2017 TAX ORGANIZER. Please return this Organizer along with copies (no originals) of the following:

Transcription

1 David L. Buterbaugh, P.C E. Morgan Trail, Ste. 15 Scottsdale, AZ TAX ORGANIZER The Tax Organizer will assist you in collecting and reporting information necessary for us to properly prepare your individual tax return. Please complete the organizer sections as appropriate and provide copies (no originals) of supporting documentation where necessary. Prior year data is included on the organizer sections for your reference. Please return this Organizer along with copies (no originals) of the following: - Your signed engagement letter, with your retainer payment - Form(s) 1095-A, 1095-B, or 1095-C (proof of health insurance coverage) - A copy of your 2016 federal and state(s) tax returns, if these were not prepared by our Firm, or if you have not already provided them to us - Form(s) W-2 (wages, etc.) - Form(s) 1099 (interest, dividends, cancellation of debt income, misc, etc.) - Schedule(s) K-1 (income or loss from partnerships, S corporations, trusts, estates, etc.) - Form(s) 1098 (mortgage interest) and property tax statements - Brokerage statements from stock, bond or other investment transactions - Realized Gains and Losses reports for sales of securities, or equivalent basis information - Closing statements/disclosures pertaining to home and other real estate transactions - Any notices received from the IRS and/or other (state) taxing authorities - All Arizona Tax Credit Donation receipts - Other charitable donation receipts for each organization you contributed $5,000 or more - Estimates paid for tax year, please include any 4th quarter estimates paid in 2018 We prepare tax returns in the order we receive complete organizers with all supporting records and retainer deposits--first come, first served. If you wish to file by April 17, the sooner you submit your records the more likely we will be able to fulfill your request. We reserve the right to extend your return if you do not provide your completed tax organizer and all requested documents by February 23, 2018.

2 We are required to electronically file federal income tax returns for individuals. You may independently choose to file on paper. If you prefer to paper file, please notify our office, so we can forward the necessary document for your signature. There is no difference in cost, other than you will incur mailing costs if you choose paper filing. Each year we customize the questionnaire to the current tax laws to increase the likelihood that we claim every allowable deduction or credit you are entitled to. PLEASE take the time to answer all questions. We take great pride in the completeness of our tax organizer. If you know of a friend that could benefit from our services, we welcome your referrals. Thank You! David L. Buterbaugh, P.C.

3 Page 3 ORGANIZER 1040 US Miscellaneous Questions If any of the following items pertain to you or your spouse for, Please check the appropriate box and provide additional information if necessary. PERSONAL INFORMATION Yes No Did your marital status change during the year? Are you in a marriage that is legally recognized in another state or country, but not in your resident state? If yes, please provide details. Did your address, telephone, or address change during the year? Did you reside in more than one state during? If yes, please provide the dates of residency. Were you physically present in any state other than AZ for greater than 180 days in? If yes, please provide details. Could you be claimed as a dependent on another person's tax return for? Have you ever received notification from the IRS regarding identity theft, and/or were you required to provide an IRS issued IP (Identity Protection) PIN number in the prior year? IF YES, please provide us with the IP PIN for as this IP PIN changes each year. If you have not received an IP PIN for, please contact the IRS as we will be unable to efile your tax return without it. DEPENDENTS Yes No Were there any changes in the number or status of dependents this year? Are you the non-custodial parent claiming a child as a dependent due to a post 2008 divorce decree or agreement? If so, you are required to submit a signed Form 8332 Release of Claim form from the custodial parent with your tax return. No other document or decree will be accepted by the IRS to claim this child as a dependent. Were any of your unmarried children, who might be claimed as dependents, 19 years of age or older at the end of? Did you have any children under age 19 or full-time students under age 24 at the end of, with interest and dividend income in excess of $1,050, or total investment income in excess of $2,100? Did you pay for child care or dependent care expenses, so that you and/or your spouse, could work or continue your education? Miscellaneous Questions

4 Page 4 ORGANIZER 1040 Yes US Miscellaneous Questions No Did you pay into and/or receive pre-tax dependent care benefits through your employer? Did you provide a home for and pay more than half of the support for a parent(s) or ancestral parent(s) that required assistance with activities of daily living? Did you complete an adoption or have a pending adoption in? INCOME Yes No Did you receive unreported tip income of $20 or more in any month? Did you cash any Series EE U.S. savings bonds issued after 1989 and pay qualified higher education expenses for yourself, spouse, or dependents? Did you receive any disability income? Did you have any foreign income or pay any foreign taxes? Did you have any gambling or lottery winnings in? If so, please provide Form(s) W2-G or 1099-G. Did you receive unemployment compensation in? If so, please provide Form(s) 1099-G. Did you receive compensation as a result of Active US Armed Services, National Guard or Reservist Service? Did you receive any income from sources outside of Arizona, and/or sell or own property outside of Arizona? HEALTH CARE COVERAGE (Please complete the enclosed Health Care Coverage Questionnaire) Yes No Did you and your dependents have healthcare coverage for the full-year? Did you receive any of the following IRS Documents? Form 1095-A (Health Insurance Marketplace Statement), 1095-B (Health Coverage) or 1095-C (Employer Provided Health Insurance Offer/Coverage) If so, please provide us a copy. If you had health care coverage during but did not receive any of the above forms, please call to obtain from your insurance provider or employer. Miscellaneous Questions (Continued)

5 Page 5 ORGANIZER 1040 Yes US Miscellaneous Questions No If you or your dependents did not have health care coverage during the year, do you fall into one of the following exemption categories: Indian tribe membership, health sharing ministry membership, religious sect membership, incarceration, exempt non-citizen or economic hardship? If you received an exemption certificate, please attach. PURCHASES, SALES AND DEBT Yes No Did you start a business or farm, purchase rental or royalty property, or acquire an interest in a partnership, S corporation, trust, or REMIC? Did you purchase or dispose of any business assets (furniture, equipment, vehicles, real estate, etc.), or convert any personal assets to business use? PLEASE do not check yes if this relates to an S-Corp or Partnership entity in which you are a member/partner. Did you buy or sell any stocks, bonds or other investment property in? If assets have been sold, please provide as much information as possible, so that we may help determine the cost basis and date of purchase of the assets. Did you purchase, sell, or refinance your principal home or second home, or did you take a home equity loan? If so, please provide a copy of the closing documents. If you sold a property please also provide the cost basis and/or the HUD/closing documents from when the property was originally purchased. Are your total mortgages on your first and/or second residence greater than $1,100,000? If so, please provide the balance and interest rate for each mortgage. Did you use proceeds from a home mortgage including home equity loan other than to buy, build, or improve your home? If so, please provide details of amounts borrowed either this year or in a prior year. Did you claim a First Time Homebuyer Credit with your 2008 return for a home you purchased in 2008? If so, please provide a copy of your 2008 return (if not prepared by our firm or previously provided to our firm). Did you purchase any residential energy-efficient, solar energy, wind energy, geothermal, or fuel cell property or improvements? If so, please provide the certification that your purchase qualifies for a tax credit, along with your receipt for the purchase. (Please note: costs associated with swimming pools and hot tubs do NOT qualify for Federal credits) Did you pay sales tax on the purchase of one or more new mobile homes, motor vehicles, or recreational vehicles? If so, please provide a copy of the bill(s) of sale. If the vehicle qualifies for a tax credit, please advise. Miscellaneous Questions (Continued)

6 Page 6 ORGANIZER 1040 Yes US Miscellaneous Questions No Did you purchase a new alternative fuel motor vehicle (fuel cell or plug-in)? If so, please provide a copy of the promissory note and your receipt for the purchase. Did you have any debts canceled or forgiven? If so, please include related documents and any Forms 1099-C or 1099-A. Did anyone owe you money which had become uncollectible? If so, please provide details of the debt, the promissory note, and steps taken to attempt to collect the debt. If you own any rental properties (commercial or residential), have you filed the required sales tax reports? RETIREMENT PLANS Yes No Did you receive a distribution from a profit-sharing, retirement plan or individual retirement arrangement (including Traditional, 401(k), IRA, SEP, SIMPLE, Qualified Plan, etc.)? If yes, please provide Form(s) 1099-R. Did you make a contribution to a retirement plan (401(k), IRA, SEP, SIMPLE, Qualified Plan, ROTH etc.)? If so, please provide details if other than a 401(k) or Simple IRA deferral reported on Form W-2. If it will benefit you, would you want to contribute to an IRA, SEP or SIMPLE IRA or to a ROTH IRA? Did you transfer any amount from one retirement plan to another retirement plan? Did you receive a distribution from a retirement plan that you subsequently rolled over into another retirement plan within 60 days of receiving the distribution? If so, we will need the related documentation of the withdrawal and rollover. Did you convert part or all of your traditional, SEP, or SIMPLE IRA to a Roth IRA in? If so, please provide details. Did you make a direct transfer from an IRA to a charitable organization? If so, please provide details. Have you attained age 70- ½ by 12/31/? If so, please list the combined value of ALL of your IRA accounts as of 12/31/2016. $ and as of 12/31/. $ Miscellaneous Questions (Continued)

7 Page 7 ORGANIZER 1040 Yes US Miscellaneous Questions No Has your spouse attained age 70- ½ by 12/31/? If so, please list the combined value of ALL of your spouses IRA accounts as of 12/31/2016. $ and as of 12/31/. $ If you are self-employed, do you maintain a Money Purchase, Profit Sharing or 401-K Plan? If so, please provide a copy of the 12/31/ investment account statement for your plan. EDUCATION Yes No Did you receive a distribution from an Education Savings Account or a Qualified Tuition Program? If so, please provide a copy of Form 1099-Q and details of the education expenses paid. Did you, your spouse, or a dependent incur any tuition expenses that are required to attend a college, university, or vocational school? If yes, you must provide Form 1098-T. This form is required in order to claim any potential credit. Which year of studies (freshmen, sophomore, junior, senior, or post grad) was the student considered in? Did you incur any unreimbursed expenses working as a teacher, counselor, or principal for classes, kindergarten through grade 12? If so, in what amount? Did you pay any student loan interest for yourself or on behalf of a dependent? If so, please provide Form 1098-E. Did you not claim a dependent, in order to allow your dependent to claim the federal education credit? Did you contribute to any Section 529 plan during? If so, please provide the amount(s) contributed in. ITEMIZED DEDUCTIONS Yes No Did you incur a loss because of damaged or stolen property? If so, please provide details and any amounts reimbursed by insurance. Did you work out of town for part of the year? Did you use your car on the job (other than to and from work)? Miscellaneous Questions (Continued)

8 Page 8 ORGANIZER 1040 Yes US Miscellaneous Questions No Did you pay any deductible investment interest in? This would be interest on a loan where you used the proceeds to purchase an investment; or interest on a loan that is secured by investment property, such as a margin loan from a securities brokerage firm. Did you pay any property taxes on any real property? If yes, please provide amounts paid by property location (if applicable). Please also provide any payment(s) that may have been made outside of a mortgage company. Did you pay out of pocket medical, dental, eye care, or prescription drug expenses not covered or reimbursed by health insurance, an HSA or a flexible spending account? ESTIMATED TAXES Yes No Did you apply an overpayment of 2016 taxes to your estimated tax (instead of being refunded)? If you have an overpayment of taxes, do you want the excess applied to your 2018 estimated tax (instead of being refunded)? Do you expect your 2018 taxable income and withholdings to be different from? If so, please describe any anticipated changes here or attach your own statement. FEDERAL AND ARIZONA TAX CREDITS Yes No Did you make a contribution in for to a State Qualified Charitable Organization (provides Assistance to the Working Poor) for the Arizona Tax Credit of up to $400 (single) or $800 (married filing joint)? If so, please provide a copy of the receipt. Did you make a contribution in for to a State Qualified Foster Care Organization for the Arizona Tax Credit of up to $500 (single) or $1,000 (married filing joint)? If so, please provide a copy of your receipt. Did you make a contribution in for to a Public or Charter School, for the support of Extracurricular Activities for the Arizona Tax Credit of up to $200 (single) or $400 (married filing joint)? If so, please provide a copy of the receipt. Miscellaneous Questions (Continued)

9 Page 9 ORGANIZER 1040 Yes US Miscellaneous Questions No Did you make a contribution in for to a Private School Tuition Organization that provides Scholarships or Grants to Qualified Schools for the Arizona Tax Credit of up to $1,087 (single) or $2,173 (married filing jointly)? If so, please provide a copy of your receipt. If you owe Arizona tax and you did not fund, or maximize ANY of the above Arizona Tax Credit Donation Organizations prior to the end of the year, would you like to do so before April 15th, 2018 to take advantage of the credit for? This would reduce the payment due to the Arizona Department of Revenue by a corresponding amount. Did you make a contribution to the Military Family Relief Fund eligible for the Arizona Tax Credit of up to $200 (single) or $400 (married filing jointly)? If so, please provide a copy of the receipt. Do you believe you qualify for any other Federal or State Tax credit or deduction that is not listed here or discussed elsewhere in your Tax Organizer? Please provide details. FOREIGN Yes No Did you have a direct or indirect interest in, or signature or other authority over, a financial account in a foreign country, such as a bank account, securities account, foreign annuity, foreign pension, foreign life insurance or other financial account? If so, please provide details. Do you own shares of stock in a non-publicly traded foreign corporation, Passive Foreign Investment Corporation, or have a direct or indirect interest in a foreign partnership, or were you a beneficiary of a foreign trust? If so, please provide details. Do you own property in a foreign country? If so, please provide details of the type of property and which country it is located. Did you receive a distribution from, or were you the grantor of, or transferor to a foreign trust? If so, please provide details. Did you receive any gifts from foreign individuals or entities in? If so, please provide details. Miscellaneous Questions (Continued)

10 Page 10 ORGANIZER 1040 US Miscellaneous Questions MISCELLANEOUS Yes No If you DO NOT want to electronically file your returns, and prefer to paper file, check YES and attach the "Taxpayer Choice Statement to File in Paper Format", which can be found on our website click Forms, Individual, and then "Taxpayer Choice Statement to File in Paper Format". Do you want to allocate $3 to the Presidential Election Campaign Fund? Does your spouse want to allocate $3 to the Presidential Election Campaign Fund? May the IRS discuss your tax return with our firm? Did you invest in a Limited /General Partnership, LLC, or S-Corporation this year? If so, please provide details. If your business is taxed as a sole-proprietor (under 50 employees), did you pay health insurance premiums for your employees? If yes, please provide details. PLEASE do not check yes if this relates to an S-Corp or Partnership entity in which you are a member/partner. If your business is taxed as a sole-proprietor, did you reimburse any employees for the cost of their health insurance premiums? If so, please provide details. PLEASE do not check yes if this relates to an S-Corp or Partnership entity in which you are a member/partner. If your business is taxed as a sole-proprietor, please provide us with a copy of any Form 1099-K or 1099-Misc received. Was your home rented out or used for business? If your business is taxed as a sole-proprietor, own a rental property or a farm, did you make any payments in that would require you to issue Form(s) 1099? These would include rent, contract labor, outside services, legal fees, etc. aggregating $600 or more for the year to a single payee for your trade or business. PLEASE do not check yes if this relates to an S-Corp or Partnership entity in which you are a member/partner. If yes, did you or will you issue and file the required Form(s) 1099 and 1096? Did you incur moving expenses due to a change of employment? Are you paying interest on a loan for a boat or recreational vehicle that has basic living accommodations, such as sleeping, restroom and cooking facilities? Did you engage the services of any household employees to whom you paid more than $1,000 in any quarter, or more than 2,000 in? If yes, provide a copy of the W-2(s) issued to each household employee. Miscellaneous Questions (Continued)

11 Page 11 ORGANIZER 1040 Yes US Miscellaneous Questions No Did you make contributions to a Health Savings Account (HSA) this year? If so, please provide a copy of Form 5498-SA and details of deposits. Did you have distributions from a Health Savings Account (HSA) this year? If so, please provide a copy of Form 1099-SA and details of any distributions that were not used for qualified medical expenditures. Did you receive a federal or state pension? If so, please provide the Form 1099-R. If you request direct deposit of refunds, has your bank or bank account changed since last year? If yes, or you did not utilize direct deposit last year, please provide a copy of a voided check. Did you refinance a home loan in? If yes, please provide the closing disclosure/statement. Were you notified as to an adjustment, or audited, by either the Internal Revenue Service or a State taxing agency? If so, please provide a copy of the notice or report. Did you or your spouse make any gifts to any one individual or trust that totaled more than $14,000? If yes, please provide details. Did you inherit or purchase any real property in? If yes, please provide details. If you are claiming a deduction for business travel, meals & entertainment or gift expenses, do you have records to support these deductions? The law requires that adequate records are maintained for travel, entertainment and gifting expenses. The documentation should include amount, time, place and business purpose, description of gift(s) (if any), and business relationship of recipient(s) MISCELLANEOUS ESTATE Yes No Do you have a will or living trust which has been updated within the last 5 years? If you do not have a will or living trust, would you like a referral to estate attorneys? Have you designated appropriate primary and contengent beneficiaries for all of your insurance, investment and retirement accounts? Have those beneficiary designations been reviewed and updated by you as deemed necessary in? Miscellaneous Questions (Continued)

12 Page 12 ORGANIZER 1040 US Miscellaneous Questions CHARITABLE CONTRIBUTIONS - IMPORTANT Charitable contributions of any amount are no longer deductible unless you have a proper receipt. There have been recent court cases where the courts have disallowed significant deductions for charitable contributions where the taxpayers did not have a proper receipt. Since a receipt is required before we are allowed to claim a deduction for a contribution, please review the following documentation requirements and indicate whether or not you have the required documentation. If an item is not applicable, please indicate N/A in the yes or no column. Contributions Made In Cash or by Check, Debit/Charge Card. The law requires that you have a receipt, letter, or other written communication from the charity documenting all charitable contributions made in cash. For contributions make by check, the law requires that you either have a receipt, a copy of a canceled check, or some other bank record (e.g. bank statement.) For contributions made by debit or charge card, you are required to to either have a receipt or a bank record (e.g. bank statement, credit card statement, etc.) Please see the following additional requirements if the contribution is $250 or more. Yes No Do you have the required documentation for contributions made by cash, check, or debit/charge card? Contributions Of $250 Or More. For all contributions by individuals of $250 or more, the law requires a receipt (written acknowledgment) from the charity to which you made the donation and amount of contribution as well as a statement as to whether you received anything in return for your contribution. If you received goods or services in return for the contribution, the receipt must include a description and an estimate of the value of the goods or services received in return for the contribution. If the goods or services received consist solely of intangible religous benefits, the receipt must include a statement to that effect. For all charitable contributions of $250 or more, do you have the required documentation? Non-cash Contributions. Did you make non-cash contributions in? If so, and the total of all items for exceeded $500, please provide a copy of the receipt(s), the date(s) of contribution, the recipient(s) of the donation, as well as a list of items donated, along with their thrift shop values. Contributions of Clothing or Household Items. Generally, a deduction is not allowed for a charitable contribution of clothing or household items unless the items are in good used condition or better. Household items generally include furniture, furnishings, electronics, appliances, linens, and other similar items. Were your contributions of clothing or household items in good used condition or better? Miscellaneous Questions (Continued)

13 Page US Client Information 1 David L. Buterbaugh, P.C E. Morgan Trail, Ste. 15 Scottsdale, AZ Telephone number: Fax number: address: (480) (480) Tax Return Appointment Date: Time: Location: This tax organizer will assist you in gathering information necessary for the preparation of your tax return. Please add, change, or delete information as appropriate. CLIENT INFORMATION Filing Status Taxpayer Spouse Address Foreign Address Filing status (table) =married filing separate and lived with spouse Year spouse died, if qualifying widow(er) (2015 or 2016) First name and initial Last name Title/suffix Social security number..... Occupation Date of birth (m/d/y) Date of death (m/d/y) =blind First name and initial Last name Title/suffix Social security number..... Occupation Date of birth (m/d/y) Date of death (m/d/y) =blind In care of Street address Apartment number City State ZIP code Region Postal code Country Filing Status 1 = Single 2 = Married filing joint 3 = Married filing separate 4 = Head of household 5 = Qualifying widow(er) Series: 1 Client Information

14 Page US Client Information (continued) 1 p2 Please add, change or delete information for. CLIENT INFORMATION Home phone Taxpayer Contact Information Spouse Contact Information Work phone Work extension Daytime phone (table)..... Mobile phone Fax number address Home phone Work phone Work extension Daytime phone (table)..... Mobile phone Fax number address Driver's license no Daytime Phone 1 = Work 2 = Home 3 = Mobile Taxpayer Authentication Spouse Authentication Driver's license state Expiration date (m/d/y)..... Issue date (m/d/y) Theft protection PIN Driver's license no Driver's license state Expiration date (m/d/y)..... Issue date (m/d/y) Theft protection PIN p2 Series: Client Information (continued)

15 Page US Dependents 2 Please add, change or delete information for. DEPENDENTS Dependent Dependent First name Last name Title/suffix Date of birth (m/d/y) Date of death Date of adoption Social security number Relationship Type of Dependent 1 = Child living w/taxpayer 2 = Child not living w/taxpayer 3 = Dependent other than child 4 = Head of household only, not a dependent 5 = Earned income credit only, not a dependent Months lived at home Type of dependent (see table) Earned income credit (see table) Earned Income Credit Claimed by: 1=taxpayer, 2=spouse First name Last name Title/suffix Dependent Dependent 1 = When applicable (default) 2 = Student age 19 to 23 3 = Disabled 4 = Force 5 = Suppress Date of birth (m/d/y) Date of death Date of adoption Social security number Relationship NOTE: If you claim the earned income credit, please provide proof that your child is a resident of the U.S. This proof is typically in the form of: Months lived at home Type of dependent (see table) Earned income credit (see table) Claimed by: 1=taxpayer, 2=spouse First name Last name Title/suffix Date of birth (m/d/y) Date of death Dependent Dependent 1. School records or statement 2. Landlord or property management statement 3. Health care provider statement 4. Medical records 5. Child care provider records 6. Placement agency statement 7. Social service records or statement 8. Place of worship statement 9. Indian tribe office statement 10. Employer statement Date of adoption Social security number Relationship Months lived at home Type of dependent (see table) Earned income credit (see table) Claimed by: 1=taxpayer, 2=spouse First name Dependent Dependent NOTE: If your child is disabled, please provide one of the following forms of proof of disability: 1. Doctor statement 2. Other health care provider statement 3. Social services agency or program statement Last name Title/suffix Date of birth (m/d/y) Date of death Date of adoption Social security number Relationship Months lived at home Type of dependent (see table) Earned income credit (see table) Claimed by: 1=taxpayer, 2=spouse Series: Dependents

16 Page US Direct Deposit & Estimates (Form 1040 ES) 3, 6 Please enter all pertinent information. DIRECT DEPOSIT / ELECTRONIC PAYMENT (3) 1=direct deposit of federal tax refund into bank account =electronic payment of balance due =electronic payment of estimated tax BANK INFORMATION Percent to Deposit Name of Bank (xx.xx) Routing Number Account Number Type of Account (Table 1) Type of Invest. (Table 2) ESTIMATED TAX / 1040-ES (6) Federal Amount Paid Date Paid TS Overpayment applied from st quarter payment nd quarter payment rd quarter payment th quarter payment Voucher Amount Additional Estimated Tax Payments Paid with extension Former spouse SSN if joint estimates State Overpayment applied from st quarter payment nd quarter payment rd quarter payment th quarter payment Amount Paid Date Paid TS Voucher Amount Additional Estimated Tax Payments Paid with extension Type of Account 2 Type of Investment 1 = Savings 2 = Checking 1 = Checking or savings (default) 2 = Taxpayer's IRA (next year limits) 3 = Spouse's IRA (next year limits) 4 = Health savings account (HSA) 5 = Archer MSA 6 = Coverdell savings account (ESA) 7 = Other 8 = Taxpayer's IRA (current year limits) 9 = Spouse's IRA (current year limits) Series: 5100, 5400 (t=taxpayer, s=spouse, blank=joint) 3, 6 Direct Deposit & Estimates (Form 1040 ES)

17 1040 US Direct Deposit & Estimates (Form 1040 ES) (cont.) Page Please enter all pertinent information. APPLICATION OF OVERPAYMENT (7.1) If you have an overpayment of taxes, do you want the excess refunded?.. or applied to 2018 estimate?.... Other (please explain): 2018 ESTIMATED TAX INFORMATION Do you expect your 2018 taxable income to be different from? Yes No If "yes" explain any differences in income, deductions, dependents, etc.: Do you expect your 2018 withholding to be different from? If "yes" explain any differences: Yes No Series: 5400 (t=taxpayer, s=spouse, blank=joint) 7.1 Direct Deposit & Estimates (Form 1040 ES) (cont.)

18 Page US Wages, Pensions, Gambling Winnings 10, 13.1, 13.2 WAGES, SALARIES, TIPS (10) Name of Employer (Box c) Please enter all pertinent amounts & attach all W-2, W-2G and 1099-R forms. Last year's amounts are provided for your reference. 1=retirement plan (Box 13) 1=spouse Wages, Tips, Other Compensation (Box 1) Federal (Box 2) Social Security (Box 4) Tax Withheld Medicare (Box 6) State (Box 17) Local (Box 19) 2016 Wages PENSIONS, IRA DISTRIBUTIONS (13.1) Name of Payer Distribution code #2 Distribution code #1 1=IRA/SEP/SIMPLE Gross Distribution (Box 1) Taxable Amount (Box 2a) Tax Withheld Federal (Box 4) State (Box 12) Value of all IRAs at 12/31/ Distribution 1=spouse GAMBLING WINNINGS (W-2G) (13.2) Name of Payer 1=spouse Gross Winnings (Box 1) Tax Withheld Federal (Box 4) State (Box 15) Local (Box 17) 2016 Winnings GAMBLING LOSSES & WINNINGS (NON W-2G) (13.2) TS Total gambling losses Winnings not reported on Form W-2G Amount 2016 Amount Series: 11, 14, 19 (T=taxpayer, S=spouse, Blank=joint) 10, 13.1, 13.2 Wages, Pensions, Gambling Winnings

19 Page US Interest & Dividend Income 11, 12 Please enter all pertinent amounts & attach all 1099-INT, 1099-OID and 1099-DIV forms. Last year's amounts are provided for your reference. INTEREST INCOME (11) Name of Payer 1=taxpayer (also enter SSN & address for seller-financed mortgage) 2=spouse Banks, S&Ls, C/Us, etc. (Box 1) Interest Income Seller- Financed Mtg. (Box 1) U.S. Bonds, T-Bills (Box 3) Tax-Exempt Interest Total Municipal Bonds In-state Municipal Bonds Early Withdrawal Penalty (Box 2) 2016 Interest DIVIDEND INCOME (12) Name of Payer 1=tp 2=sp Total Ordinary Dividends (Box 1a) Dividend Income Qualified Dividends (Box 1b) Total Capital Gain Distrib. (Box 2a) U.S. Bonds (% or amt.) Tax-Exempt Interest Total Municipal Bonds In-state Muni-bonds (% or amt.) Foreign Tax Paid (Box 6) 2016 Dividends 11, 12 Series: 12, 13 Interest & Dividend Income

20 Page US Miscellaneous Income 14.1 Please enter all pertinent amounts and attach all 1099-MISC, SSA-1099, and RRB-1099 forms. Last year's amounts are provided for your reference. MISCELLANEOUS INCOME Amount 2016 Amount Taxpayer Spouse Taxpayer Spouse Social security benefits (SSA-1099, box 5) Medicare premiums paid (SSA-1099) =treat Medicare premiums paid as SE health ins.. Tier 1 RR retirement benefits (RRB-1099, box 5)... 1=lump-sum election for SS benefits Alimony received Taxable scholarships and fellowships Jury duty pay Household employee income not on W Excess minister's allowance Alaska permanent fund dividends Income from rental of personal property Income subject to S/E tax: Other income (1099-MISC, box 3, 8) TAX WITHHELD (not entered elsewhere) Federal income tax withheld State income tax withheld Local income tax withheld Series: 200 Miscellaneous Income

21 Page US State & Local Tax Refunds / Unemployment Compensation 14.2 Please add, change or delete information as appropriate. Be sure to attach all 1099-G forms. STATE AND LOCAL TAX REFUNDS / UNEMPLOYMENT COMPENSATION (Form 1099-G) 1099-G Amount Name of payer =spouse Unemployment compensation: Total received (Box 1) Overpayment repaid State and local refunds: State and local income tax refund, credit or offsets (Box 2) 1=city or local income tax refund Tax year for box 2 if not 2016 (Box 3) Federal income tax withheld (Box 4) RTAA payments (Box 5) Taxable grants: Federal taxable amount (Box 6) State taxable amount, if different Farm amounts: Agriculture payments (Box 7) =agriculture payments are from conservation reserve program Market gain (Box 9) Number of farm =box 2 is trade or business income (Box 8) State income tax withheld (Box 11) Name of payer =spouse Unemployment compensation: Total received (Box 1) Overpayment repaid State and local refunds: State and local income tax refund, credit or offsets (Box 2) 1=city or local income tax refund Tax year for box 2 if not 2016 (Box 3) Federal income tax withheld (Box 4) RTAA payments (Box 5) Taxable grants: Federal taxable amount (Box 6) State taxable amount, if different Farm amounts: Agriculture payments (Box 7) =agriculture payments are from conservation reserve program Market gain (Box 9) Number of farm =box 2 is trade or business income (Box 8) State income tax withheld (Box 11) Series: 15, 16 State & Local Tax Refunds / Unemployment Compensation

22 Page US Education Distributions (ESA's and QTP's) 14.3 Please enter all pertinent amounts and attach all 1099-Q forms. Enter qualified education expenses below that are not entered elsewhere. Last year's amounts are provided for your reference. ESA'S AND QTP'S (Form 1099-Q) Amount 2016 Amount Name of payer =spouse Qualified expenses: Higher education (net of nontaxable benefits) Elementary & secondary education (net of nontaxable benefits). Form 1099-Q: Gross distributions (Box 1) Earnings (Box 2) Basis (Box 3) Rollover: 1=nontaxable, 2=taxable (Box 4) Distribution type: 1=private 529, 2=state 529, 3=Coverdell ESA (Box 5)... ESA's only: contributions to this ESA Value of this account at 12/31/17 (plus outstanding rollovers)... Basis in this ESA as of 12/31/ Name of payer =spouse Qualified expenses: Higher education (net of nontaxable benefits) Elementary & secondary education (net of nontaxable benefits). Form 1099-Q: Gross distributions (Box 1) Earnings (Box 2) Basis (Box 3) Rollover: 1=nontaxable, 2=taxable (Box 4) Distribution type: 1=private 529, 2=state 529, 3=Coverdell ESA (Box 5)... ESA's only: contributions to this ESA Value of this account at 12/31/17 (plus outstanding rollovers)... Basis in this ESA as of 12/31/ Name of payer =spouse Qualified expenses: Higher education (net of nontaxable benefits) Elementary & secondary education (net of nontaxable benefits). Form 1099-Q: Gross distributions (Box 1) Earnings (Box 2) Basis (Box 3) Rollover: 1=nontaxable, 2=taxable (Box 4) Distribution type: 1=private 529, 2=state 529, 3=Coverdell ESA (Box 5)... ESA's only: contributions to this ESA Value of this account at 12/31/17 (plus outstanding rollovers)... Basis in this ESA as of 12/31/ Series: 15, 16 Education Distributions (ESA's and QTP's)

23 Page US ABLE Distributions 14.4 Please enter all pertinent amounts. Last year's amounts are provided for your reference. ABLE DISTRIBUTIONS / CONTRIBUTIONS Amount 2016 Amount Name of payer or issuer =spouse Distributions (1099-QA): Gross distributions (1) Earnings (2) Basis (3) =program to program transfer (4) =ABLE account terminated (5) =recipient is not the designated beneficiary (6) Qualified disability expenses paid Amount excluded from 10% tax Excess contributions: Excess contributions withdrawn by due date of return..... Earnings on excess contributions Name of payer or issuer =spouse Distributions (1099-QA): Gross distributions (1) Earnings (2) Basis (3) =program to program transfer (4) =ABLE account terminated (5) =recipient is not the designated beneficiary (6) Qualified disability expenses paid Amount excluded from 10% tax Excess contributions: Excess contributions withdrawn by due date of return..... Earnings on excess contributions Name of payer or issuer =spouse Distributions (1099-QA): Gross distributions (1) Earnings (2) Basis (3) =program to program transfer (4) =ABLE account terminated (5) =recipient is not the designated beneficiary (6) Qualified disability expenses paid Amount excluded from 10% tax Excess contributions: Excess contributions withdrawn by due date of return..... Earnings on excess contributions Series: 3000 ABLE Distributions

24 Page US Business Income (Schedule C) 16 Please enter all pertinent amounts. Last year's amounts are provided for your reference. GENERAL INFORMATION Principal business/profession Principal business code Business name, if different from Form Business address, if different from Form City, if different from Form State, if different from Form ZIP code, if different from Form Foreign region Foreign postal code Foreign country Employer identification number Other accounting method Accounting method: 1=cash, 2=accrual Inventory method: 1=cost, 2=lower cost/market, 3=other =change of inventory method =spouse, 2=joint =first Schedule C filed for this business If required to file Form(s) 1099, did you or will you file all required Form(s) 1099: 1=yes, 2=no.. 1=not subject to self-employment tax =did not "materially participate" =personal services is not a material income producing factor =investment =minister's Schedule C =single member limited liability company =trader in financial instruments or commodities INCOME Amount 2016 Amount Gross receipts or sales (Form 1099-MISC, box 7) Returns and allowances Other income: COST OF GOODS SOLD Inventory at beginning of the year Purchases Cost of items for personal use Cost of labor Materials and supplies Other costs: Inventory at end of the year Series: 51

25 Page US Business Income (Schedule C) (cont.) 16 p2 Please enter all pertinent amounts. Last year's amounts are provided for your reference. EXPENSES Amount 2016 Amount Accounting Advertising Answering service Bad debts from sales or service Bank charges Car and truck expenses (not entered elsewhere) Commissions Contract labor Delivery and freight Dues and subscriptions Employee benefit programs Insurance (other than health) Mortgage interest (paid to banks, etc.) Other interest (not entered elsewhere) Janitorial Laundry and cleaning Legal and professional Miscellaneous Office expense Outside services Parking and tolls Pension and profit sharing plans - contributions Pension and profit sharing plans - admin. and education costs Postage Printing Rent - vehicles, machinery, & equipment (not entered elsewhere) Rent - other Repairs Security Supplies Taxes - real estate Taxes - payroll Taxes - sales tax included in gross receipts Taxes - other (not entered elsewhere) Telephone Tools Travel Total meals and entertainment in full (50%) Department of Transportation meals in full (80%) Uniforms Utilities Wages Other expenses: NOTE: If you purchased or disposed of any business assets, please complete Sheet p2 Series: 51 Business Income (Schedule C) (cont.)

26 Page US Capital Gains & Losses (Schedule D) 17 If you sold any stocks, bonds, or other investment property in, please list the pertinent information for each sale below or provide a spreadsheet file with this information. Be sure to attach all 1099-B forms and brokerage statements. Quantity Description of Property (Box 1a) Date Acquired (Box 1b) Date Sold (Box 1c) Sales Price (gross or net) (Box 1d) Cost or Basis (Box 1e) Blank=basis rep. to IRS, 1=nonrec. security (Box 3, 5) Expenses of Sale (if gross sales price entered) Federal Income Tax Withheld (Box 4) 17 Series: 52 Capital Gains & Losses (Schedule D)

27 Page US Installment Sales (Form 6252) 17 p2 Please enter all pertinent amounts. Last year's amounts are provided for your reference. PRIOR YEAR INSTALLMENT SALE Amount 2016 Amount Description of property Date acquired (m/d/y) Date sold (m/d/y) Gross profit ratio (.xxxx) Current year principal payments (-1 if none) Description of property Date acquired (m/d/y) Date sold (m/d/y) Gross profit ratio (.xxxx) Current year principal payments (-1 if none) Description of property Date acquired (m/d/y) Date sold (m/d/y) Gross profit ratio (.xxxx) Current year principal payments (-1 if none) Description of property Date acquired (m/d/y) Date sold (m/d/y) Gross profit ratio (.xxxx) Current year principal payments (-1 if none) Description of property Date acquired (m/d/y) Date sold (m/d/y) Gross profit ratio (.xxxx) Current year principal payments (-1 if none) Description of property Date acquired (m/d/y) Date sold (m/d/y) Gross profit ratio (.xxxx) Current year principal payments (-1 if none) Description of property Date acquired (m/d/y) Date sold (m/d/y) Gross profit ratio (.xxxx) Current year principal payments (-1 if none) p2 Series: 52 Installment Sales (Form 6252)