DAY CARE EXPENSE. Medical/Dental Expenses. Taxes Paid. Interest Expense Mortgage interest paid - attach Form-1098(s)

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5 DAY CARE EXPENSE Provider #1 Address City/State/Zip EIN/SS# (Mandatory) Amount Paid: Provider #2 Address City/State/Zip EIN/SS# Amount Paid: Children cared for Medical/Dental Expenses Medical insurance premiums (paid by you) Medical equipment Long Term Care insurance Nursing Care Prescription drugs Medical Therapy Glasses, contacts Hospital Hearing aids, batteries Doctor/Dental/Orthodontist Braces Mileage (no. of miles) Taxes Paid Real property tax (attach bills) Personal property tax Vehicle Tax (license, registration) Other Interest Expense Mortgage interest paid - attach Form-1098(s) Current Mortgage Interest Rate (optional) Interest paid to individual for your home (attach amortization schedule). Paid to: Name: Address: Social Security No: Interest paid

6 CASUALTY / THEFT LOSS - For property damaged by storm, water, fire, accident, or theft. Location of property Insurance reimbursement Description of property Repair costs Amount of damage Federal grants received ESTIMATED TAX PAYMENTS Federal Amount State Amount LY Jan 15 LY Jan 15 Q1 Apr 15 Q1 Apr 15 Q2 Jun 15 Q2 Jun 15 Q3 Sep 15 Q3 Sep 15 Q4 Jan 15 Q4 Jan 15 CHARITABLE CONTRIBUTIONS (receipts required) Church Salvation Army, Goodwill United Way Scouts Non-Cash (household items, clothes, etc.) Telethons Address University, Public TV Radio City/State/Zip Heart, Lung, Cancer, etc. Value of goods (attach list if more than one) Wildlife Fund, Humane Society Volunteer Mileage MISCELLANEOUS / UNREIMBURSED EMPLOYEE EXPENSES (Self Employed see next page) Dues union, professional Books, subscriptions, supplies Licenses Tools, equipment, safety equipment Uniforms (including cleaning) Sales expense, gifts Tuition, Books (work related) Entertainment Tax preparation fee Safe deposit box IRA custodial fees Investment periodical, advisory fees Job search expense Moving of household goods (job related)

7 SELF EMPLOYMENT INFORMATION Business Name: Industry Type: Business owned by: Gross Sales TP SP Self-Employment Expenses: Advertising Repairs Expense Commissions / Fees Supplies Expense Dues & Publications Taxes and Licenses Interest Expense (include auto loan) Travel Expense Insurance (non-health, non-auto) Meals & Entertainment Health Insurance Telephone Legal & Professional Fees Utilities (non-home) Office Supplies (paper, ink, etc.) Contract Labor Rent (office space) Materials & Supplies Auto Expense: Postage Purchase Price Bank charges Make Model Tools & Equipment (below $1K) Date auto placed in service Uniforms Auto (business miles) PLEASE SEE HELP Dues & Subscriptions Auto (personal miles) PLEASE SEE HELP Equipment Rental Expense Gas, repairs, tolls, taxes Auto Insurance COST OF GOODS SOLD (only if inventory kept from prior year) Inventory at beginning of year Inventory at end of year Purchases Cost of items for personal use Cost of labor HOME OFFICE EXPENSE Number of Rooms (bedroom, living room, dining room) Expenses: BUSINESS ASSETS PURCHASED Asset (equipment, computer, cars, etc.) Date Acquired Monthly rent ( if applicable) Annual mortgage interest paid ( if applicable) Annual repairs/maintenance Annual utilities (electric, gas, water, etc.) Annual home/rental insurance Real Estate Taxes Amount Paid

8 RENTAL INCOME: Property 1 Property 2 Property 3 Property 4 Basis (Purchase Price) Date Purchased Prior Depreciation (if any) Address City / State Rent Income Expenses Advertising Auto & Travel Auto Miles Cleaning & Maintenance Commissions Paid Grounds & Gardening Insurance Interest Expense Legal & Professional Management Fees Repairs & Maintenance Supplies Taxes Utilities Association Dues Pest Control Privacy Policy The nature of our work requires us to collect certain nonpublic information. We collect financial and personal information from applications, worksheets, reporting statements, and other forms, as well as interviews and conversations with our clients and affiliates. We may also review banking and credit card information about our clients in the performance of receipt of payment. Under our policy, all information we obtain about you will be provided by you or obtained with your permission. Our firm adheres to procedures and policies in place to protect your confidential information. We restrict access to your confidential information to those within our firm who need to know in order to provide you with services. We will not disclose your personal information to a third party without your permission, except where required to by law. We maintain physical, electronic, and procedural safeguards in compliance with federal regulations that protect your personal information from unauthorized access.

9 Insert any additional notes or special circumstances that we should be aware of while preparing your tax return(s):