N E W B U R G H T A X S E R V I C E newburghtaxservice.com 4155 State Route 261, Newburgh, IN 47630 812.858.1040 PREFERENCES Tax Return Copy: Paper Copy PDF on CD Notifications: Phone Text Refund: Paper Check Direct Deposit 2019 Tax Organizer: E-mail Mail TAXPAYER & SPOUSE (Circle best contact.) Name Social Security # Occupation Date of Birth Blind Tx Y N Sp Y N E-mail: Mailing Address: Tx #: Sp #: Zip: FILING STATUS S, MFJ, MFS, HH, QW Are you married? If yes, do you want to file jointly? UNSURE Did your marital status change in 2018? MARRIED DIVORCED DATE: Are you a dependent? Who lived with you? Check all that apply SPOUSE OTHER RELATED ADULT UNRELATED ADULT NO ADULTS Did everyone in your household have health insurance for all of 2018? Please provide proof of coverage: 1095-A 1095-B 1095-C HOUSEHOLD MEMBERS and / or DEPENDENTS Name on Social Security Card Social Security # Relationship Date of Birth U.S. Citizen? Income Full-time Student? 1 Y N Y N 2 Y N Y N 3 Y N Y N 4 Y N Y N 5 Y N Y N Was any dependent s unearned income more than $1,050? Did any dependent receive Social Security benefits? CHILDCARE PROVIDER Street Address, City, State Zip ID # Child: Child: Child: Do you use Dependent Care Benefits through your employer? Do you pay for childcare or domestic service in your home? M # A D M L Intvw Data Prep Ck Asmb Sign Notify ID DD Cl Sign P/U E-file Post Rvw Date Initial State Only Paper 8453 KY:Ppr Folder Multi-bill B4 Pd Xtra Doc Ref Src:
2 Mark Type PLEASE BRING ALL TAX STATEMENTS Taxpayer Spouse How many W-2s did you receive? Did you receive tips not reported to your employer? $ $ Did you receive interest on checking or savings accounts? Did you receive a distribution from a retirement account? Enter on last page. Enter on last page. Did you receive Social Security benefits? $ $ Did you receive unemployment compensation? $ $ Did you receive gambling or lottery winnings, a prize or an award? $ $ Did you have any debt cancelled, a foreclosure, or bankruptcy? $ $ Did you receive any other taxable or non-taxable income? $ $ Jury Duty Alimony Election Royalty Legal Settlement Babysitting Spiff K-1 Crops Hobby Child Support VA Benefits Other Did you BUY SELL REFINANCE Real Estate? If Yes, bring Closing Disclosure. Did you pay mortgage interest? If yes, attach 1098 $ Did you make energy improvements to your primary residence? Did you sell used items or collectibles? Type? Did you own any type of crypto currency, such as Bitcoin, at any time during 2018? Did you have a health savings account? Did you contribute money to a Roth or Traditional IRA? Enter on last page. Did you pay student loan interest? If yes, attach 1098-E $ Did you gift or transfer money, investments, or Real Estate to another person? Did you receive stock or Real Estate transferred into your name or as a gift? Were you a beneficiary of an inheritance, estate or trust? Do you have a foreign bank account or signature authority over a foreign account? Did you receive any notice from the IRS or a state taxing authority? STATE TAX QUESTIONS Did you pay property tax on a primary residence? $ Did you rent? # Months: Rent: $ Landlord/Address: County of residence on 1-1-18 for: Taxpayer: Spouse: County of employment on 1-1-18 for: Taxpayer: Spouse: Was your child enrolled in K-12 private or home school? Did you pay Indiana long term care insurance premiums? $ Did you contribute to a 529 savings account? $ How many enrolled? Did you donate to an Indiana college? School: Date: Amount: $ Did you buy on-line without paying sales tax? Amount purchased: $ EDUCATION CREDITS Student: Student: Student: What grade level in school? Did your employer pay any of the tuition? What did you pay for books and supplies? Did you receive a 529 distribution? Please provide: 1098T 1099Q Record of tuition charges and payments
ITEMIZED DEDUCTIONS MEDICAL Health insurance (Do not include premiums paid through employer) $ Long-term care insurance $ Medical, dental, optical, prescriptions (Do not include amounts paid by insurance, FSA, HSA or MSA.) $ Medical mileage Amount 3 TAXES Prior year(s) state / local tax balance due paid in 2018 $ Real Estate taxes on primary residence $ Real Estate taxes on other property $ Vehicle Excise Tax and Wheel / Sur Tax (from registration form) $ Sales tax on vehicles, boats, and motor homes $ INTEREST Did you pay interest that was not reported on a 1098 form? Do you own a second home, vacation home, cabin, motorhome, or houseboat? 1098 1098 1098 Interest Address of property securing the loan Primary or secondary residence? Prim / Sec / Neither Prim / Sec / Neither Prim / Sec / Neither Were the loan proceeds used to buy the same property that secures the loan? Is this the original mortgage? Refinance date, if applicable Payoff: Amount borrowed on new loan: If borrowed more than payoff, for what was the additional money used? Points: Loan Term: years years years CHARITABLE CONTRIBUTIONS Monetary Do you have receipts or canceled checks for all donations? $ Non-cash Do you have receipts listing item descriptions & used values? $ OTHER Gambling / lottery losses $ Casualty / theft loss in a federally declared disaster area Approximate loss $ Investment interest $
4 BUSINESS USE VEHICLES Vehicle 1 Vehicle 2 Vehicle 3 Vehicle year, make and model Business miles Commuting miles Odometer reading 01-01-18 Odometer reading 12-31-18 Loan interest Lease payments Gas, oil, service, repair, insurance, plates, carwash, etc. Vehicle registration Do you have WRITTEN evidence to support deductions? If a vehicle was purchased, traded or sold, please provide paperwork. Business Use BEGAN in 2018 Business use began on what date? What was the vehicle worth on that date? When was the vehicle purchased / leased? What was the price / leased value? Business Use ENDED in 2018 Business use ended on what date? On what date was the vehicle sold / traded? What was the sale price or trade in allowance? HOME OFFICE For a first year home office, bring the original purchase closing disclosure. Did you make improvements to your home? Did you make improvements to your home office? Is the office used regularly and exclusively for business administrative/management activities? Is there another fixed location where you conduct substantial administrative business activities? Do others use the office for computer, employment, or personal purposes? Do you meet with clients or store inventory in your home? Do you use your office to perform work for your employer? Sq ft Office Sq ft Home Gas / Electric Water Sewer Trash P/U Insurance General Repairs Cleaning Lawncare Pest Control Alarm Fees
INTEREST & DIVIDENDS (1099-INT / 1099-DIV) Source Interest Dividend Qualified Dividend Capital Gain Distribution Tax Exempt Fed. Tax Withheld Foreign Tax 7 % US CAPITAL GAINS / LOSSES (1099-B / 1099-S) Examples: Stock, Mutual Funds, Property, Collectibles, etc. Description Date Sold Date Acquired Sale Price Original Cost Sale Expense RETIREMENT / ANNUITY / HSA / ABLE (1099-R / 1099-SA) Examples: Pension, 401-K, IRA, Roth, etc. Source Type Box 7 Distribution Contribution Rollover Exception Charity Is your HSA: Self-Only Family Were all distributions used for medical expenses? ESTIMATED TAX PAYMENTS Do you want Newburgh Tax Service to calculate 2019 estimates? 2017 Refund 1 st Qtr 2 nd Qtr 3 rd Qtr 4 th Qtr Extension Apply 2018 Applied to 18 Date Pd: Date Pd: Date Pd: Date Pd: Payment refund to 19 Federal $ State $ You may this space or the back of this page for additional questions, notes and information. Privacy Policy Notice - Pursuant to FTC Rule 16CFR 313, Newburgh Tax Service does not disclose information provided to us by you to any third party without your written permission, except to the extent permitted by law with a subpoena or summons. Access to information is restricted to our employees and management. We maintain physical, electronic, and procedural safeguards to protect your information. I hereby affirm that the information provided to Newburgh Tax Service (NTS) for my 2018 tax return is accurate and complete to the best of my knowledge. NTS may ask for clarification, but will not verify all information. NTS s liability to me for the service performed is limited to the fee I pay. If information provided to NTS is inaccurate or incomplete, NTS is relieved of all liability. I will maintain all supporting documents and records that may be requested by a taxing authority upon examination. Taxpayer / Spouse Date Witness Date