Miscellaneous: Jury Duty, Gambling, Other K-1 forms from Partnership, S-Corporation, or Trust □ □ BUSINESS INCOME & EXPENSE ITEMS: If you don’t see an expense listed below, please ask. Total (Gross) Income Advertising Education Expense □ □ Asset Purchases Equipment/Supplies □ □ Auto: Parking &Tolls General Office Expense □ □ Bank/Credit Card Fees Hotel/Travel Expense □ □ Business Phone Expense Insurance □ □ Business Vehicle: Interest Paid □ □ ____Auto Legal or Professional Fees □ ____Date Placed in Service License Fees/Taxes Paid □ ____Business Miles Meals/Entertainment □ ____Total Miles Postage □ Cell Expense Rent/Lease Fees Paid □ □ Cleaning/Maintenance Repairs □ □ Commissions Paid Tools □ □ Contractors/Subcontractors Utilities □ □ Dues & Publications □ ADDITIONAL ITEMS FOR RENTAL PROPERTIES: Days Rented ____ Room Rentals (in home) Vacation Rental □ □ □ Condo/PUD Association Fees Mileage/Travel Keys/Other □ □ □ Gardening/Yard Work Mortgage Interest Property Tax □ □ □ Management Fees Termite Treatment Utilities □ □ □ DEDUCTIONS/CREDITS TO INCOME: Adoption Expense Medical Savings Account (5498-SA/1099-SA) □ □ Alimony Paid* Moving Expenses □ □ Child Care Expenses: ____Provider Name Penalty on Early Savings Withdrawal □ □ ____Phone Number ____EIN ____Amount Paid Retirement Contributions (not through employer) □ Education Expenses Self-employed Health Insurance □ □ IRAs/Keogh/SEPs (Form 5498) Teacher Expenses □ □ * Total Alimony Paid: Must have name and Social Security number of recipient, and amount paid. ESTIMATED TAXES PAID: Date of payment and amount paid for each Federal and State quarterly tax estimate. HEALTH CARE INFORMATION Did you have qualifying health care coverage (employer group plan coverage or government-sponsored □ coverage) for every month of 2016 for you, your spouse and all members of your family as claimed on your tax return? Did you or anyone in your family qualify for an exemption from the health care coverage mandate? □ Did you acquire health care coverage through the Marketplace the Affordable Care Act? If yes, provide □ Form(s) 1095-A and 1095-C.
□ Miscellaneous: Jury Duty, Gambling, Other □ K-1 forms from Partnership, S-Corporation, or Trust BUSINESS INCOME & EXPENSE ITEMS: If you don’t see an expense listed below, please ask. Total (Gross) Income □ Advertising □ Asset Purchases □ Auto: Parking &Tolls □ Bank/Credit Card Fees □ Business Phone Expense □ Business Vehicle: ____Auto ____Date Placed in Service ____Business Miles ____Total Miles □ Cell Expense □ Cleaning/Maintenance □ Commissions Paid □ Contractors/Subcontractors □ Dues & Publications □ Education Expense □ Equipment/Supplies □ General Office Expense □ Hotel/Travel Expense □ Insurance □ Interest Paid □ Legal or Professional Fees □ License Fees/Taxes Paid □ Meals/Entertainment □ Postage □ Rent/Lease Fees Paid □ Repairs □ Tools □ Utilities ADDITIONAL ITEMS FOR RENTAL PROPERTIES: □ Days Rented ____ □ Room Rentals (in home) □ Vacation Rental □ Condo/PUD Association Fees □ Mileage/Travel □ Keys/Other □ Gardening/Yard Work □ Mortgage Interest □ Property Tax □ Management Fees □ Termite Treatment □ Utilities DEDUCTIONS/CREDITS TO INCOME: □ Adoption Expense □ Medical Savings Account (5498-SA/1099-SA) □ Alimony Paid* □ Moving Expenses □ Child Care Expenses: ____Provider Name □ Penalty on Early Savings Withdrawal ____Phone Number ____EIN ____Amount Paid □ Retirement Contributions (not through employer) □ Education Expenses □ Self-employed Health Insurance □ IRAs/Keogh/SEPs (Form 5498) □ Teacher Expenses * Total Alimony Paid: Must have name and Social Security number of recipient, and amount paid. ESTIMATED TAXES PAID: Date of payment and amount paid for each Federal and State quarterly tax estimate. HEALTH CARE INFORMATION □ Did you have qualifying health care coverage (employer group plan coverage or government-sponsored coverage) for every month of 2016 for you, your spouse and all members of your family as claimed on your tax return? □ Did you or anyone in your family qualify for an exemption from the health care coverage mandate? □ Did you acquire health care coverage through the Marketplace the Affordable Care Act? If yes, provide Form(s) 1095-A and 1095-C.
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