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 Questionnaire
Name: 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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