1099-A. This could be taxable income to you! 11. Did you receive a Marcellus gas bonus check or royalty payments from gas or coal rights? YES / NO 12. PA USE TAX: Did you purchase any items from out of state companies (via: Computer / Catalogs) YES / NO If yes, you may owe PA Use Tax if the company did not collect sales tax. Please provide details. 13. Did you have Health Insurance in 2017? YES / NO Coverage for entire 2017 year? YES / NO Was health insurance Employer provided? Y / N (provide form 1095-C received from Employer) Was health insurance Self Paid? Y/ N (provide form 1095-B received from Insurance Co) Was coverage through Health Care Market Place? Y / N (provide 1095-A received from Market Place) Cover Page / Questioner Client Initials: T: S:

2 INCOME WORKSHEET CLIENT NAME: *PLEASE BRING ALL W-2 AND 1099 FORMS TO APPOINTMENT (OR MAIL / DROP-OFF WITH OTHER INFORMATION) *INTEREST INCOME: PLEASE BE SURE TO BRING 1099-INT FORMS whole numbers only no pennies PLEASE (ex: $72 not $71.63) NAME OF INSTITUTION ISSUING FORM 1099 % of GOVT BONDS EDUCATIONAL FEDERAL EARLY FEDERAL STATE STATE STATE SERIES EE TAX W/D REGULAR EXEMPT EXEMPT EXEMPT EXEMPT BONDS WITHHELD PENALTY *DIVIDEND INCOME: PLEASE BE SURE TO BRING 1099-DIV FORMS NAME OF INSTITUTION ISSUING FORM 1099 TOTAL QUALIFIED TOTAL CAP % RATE FEDERAL STATE FEDERAL FOREIGN FOREIGN ORDINARY ORDINARY GAINS SEC EXEMPT EXEMPT TAX W/H INCOME TAX PAID Federal State Local Local OP #1 Office Use Only: ( 2017 estimated vouchers) #2 #3 #4 Total Schedule B Page 1 of 6 Client initials: T

3 *PLEASE BE SURE TO BRING ALL W-2 AND 1099 FORMS (BRING) CLIENT NAME: Prizes / Awards / Lottery / Gambling.. (BRING) State Income Tax 2016 Refund Educational IRA / Distributions 1099-Q or Overpayment Received in G Basis of distribution Gains State Income Tax 2015 Refund Student Name: or Overpayment Received in G Educational IRA / Distributions 1099-Q Basis of distribution Gains Local Income Tax 2016 Refund Student Name: or Overpayment Received in 2017 (T) 1099-G Local Income Tax 2016 Refund IRA Distributions - T / R Gross 1099-R or Overpayment Received in 2017 (S) 1099-G Fed W/H Taxable W-2G IRA Distributions - T / R Gross 1099-R Alimony Received Fed W/H Taxable IRA Distributions - T / R Gross 1099-R Unemployment - Taxpayer G Fed W/H Taxable Federal Tax w/h on Unemployment.... IRA Distributions - T / R Gross 1099-R Unemployment - Spouse G Fed W/H Taxable Federal Tax w/h on Unemployment. Pension / Annuity Gross 1099-R Social Security - Taxpayer (Box 5) SSA Fed W/H Taxable Federal Tax w/h on S.S. (Box 6) Pension / Annuity Gross 1099-R Social Security - Spouse (Box 5) SSA Fed W/H Taxable Federal Tax w/h on S.S. (Box 6) Pension / Annuity Gross 1099-R Fed W/H Taxable Property Tax Rebate / Refund... Pension / Annuity Gross 1099-R Jury Duty (exclude parking & travel)... Fed W/H Taxable Other Income Health / Medical Savings Account Other Income Total distributions SA Educator (Teacher) Supplies (T/S).... ($ 250 max) IRA (Traditional / Roth) - Taxpayer... Contribution (Detail expenses over $ 250. on 2106 worksheet) each IRA (Traditional / Roth) - Spouse.... Contribution HSA-Health Savings Acct (self funded) SA Statement of 12/31/17 IRA Value (please bring form 5498) (other than listed on W-2 forms - withheld or paid by employer) (self employed only): INCOME DEDUCTIONS (not included on W-2 forms) Student Loan Interest: Taxpayer Spouse.. SEP / Simple IRA - Taxpayer Contribution Contribution SEP / Simple IRA - Spouse Name of Beneficiary: Keogh / Money Purchase Pension Contribution Contribution Keogh / Money Purchase Pension... Name of Beneficiary: Health Insurance Contribution Contribution Name of Beneficiary: Alimony Paid $ Recipient Name & SS # Page 2 of

4 CLIENT NAME: 1. Business Income & Expenses All Businesses, Landlords & Farmers MUST: 2. Rental Income & Expenses * Confirm all 1099's received from customers 3. Farm Income & Expenses ** Prepare all 1099's required for vendors (> $ 600.) 4. Sale of Assets, Equipment or Investments ( gain / loss / worthless ) If you have computerized QuickBooks records for your business, farm, or rental do not complete worksheet; download ACCOUNTANTS backup copy or bring the following: a. 1/1/17-12/31/17 Profit and Loss Previous Year Comparison Statement b. 12/31/17 Balance Sheet Previous Year Comparison Statement c. 1/1/17-12/31/17 Statement of Asset Acquisitions Quickbooks users should upload an ACCOUNTANT'S COPY through our secure portal. We will review files, make corrections and adjustments to your files, then download back to you, insuring accuracy and saving time. IF YOU HAVE INCOME FROM ESTATES / PARTNERSHIPS / S-CORPORATIONS / TRUSTS PLEASE BE SURE TO BRING K-1's TO YOUR TAX PREPARATION APPOINTMENT. Most K-1's are not issued until after April 1st and will require you to file on an extension after April 15th. *DO NOT INCLUDE AMOUNTS WITHHELD ON WAGES (W-2 FORMS)* 2016 Overpmnt 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter Paid with Total ESTIMATED TAX credited to paid by paid by paid by paid by Extension Payments PAYMENTS /15/2017 6/15/2017 9/15/2017 1/16/2018 4/15/2018 for 2017 Federal: If you have income or expenses from any of the following, please download the appropriate worksheets or contact our office. ESTIMATED TAX PAYMENTS PAID FOR 2017 State: State: Local 2016 Overpmnt 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter Paid with Total Earned Income/ credited to paid by paid by paid by paid by Extension Payments Wage Tax /31/17 7/31/ /31/2017 1/31/2018 4/15/2018 for 2017 Taxpayer (or Joint) Taxpayer (or Joint) Spouse Spouse Page 3 of 6

5 ITEMIZED DEDUCTIONS *MEDICAL EXPENSES: Chiropractor CLIENT NAME: *TAXES: Payments NOT listed on W-2 Forms Co-Pays and Deductibles state income tax paid in 2017 Dentist / Dentures Doctor State Income Taxes - Paid in Exercise Equip/Program (if prescribed)... Eyeglasses & Contacts / Supplies Hearing Aids / Batteries Grand Total State Taxes paid in = Hospital Insurance - Health & Medicare (not listed elsewhere) Payments NOT listed on W-2 Forms Insurance - Longer Term Care local earned income tax paid in 2017 Mileage $ Medical Supplies Local Income Taxes - Paid in Nursing Home / Hospice Care Parking and Tolls Physical Therapy Grand Total Local Taxes paid in = Prescriptions / Medications Rehabilitation *TAXES: Payments listed on W-2 Forms Special Education (Tuition / Meals / Lodging, etc) Local Service Tax ($ $ 52.) + = Test / X-rays Transportation / Lodging Unemployment Tax withheld on W-2 (puc / sdi / sui / unempl): = Total All State and Local Taxes Paid: = *INTEREST EXPENSE: Provide 1098 mortgage statements Mortgage Lender Origination date Outstanding Debt Intrest Paid Sales / Use Tax Paid -- Major Purchases.. / / $ $ (Auto, Boat, Truck, Motor Home, Etc) / / $ $ Real Estate / Property Taxes: / / $ $ School: County: Local: = Home Equity Origination date Outstanding Debt Intrest Paid School: County: Local: = / / $ $ School: County: Local: = / / $ $ School: County: Local: = Time Share Mortgage Grand Total = - Mtg. Int. deducted on forms (C, E, F, 2106) ( ) '- Taxes deducted other forms (C, E, F, 2106)... ( ) Total Mortgage Interest Paid: = Total Real Estate Taxes: = Investment Interest Expense Mortgage Insurance Premiums Personal Property Taxes Mortgage Points Paid - Original Loan.... (Assets held in states other than PA) Mortgage Points Paid - Refinancing..... ( Bring HUD - 1 Settlement Statement ) These are taxes assessed on the value of personal property (vehicles, etc.) Refi. Date: # of Years: Mortgage interest is limited to interest paid on debts (< $ 1,000,000.) to acquire or improve your residence. Home Equity interest is limited to interest pd on debts secured by your residence < $ 100,000.. Schedule A Page 4 of 6

6 CLIENT NAME: *CHECK / CREDIT CARD / CASH *CLOTHING & GOODS DONATED: List organization names & amount if over $ 250. Receipts & Detailed Lists Required / / / / / / / / $.14 $.14 Auto Donated ( Must have verification if over $500* ) ALL contributions > $ 250. must be verified with *Must include year / make / model / mileage receipt from qualified charitable organization verified sale proceeds and original purchase date & cost ALL Cash contributions are DISALLOWED unless confirmed with a written receipt from the qualified charitable organization. WARNING: Not all "non-profit" organizations are qualified charitable organizations Investment Expense: Tax Preparation Fees Custodial Fees - IRA/SEP/Etc Tax Related Publications Financial Planning Fees Tax Preparation Mileage $.535 = Safe Deposit Box or Safe Publications Legal Fees: Income / Job Related (only) Tax Related (only) Legal fees to establish a will or trust are not deductible. LOSSES ON IRA'S AND ANNUITIES: ( Total liquidation of all like assets is required ) GAMBLING LOSSES ( Limited to winnings as reported on 1099-G) ESTATE TAXES: (Paid on taxable income ie: IRA, Annuity, Bonds, etc ) CASUALTY LOSSES: ( Flood / Fire / Theft ) -- Bring Itemized List and police or fire report (per loss).. Job Related Exp: 2106 Worksheet Job Hunting Exp: 2106 Worksheet Job Related Educ. Exp: 2106 Worksheet CHARITABLE CONTRIBUTIONS If your total annual "GOODS" contributions exceed $500 you must have the following: 1. Receipt from QUALIFIED charity, including name and address of qualifying charitable organizations 2. Detailed "item by Item" list, including description, original cost and purchase date if possible. 3. Proof of cost (if available) and proof of valuation (if original receipts are not available pictures when donated will help) Valuation guides for "Clothing & Goods" contributions can be found on the internet MISCELLANEOUS DEDUCTIONS Educator Exp (in excess of $250): 2106 Worksheet Moving Exp: 3903 Worksheet Page 5 of 6

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8 CHILD AND DEPENDENT CARE EXPENSES CLIENT NAME: This worksheet is designed to aid you in the organization of necessary information for Child Care Expenses. List persons or organization who provide care. MUST HAVE STATEMENT FROM CHILDCARE PROVIDER TO RECEIVE CREDIT Care Recipient's Name Care Provider's Name and Address Care Provider's SS# or EIN Amount Paid POST HIGH SCHOOL EDUCATION EXPENSES MUST HAVE 1098-T OR 1098-E FROM EDUCATIONAL INSTITUTION TO RECEIVE CREDIT OR DEDUCTION Student #1 Student #2 Student #3 Name of Student Year of Schooling (circle one ). (G= Grad School) G G G Educational Institution - Name Total Tuition (Must provide form 1098-T, from school) Qualified Lab & Facility Fees Required Books and Equipment Non-Taxable Assstance - (VA, G.I. Bill, etc) - Grants / Scholarships received Withdrawals from Educational or Roth IRA / 529 Plan.. - Net subject to credit or deduction = = = = ENERGY & VEHICLE CREDITS Energy Tax Credit - As of 1/1/17 the federal energy tax credit has for the most part been ELIMINATED. Only "renewable" (Wind, Solar, Goethermal) energy credits are available for the 2017 tax year. Vehicle Tax Credits - The federal "Hybrid" vehicle tax credit is still available to a limited number of vehicles. If you purchased a NEW Hybrid vehicle in 2017, bring the acquisition & registration informaiton. Page 6 of 6

2018 Individual Worksheet Questionnaire:

2018 2018 2018 Individual Worksheet Questionnaire: Client Name: Email address: Mobile Telephone#: ATTENTION: Business Owners: (which includes Sole Proprietors; Rental Property Owners; Farms; Corporations