If you prefer to mail your tax information instead of delivering them in person please follow these instructions.

Assemble all your tax documents (W-2’s, 1099”s, INT, DIV etc.) and a copy of last years return if you have one.

Look over the attached client tax questionnaire and fill out the parts that pertain to you.

Mail all the above information to

Mary Richman

Tax Break Today

333 Iron Ore Road

Manalapan, NJ 07726

Whether you use the US Mail, UPS, FedEx etc. is up to you but I recommend that you ask for a tracking number to insure proper delivery.

The US postal service has flat rate Priority mail envelopes for $4.90

For payment you have two options.

You may include a check with your documents payable to Tax Break Today. Call or email to confirm price.

Or if you are planning to pickup your finished return you may pay at that time.

The forms below will help insure you receive all the tax deductions and credits that you are entitled to.

Not all the questions will apply to you, answer what you can. If you have your financial information organized on another form you may use that instead; but you may want to read through this form to ensure you haven’t missed anything.

CLIENT QUESTIONNIRE - FACT SHEET

NOTE: New clients please fill in all boxes in top half of page – returning clients indicate only where there are changes.

______

14. Your Social Security Number ______Spouse’s Social Security Number______

Part III Check ALL Income sources you had in 2009 - BRING DOCUMENTATION

Salary/Wages – W-2 / Social Security/Railroad Retirement / Lottery/Gambling Winnings
Self-Employed Business Income / Pension / Retirement Income / Interest – 1099-INT
Independent Contractor - 1099 / IRA Distributions / Dividends – 1099-DIV
Commissions/Fees / Rental Property Income / Mutual Fund Distributions – 1099
Cash Payments / Partnership/S-Corporation – K-1 / Municipal Bonds
Alimony Received / Estate/Trust – K-1 / Farm Income
Unemployment $ ______/ Military BAS/BAH $______/ Other Income (Enclose Details)
Tip Income / Did You Sell a Personal Residence? / Installment Sale
Did You Sell Any Stocks/Bonds? / Did You Sell Other Real Estate?
(If yes, enclose 1099-B & cost info.) / (Enclose settlement statements.)

Part IV Retirement Contribution

IRA Contributions: / Taxpayer $______/ Spouse $______
Traditional Roth / Traditional Roth
SIMPLE/SEP/KEOGH Contributions: / Taxpayer $ / Spouse $

Part V Child and Dependant Care Expenses ______

Dependent Cared For: / ______
Care Provider’s Name: / ______/ Provider’s SSN/EIN: / ______
Provider’s Address / ______/ Amount Paid to Provider: / $______
Dependent Cared For: / ______
Care Provider’s Name: / ______/ Provider’s SSN/EIN: / ______
Provider’s Address / ______/ Amount Paid to Provider: / $______

Part VI Employee Business Expenses That you were NOT reimbursed for______

Prof. Association or Union Dues / $______/ Business Vehicle Mileage 1/1 – 6/30
Uniforms (not street clothes) / $______/ Business Vehicle Mileage 6/30 12/31 / ______
Uniform Cleaning / $______/ Total Mileage on Vehicle in 2009 / ______
Safety Equipment / $______/ Out of Town Transportation / $______
Tools & Other Work Equipment / $______/ Out of Town Lodging / $______
Business Meals & Entertainment / $______/ Other ______/ $______

Part VII Expenses______

State Tax Paid with 2009 Return $______
Alimony Paid $______
Recipient’s S.S.# ______/______/______/ State Estimated Tax Payments 2009 $______
Did you pay college tuition for yourself, your spouse, or your dependents in 2009? / $ / Educational expenses (such as a computer, books, etc.) / $______
Buy a brand new vehicle? If yes, date of purchase:______/ $ / Did you have a foreclosure or did the bank cancel any part of your mortgage loan? / $
Did you Receive an Economic Recovery Payment from Social Security Administration, Railroad Retirement Board, or Veterans Administration? If yes, how much? / $250 $500 / Did you Purchase and install Energy efficient home items? (such as windows, furnace, insulation, etc.)
Classroom supplies if you are a teacher / $______
$

MEDICAL EXPENSES Amount

/

INTEREST PAID Amount

Doctors /

Mortgage on Main Home

Dentists / Paid to Financial Institution (1098)
Other Medical Professionals / Paid to Individual
Prescription Drugs / Name: SSN:
Surgical Procedures / Address:
Medical Lab Fees /

Points Paid on New Mortgage

Hospitals / (Enclose Settlement Statement)
Glasses and Contact Lenses /

Home Equity Loan/Second Mortgage

Medical Equipment Rental /

Mortgage on Second Home

Prescribed Physical Aids / Paid to Financial Institution (1098)
Skilled Nursing Care / Paid to Individual
Medical Insurance / Name: SSN:
Dental Insurance / Address:
Long Term Care Insurance / Investment Interest Paid
Medicare Part B
Medical Transportation /

CHARITABLE CONTRIBUTIONS

Medical Miles Driven in Your Vehicle / (Receipt required for single donations of $250 or more.)
Other Medical (Describe) / Church/Temple/Mosque
United Way
CASUALTY OR THEFT LOSS / Scouts
Type of Property: / Other (list)
Describe Loss:
Cost or Basis of Property
Insurance Reimbursement / MISCELLANEOUS DEDUCTIONS
Fair market Value before loss / Tax Return Preparation Fee (2008)
Fair market value after loss / Gambling Losses
Other
TAXES / Safe Deposit Box (store investments)
Real Estate / Job Search – Resume
Personal Property / Agency Fees
Other / Travel
PLEASE ANSWER ALL QUESTIONS – For Yes answers, provide details on the lines below.
1. / Do you (or your spouse) with to designate $3.00 of your taxes to the Presidential Campaign Fund? Taxpayer Yes No Spouse / Yes / No
2. / Did you or your spouse barter goods or services with others? / Yes / No
3. / Did you move during the past year because of your job? / Yes / No
4. / Did you or your spouse pay premiums or receive benefits from long term care insurance? / Yes / No
5. / Did you or your spouse receive educational benefit payments from your employer? / Yes / No
6. / Do you or your spouse have a foreign bank or investment account? / Yes / No
7. / Did you or your spouse open a health savings account (HAS) during the year? / Yes / No
8. / Did you receive reimbursement from insurance or another source for prior year casualty losses or medical deductions? / Yes / No
9. / If you or your spouse has reached age 70 and a half, have you begun your mandatory withdrawals from retirement savings accounts? / Yes / No
10. / Did you make any Estimated Tax Payments in 2009 for your 2010 tax liability
If yes how much $ / Yes / No