Roderer Financial & Tax Group, LLC.
Phone:937-331-8671 Fax: 937-262-7504
Have we prepared your taxes before? If so, what year(s) ______
Are we preparing your taxes for this year? ______If not – what year? ______
NOTE: As information and situations change from year to year, we ask you to help us complete your tax return in your very best interest.
PERSONAL INFORMATION (Information provided must agree with SSA and IRS)
TAXPAYER SPOUSE
SSN (Social Security Number) ______
First Name & Middle Initial ______
Last Name & Suffix (e.g. Jr, Sr, etc) ______
Date of Birth (Month/Day/Year) ______
Occupation (e.g. Sales, Teacher, Retired) ______
Home Phone (000-000-0000) ______
Cell Phone (000-000-0000) ______Work ______Cell ______Work______
E-mail Address(es) ______
Home Address ______Apt/Lot # ______City ______Zip+4 ______
FILING STATUS Please circle correct status(All filing status categories are based on your status as of December 31stof last year)
1. Single 2. Married Filing Joint 3. Married Filing Separate 4. Head of Household 5. Qualifying Widow(er) with dependent child
Can anyone else claim you as a dependent on their tax return? (Y/N) Taxpayer ______Spouse ______
Do you want to contribute to the Presidential Election Campaign? (Y/N) Taxpayer ______Spouse ______
Are you considered legally blind per IRS regulations? (Y/N) Taxpayer ______Spouse ______
Do you own _____ your home or do you rent _____ your home?
What city do you reside? ______Do you normally file city income taxes?___Y/N
INCOME (Please, check all that apply and/or list the number of forms you have for each category)
Wages (W2) ______Unemployment (1099G) ______Taxable Interest (1099Int) ______Dividends (1099Div) ______
Gambling (W2G) _____ Retirement/Pension (1099R) _____ Railroad Retirement (1099RBB) _____ Social Security (1099SSA) ______
Jury/Witness Duty _____ Miscellaneous (1099Misc) ______Capital Gain/Loss Stock Sales ______Self Employment (Schedule C) ______
(Please provide cost basis)
Rental Income/Loss______Alimony Received/Paid ______IRA Distributions ______Rollover Amount ______
DEDUCTIBLE ITEMS (Please list the amount you spent or number that applies in each category)
Medical Ins.$______Medicare Ins. $______Long Term Care Ins. $______Medical Miles: ______Total Miles Driven______
Doctors/Hospital: $______Dental Care: $______Eye Care: $______Prescriptions: $______
Extra Sales Taxes Paid: $______Real Estate Tax Paid: $______Mortgage Interest Paid: $______Points Paid: ______
Cash Donations: $______Other Than Cash $______Charitable Mileage: ______Tax Preparation Fees $______
Investment Expenses:$______Employee Expenses $______Casualty Losses $______Gambling Losses If You Won $______
POSSIBLE CREDITS (Statements and/or invoices are recommended)
Did You Pay Any Student Loan Interest last year? (Y/N _____ If Yes, How Much $______For Whom ______
Did You Pay Any Tuition last year? (Y/N) ____ If Yes, How Much $______For Whom: ______
Did you sell a homelast year? (Y/N) ____ If Yes, we should see your “Closing Statement” for that transaction.
Did you purchase ahome last year? (Y/N) ______If Yes, we should see your “Closing Statement” to maximize your “Credits/Deductions”.
Did you make energy improvements last year? (Y/N) ______Amount Spent $______On What ______
Did you make any large purchases, such as a motor vehicle or boat? ______
Did you make Estimated Tax Payments? (Y/N) ______If Yes, we need the dates and amounts paid.
Date: ___/___/___ Amt $______Date:___/___/___ Amt $______Date:___/___/___ Amt $______Date:___/___/___ Amt $______
Will you need Estimated Payment Vouchers for next year? (Y/N) ______If Yes, how much do you want to pay each time?
Date: ___/___/___ Amt $______Date:___/___/___ Amt $______Date:___/___/___ Amt $______Date:___/___/___ Amt $______
Retirement or Severence
Did you or your spouse contribute to a Roth IRA or convert an existing IRA into a Roth IRS? ______
Did you or your spouse roll into a Roth IRA any distributions from a retirement plan, annuity, or deferred compensation plan? ______.
Did you or your spouse turn age 70 ½ and have money in an IRA or retirement account without taking any distribution? ______
Did you or your spouse retire or change jobs? ______
Did you or your spouse receive deferred, retirement or severance compensation? _____
If yes, enter the date received (Mo/Da/Yr). ______
FINAL FEW QUESTIONS
Did you become a widow(er) last year? (Y/N) ______If yes, Date Spouse Died (Mo/Day/Year)______
May the IRS or another taxing authority discuss your return with the preparer? (Y/N) ______Initials TP-______SP- ______
Would you prefer to e-file your Tax Return? Safer, Faster, and No Extra Charge!! (Y/N) ______Initials TP-______SP- ______
If you choose e-file, we will need your Prior Year AGI (Adjusted Gross Income amount) $______or your prior year 5-digit PIN #______
Note: By providing your prior year return (recommended), we can ascertain this information which is necessary for e-file.
If you are entitled to a refund, please select how you wish to receive your refund. If by check in the mail, Please initial here TP-_____ SP-______
If by Direct Deposit, initial here TP-______SP-______(For Direct Deposit, we will need a voided check, please attach where indicated)
Taxpayer Signature: ______Date Signed:______
Spouse Signature: ______Date Signed:______
<“Attach Your Voided Check Here” >
DEPENDENT INFORMATION
Taxpayer Name:______SSN______
DEPENDENT INFORMATION:(If Applicable)
< 1 > < 2 > < 3 > < 4 >
First Name (as per SSA) ______
Last Name (as per SSA) ______
Suffix (If Applicable) ______
SSN (as per SSA) ______
Relationship To You ______
# of Months Lived with You ______
Date of Birth (Mo/Day/Year) ______
Childcare Expense (Y/N) ______
Student During Year (Y/N) ______
Name of School Attended ______
Is This Child Disabled? ______
Type of Disability ______
Income over $3,800 Y/N) ______
This Child Is Unmarried (Y/N) ______
Child Care Provider Information (Statement from Provider is Recommended)
Provider EIN/SSN ______
Name of Provider ______
Provider Address ______
Provider City, State, Zip ______
Amount Paid For Tax Year ______
Carryover Amt Previous Year ______
Health Care Coverage QuestionnaireName: SSN:
Had health care coverage / For the entire year / For part of the year / No coverage
Yes No / Did anyone besides taxpayer or spouse pay for health care coverage for anyone listed above?
Yes No / Did you pay for healthcare coverage for anyone not listed above?
If you had coverage for any part of the year: Where was it obtained?
Employer / Medicare / Medicaid / Marketplace (Exchange) / Other
If youDIDN’Thave coverage for part or all of the year:
Answer YES if it applies to any member of the household ( Skip if you HAD coverage all year)
Yes No / Was you previous insurance policy cancelled in 2015?
Yes No / Do you have an Exemption from the Marketplace (also called the Exchange)?
Yes No / Was coverage offered by taxpayer’s or spouse’s employer?
Yes No / Are you a member of a federally-recognized Indian tribe?
Yes No / Are you a member of a health care sharing ministry?
Yes No / Did you live in the United States the entire year?
Yes No / Are you enrolled in TRICARE?
Yes No / Did you apply for CHIP coverage?
Yes No / Do any of the following apply to you? Do NOT indicate which one.
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