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FU LL LEGALNAME YOURS: SOCIAL SECURITY #
BIRTH DATE
S P O US E S:
DEPENDENT 1:
DE P E ND EN2 : T
DE P E ND E N3 : T
ADDRESS, CITY,ZIP:
E M A I L DD R ES S: A
H OMEP H O NE #:
YOUROCCUPATION:
Y OU RC E L LPHO NE #:
S P O US E C C U PA T IO N : O
S P OU S E ELL C PHO NE #
TAX PAYMENTS REFUND & INFORMATION
YES NO D U R I N G 0 1 1 D I DY O U , . . . 2 . PAY ESTIMATED INCOME TAXES I F Y E S ,P L E A S E . . . ENTER DATEANDAMOUNT FORFEDERAL ANDSTATE PAYMENTS
WA N TYOU RR EF U ND IR E C T E P OS ITE D D D
E N TE R OU TIN G N DACCO UNT R A NUM BER HERE
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YES
NO
p U R T N G0 1 1 , p t p Y O U . . . . 2
ffi
INCOME
RECEIVE W-2 WAGES ATTACH FORMS W-2 FORALL WAGESEARNED DURING THEYEAR INDICATE TYPEANDAMOUNTS
HAVEHEALTH INSURANCE PREMIUMS, FLEXIBLE H E AL T H EN D IN G , H ILD C A R E , R E TIR E ME N T SP C OR SAVINGS WITHHELD FROM YOURPAYCHECK
RECEIVE INTEREST DIVIDENDS OR
ATTACH FORMS 1099FORALL INTEREST DIVIDENDS OR EARNED ATTACHFORMS1099FORALL TAXABLE BENEFITS RECEIVED
RECEIVE SOCIAL SECURITY, DISABILITY, UNEMPLOYMENT, RETIREMENT OR PLAN BENEFITS
PAYOR RECEIVE ALIMONY
E N TE R MOU N T E RE A H
SELLANY ASSETS, SUCHAS A HOME,LAND, STOCKS, BONDS OR
PROVIDE DETAILS BOTHTHE PURCHASE OF AND SELL, IN C LU D IN GU R C H ASE CE P PRI ANDDATE F PURCHASE O ATTACH SCHEDULE FOR EACHACTIVIry A K-1
RECEIVE INCOME FROMPARTNERSHIPS. S-CORPS, ESTATES, TRUSTS OR
RECEIVE SELF-EMPLOYED, RENTAL, OR FARMINCOME RECEIVESTATETAX REFUNDS, GAMBLING WINNINGS, JURY DUTY PAY, PRIZES. ANY OTHERINCOME OR
INDICATE GROSSAMOUNTRECEIVED AND DETAILOF ALL EXPENSES PAID(INCLUDE MILEAGE ANDCELLPHONEUSAGE) ATTACHDETAILS INCLUDING AMOUNTS
DEDUCTIONS
PAYMORTGAGE INTEREST YOURHOME ON PAYPROPERWTAX ON YOURHOME PAYPROPERTY TAX ON YOURAUTOMOBILES , BOATS, O R OT H ER ER SON AP R OP E R TY P L CONTRIBUTE CASHTO CHARITABLE ORGANIZATIONS ATTACH FORM1098FORMORTGAGE INTEREST PAID E N TE R MOU N T E RE A H ENTER AMOUNT HERE
ENTER AMOUNT HERE
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YES
NO
D U R I N G 0 1 1D I D Y O U . . . . 2 . MAKE NONCASH CONTRIBUTIONS CHARITIES TO
I F Y E S ,P L E A S E . . . . ATTACHRECEIPTS WITH VALUEOF DONATTONS NOTED
PAY MEDICAL (INCLUDING EXPENSES HEALTH INSURANCE, ENTER TYPEAND AMOUNTS COPAYS,DENTISTS, EYE DOCTORS, PRESCRIPIONS, ETC.) THAT EXCEED7.5% OF YOUR TOTALINCOME PAY FOR JOB HUNTINGEXPENSES, INVESTMENT FEES, UNREIMBURSED EMPLOYEE (INCLUDING EXPENSES MILEAGE) THAT EXCEED2% OF YOURTOTALINCOME HAVE GAMBLING LOSSES
ENTERTYPEAND AMOUNTS
ENTERAMOUNTHERE
CREDITS ADJUSTMENTS &
PAY FOR CHILDCARE THATYOU AND YOUR SO (IF SPOUSE APPLICABLE) COULD WORK ATTACHTHE CHILDCARE PROVIDERS YEAR END STATEMENT
PAY FOR HIGHEREDUCATION FORYOURSELF, YOURSPOUSE, DEPENDENTS OR
ATTACHFORI\4 1098-T
CONTRIBUTE AN IRA,SEP OR SIMPLE TO PI-AN PAY FORSELFEMPLOYED HEALTH INSUMNCE PAYMOVING EXPENSES MOVEMORETHAN TO 50MILES
ENTER TYPEANDAMOUNT HERE ENTER AMOUNT HERE
ENTER AMOUNT HERE
PAY EDUCATOR EXPENSES
E N TE R MOU N T E RE A H
PAYSTUDENT LOANINTEREST E NT E R YQU ES T IO NO R M AT T E R S N E E D D IS C U S S E R E : AN S WE TO H
E N TE R MOU N T E RE A H
THIS TAX ORGANIZERIS NOT INTENDED IDENTIFYALLPOSSIBLE TO SOURCESOF INCOIJE,DEDUCTIONS, CREDITS,BUT IS DESIGNED IDENTIFY OR TO MOST INCOIVE, DEDUCTJONS, AND CREDITSFOR MOSTTMPAYERS. COPYRIGHT 2011. U.S.TAX & FINANCE,ALL RIGHTSRESERVED
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