ROLAND & DIELEMAN 2018 TAX WORKSHEET

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1 ROLAND & DIELEMAN 2018 TAX WORKSHEET FARM TH Ave. Grinnell, IA (641) West 3 rd Street Tama, IA (641) (Grinnell) (641) (Mon./Sat.) th St. Sully, IA (641) (Mon.) Taxpayer SS# Occupation Birth date Taxpayer SS# Occupation Birth date Address City State Zip Phone No. Cell Phone # County # School District Address PLEASE ATTACH A VOIDED CHECK IF YOU WANT DIRECT DEPOSIT OF YOUR TAX REFUND PROVIDING A CHECK EACH YEAR HELPS US TO VERIFY THE CORRECT ACCOUNT Note: SOCIAL SECURITY NUMBERS ARE NEEDED FOR ALL NEWBORNS! Dependents Birth Date SS # Relationship W-2 INFORMATION (Please bring in copies of W-2 forms) *Taxpayer or Spouse Employer T or S* Amount PENSIONS, IRAS, LUMP-SUM DISTRIBUTIONS, GAMBLING (Bring all 1099 Information Forms) *Taxpayer or Spouse I hereby verify that the income and expense information filled out on this worksheet can be substantiated. Signature of Taxpayer

2 OTHER INCOME (Bring 1099 Information Forms) Unemployment Social Security (Gross) Alimony Received Taxpayer Spouse OTHER EXPENSE IRA Contributions Keogh/SEP Contribution Early Withdrawal Penalty Interest Alimony Paid Student Loan Interest Paid Classroom Materials paid by teachers Did you and your dependents have health insurance in 2018? YES No Please bring form 2095-B or 1095-C if you received one. Did you purchase health insurance through the health insurance market place? Yes No If so, please provide form 1095-A issued by the exchange. INTEREST INCOME (Bring 1099s to your appointment) *Joint, Taxpayer or Spouse J, T, S* Amount DIVIDEND INCOME (Bring 1099s to your appointment) MEDICAL DEDUCTIONS Medical Insurance (To Whom) Medical Insurance is Pretax After Tax Medical Insurance Nursing Home Medical, Dental, Opticians, Hospitals MSA or HAS Contribution Number of miles for medical

3 TAXES Real Estate Vehicle License INTEREST EXPENSE Home mortgage* Mortgage Insurance as Reported on 1098 Home mortgage paid To individual (To Whom, Address, SS#) CONTRIBUTIONS Cash (with receipts/checks) Other than Cash (Goodwill, Salv. Army, etc.) Please bring receipts Union/Prof. Dues Unreimbursed employee Business expense Uniforms & safety shoes Req. Educ. Costs (list) Adoption Expense Detail Points Investment Expense Please bring form received from Tax Preparation Financial institution (Form 1098) # of business nights away from home POST-SECONDARY EDUCATION EXPENSES Private School Tuition Grade level of student Tuition Paid Books We must have form 1098-T from the college or university. Expenses for school registration, book fee, drivers education, athletic shoes, musical instrument rental Did you make a contribution to the Iowa College Savings Plan in 2018? provide receipt. Did you make a contribution to a Qualified Iowa School Tuition Organization? certificate. If so, please Please bring Did you make improvements to increase the energy efficiency of your home? What was the cost? Description Cost (Credit not available if you already used 500 in prior years) Solar Water Heating Equipment Did you purchase a home in 2018? (Please bring a copy of the closing statement for the purchase or sale of your residence)

4 Did you suffer a casualty loss from severe storms, tornadoes or flood? Amount and date of loss Date Were you a member of a volunteer fire department or a first responder? CAPITAL GAINS AND LOSSES Please enclose copies of ALL 1099 forms and other documents relating to sale. Description of property Taxpayer Spouse Joint Date acquired (Mo, day, yr) Date sold (Mo, day, yr) Sales Price Cost or other basis LOSS GAIN CHILD AND DEPENDENT CARE EXPENSES Child Care Provider Address, City, State, Zip SS#or EI# Paid Property A Property B Property C RENTAL & ROYAL INCOME Rents received Royalties received RENTAL & ROYALTY EXPENSES Advertising Auto & travel Cleaning & maintenance Commissions Insurance Legal & other professional fees Mortgage interest Other interest Repairs Supplies Taxes Utilities Other Business miles / rental activities

5 FARM INCOME Sale of LIVESTOCK RAISED, Except Dairy & Breeding Stock Number Kind of Animals HOGS CATTLE SHEEP Sale of LIVESTOCK PURCHASED, Except Dairy & Breeding Stock Number Kind of Animals Sale Price Cost HOGS CATTLE SHEEP Sale of SOWS, DAIRY, OR BREEDING Animals Date Purchased Cost Number Kinds of Animals or Raised Date Sold Sale Price (if purchased)

6 Seed Corn or Beans Raised Dairy Product Sold Wool Sold Corn Sold Beans Sold Other Grain Sold Hay and Straw Sold Seed Sold Machine work Patronage dividends (Gross amount) (Bring 1099) U.S. Gov t payments (Bring 1099) Fed. Gasoline Tax Credit St. Gas Tax Refund received or credit Insurance received (Bring 1099) Grain Sealed

7 FARM EXPENSES Truck expense Auto expense: Total Farm Share % Miles Chemicals Soil and conservation expense Machine hire Feed bought Fertilizers and lime Freight and trucking paid Fuel (gas, oil, grease: for tractor, tank heater and dryer) Insurance on buildings, machinery, stock and crops (exclude residence & contents) Interest on business debts Farm Labor - wages Taxes Deducted Farm Labor - No taxes deducted Cash rent paid Repairs Seeds bought Storage and warehousing Supplies and small tools bought Property taxes paid to County (exclude residence) Electricity and telephone, Total Farm Share % Water % Personal Veterinary and stock medicine Breeding fees paid

8 OTHER FARM BUSINESS EXPENSES Farm organization dues Farm papers or journals Bank service charge and deposit box Business travel expense (other than by personal car or truck) Legal business fees and tax work Meals for hired help Number of meals Payroll taxes - employer share Advertising Livestock Registrations CCC Grain Repurchased CCC repayment Other farm expenses (specify): Marketing expense Retirement Plan No. of gallons of gasoline purchased for farm purposes (non highway) gallons

9 CAPITAL EXPENDITURES Improvements (Include Cost of Labor and Materials) New building Kind Date New feed floors Kind Date New fences Kind Date Drain tile Kind Date Other Kind Date Other Kind Date Other Kind Date Other Kind Date NEW OR USED MACHINERY BOUGHT Description Item traded, GVW (Indicate New/Used) Date Cost Cash Paid if any (Vehicles)

10 MACHINERY OR OTHER CAPITAL ASSETS SOLD Description Date Bought Date Sold Sale Price Cost DAIRY OR BREEDING STOCK PURCHASED IN 2017 Expected Description Date Cost Yrs of Use

TAX ORGANIZER Page 3

TAX ORGANIZER Page 3 TAX ORGANIZER Page Basic Taxpayer Information Taxpayer Spouse Taxpayer Spouse First Name Initial Last Name Social Security No. Check if Date of Occupation Dependent Presidential Birth Disabled Blind of