LEVY, LEVY AND NELSON

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Eugenia Blankenship
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1 LEVY, LEVY AND NELSON A PROFESSIONAL ACCOUNTANCY CORPORATION CALABASAS ROAD, SUITE 2012 CALABASAS, CA PHONE:(818) FAX:(818) APPOINTMENTS@LEVYNELSON.COM TAX RETURN YEAR INCOME TAX WORKSHEET NAME Taxpayer OCCUPATION Spouse Home Address City State Zip Home Phone: Cell (Yours) Cell (Spouse) (Yours): (Spouse): DEPENDENTS - (If different from last year) INCLUDE CHILDREN AND OTHERS YOU SUPPORT NAME BIRTHDATE SOCIAL SECURITY# INCOME CHILD CARE INFORMATION CHILD CARE INFORMATION Child's Name _ Child's Name Name of Provider Name of Provider Address Address City State Zip City State Zip EDUCATION EXPENSES Tuition Paid Students Name If College applies, please check the level completed last year: Phone Number Identification Number (MANDATORY) Amount Paid Phone Number Identification Number (MANDATORY) Amount Paid_ Freshman Sophomore Grad Student Junior Senior 1098-T form required QUESTIONS YES NO 1. Did you have health insurance last year? 2. Do you have the same checking account as last year for direct deposit of refund? 3. Did you marry or divorce last year? 4. Did you pay or receive alimony? 5. Are there any changes to your dependents? 6. Did you sell any stocks or investments last year? 7. Do you have any foreign bank accounts or foreign brokerage accounts? 8. Did you purchase a new home or refinance? (Please provide lender's closing statement) 9. Did you sell any real estate last year? 10. Did you receive a distribution from your IRA or pension last year _ 11. Did you contribute to an Individual Retirement Account (IRA) last year? 12. Did you move (rollover) your IRA? 13. Did you give anyone a gift over $14,000 last year? If you received an IRS or Franchise Tax Board notice last year please provide a copy!

2 FORMS OF INCOME Please provide us with any of the following that apply: All W-2 forms Social Security Benefits (Form 1099-SSA) Pension or annuity (Form 1099-R) Gambling/Lottery/Prizes (Form W-2G) Dividends (Form 1099-DIV) Interest (Form 1099-INT) ESTIMATED TAX PAYMENTS Please list the payments you made (if required) Voucher 1- Due 4/15 Voucher 2- Due 6/15 Voucher 3- Due 9/15 Voucher 4- Due 1/15 Extension Payment DATE PAID TAXES (Rental Property Excluded) Property Tax (Home) Other Property Tax Car Registration Boat/ R.V. Registration Other Registration CHARITABLE DONATIONS (Money) NAME OF CHARITY 1 VOUCHER MEDICAL PAYMENTS Drugs Doctors, Dentists & Nurses Hospitals & Nursing Homes Labs & X-Rays Glasses & Hearing Aid Therapists Partnership Income (K-1) Unemployment Compensation (Form 1099-G) State Tax Refund (Form 1099-G) Stock/Investment Sales (Form 1099-B) Health Savings Account (Form HSA) Credit Card Income (Form 1099-K) PAID TO IRS (Federal) $ Health Long Term Care Mileage to Doctors Other Reimbursement PAID TO FRANCHISE TAX BOARD (State) $ INTEREST PAID- Please provide us with all 1098 forms Home Mortgage Home Mortgage 2nd Mortgage Student Loan Interest R.V. or Boat Interest NON-CASH DONATIONS (Furniture, Clothing, etc) PLEASE BRING RECEIPTS NAME OF CHARITY USED VALUE DESCRIPTION OF DONATION 1 2 3

3 HEALTH INSURANCE YES NO INSURED UNDER ACA? (AFFORDABLE CARE ACT) PLEASE PROVIDE FORM 1095-A, B, C IF APPLICABLE UNREIMBURSED EMPLOYEE BUSINESS EXPENSES (It is necessary to keep accurate records of these expenses) IF SELF-EMPLOYED - USE PAGE 4 Computer & Software Educational Expenses Gifts Internet Services Job Search License Fee Meals & Entertainment Office Expenses Online Fees Publications Telephone Tools Travel Expenses Uniform & Laundry Union Dues Website Other: Description of Vehicle Date Purchased/Leased Total Miles Driven (Last Year) Business Miles (Last Year) Daily Roundtrip Commute Parking & Tolls Gas Repairs Tires Registration Lease Payments Interest Washes Loan Payments VEHICLE EXPENSES Applies to Business Owners & Employees who use their car for work besides commuting VEHICLE 1 VEHICLE 2 ADDITIONAL INFORMATION Anticipated changes in next year's income or deductions: Preparer Questions:

4 BUSINESS INCOME & EXPENSES Name of Business: Type of Business Address: INCOME RECEIVED Advertising Auto (Please fill-in auto exp on pg. 3) Bank Charges Business License Client Gifts Commissions Computer Purchases Consultants Dues & Subscriptions Education & Seminars Equipment Purchases Employee Payroll (bring year end payroll reports) Health Premiums Merchant Fees Office Outside Labor Parking Payroll Taxes Postage Printing Refunds Given Rent Repairs & Maintenance Telephone Travel Utilities Other (Describe) Internet & Website Legal & Professional Licenses & Permits Meals & Entertainment Please provide all 1099 forms received and given

5 RENTAL PROPERTIES RENTAL #1 RENTAL #2 RENTAL #3 Name of Property Address City State Zip RENTS RECEIVED FOR THE YEAR Rental Expenses: Advertising Association Dues Auto: # Miles Driven Bank Charges Cleaning Commissions Gardening Improvements(Explain) Interest (Provide 1098) Legal Management Fees Paint & Décor Pest Control Plumbing & Electrical Pool Care Property Tax Repairs Trash Removal Travel Utilities Other (List):

SUN-KAP ENTERPRISES,LLC TAX AND FINANCIAL PLANNING 1260 Huntington Dr., Suite 205 South Pasadena, CA Phone Fax

SUN-KAP ENTERPRISES,LLC TAX AND FINANCIAL PLANNING 1260 Huntington Dr., Suite 205 South Pasadena, CA 91030 Phone 323-254-2729 Fax 323-254-2739 NOTE: REMEMBER TO BRING ALL OF YOUR W-2, 1099, 1098, K-1 AND