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(Use the F1 key for HELP on an input field; use the TAB or ARROW keys to move between input fields) / TAX YEARPERSONAL INFORMATION
/ …TAXPAYER… / …SPOUSE…NAME
Social Security Number
Date of Birth
Occupation
Home Phone
Work Phone
Cell Phone
Email Address
Address / Street City State Zip Code
NJ
Marital Status / Married Single
Divorced…Date of Divorce:
Widow(er)…Date of Spouse's Death: / Will file a JOINT return?………..Yes No
Will file as Head of Household?….Yes No
Notes/Questions:
Was a "Economic Recovery Payment" received this year?
Yes No (Soc. Sec. recipients & SSI beneficiariest)
If YES, how much? $______
TAXPAYER / SPOUSE
Legally Blind? / Yes No / Yes No
Disabled? / Yes No / Yes No
Pres. Campaign Fund? / Yes No / Yes No
DEPENDENTS - Children and Others… (Provide percentage of support furnished by you for NON-children dependents)
Name
(first, last) / Relationship (son, mother, daughter, etc.) / Date of Birth / Social Security Number / # Months Lived With You / Disabled? / Full-Time Student? / Dependent's Gross Income
SonDaughterMotherFatherGrandmotherGrandfatherAdopted ChildFoster ChildSisterBrotherAuntUncleNieceNephewMother-in-lawFather-in-lawSister-in-lawBrother-in-lawStepsonStepdaughterOtherNone / 121110987654321 / YesNo / YesNo / $
SonDaughterMotherFatherGrandmotherGrandfatherAdopted ChildFoster ChildSisterBrotherAuntUncleNieceNephewMother-in-lawFather-in-lawSister-in-lawBrother-in-lawStepsonStepdaughterOtherNone / 121110987654321 / YesNo / YesNo / $
SonDaughterMotherFatherGrandmotherGrandfatherAdopted ChildFoster ChildSisterBrotherAuntUncleNieceNephewMother-in-lawFather-in-lawSister-in-lawBrother-in-lawStepsonStepdaughterOtherNone / 121110987654321 / YesNo / YesNo / $
SonDaughterMotherFatherGrandmotherGrandfatherAdopted ChildFoster ChildSisterBrotherAuntUncleNieceNephewMother-in-lawFather-in-lawSister-in-lawBrother-in-lawStepsonStepdaughterOtherNone / 121110987654321 / YesNo / YesNo / $
… Does every dependent have HEALTH INSURANCE Coverage? If NO, please explain / YesNo
Provide the following information and/or documentation:
• New Clients ONLY… Last year’s tax returns (3 years preferable)… federal and state(s)
• Tax-related statements received… form W-2 from each employer, 1099's, etc. (see DOCUMENTATION Checklist, below)
Answer these questions to determine MAXIMUM Deductions…(provide COMPLETE details for each YES answer)
1. Are you SELF-EMPLOYED, or did you receive hobby income? (If Yes, refer to page 5) / Yes No
2. Did you receive income from raising animals or crops? / Yes No
3. Did you receive RENTAL INCOME from real estate or other property? / Yes No
4. Did you receive income from gravel, timber, minerals, oil, gas, copyrights, or patents? / Yes No
5. Did you withdraw or write checks from a mutual fund? (Broker Fund Statements: Dates, Selling Price, Purchase Cost) / Yes No
6. Did you have a FOREIGN bank account, trust, or business? / Yes No
7. Did you provide a home for or help support anyone not listed above as a dependent? / Yes No
8. Did you receive any correspondence from the IRS or a State Dept. of Taxation? (if Yes, provide copies) / Yes No
9. Were there any births, deaths, marriages, divorces, or adoptions in your immediate family? / Yes No
10. Did you give a gift of more than $13,000 in cash or property to one or more people (directly or in trust)? / Yes No
11. Did you go through bankruptcy proceedings? / Yes No
12. Did you purchase gasoline, oil, or special fuels for non-highway vehicles? / Yes No
13. If you paid RENT, how much did you pay (at each address)? / $ / $
14. If you lived at more than one address during the year---provide the addresses, dates, and number of days at each address…
15. Did you pay interest on a student loan for yourself, spouse, or a dependent during the year? / Yes No
16. Did you pay expenses for yourself, spouse, or a dependent to attend classes beyond high school? / Yes No
17. Did you incur a Casualty/Theft Loss? (Property damage/loss resulting from a sudden, unexpected, or unusual event) / Yes No
18. Did you buy a Hybrid Gas-Electric or all electric car after 2006? (Date Purchased, Make, Model, Cost) / Yes No
DOCUMENTATION Checklist
WAGE, SALARY INCOME / Provide form W-2 from each employer.INTEREST INCOME (Bank, Savings & Loan, etc.) / Provide form 1099-INT and year-end broker statements; provide information on TAX EXEMPT income, e.g. NJ and Other States Municipal Bonds.
DIVIDEND INCOME (Mutual Funds & Stock/Bonds) / Provide form 1099-DIV and year-end broker statements.
PARTNERSHIP, TRUST, ESTATE INCOME / Provide form K-1 from each payer of income from partnerships, limited partnership, S-corporations, trusts, and estates.
SECURITIES and INVESTMENTS SOLD (stocks, bonds, mutual funds, gold/silver, partnership interests) / Provide form 1099-B and broker confirmation slips for each sale plus date acquired, date sold, purchase cost, and sales price.
RENTAL INCOME (refer to page 6) / Provide details of all Rental Income and Rental Expenditures for each separate rental unit.
PROPERTY / REAL ESTATE SOLD / Provide form 1099-S and closing statements for both the sale and purchase of each property (both residential & rental properties). Also, provide dates of residency and a list showing the cost of all major (capital) improvements made to each property.
INDIVIDUAL RETIREMENT ACCOUNTS (IRA)
CONTRIBUTIONS for CURRENT TAX YEAR
Amount / Date / Conventional or Roth IRA?
Taxpayer / $ / Conventional Roth
Spouse / $ / Conventional Roth
Amounts Withdrawn from IRA Accounts (Provide forms 1099-R & 5498)
Plan Trustee / Reason for Withdrawal / Amount / Withdrawn by: / Rolled Over?
$ / Taxpayer Spouse / Yes No
$ / Taxpayer Spouse / Yes No
$ / Taxpayer Spouse / Yes No
PENSION, ANNUITY INCOME (Provide form 1099-R and statements from employer or insurance company with information on cost of or contributions to the plan)
Payer / Amount / Reason for Payment / Reinvested?
$ / Yes No
$ / Yes No
$ / Yes No
Did you receive: / TAXPAYER / SPOUSE
Social Security Benefits? / Yes No / Yes No / (If Yes, provide forms SSA 1099 and/or RRB 1099)
Railroad Retirement? / Yes No / Yes No
OTHER INCOME (including NON-TAXABLE Income)
Alimony Received / $ / Jury Duty / $
Commissions / $ / Workers' Compensation / $
Child Support / $ / Disability Income / $
Scholarships (Grants) / $ / Veteran's Pension / $
Unemployment Compensation (less repayments) / $ / Payments from Prior Installment Sale / $
Prizes, Bonuses, Awards / $ /
NJ State Income Tax Refunds
/ $Unreported Tips / $ / NJ Homestead Rebate / $
Director or Executor Fees / $ / NJ Property Tax Reimbursement - Senior Freeze / $
Gambling, Lottery Winnings / $ / Other State Income Tax Refunds- / $
Gambling, Lottery LOSSES / $ ( ) / Other- / $
ESTIMATED TAXES PAID
Due Date / Date Paid / FEDERAL-IRS / STATE of NJ / State (other)- / State (other)-
Applied From Prior Year's Refund / $ / $ / $ / $
1st Qtr-APRIL 15 / $ / $ / $ / $
2nd Qtr-JUNE 15 / $ / $ / $ / $
3rd Qtr-SEPT 15 / $ / $ / $ / $
4th Qtr-JAN 15 / $ / $ / $ / $
MEDICAL & DENTAL EXPENSES
Long-Term Care Insurance Premiums / Husband / $ / Wife / $ / Dependent (name) / $
Insurance Premiums-Medical, Dental, Medicare / $ / Insulin; Weight Loss Expenses / $
Prescription Drugs (no "over the counter" drugs) / $ / Medical Therapy, Psychotherapy / $
Doctors, Dentists, Psychological Counseling / $ / Hospitals, Nursing Home, Nursing Care / $
Glasses, Contact Lens & Supplies / $ / Lodging, Parking Fees, Phone (toll calls) / $
Hearing Aids & Batteries / $ / Other (describe) / $
Labs & X-Rays; Medical Equipment & Supplies / $ /
INSURANCE Reimbursement Received
/ $Health Savings Accounts (HSA) contributions / $ / Medical Auto Mileage--number of miles
TAXES PAID
Real Estate/Property Tax (provide bills) / $ / Balance(s) due and paid with last year’s STATE income tax return(s) / $
Personal Property Tax (auto, boat, plane, etc.) / $
Sales Tax Paid on new vehicle or boat purchases / $ / Other- / $
Sales Tax Paid on all other purchases / $ / Other- / $
HOME MORTGAGE INTEREST EXPENSE (provide form 1098 and HUD-1 Settlement Statement for sales/purchases)
Mortgage Interest Paid to a Bank, S&L, etc. / $ / Interest paid to an Individual for your home / $Points Paid to a Bank, S&L, etc. / $ / (provide amortization schedule)
Home Equity Lines / Loans / $ / Paid to:
Mortgage Insurance Premiums / $ / Name-
Other- / $ / Social Security Number-
Address-
CHARITABLE CONTRIBUTIONS
Religious, Church, Temple / $ / Other- / $
United Way, Red Cross / $ / Other- / $
Scouts / $ / Expenses in connection with a charitable organization- / $
Telethons / $
Colleges, Public TV/Radio / $ / NON-CASH (clothing, other articles, etc.-- if over $500 provide: name of charity, address, date, & amount of each donation) / $
Heart, Lung, Cancer, etc. / $
Wildlife Fund / $
Salvation Army, Goodwill / $ /
Mileage--number of miles used for charity
CHILD & OTHER DEPENDENT CARE EXPENSES (show Amounts Paid for each child)Name of Care Provider / Address of Care Provider / Social Security Number or Employer ID No. / Amount Paid
$
$
JOB-RELATED MOVING EXPENSES
Date of Move (attach IRS Form 4782) / Other (describe) / $
Cost to Move Household Goods / $ / Miles from old home to old place of work / mi.
Lodging Cost During Move / $ / Miles from old home to new place of work / mi.
EMPLOYMENT-RELATED EXPENSES PAID (NOT SELF-EMPLOYMENT EXPENSES)
Dues--Union, Professional / $ / Entertainment & Meals / $
Books, Subscriptions, Supplies / $ / Continuing Education (tuition, fees, supplies) / $
Licenses, Fees / $ / Other (describe) / $
Tools, Equipment, Safety Equipment / $ / Other (describe) / $
Uniforms (including cleaning expense) / $ / Educator Expenses (grades K-12) / $
OFFICE IN THE HOME Employee ONLY --- if Self-Employed, go to page 5, BUSINESS INCOME and EXPENSE
Square footage of entire home / sq. ft. / Rent / $ / Maintenance / $
Square footage of home office / sq. ft. / Insurance / $ / Other (describe) / $
Square footage of space used for storage / sq. ft. / Utilities / $
Ø Provide HUD Closing Statement for home Purchase
nd cost of all major capital improvements since the purchase (e.g., new roof, room addition, driveway, etc.) / 2nd Phone / $
Employee BUSINESS MILEAGE (using your personal vehicle) / BUSINESS TRAVEL
Is there evidence to support the deductions? Yes No
If YES, do you have written records? Yes No / If you are not reimbursed for the exact amount, provide the total expenses.
Do you sell or trade in a used car used for business? Yes No / Airfare, Train, etc. / $
(if Yes, provide a copy of the purchase agreement) / Lodging and Tips / $
Vehicle #1 / Vehicle #2 / Meals and Tips / $
Who used the vehicle? / You Spouse / You Spouse / Meals-number of days
Amount Reimbursed by Employer
/ $ / $ / Taxi, Automobile Rental / $Make of Vehicle / Laundry, Valet / $
Year of Vehicle / Other- / $
Date Originally Acquired / Other- / $
COST of Vehicle / $ / $ / Reimbursement Received / $
TOTAL Miles (personal & business) / miles / miles /
Bank DEPOSIT/WITHDRAWAL & Electronic Filing Information
Do NOT file electronicallyBusiness Miles (NOT to and from work) / miles / miles
Driving for your employer / miles / miles
From 1st to 2nd job / miles / miles / Bank Name:
Education (one-way, work to school) / miles / miles
Job Seeking, Temporary Job Sites / miles / miles / Branch Name, if applicable:
Other Business; Rental Car / miles / miles
Round Trip Commuting Distance / miles / miles / Routing Transit Number (RTN):
Gas, oil, lubrication, repairs / $ / $
Batteries, tires, etc. / $ / $ / Depositor Account Number:
Licenses and taxes / $ / $
Wash & wax, garage rent / $ / $ / Type of Account: Checking Other
(Provide a copy of a VOID or canceled check from the above bank account)
Insurance / $ / $
Interest on vehicle loan / $ / $
LEASE Payments - per MONTH / $ / $ / Ownership of Account:
Self Spouse Joint
LEASE Payments – yearly total / $ / $
Date of first lease payment
Term of Lease (months) / months / months /
Cost at beginning of lease, if purchased / $ / $
EDUCATION EXPENSES (Tuition and Fees, Books and Supplies, Room and Board, Student Loan Interest)
Student's Name / Type of Expense / Amount / Student's Name / Type of Expense / Amount
---Tuition and FeesBooks and SuppliesRoom and BoardStudent Loan Interest / $ / ---Tuition and FeesBooks and SuppliesRoom and BoardStudent Loan Interest / $
---Tuition and FeesBooks and SuppliesRoom and BoardStudent Loan Interest / $ / ---Tuition and FeesBooks and SuppliesRoom and BoardStudent Loan Interest / $
---Tuition and FeesBooks and SuppliesRoom and BoardStudent Loan Interest / $ / ---Tuition and FeesBooks and SuppliesRoom and BoardStudent Loan Interest / $
---Tuition and FeesBooks and SuppliesRoom and BoardStudent Loan Interest / $ / ---Tuition and FeesBooks and SuppliesRoom and BoardStudent Loan Interest / $
MISCELLANEOUS DEDUCTIONS
Alimony paid to:Social Security Number: / $ / Investment Consultants / $
IRA or Keogh Fees / $
Investment & Margin Interest Paid / $ / Tax Preparation and Consulting Fees / $
Safe Deposit Box Rental / $ / Other- / $
Mutual Fund Fees / $ / Other- / $