Nelson D. Blinn, CPA Frank J. Farrell, CPA BLINN, FARRELL & COMPANY CERTIFIED PUBLIC ACCOUNTANTS 60 Bailey Boulevard Haverhill, MA 01830 Telephone (978) 372-8518 Fax (978) 372-6462 www.blinnfarrell.com Lucien R. Lacroix, CPA Robert B. Leavitt, CPA January 31, 2016 Dear Client: It is very important that you read this letter and complete the attached questionnaire. The cost of preparing your tax return depends on how well the information is organized when we receive it. Organize your information according to the different categories listed in the questionnaire. This reduces our time in preparing your return and also gives you a chance to review your information to see that everything has been included. The way your information comes to us is very important in achieving efficiency in the preparation of your return and is the key to keeping preparation costs down. Please return the organizer with all related documents, including Forms W-2, 1098, 1099-B, (with proper dates of stock purchases and sales), and all other 1099s and K-1 s to our office as soon as possible so we can begin your tax preparation. Federal government requires Health Coverage for all individuals. Please provide us with your Form 1095-A (insurance purchased through marketplace) or Form 1095-B (insurance purchase through private company). Massachusetts law states that residents age 18 and over must have health insurance. If insured, your insurance company will provide you with Form 1099-HC. Please be sure to include 1099HC with your tax information. To all clients who make estimated tax payments, please take your time to properly complete the section on page 4 of the attached form. Direct Deposit of your refund can be arranged as long as you provide a voided check when submitting your tax information. Bank account information must be provided prior to the preparation of your return. If you have any questions regarding the attached questionnaire, or other tax-related matters, please do not hesitate to contact our office. Very truly yours, Blinn, Farrell & Company 1
BLINN, FARRELL & COMPANY 2015 INCOME TAX DATA QUESTIONNAIRE SECTION 1 PERSONAL: Name Taxpayer: Spouse Name (as shown on Social Security card): Address City State Zip Telephone # (Work) (Cell) (Home) Email address: Your Social Security # Date of Birth: Spouse s Social Security # _Date of Birth: _ Occupation(s): Spouses Occupation: Filing Status: Single Married Joint/Separated Head of Household Do you have a Will: Yes No SOCIAL SECURITY INFORMATION (Provide Form SSA-1099): Amount of Social Security received: Husband Wife Amount withheld for Medicare insurance: Husband Wife Amount withheld for taxes: Husband Wife Do you wish to designate $3 of your taxes to the presidential election campaign funds? Yes No Does your spouse wish to contribute? Yes No Dependent Information: Full Time Student Name Social Security # DOB: Yes or No Name Social Security # DOB: Yes or No Name Social Security # DOB: Yes or No Name Social Security # DOB: Yes or No Please note: All Children are required to have a social security number in order for you to claim them as dependants Also, dependents under age 19 or full-time students under age 24 must file if they have unearned income in excess of $2,100. Do you have children in college? Yes No If yes, what year is student in college: 1 st 2 nd 3 rd 4 th Education Loan Interest: Tuition paid in 2015: Loan origination date: Related Education Expenses: (books, etc.) 2
SECTION 2 INCOME: Please indicate which types of income items you have. We will need all pertinent records and documents, including original W-2 s, 1099 s and K-1 s relative to partnerships, trusts, etc. Wages (forms W2) Pensions (1099R) Commissions # of W-2 forms Annuities Director Fees Interest (forms 1099) # of 1099 forms (Attach Royalties (bonuses & prizes) Alimony list of banks, stocks, bonds, healthcare, etc.) Dividends (forms 1099) Subchapter S Tips # of 1099 forms Partnerships Unemployment Compensation Rental Income & Expenses (attach itemized list) Estates Farm Business Trusts Lottery & Gambling income Sales of securities, personal residence or other property Debt Forgiven (supply detail) Foreclosure Proceedings (supply details) Were you a grantor or transferor for a foreign trust, have an interest in or a signature or other authority over a bank account, securities account, or other financial account in a foreign country? Yes No No. of Date Purchase Date Sales Description Shares Acquired Cost Sold Price / / $ / / $ / / $ / / $ / / $ / / $ SECTION 3 DEDUCTIONS: Medical: Taxes: Health Insurance premium (not Medicare) Real Estate $ Long-term health care insurance Medicine and drugs Personal Property Doctors, dentists, etc. Excise/county-vehicles Medical transportation miles Other: Hospital Sales tax on: Nursing Home Automobiles, boats, RVs or Cash reimbursements received Airplanes By you Other Interest: Home mortgage Other (equity, etc.) 3
SECTION 3 DEDUCTIONS (continued): Please complete this section accurately to avoid receiving government notices. Balance of 2014 taxes paid in 2015 (Please fill in date paid) Date Federal State Estimated payments for 2015:) (Please fill in date paid) Date Federal State Contributions*: Other Deductions: Subscriptions Cash, Credit Card or Check $ Safety deposit box Non cash Charitable Contribution $ Tax preparation fees Charitable Mileage Investors expenses Union dues *All charitable contributions must have a receipt, which Job Search Costs must be kept in your possession. Business mileage** Vehicle used Date in service Total mileage: ** (Adequate records must substantiate all business travel/mileage deductions. Mileage logs must be maintained for all vehicles used in a trade or business. Failure to maintain these logs could result in a disallowance of the deduction). Massachusetts Renters: Landlord s name and address: Rent paid in 2015 $ If not entire year then date from to 2015. 4
SECTION 4 OTHER DEDUCTIIONS OR CREDITS: Check item(s), which you feel you are entitled a deduction or tax credit on your 2015 income tax return. Taxpayers are required to have complete substantiation of travel and entertainment expenses. Disability income exclusion Moving expenses Foreign tax credit Casualty or theft loss(es) Retirement plan (IRA,Keough) ***Expenses for work related childcare Education expenses to improve skills (in present occupation) Gambling Losses Employment fees Employee business expenses or outside salesman s exp. Alimony paid Credit for federal tax on off-highway fuel Forfeited interest penalty for premature withdrawal Adoption expenses Other Teacher - Educator Costs *** Internal Revenue Service will not recognize this deduction without the name, address and taxpayer identification number of the childcare provider. Provider Name & Address: Federal ID# Did you make any gifts of more than $14,000 to any individual(s) in 2015? Yes No Did you make any energy efficient improvements, i.e. solar, wind, geothermal. If yes, describe type and cost: Type: Cost: INSURANCE: Did you enroll for lower cost marketplace coverage through Healthcare.gov under the Affordable Care Act? Yes No (If yes, please provide Form 1095-A) MASSACHUSETTS RESIDENTS: Massachusetts Commuting Expenses paid in 2015: Fast Lane account $ MBTA Passes (bus, rail or boat) $ Lead Paint Credit Amount paid for deleading $_ MASSACHUSETTS RESIDENTS OVER 65 YEARS OLD: *Rent paid in 2015 $ *Real Estate tax paid in 2015 $ *Water & Sewer bill paid in 2015 $ Did you receive any Federal and/or State subsidiary? Yes No If you own your own home, what is your assessed value, per your real estate tax bill? $ (Please provide us with a copy of this documentation) 5
MASSACHUSETTS RESIDENTS IN 2015 (This information must be completed to file your Massachusetts tax return.) Massachusetts Use Tax due on Out-of-State purchases made in 2015: A Massachusetts use tax is due on your taxable purchases from out-of-state businesses of tangible personal property purchased for use in Massachusetts on which you did not pay Massachusetts sales or use tax. The use tax does not apply to out-of-state purchases that are exempt from the sales tax (for example: clothing that costs $175 or less). Examples of taxable items include: computers, furniture, jewelry, cameras, appliances, and any other item that is not exempt. Generally, anyone who pays a sales or use tax to another state or territory of the United States on tangible personal property to be used in Massachusetts is entitled to a credit against the Massachusetts use tax, up to 6.25%. This credit is allowed for sales or use tax paid to another state only if that state has a corresponding credit similar to the Massachusetts credit. See TIR 03-1 for more information. Prepare and retain with your records a list of your out-of-state purchases in 2015 that are subject to the Massachusetts use tax. Complete the worksheet below to calculate your use tax. If there were no purchases in 2015, please check here. For more information about use tax, visit DOR s website at www.state.ma.us/dor Form 1, Line 33 Worksheet Use Tax Due on Out-of-State Purchases Line 1. Total of purchases in 2015 subject to Massachusetts use tax Line 2. Use tax. Multiply Line 1 by.0625 (6.25%) Line 3. Credit for sales/use tax paid to other states or jurisdictions. Add the amount of any sales/use tax paid to another state or jurisdiction, or 6.25% of the sales price, whichever is less, on each purchase reported on Line 1 Line 4. Total amount due. Subtract Line 3 from Line 2. Not less than 0. 6