2217 E CEDAR AVE FLAGSTAFF, AZ (928)

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1 2217 E CEDAR AVE FLAGSTAFF, AZ (928) Dear New Client: The 2012 Tax Organizer will assist you in collecting and reporting information necessary for us to properly prepare your 2012 income tax return. Please complete the organizer sections as appropriate and provide supporting documentation where necessary. Prior year data is included on the organizer sections for your reference. Please provide us with the following additional information: - A copy of your 2011 tax return, if not prepared by this office - Form(s) W-2 (wages, etc.) - Form(s) 1099 (interest, dividends, etc.) - Schedule(s) K-1 (income/loss from partnerships, S corporations, etc.) - Form(s) 1098 (mortgage interest) and property tax statements - Brokerage statements from stock, bond or other investment transactions - Closing statements pertaining to real estate transactions - All other supporting documents (schedules, checkbooks, etc.) - Any tax notices received from the IRS or other taxing authorities Thank you for your help in the completion of the Tax Organizer. Please contact us if you need further assistance. Sincerely, LUANN ROBERTS CPA

2 ORGANIZER US Tax Organizer Page 1 LuAnn McCormick Roberts, CPA 2217 E CEDAR AVE FLAGSTAFF, AZ Telephone number: Fax number: address: (928) LUANN@LMRCPA.COM Tax Return Appointment Date: Time: Location: This tax organizer will assist you in gathering information necessary for the preparation of your 2012 tax return. Please enter all pertinent 2012 information. NOTE: If you claim the earned income credit, please provide proof that your child is a resident of the United States. This proof is typically in the form of: school records or statement, landlord or property management statement, health care provider statement, medical records, child care provider records, placement agency statement, social service records or statement, place of worship, Indian tribal office statement, or employer statement. NOTE: If your child is disabled, please provide one of the following forms of proof of disability: doctor statement, other health care provider statement, or social services agency or program statement. CLIENT INFORMATION First name and initial..... Last name Title/suffix Social security number... Occupation Date of birth (m/d/y) Date of death (m/d/y) =blind Home phone Work phone Work extension Cell phone address In care of Street address Apartment number.. Address City State ZIP code DEPENDENTS First name Last name Title/suffix Date of birth (m/d/y) Social security number... Relationship Months lived at home.... First name Last name Title/suffix Date of birth (m/d/y) Social security number... Relationship Months lived at home.... Taxpayer Dependent No. Dependent No. Spouse Dependent No. Dependent No. Tax Organizer

3 ORGANIZER US Tax Organizer Page 2 Please enter all pertinent 2012 information. If you have attached a government form for an item, check the box and do not enter a 2012 amount. WAGES, SALARIES AND TIPS Employer name: 2012 Amount 2011 Amount Attach Forms W-2 INTEREST INCOME Payer name: Attach Forms 1099-INT DIVIDEND INCOME Payer name: Attach Forms 1099-DIV PENSIONS, IRA AND GAMBLING INCOME Payer name: Attach Forms 1099-R & W-2G Winnings not reported on W-2G Total gambling losses OTHER GOVERNMENT FORMS - INCOME Form 1099-B - Sales of stock (also include transaction history) Form 1099-MISC - Miscellaneous income Form 1099-K - Merchant card and third party network payments..... Form 1099-S - Sales of real estate (also include closing statements) Attach Forms 1099 Taxpayer: Form 1099-G - State tax refunds Attach Forms 1099 Form SSA Social security benefits Form 1099-G - Unemployment compensation Spouse: Form SSA Social security benefits Form 1099-G - Unemployment compensation Attach Forms 1099 Attach Forms 1099 MISCELLANEOUS INCOME Taxpayer: Alimony received Other: Spouse: Alimony received Tax Organizer

4 ORGANIZER US Tax Organizer Page 3 RETIREMENT PLAN CONTRIBUTIONS Taxpayer: Traditional IRA contributions (1=maximum) Amount 2011 Amount Roth IRA contributions (1=maximum) Self-employed, SEP, SIMPLE, & qualified plan contributions (1=maximum) Spouse: Traditional IRA contributions (1=maximum) Roth IRA contributions (1=maximum) Self-employed, SEP, SIMPLE, & qualified plan contributions (1=maximum) OTHER GOVERNMENT FORMS - DEDUCTIONS Form 1098-E - Student loan interest Form 1098-T - Tuition and related expenses Attach Forms 1098 ADJUSTMENTS TO INCOME Taxpayer: Self-employed health insurance premiums Educator expenses Expenses from rental of personal property Other adjustments to income: Alimony paid - Recipient name & SSN Spouse: Self-employed health insurance premiums Educator expenses Expenses from rental of personal property Other adjustments to income: Alimony paid - Recipient name & SSN MEDICAL AND DENTAL EXPENSES Prescription medicines and drugs Doctors, dentists and nurses Hospitals and nursing homes Insurance premiums Long-term care premiums - taxpayer Long-term care premiums - spouse Insurance reimbursement Out-of-pocket lodging and transportation expenses Number of medical miles Other: TAXES PAID State income taxes - 1/12 payment on 2011 state estimate State income taxes - paid with 2011 state extension State income taxes - paid with 2011 state return State income taxes - paid for prior years and/or to other states Tax Organizer

5 ORGANIZER US Tax Organizer Page 4 TAXES PAID (continued) City/local income taxes - 1/12 payment on 2011 city/local estimate City/local income taxes - paid with 2011 city/local extension City/local income taxes - paid with 2011 city/local return State and local sales taxes (except autos and special items) Use taxes paid on 2012 purchases Use taxes paid on 2011 state return Sales tax on autos not included above Sales taxes paid on boats, aircraft, and other special items Real estate taxes - principal residence Real estate taxes - property held for investment Foreign income taxes Personal property taxes (including automobile fees in some states)... INTEREST PAID Home mortgage interest and points paid: 2012 Amount 2011 Amount Attach Tax Notice Attach Forms 1098 Home mortgage interest not on Form 1098 (include name, SSN, & address of payee): Points not reported on Form 1098: Mortgage insurance premiums on post 12/31/06 contracts Investment interest (interest on margin accounts): Passive interest CASH CONTRIBUTIONS NOTE: No deduction is allowed for cash or check contributions unless the donor maintains a bank record, or a written communication from the donee, showing the name of the organization, contribution date(s), and contribution amount(s). Volunteer expenses (out-of-pocket) Number of charitable miles NONCASH CONTRIBUTIONS NOTE: No deduction is allowed for contributions of clothing and household items that are not in good used condition or better, in addition, a deduction for any item with minimal monetary value may be denied. MISCELLANEOUS DEDUCTIONS Union and professional dues Tax return preparation fee Safe deposit box rental Investment expenses Estate tax, section 691(c) Unreimbursed employee expenses: Other: Tax Organizer

6 Page 1 ORGANIZER US Miscellaneous Questions If any of the following items pertain to you or your spouse for 2012, please check the appropriate box and provide additional information if necessary. Yes No Did your marital status change during the year? Did your address change during the year? Could you be claimed as a dependent on another person's tax return? Were there any changes in dependents? Did you receive unreported tip income of $20 or more in any month? Did you receive any disability income? Did you buy or sell any stocks, bonds or other investment property? Did you purchase, sell, or refinance your principal home or second home, or did you take a home equity loan? Did you make any residential energy-efficient improvements or purchases involving solar, wind, geothermal or fuel cell energy sources? Did you receive a distribution from or make a contribution to a retirement plan (401(k), IRA, etc.)? Did you transfer or rollover any amount from one retirement plan to another retirement plan? Did you convert part or all of your traditional, SEP, or SIMPLE IRA to a Roth IRA in 2012? Did you, your spouse, or a dependent incur any tuition expenses that are required to attend a college, university, or vocational school? Did you incur a loss because of damaged or stolen property? Did you use your car on the job (other than to and from work)? Do you want to electronically file your tax return? May the IRS discuss your tax return with your preparer? Was your home rented out or used for business? Were you notified or audited by either the Internal Revenue Service or the State taxing agency? Miscellaneous Questions

7 Page 2 ORGANIZER US Miscellaneous Questions Were you (or your spouse) the beneficiary of COBRA premium assistance for any month during 2012? ARIZONA QUESTIONS Did you (and/or your spouse) live in AZ all year? Did you/spouse receive income from any source outside AZ? Are you/spouse in military? Did you provide support for a person over 65, related to you or not? If you reported any gambling winnings as income, were any from AZ Lottery? Are you/spouse a Native American living or working on your own reservation? Did you make any contributions or pay fees to an AZ public school? Did you make contributions to an AZ school tuition organization? Did you install a solar energy/hot water device in your AZ residence? Did you make any contributions to a charity that provides assistance to the working poor (often United Way)? Did you convert and existing fireplace to a wood stove or gas fired fireplace? I know I can claim medical expenses on my AZ itemized deductions, even though I may not be able to on the Federal? Miscellaneous Questions (Continued)

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9 2217 E. Cedar St Flagstaff, AZ Mobile: (928) Phone: (928) Fax: (928) Medical Deductions If you can itemize your deductions (file Schedule A) then you should take advantage of Medical Expense deductions. Although the medical deductions may be limited on your federal tax return, they are FULLY deductible on your Arizona tax return. What Medical Expenses Are Deductible? Here are a few suggestions: Acupuncture Fees Alcoholism Treatment (including mileage to AA meetings) Bandages and medical supplies Breast Reconstruction Surgery, but not cosmetic surgery Birth Control Pills Chiropractor Fees Christian Science Practitioner Fees Contact Lenses and Eyeglasses (also materials such as saline solution and enzyme cleaner) Crutches (buy or rent) Dental Treatment (X-rays, fillings, braces, extractions, dentures, etc.) Diagnostic Devices (such as blood sugar test kit for diabetes) Equipment installed for medical purposes in your car and home Eye Surgery (such as laser eye surgery or radial keratotomy) Fertility Enhancement Health treatment prescribed by a physician and the physician issues a statement that the treatment is necessary Hearing Aids (including batteries) Hospital Services (including meals and lodging) Insurance Premiums You can include in medical expenses insurance premiums you pay for policies that cover medical care. Medicare A: If you are covered under social security, you are enrolled in Medicare A. The payroll tax paid for Medicare A is not a medical expense. However, it you are not covered by SS and voluntarily enroll in Medicare A and these payments would be deductible. 1

10 Medicare B: This is a supplemental medical insurance. Premiums you pay for Medicare B are a medical expense. Insurance Premiums You Cannot Include: Employer-Sponsored Health Insurance Plans (unless included on your W-2, box 1), Life insurance policies, Policies providing payment for loss of earnings, Policies for loss of life, limb, sight, etc. Long-Term Care premiums paid for qualified long-term care insurance contracts. Dependents with disabilities. You can include in medical expenses advance payments to a private institution for lifetime care, treatment, and training of your physically or mentally impaired child upon your death or when you become unable to provide care. The payments must be a condition for the institution's future acceptance of your child and must not be refundable. Medical Conferences: You can include in medical expenses amounts paid for admission and transportation to a medical conference if the medical conference concerns the chronic illness of yourself, your spouse, or your dependent. Nursing Home or Private Nursing Services Operations (legal) that are not for unnecessary cosmetic surgery. Osteopath Fees Special Education fees you pay on a doctor's recommendation for a child's tutoring by a teacher who is specially trained. Stop-Smoking Programs (but not for drugs that do not require a prescription) Transportation (Bus, taxi, train, or plane fares or ambulance service.) You can also include parking fees and tolls. Weight-Loss Program You can include in medical expenses amounts you pay to lose weight if it is a treatment for a specific disease diagnosed by a physician (such as obesity, hypertension, or heart disease). This includes fees you pay for membership in a weight reduction group and attendance at periodic meetings. You cannot include membership dues in a gym, health club, or spa as medical expenses, but you can include separate fees charged there for weight loss activities. You cannot include the cost of diet food or beverages. You cannot include in medical expenses the cost of a weight-loss program if the purpose of the weight loss is the improvement of appearance, general health, or sense of well-being. What Medical Expenses Are Not Deductible? Baby Sitting, Childcare, and Nursing Services for a Normal, Healthy Baby Controlled Substances Cosmetic Surgery Dancing Lessons Diaper Service Electrolysis or Hair Removal Flexible Spending Account Funeral Expenses Hair Transplant Health Club Dues Health Coverage Tax Credit Health Savings Accounts Household Help Illegal Operations and Treatments Maternity Clothes Medical Savings Account (MSA) Medicines and Drugs From Other Countries Nonprescription Drugs and Medicines Nutritional Supplements Personal Use Items Swimming Lessons Teeth Whitening Veterinary Fees 2