O'CONNOR, WELLS & VANDER WERFF, LLC

2014 PERSONAL TAX WORKSHEET

Taxpayers Name(s) Enter any out-of-state purchases for which you paid no Wisconsin sales tax? $

Residence: County Wisconsin Voluntary Donations – List Fund(s): ______$

City, Town or Village Capital Loss Carryovers: (State) ST $ > LT $ >

Public High School District Capital Loss Carryovers: (Federal) ST $ > LT $ >

1.  Capital Gains or Losses on Sale or Exchange of Non-Business Assets, Including Personal Residence. Attach Form 1099 Information Statements.

Description of Property Code Date Acquired Date Sold Sales Price Cost Basis Gain / (Loss)

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

Total Capital Gain Distributions $

2. Installment Sales

Description Principal Rec’d $ x GP% = Gain $

Description Principal Rec’d $ x GP% = Gain $

Description Principal Rec’d $ x GP% = Gain $

3. IRA Distributions – Attach Form 1099-R Gross Taxable Federal State X if Subject to

Name of Payer T or S Distribution Amount Withholding Withholding Rollover Penalty

$ $ $ $

$ $ $ $

$ $ $ $

$ $ $ $

$ $ $ $

$ $ $ $

4. Pensions & Annuities – Attach Form 1099-R Gross Taxable Federal State X if Subject to

Name of Payer T or S Distribution Amount Withholding Withholding Rollover Penalty

$ $ $ $

$ $ $ $

$ $ $ $

$ $ $ $

$ $ $ $

$ $ $ $

5. Social Security Benefits

Attach Form 1099-SSA Taxpayer $ $

Spouse $ $

6. Unemployment Compensation

Attach Form 1099-G Taxpayer $ $ $

Spouse $ $ $

7. Rental Property – If you have rental properties, please complete the attached rental worksheet. Rental

Net Income (Loss) =

8. Partnerships, LLCs, S-Corps, Trusts, Etc. – Attach Schedule(s) K-1

Nonpassive Ordinary Guaranteed Total Tax

Entity Name Passive T or S Income (Loss) Payments Section 179 Other Income (Loss) Credits

N / P $ $ $ $ $

N / P $ $ $ $ $

N / P $ $ $ $ $

N / P $ $ $ $ $

N / P $ $ $ $ $

N / P $ $ $ $ $

N / P $ $ $ $ $

N / P $ $ $ $ $

9. Other Income Amount Total

Wisconsin Tax Refund (if you itemized in 2013) $ Schedule E =

Tips, Gratuities & Prizes (including Gambling Winnings-Attach Form W2-G) $

Alimony Received $

Other (List) T or S $

T or S $

T or S $

ADJUSTMENTS TO INCOME:

1. Retirement Plans Date of Contribution Keogh SEP SIMPLE Roth IRA Traditional IRA

Taxpayer
Spouse

2. Student Loan Interest Deduction Interest Paid $

3. Educator’s Qualified Expenses – Max. of $250 unreimbursed expenses at elementary and secondary education levels Amount $

4. Alimony Paid Payee's Name Social Security Number Amount $

5. Moving Expenses - If you moved over 50 miles to secure new employment, please attach details on separate sheet.

6. Health Savings Account (HSA) - Attach Form 1099-SA Contributions $

7. Domestic Production Activities Deduction (Schedule C____ F____ K-1____ Form 1099-PATR____) Deduction $

Packager / / 15

ITEMIZED DEDUCTIONS: Page 2

1. Medical Expenses: (Report Agri-Biz Plan/BASE totals on farm/business worksheet) 4. Gifts to Charity: Cash (with receipt) or Check:

Medicare Insurance $ $ Long-Term Care Insurance $ $

Health Insurance Premiums $ $ Number of Weeks Employed ______$

Does your employer cover a portion of health insurance? Yes or No $

Less: SE Health Insurance Deduction (100%) $ $

Prescription Medicine & Drugs $ $

Doctor, Dentist, Nurse, Hospital, Etc $ $

Glasses & Contacts $ $

Hearing Aids & Batteries $ Transportation: miles @ 14¢ per mile $

Transportation: ______miles @ 23.5¢ per mile $ Non-Cash Donations of Property (by organization):

Other (List): $ $ $ $

$ $

2. Taxes Paid: 5. Miscellaneous Deductions:

State Income Taxes Paid: Tax Preparation Fee $

Wisconsin Withholding (Forms W-2 & 1099) $ Safe Deposit Box $

Wisconsin Estimated Tax Payments in 2014 $ Professional Dues, Books, and Supplies $

Balance due with 2013 State Return $ Union Dues $

Sales Tax Paid (On Major Items) $ Work Tools $

Real Estate Taxes on Personal Residence $ Uniforms Required by Employer $

Other Real Estate Taxes $ Protective Clothing (Safety Shoes, Glasses, etc.) $

Other (List): $ Job Seeking Expense $

$ Unreimbursed Employee Business Expenses for

auto, travel, meals, etc. $

3. Interest Paid: $

Home Mortgage - Attach Form(s) 1098 $ Other (List): $

Home Equity Loan (AMT adjustment $______) $

Mortgage Insurance Premiums $ 6. Gambling Losses – Attach schedule.

If your Home Loan is paid to an Individual, please list: (Deductible to the extent of winnings reported) $

Name SSN:

Address 7. Casualty or Theft Losses – Attach schedule.

Points - Date Paid / / $

Investment Interest Expense $ Standard Deduction

To whom paid? + Adjustments Total =

TAX CREDITS:

Health Insurance Tax Credit = $ (From Schedule C____ F____K-1____)

First-Time Homebuyer – Recapture of 2008 Credit = $

Adoption Credit – List any adoption expenses incurred in 2014 on a separate sheet. Is the adoption final? Please circle: YES or NO

Residential Energy Efficient Property Credit - If you made any energy efficient improvements or incurred residental energy property costs to your main home in 2014, please bring along your invoices and the manufacturer’s certification for this qualifying property. Credit = $

Child & Dependent Care Credit - Did you pay someone to care for your child or other qualifying person while you worked? Was it in or out of your home?

Dependent Cared For Name & Address of Child Care Provider Social Security# or Federal ID# In or Out Amount

$

$

$

Less: Dependent Care Benefits (W-2 Box 10) $ < >

Net $

Post-Secondary Education Credits – Attach Form 1098-T At Least Year in Tuition & Fees Pd Books, Supplies

Name of Student Name & Address of Institution Federal ID# (EIN) ½ time School Net of Grants & Equipment

- $ $

- $ $

- $ $

- $ $

Wisconsin Education Deductions – (Private School Tuition and EdVest) Year in School Contributions

Name of Student Name & Address of School Federal ID# (EIN) K-8 9-12 Tuition Paid to EdVest

- $ $

- $ $

- $ $

- $ $

Wisconsin Homestead Credit – If you qualify, please submit a copy of your 2014 real estate tax bill or a “Rent Certificate” signed by your landlord.

List court ordered support received, if any: $

Wisconsin Property Tax / Rent Credit – Enter the amount of real estate taxes paid in 2014 on your personal residence: $

OR Rent paid on personal residence: $ Did the landlord pay for heat? Please circle: YES or NO

Estimated Tax PAYMENTS: List all payments made with Federal and Wisconsin Estimated Tax Vouchers below:

Date Paid Federal Amount Date Paid State Amount

2013 Overpayment Applied to This Year $ $

First Installment (Due 4-15-14) $ $

Second Installment (Due 6-16-14) $ $

Third Installment (Due 9-15-14) $ $

Fourth Installment (Due 1-15-15) $ $

TOTAL $ TOTAL $