CLIENT INCOME TAX INFORMATION - 2013 RETURNS
NAME: ______PHONE: ______
(Home)(Business or cell)
ADDRESS :______
(Street)(City) (State)(Zip)(School District)
EMAIL: ______
DEPENDENT CHILDREN
NAMESOCIAL SECURITY #DATE OF BIRTH COLLEGE STUDENT
______YES / NO
______YES / NO
______YES / NO
OTHER DEPENDENTS OR PERSONS RESIDING IN YOUR HOUSEHOLD (Discuss with us) ______
Do you rent your residence? If so, rent paid in 2013: $______
Name and address of landlord: ______
Location of property, if different from current address: ______
Do you expect a significant (20%) increase/decrease in income of 2014? (Discuss with us) ______
Did you have income from any of the following sources?:
YES / NOYES / NOYES / NO
______Rent______Interest* **______Cancellation of Debt
______Dividends*______Partnership or Sub-S Corp.______Alimony
______Trust or Annuities______Unemployment Comp.*______Gambling Winnings*
______Estate______Commissions & Fees*______Health or Medical Savings Acct Withdrawals
______Wages (Furnish W-2s)______Prizes & Misc.*______Education Savings Plan Withdrawals
______Social Security*______Retirement*______Scholarships (Form 1098T)
*Furnish 1099s or W2Gs.
**If received from an individual, show name, address and social security number (SSN).
YES / NO
______Did you sell stock, mutual funds or real estate?
(Furnish buy & sell slips or closing statement. It is important that we have exact dates of sale.)
______Did you acquire a home or other property? (Bring closing statement.)
______Did you make significant purchases subject to state sales tax?
______Did you make any energy efficient improvements to your residence? (Furnish with invoice for material and labor.)
______Did you have a Keogh, SEP or IRA account?
______Did you or your spouse “rollover” a profit sharing or retirement plan distribution into another plan?
______Did you recharacterize any IRA’s this year?
______Did you have any investment expenses? (Discuss with us)
______Did you purchase, sell, or refinance your principle home or make a home equity loan during the year?
If yes, please bring escrow papers and other pertinent information.
______Did you have employee expenses that were not reimbursed? (Please furnish details)
______Did you make any gift over $14,000 to any one person in 2013?
______Are you a National Guard member or an Armed Forces reservist and travel more than 100 miles and stay overnight to fulfill duty?
______Are you a teacher and if so, did you incur out-of-pocket classroom costs in 2013? Amount $______
______Did you pay any individual $1,800 or more to perform household services during the year, such as babysitting, cleaning, cooking or gardening?
______Was any debt on your principal residence reduced or forgiven in 2013? If yes, provide details.
______Did you purchase a home for your personal residence between April 8, 2008 and December 31, 2008?
If yes, was the First-Time Homebuyer Credit taken on the home? _____ Yes _____ No
______Did you receive Cobra premium assistance? If so, provide amounts.
MEDICAL EXPENSESINTEREST
Medicine & Drugs$______If paid to individual, show name, address, and SSN:
Hospital Ins. Premium $______$______
Long Term Care Premiums*$______
Doctors, Dentists, etc.$______
Hospitals$______Home Mortgage $______
Mileage (for medical purposes)$______Points Paid ______
Other—Itemized$______
______
OTHER DEDUCTIONSStudent Loan Interest $______
Tax Return Preparation$______
Union Dues$______TAXES
Special Uniform & Laundry$______Real Estate $______
Safe Deposit Box$______(Deductible on Indiana return without itemizing.)
Professional Dues$______State Income $______
Alimony$______Personal Property $______
Small Tools$______Intangibles $______
Employment Agency Fees$______Auto State Excise Tax $______
Educator Expenses$______
Others (list):$______CHILD CARE EXPENSES
Payee Name ______
CASUALTY AND THEFT LOSSESAddress ______
Total Loss$______SSN ______
Recovered by Insurance$______Children Cared For ______
Amount Paid ______
CONTRIBUTIONS
Church$______United Way $______
Red Cross$______Salvation Army $______
Boys Club$______Easter Seals $______
Mental Health$______March of Dimes $______
Cancer Fund$______Heart Fund $______
Scouts$______YMCA or YWCA $______
4-H$______Other (list) $______
Mileage (for charitable purposes) ______
COLLEGE OR UNIVERSITY CONTRIBUTIONS* Is your long-term care policy
NameDateAmountan Indiana Partnership policy?
______$______ENERGY EFFICIENT HOME IMPROVEMENTS (Such as solar electric property, fuel cells,
______$______solar water heating, geothermal heat pump, small
wind energy property, storm windows/doors,
______$______insulation, water heater or heating and air
conditioning unit.)Bring in invoices.
NON-CASH CONTRIBUTION
Method of Description of Improvement Date Amount
NameValuationValue______$______
______$______$______
______$______$______
______$______
COLLEGE TUITION AND EDUCATIONAL EXPENSES(Bring in any College invoices and Form 1098-T)
Date ofStudent’s Grade
Institution PaidPaymentAmountStudent’s Nameor Year in College
______$______
______$______
______$______
Rev. 6/13
Word Doc. Miller & Stewart LLC Client Income Tax Information