General Information. Filing Status. Taxpayer's Address. Preparer's Information

Transcription

1 General Information First Middle Initial Last Suffix Social Security Number... Date of Birth Date of Death Home Phone Work Phone Cell Phone Fax Number Legally Blind Totally Disabled Claimed as a Dependent... Presidential Election Fund ($3) Occupation address Taxpayer Check ("X") which phone number to list on return. Spouse State of Residence as of 12/31.. County of Residence as of 12/31. School District as of 12/31.. Sales tax rate of locality in % % If Part Year, Period of Residency. to to Filing Status Status on 2015 return : Status as of 12/31/2016 : 1 Single Enter ("X") in the box 2 Married filing joint 3 Married filing separately (Enter spouse's name and above) Taxpayer's Address 4 Head of Household Non-dependent name: Non-dependent : 5 Qualifying widow(er) with minor child Year spouse died Street Apt/Suite : City State Zip Code If address is in a foreign country, enter that country.. Foreign province/county.. If a bona fide resident of a U.S. territory, enter territory.. Preparer's Information Preparer's name Firm's name Street Cynthia Singleton Singleton & Associates Inc 7700 Old Branch Avenue Suite D201 Foreign postal code City Clinton State MD Zip Code 20735

2 Questions Yes No Basic Information 1 Did your marital status change since last year? 2 Were you in a Registered Domestic Partnership, civil union or same-sex marriage during 2016? 3 Are there any changes in your dependents from last year? 4 Did you have any children under 19 (or 24 if a full time student) who received more than $1,050 in investment income? 5 Are all your dependents either US residents or citizens? 6 Did you provide over half of the support for someone you aren't claiming as a dependent? 7 Are you being claimed (or are eligible to be claimed) as a dependent on anyone else's return? 8 Did you or a member of your family have minimum essential coverage in 2016? (The entity that provided the coverage may have sent you a Form 1095-A, 1095-B, or 1095-C, that lists individuals in your family who were enrolled in minimum essential coverage and shows their months of coverage.) 9 Did you have a Health Insurance Marketplace granted coverage exemption or are you claiming a coverage exemption? 10 Were either you or your spouse in the military or National Guard? 11 Did you purchase or sell your principal residence? 12 Have you been notified by the IRS of changes to a prior year's return, or received any other tax correspondence? 13 Were there any changes to a prior year's income, deductions, or credits? 14 Did you make gifts of more than $14,000 to any one person? 15 Did you file Form 8839, Adoption Credit, in a previous year or incur adoption expenses in 2016? 16 Did you claim a First-time Homebuyer Credit for a home purchased in 2008? 17 Was there a disposition or change in use of your main home for which you claimed the First-time Homebuyer Credit? 18 Do you want to e-file your return? 19 If you are due a refund, how do you want to receive it? Check sent to you in the mail Other quick refund via a bank product Apply to next year's estimates Direct deposit (please provide voided blank check) Type of account: Checking Savings If you owe taxes, how do you want to pay them? Paper check sent with my return Credit card Installment Agreement Direct debit from my bank account (please provide a voided blank check) Type of account: Checking Savings 20 Do you want to allow your tax preparer to discuss this year s return with the IRS? If no, enter another person (if desired) to be allowed to discuss this return with the IRS: Designee's Phone Personal identification name Number Number (5 digit PIN) Yes No Income 1 Did you have an interest in or signature authority over a financial account in a foreign country? 2 Were you the grantor of or transferor to a foreign trust? 3 Did you receive income from a foreign source or pay taxes to a foreign government? 4 Did you receive tip income NOT reported to your employer? 5 Did you barter your services for goods or services from someone else? 6 Did you receive any tax-exempt income, such as interest or dividends from municipal bonds or a mutual fund account? 7 Did you make a loan to someone at an interest rate below market rate? 8 Did you receive, or expect to receive, a Schedule K-1 (or substitute K-1) from a trust, estate, partnership, or S corp? 9 Did you cash in any U.S. savings bonds? 10 Did you own an interest in a Real Estate Mortgage Investment Conduit (REMIC)? 11 Did you receive a state or local refund, or a refund of any other deduction you itemized in a prior year? (attach 1099-G) 12 Did you receive disability income? 13 Do you have gambling winnings? (If yes, be sure to include in gambling expenses) 14 Did you receive any unemployment benefits? 15 During 2016, did you receive payments from a Long-Term Care insurance contract? 16 Did you receive employer-provided adoption benefits for a previous year? 17 Did you receive any distributions from a retirement plan? (If Yes, attach all 1099-Rs) 18 Did you rollover a retirement plan distribution into another plan? 19 Did you receive Social Security benefits? 20 During 2016, did you receive a housing allowance for ministerial services you provided? 21 Did you receive alimony? 22 Did you convert a traditional IRA to a Roth IRA? 23 Did you exchange any securities or investments for something other than cash? 24 Do you have any short sales, commodity sales, or straddles?

3 25 Did you receive Form 2439? 26 Did you buy or sell any bonds? 27 Did you receive stock from a stock bonus plan with your employer? 28 Did you sell any other personal assets at a gain? 29 Did you sell any real estate (other than your home) during the year? 30 Did you sell any assets using the installment method? 31 Did you receive proceeds from a prior year installment sale? 32 Did you purchase a rental property? 33 Did you exchange any property for other property? 34 Did you receive any income not reported in this Organizer? Yes No Business and Rental Property Income 1 If you own rental property, do you qualify as a Real Estate Professional? 2 Did you start or acquire a new business? 3 Did you sell any part of an existing business, or sell business assets? 4 Did you cease operating any business or rental property? 5 Did you remove any of your business assets for personal use? Yes No Business and Rental Property Deductions 1 Did you use part of your home for business purposes? 2 Did you make any contributions to a Keogh or a self-employed SEP plan for 2016? 3 Do you pay for any health or long term care insurance through your business? 4 If you or your spouse are self-employed, are either of you covered under an employer's health plan? 5 Did you purchase any furniture or equipment for your business? Yes No Other Deductions 1 Did you make any contributions, or plan to make contributions, to a traditional or Roth IRA for 2016? 2 Did you make any contributions to HSA (Health Savings Account) in 2016? 3 Did you use your car on the job (other than to and from work)? 4 Did you work out of town for part of the year? 5 Did you incur any travel and entertainment expenses for business purposes? 6 Did you pay expenses for the care of your child or other dependent so you could work? 7 Did you lose property or have damage to a property due to a casualty, theft, or condemnation? 8 Did any security become worthless during 2016? 9 Did any debts become uncollectible during 2016? 10 Did you purchase a 'clean fuel' or electric hybrid vehicle in 2016? 11 Did you make energy efficient improvements to your home or purchase any energy-saving property during 2016? 12 Did you contribute less than an entire interest in any property to charity? 13 Did you refinance a mortgage or take out a home equity loan during 2016? 14 Did you incur moving expenses during the year due to a change of employment? 15 Did you pay any educational tuition or fees for you or a dependent? 16 Did you pay any student loan interest? 17 Did you make any federal or state estimated payments? 18 Did you have a certain trade or business from which you figured your domestic production activities deduction? 19 Did you pay alimony?

4 Comments

5 Dependent Information No. of Enter "X" if applicable Months Amount Paid US Full- time Paid Not a in Home Date of for Dependent Citizen Student or Education Dependent First Last in 2016 Relationship Birth Care Expenses Disabled Expenses this Year

6 Wages W-2 Information Box 1 Box 2 Box 16 Box 17 "X" if Wages, Tips Federal Income State State Income spouse Employer's Other Comp Tax Withheld Wages Tax Withheld

7 Retirement Income 1099-R Information Box 1 Box 4 Box 14 Box 12 "X" if Gross Federal Income State State Income spouse Payer's Distribution Tax Withheld Distribution Tax Withheld

8 Interest Income Please provide copies of all Form 1099-INT or other statements reporting interest income. * F/S/J - enter ownership (F)iler, (S)pouse, Taxable Interest Income Tax Exempt Interest Specified Priv Act Interest or (J)oint. Current Year Prior Year Current Year Prior Year Current Year Prior Year *F/S/J Payer Amount Amount Amount Amount Amount Amount Dividend Income Please provide copies of all Form 1099-DIV or other statements reporting dividend income. * F/S/J - enter ownership (F)iler, (S)pouse, Ordinary Dividends Qualified Dividends Capital Gains or (J)oint. Current Year Prior Year Current Year Prior Year Current Year Prior Year *F/S/J Payer Amount Amount Amount Amount Amount Amount

9 Self-Employed Business Income and Expenses (Schedule C) Enter "X" in one box: Filer Spouse General Information Employer Identification Number (do not enter Social Security Number) Principal business or profession Business name Business address City State Zip Foreign Country Foreign Province/State..... Postal Code General Check Boxes (Enter "X" where applicable) 1 Accounting Method Cash Accrual Other - (Specify) 2 Did you "materially participate" in this business? Yes No 3 Check ('X') if you started or acquired this business in Did you make any payments in 2016 that would require you to file Form(s) 1099? Yes No Business Income Current Year Prior Year * Report statutory income as W-2 income. Amount Amount 5 Income reported on 1099 MISC Gross receipts or sales not reported on Form 1099 or Form W Returns and allowances Other income Inventory (Enter "X" where applicable) 12 Method(s) used to value closing inventory... Cost Lower of cost or market Other 13 Any change in determining quantities, costs, or valuations between opening and closing inventory? Yes No 14 Inventory at the beginning of year Purchases less cost of items withdrawn for personal use Cost of labor Materials and supplies Other Costs Inventory at end of year Current Year Amount Prior Year Amount Assets Placed in Service This Year Date Placed Purchase Description: In Service Amount A A B B C C D D E E F F G G

10 Business Self-Employed Business Expenses Cont. (Schedule C) Current Year Prior Year Expenses Amount Amount 20 Advertising Contract labor Commissions and fees Depletion Employee benefit programs (other than on line 35) Insurance (other than health) Interest: 26 Mortgage (paid to banks, etc.) Other Legal and professional services Office expense Pension and profit-sharing plans Rent or Lease: 31 Machinery rental or lease Equipment rental or lease Other business property rental or lease Repairs and maintenance Supplies (not included in inventory cost of goods sold) Taxes and licenses Travel, Meals, and Entertainment: Travel Meals and entertainment 46 Enter "X" in the box if subject to DOT hours of service limits Utilities Wages Other Expenses:

11 Business Vehicle Information (Schedule C) 1 Date vehicle was placed in service Cost of vehicle Total miles driven for the year Business miles driven during the year Commuting miles included on line Parking fees and tolls Vehicle Interest Vehicle Personal Property tax Actual Expenses 9 Gasoline, oil and repairs Vehicle Insurance Vehicle registration fees Vehicle lease or rental Vehicle - Vehicle - Current Year Prior Year Current Year Prior Year Amount Amount Amount Amount 1 Date vehicle was placed in service Cost of vehicle Total miles driven for the year Business miles driven during the year Commuting miles included on line Parking fees and tolls Vehicle Interest Vehicle Personal Property tax Actual Expenses 9 Gasoline, oil and repairs Vehicle Insurance Vehicle registration fees Vehicle lease or rental Vehicle - Vehicle - Current Year Prior Year Current Year Prior Year Amount Amount Amount Amount

12 Home Office Number Description of Home Office Address City State Zip Check ("X") box: Home Office Expenses Daycare Current Year Prior Year Area of Home Amount Amount 1 Area used regularly and exclusively for business, regularly for daycare, or for storage of inventory or product samples Total area of home Daycare only - Part of Home Used Nonexclusively for Daycare 3 Multiply days used for daycare during year by hours used per day Enter total hours home was available for daycare during year Expenses related to entire home including business portion (Indirect) 5 Casualty losses Excess mortgage interest Insurance Rent Repairs and maintenance Utilities Other Expenses: a 11a b 11b c 11c d 11d e 11e Current Year Prior Year Business Allocation: Allocation % Allocation % Business 1: Business 2: Business 3: Business 4: Business: Current Year Prior Year Additional expenses related to business portion only (Direct) Amount Amount 12 Casualty losses Excess mortgage interest Insurance Rent Repairs and maintenance Utilities Other Expenses: a 18a b 18b c 18c d 18d e 18e

13 Sale of Stocks, Bonds, Real Estate, and Other Non-Business Assets * F/S/J - enter ownership (F)iler, (S)pouse, or (J)oint. Gross Sales Price (Less Cost or *F/S/J Description Date Acquired Date Sold expenses of sale) Other Basis

14 Sale of Stocks, Bonds, Real Estate, and Other Non-Business Assets * F/S/J - enter ownership (F)iler, (S)pouse, or (J)oint. Gross Sales Price (Less Cost or *F/S/J Description Date Acquired Date Sold expenses of sale) Other Basis

15 Sale of Stocks, Bonds, Real Estate, and Other Non-Business Assets * F/S/J - enter ownership (F)iler, (S)pouse, or (J)oint. Gross Sales Price (Less Cost or *F/S/J Description Date Acquired Date Sold expenses of sale) Other Basis

16 K-1 Income Please provide copies of all Schedule K-1s, or other statements, reporting income from partnerships, S corporations, or estates and trusts. Enter "S" if K1 (1120S) Unreimbursed * F/S/J - enter ownership (F)iler, (S)pouse, or (J)oint. Enter "P" if K1 (1065) Partnership Exp. *F/S/J Entity Enter "E" if K1 (1041) Current Year

17 Social Security and Railroad Retirement Current Year Prior Year Filer Amount Amount 1 Enter the total amount from box 5 of all your Forms SSA Enter the total taxes withheld from box 6 of all your Forms SSA Enter the total amount from box 5 of all your Forms RRB Enter the total taxes withheld from box 10 of all your Forms RRB Enter the total amount of Medicare B Premiums withheld Enter the total amount of Medicare D Premiums withheld Spouse 7 Enter the total amount from box 5 of all your Forms SSA Enter the total taxes withheld from box 6 of all your Forms SSA Enter the total amount from box 5 of all your Forms RRB Enter the total taxes withheld from box 10 of all your Forms RRB Enter the total amount of Medicare B Premiums withheld Enter the total amount of Medicare D Premiums withheld

18 Miscellaneous Income Filer Spouse Current Year Prior Year Current Year Prior Year Amount Amount Amount Amount 1 Refund from state Unemployment compensation Prizes and awards Scholarships and fellowships Bartering income Fees received for jury duty Income from rental of personal property, if not in the business of renting such property Precinct election board duty Alaska Permanent Fund Dividends Net operating loss carryover (negative no.) Canceled debts Other income not provided for in this Organizer 15 Adjustments to Income * F/S/J - enter ownership (F)iler, (S)pouse, or (J)oint. Current Year Prior Year *F/S/J Amount Amount 1 Educator expenses Student loan interest Health Savings account deduction Moving expenses Self-employed SEP, SIMPLE, or other qualified plans Penalty on early withdrawal of savings Tuition and fees Other Adjustments to Income * F/S/J - enter ownership (F)iler, (S)pouse, or (J)oint. Current Year Prior Year *F/S/J Amount Amount 1 Performing-arts-related expenses Foreign housing deduction Jury duty pay given to your employer Reforestation amortization Repayment of sub-pay under the Trade Act of Contributions to Section 501(c)(18)(D) pension plans Attorney fees and court costs paid for actions settled or decided after October 22, 2004 involving unlawful discrimination claims, but only to the extent of gross income from such actions Attorney fees and court costs you paid in connection with an award from the IRS for information you provided that helped the IRS detect tax law violations, up to the the amount of the award includible in your gross income 8 9 Employee business expenses of fee-basis state or local government officials 9 10 Expenses from the rental of personal property but were not in the business of renting such property Contributions by chaplains to section 403(b) plans Archer MSA deduction

19 IRA and Other Contribution Information Traditional IRA Contributions Current Year Prior Year Filer Amount Amount 1 Enter total traditional IRA contributions made for Enter contributions, on line 1, made after 12/31/2016 and before 04/15/ Enter value of all traditional IRAs on 12/31/ Enter amount of any outstanding traditional rollovers as of 1/1/ Spouse 5 Enter total traditional IRA contributions made for Enter contributions, on line 5, made after 12/31/2016 and before 04/15/ Enter value of all traditional IRAs on 12/31/ Enter amount of any outstanding traditional rollovers as of 1/1/ Roth IRA Contributions Current Year Prior Year Filer Amount Amount 1 Enter 2016 Roth IRA contributions Enter value of all Roth IRAs on 12/31/ Spouse 3 Enter 2016 Roth IRA contributions Enter value of all Roth IRAs on 12/31/ SIMPLE IRA Current Year Prior Year Filer Amount Amount 1 Enter value of all SIMPLE IRAs on 12/31/ Spouse 2 Enter value of all SIMPLE IRAs on 12/31/ Education (Coverdell ESA) Current Year Prior Year Filer Amount Amount 1 Enter 2016 Coverdell ESA contributions Enter value of the Coverdell ESA on 12/31/ Spouse 3 Enter 2016 Coverdell ESA contributions Enter value of the Coverdell ESA on 12/31/ Other Current Year Prior Year Filer Amount Amount 1 Repayment of qualified reservist distributions Spouse 2 Repayment of qualified reservist distributions

20 Medical and Dental - Itemized Deductions 1 Prescription medications Fees for doctors, dentists, etc Fees for hospitals, clinics, etc Lab and X-ray fees Medical aids such as glasses, contacts, hearing aids, wheelchair, etc Medical equipment and supplies Medical mileage (number of miles driven) 7 8 Medical parking, tolls and local transportation Lodging for medical purposes (up to $50 per night per person) Health/Dental/Other ins. premiums (do not include self-employed plans) Long Term Care insurance premiums (taxpayer) Long Term Care insurance premiums (spouse) Expenses to stop smoking Health insurance premiums - coverage established under your business (1) Health insurance premiums - coverage established under your business (2) Long Term Care insurance premiums - coverage est. under your business (1) Long Term Care insurance premiums - coverage est. under your business (2) Insurance reimbursement for any medical and dental expense listed above 22 Current Year Amount Prior Year Amount

21 Taxes - Itemized Deductions Current Year Prior Year Real Estate Taxes Amount Amount 23 Principal residence Real estate taxes from Schedule E properties Real Estate Not Held For Investment Real Estate Held For Investment Personal property taxes 35 Non-business portion of vehicle personal property taxes Non-Personal Property Taxes 41 K1 (1065) - Other deductions/taxes K1 (1120S) - Other deductions/taxes K1 (1041) - Other deductions/taxes

22 Interest - Itemized Deductions Current Year Prior Year Home Mortgage Interest and Points Reported on Form 1098 Amount Amount 47 Lender Lender Lender Lender 50 Home Mortgage Interest Not Reported on Form : 51 Address: : 52 Mortgage insurance premiums paid on 2016 acquisition indebtedness for principal residence Refinancing Points 53 Description Points paid Date of loan Total number of scheduled loan payments Number of payments made in Description Points paid Date of loan Total number of scheduled loan payments Number of payments made in Description Points paid Date of loan Total number of scheduled loan payments Number of payments made in Description Points paid Date of loan Total number of scheduled loan payments Number of payments made in Investment interest paid

23 Unreimbursed Employee Expenses - Itemized Deductions List car, truck, transportation, meals and entertainment expenses on Employee Expenses tab Filer 58 Union and professional dues Professional subscriptions Uniform and protective clothing Job search costs Spouse Current Year Prior Year Current Year Prior Year Amount Amount Amount Amount Certain Miscellaneous Deductions - Itemized Deductions If investment Current Year Prior Year related enter "X" Amount Amount 68 Tax preparation fees Certain attorney and accounting fees Safe deposit box rental IRA Custodial fees Investment counsel and advisory fees Losses on deposits in insolvent or bankrupt financial institutions Convenience fees paid with credit or debit card for federal taxes in Other Miscellaneous Deductions 85 Federal estate tax on income in respect of a decedent Amortizable bond premiums on bonds acquired before 10/23/ Gambling losses (if gambling income) Repayment of income From K1 Input Worksheet (1065 & 1120S) - Portfolio deduction Certain unrecovered investment in a pension

24 Charity - Itemized Deductions Current Year Prior Year * Total contributions $500 or less. See Non-Cash Charity if over $500. Amount Amount 1 Gifts To Charity Other Than By Cash or Check* Total Miles driven for charitable activities Parking fees, tolls and local transportation for charitable activities Gifts To Charity By Cash or Check

25 Noncash Charitable Contributions (Total of Contributions more than $500) Information on Donated Property (a) and Address of the Donee Organization 1 Address City State Zip Code 2 Address City State Zip Code 3 Address City State Zip Code 4 Address City State Zip Code 5 Address City State Zip Code (b) Description of Donated Property Note: If the fair market value for an item is $500 or less, you do not have to complete columns (d), (e), and (f). (c) Date of the (d) Date Acquired (e) How (f) Cost or (g) Fair Market Value (h) Method Used to Contribution mm/dd/yyyy Acquired Adjusted Basis F. M. V. Determine the F. M. V

26 Noncash Charitable Contributions (Total of Contributions more than $500) Information on Donated Property (a) and Address of the Donee Organization 1 Address City State Zip Code 2 Address City State Zip Code 3 Address City State Zip Code 4 Address City State Zip Code 5 Address City State Zip Code (b) Description of Donated Property Note: If the fair market value for an item is $500 or less, you do not have to complete columns (d), (e), and (f). (c) Date of the (d) Date Acquired (e) How (f) Cost or (g) Fair Market Value (h) Method Used to Contribution mm/dd/yyyy Acquired Adjusted Basis F. M. V. Determine the F. M. V

27 Noncash Charitable Contributions (Total of Contributions more than $500) Information on Donated Property (a) and Address of the Donee Organization 1 Address City State Zip Code 2 Address City State Zip Code 3 Address City State Zip Code 4 Address City State Zip Code 5 Address City State Zip Code (b) Description of Donated Property Note: If the fair market value for an item is $500 or less, you do not have to complete columns (d), (e), and (f). (c) Date of the (d) Date Acquired (e) How (f) Cost or (g) Fair Market Value (h) Method Used to Contribution mm/dd/yyyy Acquired Adjusted Basis F. M. V. Determine the F. M. V

28 Unreimbursed Employee Business Expenses - Short Form Enter "X" in one box: Filer Occupation in which you incurred these expenses Spouse Current Year Prior Year Meals and Entertainment Amount Amount 1 Meals and entertainment expenses Enter "X" in the box if subject to DOT hours of service limits Other Expenses 3 Parking fees, tolls, and transportation, including train, bus, etc., that DID NOT involve overnight travel or commuting to and from work Travel expense while away from home overnight, including lodging, airplane, car rental, etc. DO NOT include meals and entertainment

29 Occupation in which you incurred these expenses Vehicle Information - Unreimbursed Employee Business Expenses - Short Form Vehicle - Vehicle - Current Year Prior Year Current Year Prior Year Amount Amount Amount Amount 1 Date vehicle was placed in service Cost of vehicle Total miles driven for the year Business miles driven during the year Commuting miles included on line Parking fees and tolls Vehicle Interest Vehicle Personal Property tax Actual Expenses 9 Gasoline, oil and repairs Vehicle Insurance Vehicle registration fees Vehicle lease or rental Date vehicle was placed in service Cost of vehicle Total miles driven for the year Business miles driven during the year Commuting miles included on line Parking fees and tolls Vehicle Interest Vehicle Personal Property tax Actual Expenses 9 Gasoline, oil and repairs Vehicle Insurance Vehicle registration fees Vehicle lease or rental Vehicle - Vehicle - Current Year Prior Year Current Year Prior Year Amount Amount Amount Amount

30 Employee Business Expenses Enter "X" in one box: Filer Occupation in which you incurred the expenses Spouse Current Year Prior Year Meals and Entertainment Amount Amount 1 Meals and entertainment expenses Enter "X" in the box if subject to DOT hours of service limits Travel Expenses 3 Parking fees, tolls, and transportation, including train, bus, etc., that DID NOT involve overnight travel or commuting to and from work Travel expense while away from home overnight, including lodging, airplane, car rental, etc. DO NOT include meals and entertainment Other Employment Related Expenses 5 Business gifts Employment related education expenses Trade publications Employer Reimbursements 13 Enter employer reimbursements reported under code "L" in box 12 of Form W Enter other employer reimbursements not reported to you in box 1 of Form W Enter the total expense for meals and entertainment for the period covered by the reimbursements

31 Occupation in which you incurred these expenses Vehicle Information - Unreimbursed Employee Business Expenses Vehicle - Vehicle - Current Year Prior Year Current Year Prior Year Amount Amount Amount Amount 1 Date vehicle was placed in service Cost of vehicle Total miles driven for the year Business miles driven during the year Commuting miles included on line Average daily roundtrip commuting miles Parking fees and tolls Vehicle Interest Vehicle Personal Property tax Actual Expenses 10 Gasoline, oil and repairs Vehicle Insurance Vehicle registration fees Vehicle lease or rental Value of employer-provided vehicle (if 100% is included in W-2) Date vehicle was placed in service Cost of vehicle Total miles driven for the year Business miles driven during the year Commuting miles included on line Average daily roundtrip commuting miles Parking fees and tolls Vehicle Interest Vehicle Personal Property tax Actual Expenses 10 Gasoline, oil and repairs Vehicle Insurance Vehicle registration fees Vehicle lease or rental Value of employer-provided vehicle (if 100% is included in W-2) Vehicle - Vehicle - Current Year Prior Year Current Year Prior Year Amount Amount Amount Amount

32 Adoption Expenses 1 Provide the Following Information on Each Eligible Child Enter "X" if Child Was: Child's Year Born BEFORE A Child A Child's of Birth 1999 and With Special Foreign Identifying Number First Last Disabled Needs Child ( or ATIN) 1st Child 2nd Child 3rd Child 4th Child 2 Expenses you paid in Expenses you paid in 2016, if the adoption was final in Expenses you paid in 2016, if the adoption was final before st Child 2nd Child 3rd Child 4th Child Enter "X" in the appropriate box 5 Did you receive Employer-Provided-Adoption-Benefits in a prior year? Yes No