2018 Individual Worksheet Questionnaire:

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June May
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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 two questions and requirements by the IRS with regard to YOUR issuing 1099 forms. YOU MUST complete both questions on our worksheets for Businesses (C); Rental (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. Mortgage interest proof required to be deductible, including origination date, type of debt & purpose of debt (1) original mortgage debt, (2) refinancing of original mortgage debt, (3) Home Equity Debt YOU are required to maintain proof of the debt. Please provide us with a copy of your 2018 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 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! 7. Did you receive a Marcellus gas bonus check or royalty payments from gas or coal rights? YES / NO 8. 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. 9. Did you acquired your Health Insurance for 2018 through the "Health Care Market Place? YES / NO If you answered YES to QUESTION #9, you MUST provide form 1095-A for proof of cost & credit. FACTS to consider before you answer Questions 10-13, or complete pages 4 & 5 A. State income tax + Earned / Wage tax + Real Estate tax deductions are limited to $ 10, TOTAL B. Mortgage interest is limited to ONLY the debt associated with the purchase or improvement of residence. C. Home Equity interest is ONLY deductible if proceeds were to acquire, ReFi or improve the residence. D. Employment related expenses, Financial Planning and Tax Preparation fees are NOT DEDUCTIBLE. E. The new Standard Deduction limits are $ 24, if Married Filing Jointly / $ 12, if single. 10. 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. 11. Did you buy / sell / refinance a home? If yes, please provide the settlement documents (HUD-1). YES / NO Address Change?: 12. Did you pay real estate taxes? See page 4 (bring mortgage statement form 1098 if applicable) YES / NO 13. 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. 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: ( 2018 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 2017 Refund Educational IRA / Distributions 1099-Q or Overpayment Received in G Basis of distribution Gains State Income Tax 2016 Refund Student Name: or Overpayment Received in G Educational IRA / Distributions 1099-Q Basis of distribution Gains Local Income Tax 2017 Refund Student Name: or Overpayment Received in 2018 (T) 1099-G Local Income Tax 2017 Refund IRA Distributions - T / R Gross 1099-R or Overpayment Received in 2018 (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 Additional expenses are NOT deductible each IRA (Traditional / Roth) - Spouse.... Contribution HSA-Health Savings Acct (self funded) SA Statement of 12/31/18 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 & SS# of Beneficiary: Keogh / Money Purchase Pension Contribution Contribution Keogh / Money Purchase Pension... Name & SS# of Beneficiary: Health Insurance Contribution Contribution Name & SS# 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. 1/1/18-12/31/18 Profit and Loss Previous Year Comparison Statement b. 12/31/18 Balance Sheet Previous Year Comparison Statement c. 1/1/18-12/31/18 Statement of Asset Acquisitions Quickbooks users upload an ACCOUNTANT'S COPY through our secure portal (div date 1/15/19). 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. S-Corporation & Partnership tax forms are due 3/15/19, unfortunately most are do not provide K-1's until after April 1st. *DO NOT INCLUDE AMOUNTS WITHHELD ON WAGES (W-2 FORMS)* 2017 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 /16/2018 6/15/2018 9/17/2018 1/15/2019 4/15/2019 for 2018 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 2018 State: State: Local 2017 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 /16/2018 6/15/2018 9/17/2018 1/15/2019 4/15/2019 for 2018 Taxpayer (or Joint) Taxpayer (or Joint) Spouse Spouse Page 3 of 6

5 ITEMIZED DEDUCTIONS CLIENT NAME: *MEDICAL EXPENSES: Total tax deduction is limited to $ 10, Chiropractor *TAXES: Payments NOT listed on W-2 Forms Co-Pays and Deductibles state income tax paid in 2018 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 2018 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 MUST exceed 7.5% of Adjusted Gross Income to qualify 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 Not Allowed Grand Total = - Mtg. Int. deducted on forms (C, E, F) ( ) - Taxes deducted other forms (C, E, F )..... ( ) 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..... These are taxes assessed on the value of personal property (vehicles, etc.) ( Bring HUD - 1 Settlement Statement ) Refi. Date: # of Years: Total tax deduction is limited to $ 10, of above 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 to acquire or improve residence. Schedule A Page 4 of 6

6 *CHECK / CREDIT CARD / CASH List organization names & amount if over $ 250. NAME - Qualified Charitable Organization CLIENT NAME: *CLOTHING & GOODS DONATED: Receipts & Detailed Lists Required $ Clothing: bags; Date: / / $ $ / / $ $ / / $ $ / / $ $ $.14 $ Grand Total (Receipted) $ Auto Donated ( Must have verification if over $500* ) ALL contributions > $ 250. must be verified with receipt from qualified charitable organization CHARITABLE CONTRIBUTIONS All CASH contributions are DISALLOWED unless confirmed with a written receipt from the qualified charitable organization. Checks & Credit Cards acceptable WARNING: Not all "non-profit" organizations are qualified charitable organizations 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 Miscellaneous Deductions are limited to the following: A. Casualty losses ONLY allowable if the loss occurred in a Presidentially declared disaster area B. Federal Estate tax related to income that was taxable to the estate $ C. Gambling Losses Limited to gambling winnings (Proof of losses is required by law) $ D. REALIZED Losses on Annuities / Traditional IRA s NOT previously DEDUCTED when contributed. Itemized deductions allowed for 2017 that were eliminated effective 1/1/18 1. Educational expenses incurred as required by employer, trade or profession were ALL ELIMINATED 2. Excess administrative expenses from a pass-through Estate / Trust K-1 Not determined YET? 3. Expenses incurred by employees in the performance of their job were ALL ELIMINATED 4. Investment expenses IRA fees, Financial Planning, Financial publications were ALL ELIMINATED 5. Job hunting and job placement fee deductions were ALL ELIMINATED 6. Tax related legal fees and Tax preparation fees were ALL ELIMINATED 7. Temporary housing and travel related to employment were ALL ELIMINATED In short, Federal form 2106 has been COMPLETELY ELIMINATED. *Must include year / make / model / mileage verified sale proceeds and original purchase date & cost Pennsylvania STILL allows items #1, 2, 4 & 6, but with LIMITATIONS. The expenses MUST be required by your and unreimbursed by your employer. Only receipted expenses are allowed. PA does not allow the use of Per Diem rates, except mileage. Page 5 of 6

7 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 Efficient Home Improvements & Vehicle Tax Credit: A. If you had new Doors, Windows or Insulation installed at your Personal Residence Bring Receipts. B. If you had a new Air Conditioner, Furnace or Hot Water System installed - Bring Receipts C. If you purchased new Appliances for your home that are removable, don t bring the receipts. D. If you purchased a new Electric or Hybrid Vehicle, bring the receipt, it MAY qualify for tax credit. Page 6 of 6

2017 Individual Worksheet Questionnaire:

2017 2017 2017 Individual Worksheet Questionnaire: Client Name: Email address: Mobile Telephone#: ATTENTION: Business Owners: (which includes Sole Proprietors; Rental Property Owners; Farms; Corporations