Tax Year INDIVIDUAL TAX PREPARATION CHECKLIST

The Miller Associates 820 N River Street Loft 206 Portland, OR 97227 www.themillerassociates.com 503-891-6659 Fax 503-280-1100 INSTRUCTIONS: Tax Year INDIVIDUAL TAX PREPARATION CHECKLIST If this is your first year with The Miller Associates, please include a copy of your most recently filed tax return. Name: Taxpayer SS No. Birthdate/Age _ Spouse SS No. Birthdate/Age _ Address: Telephone (Home) ( ) Telephone (Work) ( )_ Cell Phone: Taxpayer Spouse Email Address: Taxpayer Spouse Occupation: Taxpayer Spouse Check One: Single Married Filing Joint Surviving Widow/Widower Married Filing Separately (enter spouse s name/ss No. Above) Unmarried Head of Household Dependents Name Birthdate/ Age Social Security Number* Relationship No. of Months lived in your home in 2015 No. of Months of Qualifying Healthcare Coverage *A personal exemption is disallowed for any dependent unless the Social Security number is provided on the tax return. Members of your family attending college may make you eligible for an American Opportunity Credit, Lifetime Learning Credit, or Tuition and Fees Deduction. # Students Taxpayer: 65 or over Blind/Disabled Spouse: 65 or over Blind/Disabled Estimated Tax Payments 1 st Quarter 2 nd Quarter 3 rd Quarter 4 th Quarter Federal State City Date Paid Date Paid Date Paid Date Paid TOTAL

Wage Income Employer s Name T or S Wages Federal W/H FICA Medicare State W/H City W/H Retirement Benefits Received (Enclose all 1099R Forms) Payer T or S Plan Type Payer T or S Plan Type Interest Income (Enclose all 1099-INT Forms) Payer T or S Seller Financed Mortgage Early Withdrawal Penalty Tax Exempt (Y or N) Total Municipal Bond Interest Earned in 2015: $ For seller financed mortgage: Buyer s name, Social Security number and addresses: Dividend Income (Enclose all 1099-DIV Forms) Payer T or S Total Qualified Dividends Capital Gain Dist. Non-Taxable Do you have funds in a foreign account? Yes No Did you have any stock sales in 2015? If yes, submit all 1099B forms. Yes No Installment Sale Payments Received: Interest $ Principal $ Buyer s name: SS # Address: Other Benefits/Income Received (Enclose all 1099, SSA-1099, K-1s and other Misc. Forms) Taxpayer Social Security Unemployment Alimony State Refund Other Spouse 2

Capital Assets Sold (Securities, Real Estate, etc.) Attach Forms 1099B and 1099S Description of Property Date Acquired Date Sold Sale Price Depreciation Taken (if applicable) Cost or Basis *To qualify for long term capital gain rates, assets sold must have been held for more than one year. Rental Income (Attach 1099 Forms) Please use our Retal Worksheet to provide your Schedule E expenses. Improvements to Personal Residence Note: If you refinanced your home this year, please bring a copy of your closing statement. For Schedule C, E, F, 2106 Description Date Purchased Cost 3

Business Income (Attach 1099-MISC Forms) Farm Income (Attach 1099 Forms) Please use our Sole Proprietor Checklist and Business Expenses Catagories Worksheet to include your Schedule E and/or F income/expenses 4

Retirement Contributions for 2015 Do you want to make any nondeductible IRA contributions? Yes Taxpayer Spouse IRA or Roth, Specify SEP Keogh Other: No Personal Itemized Deductions Medical Prescription Drugs. Medical Insurance Premiums.... Long Term Care Ins. Premiums Medicare Premiums.. Doctors/Dentists Clinic/Lab Tests Hospitals Eyeglasses/Hearing Aids.. Orthopedic Shoes/Braces.. Medical Long Distance Phone. Other...... Miles... Fares: Taxi, Bus, etc... Do you have a medical savings acct.? Interest Deductible Home Mortgage Interest Paid to Financial Institutions Home Equity Interest.. Deductible Home Mortgage Interest Paid to Individuals:* Name Address:* Social Security No.:*_ *Failure to provide is subject to a $50 penalty. Deductible Points (Include Amortization Points from Prior Years) Investment Interest (list)......... Taxes Real Estate.... Personal Property. State & Local Income Tax State & Local General Sales Tax.*...... *Not yet extended Charitable Contributions Cash Contributions*............ Other Than Cash Contributions. _... _... Miles for Charity *Contributions of $250 or more require written substantiation from the organizations. Miscellaneous Deductions Subject to 2% AGI Unreimbursed Employee Business Expense Union & Professional Dues Safe Deposit Box Rental.. Tax Return Preparation Fee. Business Publications Business Telephone Calls Tools, Supplies, Equipment Employment-Related Education Investment Expenses Other_... Miscellaneous Deductions Not Subject to 2% AGI Gambling Losses (limited to winnings).. Household Employee Information Household Employer EIN: Did you pay any one household employee $1,900 or more in 2015? Yes No Did you withhold Federal income tax during 2015 at the request of any household employee? Yes No Did you pay total cash wages of $1,000 in any calendar quarter of 2015 to household employees? Yes No Was the employee under age 18? Yes No Student? Yes No Do you have a Form I-9 on file for your household employee? Yes No Household Employee Name: Social Security Number: Address: Gross Wages FITW SS Withheld Employer Share FICA Advance EIC FUTA State Unemployment Moving Expenses Enter No. of miles from your old home to your new workplace _. Enter No. of miles from your old home to your old workplace. Date of Move Arrival at New Location Cost to Ship and Pack Household Goods Reimbursements (on W-2)? Yes No Cost to Travel to New Home. Other: Cost of Lodging during Move 5

Employee Business Expense Please use our Employee Business Worksheet to provie your employee business expenses. Child Care Deductions (Number of Dependents Qualifying:_) Provider s Name & Address (Include Individual s Name and/or Org. Name) SS No. or Federal ID Did you receive employer-provided dependent care assistance benefits? Yes No : $ Sale of Personal Residence (Attach copy of closing/settlement statement) Date Old Residence Acquired Cost or Basis of Old Residence Cost of Improvements (landscaping, driveway, roof, etc.) Date Old Residence Sold Selling Price Expenses of Sale (commissions, legal fees, points, deed stamps, etc.) Was any part of residence rented or used for business? Was it your principal place of residence for 2 of the last 5 years, ending on date of sale? Date New Residence Acquired (or construction began) Date you occupied new residence Cost of New Residence If married do you and/or your spouse meet the ownership and residence requirements? Do you wish to designate your tax preparer or someone else to be contacted by the IRS in case any questions arise regarding your tax return? If yes, name the person. Yes No _ 6

INSTRUCTIONS: Please answer the following questions and submit details for any question answered Yes. YES NO 1) Did any births, adoptions, marriages, divorces, or deaths occur in your family last year? If yes, provide details. 2) Will the address on your current returns be different from that shown on your prior year returns? If yes, provide the new address and date moved. 3) Were there any changes in dependents from the prior year? If yes, provide details. 4) Are you entitled to a dependency exemption due to a divorce decree? 5) Did any of your dependents have income of $1,000 or more ($400 if selfemployed)? 6) Did any of your children under age 19, age 24 if they are a full time student, have investment income over $2,000? If yes, do you want to include your child s income on your return? 7) Are any dependent children married and filing a joint return with their spouse? 8) Did any dependent child 19-23 years of age attend school full-time for less than five months during the year? 9) Did you receive any income from any legal proceedings, cancellation of student loans, unemployment, or other indebtedness during the year? If yes, provide details. 10) Did you make any gifts during the year directly or in trust exceeding $14,000 per person? 11) Did you have any interest in, or signature, or other authority over a bank, securities, or other financial account in a foreign country? 12) Were you the grantor, transferor or beneficiary of a foreign trust? 13) Were you a resident of, or did you have income from, more than one state during the year? If so, provide details. 14) Do you wish to have $3 (or $6 on joint return) of your taxes applied to the Presidential Campaign Fund? 15) Do you wish to contribute to any state fund(s)? If yes, indicate amount(s) and which fund(s):

YES NO 16) Do you want any overpayment of taxes applied to next year s estimated taxes? 17) Did you and all members of your household maintain minimum essential health coverage for all months of 2015? 1. If yes, enclose documentation such as Form 1095-A, Health Insurance Marketplace Statement, statement of coverage from your employer, or a medical bill showing payment by an insurance company, insurance card, and Medicare card. 2. If no, but you and all members of your household were covered for a part of 2015, provide documentation showing the months covered. 18) If you or your household did not maintain minimum essential health coverage: 1. Were you offered coverage through your or your spouse that you declined? 2. If yes, did the coverage offer minimum value and was it affordable? 3. Were you or any member of your household eligible for Medicare or Medicaid but did not enroll? 19) Did you and your family receive any advance premium tax credits? 1. If yes, enclose Form 1095-A, Health Insurance Marketplace Statement. 20) Are more than one tax household sharing the premium tax credit? Examples include adult nondependent children, situations of divorce or new marriage. 21) Do you want any federal or state refund deposited directly into your bank account? If yes, enclose a voided check. a. Do you want any balance due directly withdrawn from this same bank account on the due date? b. Do you want next year s estimated taxes withdrawn from this same bank account on the due dates? 22) Do either you or your spouse have any outstanding child or spousal support payments or federal debt? 23) If you owe federal or state tax upon completion of your return, are you able to pay the balance due? 24) Do you expect a large fluctuation in your income, deductions or withholding next year? If yes, provide details. 25) Did you receive any distribution from an IRA or other qualified plan that was partially or totally rolled over into another IRA or qualified plan within 60 days of the distribution (Form 1099R)? 26) If you received an IRA distribution, which you did not roll over, provide details (Form 1099R).

YES NO 27) Did you convert IRA funds into a Roth IRA? If yes, provide details (Form 1099R). 28) Did you receive any disability payments this year? Did you have any taxable distributions from an ABLE account? 29) Did you receive tip income not reported to your employer? 30) Did you sell or purchase a principal residence or other real estate? If yes, provide settlement sheet (HUD-1) and Form 1099-S. 31) Did you collect on any installment contract during the year? Provide details. 32) Did you receive tax-exempt interest or dividends not reported on Forms 1099-INT or 1099 -DIV? 33) During this year, do you have any securities that became worthless or loans that became uncollectible? 34) Did you receive unemployment compensation? If yes, provide Form 1099-G. 35) Did you receive, or pay, any Alimony during the year? If yes, provide details. 36) Did you have any casualty or theft losses during the year? If yes, provide details. 37) Did you have foreign income, pay any foreign taxes, or file any foreign information reporting or tax return forms? Provide details. 38) Did you, or do you plan to contribute before April 18, 2016, to a traditional IRA, or Roth IRA for last calendar year? If yes, provide details (note that some states may have earlier due dates, such as ME or MA). 39) Did you, or do you plan to contribute before April 18, 2016 to a health savings account (HSA) for last calendar year? If yes, provide details. 40) Did you receive any distributions from an HSA? If so, provide details. 41) Has the IRS, or any state or local taxing agency, notified you of changes to a prior year s tax return? If yes, provide copies of all notices or correspondence received. 42) Are you aware of any changes to your income, deductions, and credits reported on any prior years returns? 43) Did you purchase gasoline, oil, or special fuels, for non-highway use vehicles?

44) Did you purchase an energy-efficient or other new vehicle? If yes, provide purchase invoice. YES NO 45) Were either you or your spouse eligible to participate in an employer s health insurance or long-term care plan? 46) If you, or your spouse, have self-employment income, do you want to make a retirement plan contribution? 47) Did you acquire any qualified small business stock? 48) Were you granted or did you exercise any stock options? If yes, provide details. 49) Were you granted any restricted stock? If yes, provide details. 50) Did you pay any household employee over age 18 wages of $1,800 or more? 1. If yes, provide copy of Form W-2 issued to each household employee. 2. If yes, did you pay total wages of $1,000 or more in any calendar quarter to all household employees? 51) Did you surrender any U.S. savings bonds? 52) Did you use the proceeds from Series EE U.S. savings bonds purchased after 1989 to pay for higher education expenses? 53) Did you realize a gain on property which was taken from you by destruction, theft, seizure, or condemnation? 54) Did you start a business? 55) Did you purchase rental property? If yes, provide settlement sheet (HUD-1). 56) Did you acquire or dispose of any interests in partnerships, LLCs, S corporations, estates or trusts this year? If yes, provide Schedule K-1 that the Organization has issued to you. 57) Do you have records to support travel, entertainment, or gift expenses? The law requires that adequate records be maintained for travel, entertainment, and gift expenses. The documentation should include amount, time and place, date, business purpose, description of gift(s) (if any), and business relationship of recipient(s). 58) Has your will or trust been updated within the last three years? If yes provide copies. 59) Did you incur expenses as an elementary or secondary educator? If so, how much?

YES NO 60) Did you make any energy-efficient improvements (remodel or new construction) to your home? 61) Can the IRS and state tax authority discuss questions about this return with the preparer? 62) Did you make any large purchases or home improvements? 63) Did you pay real estate taxes on your principal residence? If so, how much? 64) Have you been a victim of identity theft in prior years? If you have a federal IP PIN, please contact us.

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