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N E W B U R G H T A X S E R V I C E newburghtaxservice.com

4088 Hwy. 261, Newburgh, IN 47630 812.858.1040

Available as a fill-in form at

FILING PREFERENCES

I prefer to receive my tax refund(s) by: Direct Deposit * Paper Check
I prefer to receive my tax return as a: PDF on CD Paper Copy
I prefer to receive the2014Income Tax Organizerby: E-mail Mail

* VOIDED CHECK or BANK DEPOSIT SLIP with account number MUST be included.

TAXPAYER &SPOUSE

Name / Social Security # / Occupation / Date of Birth / Blind
Tx / Y N
Sp / Y N
E-mail: / TxWork #: / SpWork #:
Home Phone #: / TxCel’ #: / SpCel’ #:
Mailing Address: / Zip:

FILING STATUS

Single Are you a dependent? YES NO Was a divorce final in 2013? YES NO
Married Filing Jointly
Married Filing Separately Did you live with your spouse at any time during 2013? YES NO
Head of Household Did you share a residence with another adult at any time during 2013? YES NO
Qualifying Widow/er
DEPENDENTS
Name on Social Security Card / Social Security # / Relationship to you / Date of Birth / Months lived with you in ‘13 / Full-time Student
1 / Y N
2 / Y N
3 / Y N
4 / Y N
YES NO Was any dependent’s unearned income more than $1,000?
YES NO Did any dependent receive Social Security benefits?

CHILDCARE

Provider Name / Street Address
City, State Zip / ID # / Amount for Child# / Amount for Child# / Amount for Child#
$ / $ / $
$ / $ / $
$ / $ / $
YES NO Do you useDependent Care Benefits through your employer?
YES NO Do you pay for childcare or domestic service in your home?
# / A DO M / Intvw / Prep / Ck / Asmb / Pr Sign / Notify / ID / DD / Cl Sign / P/U / E-file / Post / Rvw
Date
Initials
Fed: No/ Ppr / 8453 / IN: Ppr / KY: Ppr / ___: Ppr / Folder / FAFSA / Pers Prop / On-file / Multi-bill / B4 Pd / Xtra Doc / Ref Src:
YES NO / 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 a 2012 state tax refund? / $ / $
Did you receive unemployment compensation? / $ / $
Did you receive Social Security benefits? / $ / $
Did you receive gambling or lottery winnings,a prize or award? / $ / $
Mark Type / Did you receive any other taxable or non-taxable income? / $ / $
Jury Duty Election Hobby K-1 Royalty Legal Settlement Crops Alimony Spiff
Child Support Other
YES NO / The following items may affect your tax return. Please answer carefully.
Did you BUY SELL REFINANCE Real Estate? If Yes,bring closing statement HUD-1
Did you move from a house for which you tookFirst Time or Long Time Homebuyer Credit?
Did you receive any notice from the IRS or state taxing authority?
Did you experience debt cancellation, foreclosure,or bankruptcy?
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 sell used items or collectibles on-line?
Did you make energy efficient improvements to your primary residence?
If yes, did you take energycredit in? 2006, 2007, 2009, 2010 or 2011? YES NO

INVESTMENT INCOME (1099-INT / 1099-DIV)

Source / Interest / Dividend / Qualified Dividend / Capital Gain
Distribution / Tax Exempt / Fed. Tax Withheld / Foreign Tax / % 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 (1099-R, 1099-SA) Examples: Pension, 401-K, IRA, Roth, etc.

Source / Type / Box 7 / Distribution / Contribution / Rollover / Exception / QCD
Is your HSA? Self-Only Family Were distributions used only for medical expenses? YES NO

EDUCATION CREDITS & DEDUCTIONS

YES NO / Bring 1098T / 1099-Q / Student: / Student: / Student:
What grade level in school?
Did you pay for books and supplies? / $ / $ / $
Did your employer pay any of the tuition? / $ / $ / $
Did you receive a 529 distribution / 1099-Q? / $ / $ / $
Did you pay student loan interest? / $ / $ / $
Is Box 1 of the 1098-T blank? If YES, bring record of tuition charges and payment dates.
INDIANA / Real Estate tax on main home $ / Taxpayer / Spouse
YES NO / County of Residence on 1-1-13
County of Employment on 1-1-13
Was a child enrolled in K-12 private or home school? How many?
Did you contribute to the College Choice 529 plan? $ Acct#:
Did you donate to an IN college? School: Date: Amount: $
Did you buy on-line without paying sales tax? Amount purchased: $
Did you pay for for IN long term care insurance? $
Did you rent? # Months: Rent: $ Landlord/Address:

ESTIMATED TAX PAYMENTS Do you want Newburgh Tax Service to calculate 2013 estimates? YES NO

2012 Refund Applied to ‘13 / 1st Qtr
Date Pd: / 2nd Qtr
Date Pd: / 3rd Qtr
Date Pd: / 4th Qtr
Date Pd: / Extension Payment / Apply 2013 refund to ‘14
Federal / $ / $ / $ / $ / $ / $ / $
State / $ / $ / $ / $ / $ / $ / $

WORKSHEET Notes, additional information, questions, etc. ESTIMATED FEE

Form / Fee
$
$
$
$
$
$
$
$
$
$
$
TOTAL / $

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. Wemaintain physical, electronic, and procedural safeguards to protect your information.

Ihereby affirm that the information provided to Newburgh Tax Service (NTS) for my 2013 tax return is accurate and complete to the best of my knowledge. An NTS employee 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. Iwill maintain all supporting documents and records that may be requested by a taxing authority upon examination.

______

Taxpayer Date Spouse Date Witness Date