The Bottom Line Financial Services Incorporated

TAX ORGANIZER

The Bottom Line Financial Services Incorporated

258 S. 11th Street

Phila. Pa. 19107

215.238.0230 voice 215.701.7538 fax

(If you are a new client, please send a copy of last year’s tax return)

FOR TAX YEAR ______

Your Name / S.S. # - - / Birthdate / /
Spouses Name / S.S. # - - / Birthdate / /
Mailing Address / Home Phone Number Work or Cell Phone Number
( ) - ( ) -
E-mail Address

DEPENDENTS

NAME / S.S. # / D.O.B. / RELATIONSHIP

Was there anyone else you contributed support that resides in the U.S., Canada or Mexico?

NAME / S.S. # / D.O.B. / RELATIONSHIP / % SUPPORTED / INCOME OF PERSON
$
$

CHILD OR DEPENDENT CARE

Did you pay a baby-sitter last year?

NAME OF SITTER / S.S. # / ADDRESS / AMT. PD.
$
$

If your sitter is an adult & works in your home, you are required to file W-2 forms by January 31. If you want us to prepare

These forms contact us right away.

ESTIMATED TAXES

CREDIT FROM PRIOR
YEAR’S VOUCHER
PAYMENTS / FIRST QUARTER (APRIL 15) / SECOND QUARTER
(JUNE 15) / THIRD QUARTER
(SEPT. 15) / FOURTH QUARTER
(JAN. 15) / TOTAL FOR YEAR
Federal
$ / $ / $ / $ / $ / $
State
$ / $ / $ / $ / $ / $

INCOME

Wages, Salaries, Tips, Etc. (Attach W-2s)

Interest income from Seller-Financed Mortgages & Individuals:

Interests from Banks & Financial Institutions (Attach 1099 Int)

Include all that have your Social Security number on them.

NAME / AMOUNT / NAME / AMOUNT
______/ $______/ ______/ $______
______/ $______/ ______/ $______
Did you sell or turn in any U.S. Savings Bonds? / YES / NO

If yes, please list information: ______

Nontaxable Interest: (Attach Information)
Did you have any foreign bank accounts? / YES / NO

If yes, please explain______

Did you have any penalties on Early Withdrawal of Savings Certificates? / YES / NO

If yes, list or attach information______

Dividends: (Attach 1099Div’s) Capital Gain Distributions: (Attach 1099B’s) Education Distributions: (Attach 1099Q’s)

Nontaxable Distributions: (Attach 1099s)Pensions: (Attach 1099Rs)

Exclusions of Reinvested Dividends from Public Utility: Attach Information. Did you serve in a Combat Zone? ______

Did you contribute to your pension plan? ______If yes, have you already recovered your contribution? ______

Did you have any Rollovers?_____ If yes, Attach 1099 Distribution & Rollover papers Alimony: How much did you receive? $_____

OTHER INCOME

Estate & Trusts / $______/ (Attach K-1s) / Jury Duty / $______
S-Corporations / $______/ (Attach K-1s) / Other / $______
Partnerships / $______/ (Attach K-1s) / Other / $______

Did you have any tips that you did not report to your employer? If not reported, how much did you receive? $______

Prizes & Awards $______State Tax Refund $______Unemployment Compensation $______

Lump Sum Distributions $______(Attach 1099R”s) Gambling Winnings (Attach W-2 G’s) $______

Gains & Losses from Sale of Property, Stock, Etc. (Attach 1099 B’s)

Description / Date Bought / Date Sold / Sale Price / Cost & Expense / Gain or Loss
______/ ___/___/___ / ___/___/___ / $______/ $______/ $______
______/ ___/___/___ / ___/___/___ / $______/ $______/ $______
______/ ___/___/___ / ___/___/___ / $______/ $______/ $______

SALE OF RESIDENCE - Please send or bring escrows of purchase & sale of new house. Also list improvements on old house.

DID YOU HAVE ANY OTHER INCOME FROM ANY OTHER SOURCE?

Source / ______/ Amount / $______
Source / ______/ Amount / $______
Source / ______/ Amount / $______

SOCIAL SECURITY

How much did you receive? $______How much did your spouse receive? $______(Attach SSA 1099s)

If you paid any individuals or Partnership $600.00 or more for rent or services for business purposes, you are required to file 1099s prior to

February 28th. If you would like us to prepare these, please contact us right away.

FARM INCOME - If you had any Farm Income, attach or bring in the information.

BUSINESS INCOME / BUSINESS EXPENSES (FOR SELF EMPLOYED)

What is the main business activity?______
Business Name______
Business Address______
How much is your GROSS BUSINESSINCOME? $______(Attach 1099 Miscs)
HOW MANY MILES DID YOU DRIVE FOR BUSINESS PURPOSES? ______
Merchandise / $______/ Real Estate Taxes / $______
Costs of Goods / $______/ Other Taxes & Licenses / $______
Materials & Supplies / $______/ Travel (no meals) / $______
Advertising / $______/ Meals & Entertainment / $______
Bad Debts / $______/ Utilities & Telephone / $______
Car & Truck Expense / $______/ Wages & Salaries / $______
Commissions / $______/ Bank Service Charges / $______
Insurance (other than health) / $______/ Tools / $______
Mortgage Interest / $______/ Uniforms / $______
Other Interest Paid / $______/ Safety Items / $______
Legal & Professional Fees / $______/ Freight & Shipping / $______
Office Expenses / $______/ Dues & Publications / $______
Rent on Business Property / $______/ Laundry & Cleaning / $______
Equipment Rentals / $______/ (other) / $______
Repairs / $______/ (other) / $______
Supplies / $______/ (other) / $______

INCOME FROM PROPERTY RENTAL

RENTAL 1 / RENTAL 2 / RENTAL 3
Rents Received (Attach all 1099s) / $______/ $______/ $______
Advertising Costs / $______/ $______/ $______
Association Dues / $______/ $______/ $______
Auto & Travel / $______/ $______/ $______
Cleaning & Maintenance / $______/ $______/ $______
Commissions / $______/ $______/ $______
Gardening / $______/ $______/ $______
Insurance / $______/ $______/ $______
Legal & Professional Fees / $______/ $______/ $______
Licenses & Permits / $______/ $______/ $______
Management Fees / $______/ $______/ $______
Miscellaneous / $______/ $______/ $______
Mortgage Interest / $______/ $______/ $______
Other Interest Paid / $______/ $______/ $______
Painting & Decorating / $______/ $______/ $______
Painting Equipment (brushes, ladders, etc. ) / $______/ $______/ $______
Pest Control / $______/ $______/ $______
Plumbing & Electrical / $______/ $______/ $______
Repairs / $______/ $______/ $______
Supplies / $______/ $______/ $______
Cleaning Supplies / $______/ $______/ $______
Tools / $______/ $______/ $______
Taxes / $______/ $______/ $______
Telephone / $______/ $______/ $______
Utilities / $______/ $______/ $______
Wages & Salaries / $______/ $______/ $______
Other (list) / $______/ $______/ $______
Other (list) / $______/ $______/ $______
Other (list) / $______/ $______/ $______

RENTAL INCOME (continued)

What type of property is the rental? (i.e. four bedroom house, warehouse, trailer park, etc.)

RENTAL 1______/ RENTAL 2______/ RENTAL 3______

When did you purchase your rental property? (Mm/Yy)

RENTAL 1...... ______/______/ RENTAL 2...... ______/______/ RENTAL 3 ...... ______/______

How much did the rental property cost you?

RENTAL 1 $______/ RENTAL 2 $______/ RENTAL 3 $______

Did you have any Farm Rental Income? ______If yes, attach information. Did you have any Royalties? ______If yes, attach information & 1099s. Did you receive an Education Distribution?______

DEDUCTIONS

MEDICAL

Medicines / $______/ Drugs / $______
NAME / Amount Paid After
Insurance Reimbursement / NAME / Amount Paid After
Insurance Reimbursements
Doctors:______/ $______/ Specialists:______/ $______
______/ $______/ ______/ $______
______/ $______/ ______/ $______
Dentists: ______/ $______/ Chiropractors:______/ $______
______/ $______/ ______/ $______
______/ $______/ ______/ $______
Orthodontists: ______/ $______/ Clinics:______/ $______
______/ $______/ ______/ $______
______/ $______/ ______/ $______
Practitioners:______/ $______/ Hospitals:______/ $______
______/ $______/ ______/ $______
Transportation & Lodging_ / $______/ Insurance Premiums (include Medicare) / $______
Prenatal Care / $______/ Postnatal / $______
Eyeglasses / $______/ Hearing Aids / $______
X-Rays / $______/ Lab Fees / $______
Medical Lodging / $______/ Bandages / $______
Therapy Equipment / $______/ Crutches / $______
Medical Supplies & Appliances / $______/ Diabetic Expense / $______
Prosthesis Expense / $______/ Therapy Pool / $______
Required Air Conditioning Expense / $______/ Electrical Expense / $______
Repairs & Filters / $______/ Stop Smoking Expense / $______

TAXES

Did you pay State Taxes last year? _____ How much? $______Did you pay State Taxes last year for prior years? _____ How much? $______Did you pay Sales Taxes on Major Purchases last Year?______How much? $______

Auto License Fees / $______/ Auto Sales Tax / $______
Real Estate Taxes / $______/ Property Taxes / $______
Irrigation Taxes / $______/ Personal Property Taxes / $______
Boat Taxes / $______/ Other Taxes / $______

Did you buy any cars, boats, motorcycles, R.V.s, trailers, mobile homes, airplanes, etc.?______(Attach Information.)

DEDUCTIONS (CONTINUED)

INTEREST: (Attach all 1098s)

1ST HOME / NAME / AMOUNT / 2ND HOME / NAME / AMOUNT
Mortgages...... / ______/ $______/ Mortgages...... / ______/ $______
2nd Home Mortgage.. / ______/ $______/ 2nd Home Mortgage... / ______/ $______
Late Charges...... / ______/ $______/ F.H.A. Charges / ______/ $______
Mortgage Insurance...
College Loan Interest
College Loan Interest / ______
______/ $______$______$______/ Real Estate Loan Fees
Points ……………….
College Loan Interest / ______/ $______$______$______

CONTRIBUTIONS

Churches / $______/ Payroll Deductions / $______
Missions / $______/ Youth Programs / $______
Evangelists / $______/ Muscular Dystrophy / $______
Bazaar / $______/ Salvation Army / $______
Public Schools / $______/ County Fairs / $______
Jaycees / $______/ Boy - Girl Scouts / $______
Heart Fund / $______/ Xmas / Easter Seals / $______
Cancer Fund / $______/ United Way / $______

Did you donate any non - cash items such as food or used clothing? Please list description and value: ______

Miscellaneous

Union Dues / $______/ Spouse Dues / $______
Tax Preparer Fee / $______/ Audit Fees / $______
Extension Fees / $______/ Business Dues / $______
Books & Publications / $______/ Safety Items / $______
Fire Retardant Clothing / $______/ Safety Boots / $______
Protective Eye Wear / $______/ Mosquito Spray / $______
Gloves / $______/ Work Watch / $______
Tools / $______/ Flashlights / $______
Batteries / $______/ Water Jugs / $______
Uniforms / $______/ Telephone for Business / $______
Cleaning / $______/ Protective Headgear / $______
Investment Expense / $______/ Sales & Promo Costume / $______
Adoption Expense / $______/ Safety Deposit Box / $______
Record Keeping Costs / $______/ Safety Glasses / $______
Other ( list ) / $______/ Other ( list ) / $______

CONTINUED EDUCATION & 1ST TWOYEARSCOLLEGE STUDENT CREDIT

Name of Student

/ ______
Name of Institution / ______/ Travel Expense / $______
Education Purpose / ______/ Tuition Expense / $______
Dates Attended / ______/ Supplies Expense / $______
Name of Student / ______
Name of Institution / ______/ Travel Expense / $______
Education Purpose / ______/ Tuition Expense / $______
Dates Attended / ______/ Supplies Expense / $______

EMPLOYEE BUSINESS EXPENSE

Did you use your personal vehicle to run errands, chase parts, carry job tools, etc. for your employer? Include Job Hunting.

Please explain: ______

How many miles did you drive for the year? ______How many miles did you drive for business? ______

Description of vehicle: Make ______Model ______Year______

Did you purchase an automobile last year? ______please enclose purchase papers.

Auto License Fee / $______/ Auto Sales Tax / $______
Auto Interest / $______/ Parking & Tolls / $______

OPTIONAL

Oil & Lubrication / $______/ Auto Club / $______
Washing & Polishing / $______/ Tires, Batteries, Etc. / $______
Repairs / $______/ Insurance / $______
Fuel / $______/ Other ( list ) / $______

TRAVEL & EXPENSES OTHER THAN AUTO

Plane & Rail Fares / $______/ Bus Fares / $______
Taxi & Public Transit / $______/ Car Rentals / $______
Lodging / $______/ Meals / $______
Telephone, Fax, Postage / $______/ Tips & Baggage Charge / $______
Laundry & Cleaning / $______/ Other ( list ) / $______

SALES EXPENSE

Lunches, Dinners, Etc. / $______/ Show & Event Tickets / $______
Organization Dues / $______/ Gifts / $______
Stationary & Postage / $______/ Basic Phone / $______
Long Distance Phone / $______/ Other ( list ) / $______

Did you make any modifications to your home for the handicapped? Please Describe: ______

Cost of modifications $______

Did you move last year? ______How many miles did you move? ______Date Moved ____/____/____

Transportation Cost $______Storage Cost $______Travel & Lodging $______

How much were you reimbursed that was not included in your wages? $______

Did you or your spouse contribute to a REGULAR IRA, ROTH IRA, SIMPLE or KEOGH? $______

Do you or your spouse have a retirement plan at work? ______

Did you payalimony? ______How much? ______

Recipients Name & S. S. # ______

DECLARATION:

I have provided the information on this form to the best of my knowledge and hereby declare it is complete and ready for the preparation of my/our income tax returns. Where business deductions shown, I acknowledge having spent these amounts and have kept a log or diary of such activities, pursuant to section 274(a) and can fully substantiate such deductions.

______

SIGNATURE (must be signed) DATE

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