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FU LL LEGALNAME YOURS:
SOCIAL SECURIry #
BIRTH DATE
S P O US ES :
D E P E N D E N1 : T
DE P E ND EN2 : T
DE P E ND E N3 : T
ADDRESS, CITY, ZIP:
EMAIL ADDRESS:
H OME H ONE P #:
YOUROCCUPATION:
Y OU RC E LLPHO NE #:
SPOUSE OCCUPATION:
S P OU S E ELLPHO NE C #
TAX PAYMENTS REFUND & INFORMATION
YES NO D U R I N G 0 1 , D I DY O U . . . . 2 1 PAYESTIMATED INCOME TAXES I F Y E S .P L E A S E . . . . ENTER DATEANDAMOUNT FORFEDERAL AND STATEPAYMENTS
WA N TYOU RR EF U ND IR E E 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
D U R I N G 0 1 1 D I DY O U . . . , 2 .
I FY E S . L E A S E . . . . P
INCOME
RECEIVE W-2 WAGES ATTACH FORMS W-2 FORALLWAGESEARNED DURING THEYEAR INDICATE ryPE ANDAMOUNTS
HAVEHEALTH INSURANCE PREMIUMS, FLEXIBLE H EA L T H PE N D IN G,H ILD C A R E , R E TIR E ME N T S C OR SAVINGS WITHHELD FROMYOURPAYCHECK
RECEIVE INTEREST DIVIDENDS OR
ATTACH FORMS 1099FORALL INTEREST DIVIDENDS OR EARNED ATTACHFORMS1099FORALL TAXABLE BENEFITS RECEIVED
RECEIVE SOCIAL SECURIry,DISABILITY, UNEMPLOYMENT, RETIREMENT OR PLAN BENEFITS
PAYOR RECEIVE ALIMONY
ENTER AMOUNT HERE
SELLANYASSETS, SUCHAS A HOME,LAND, STOCKS, BONDS OR
PROVIDE DETAILS BOTHTHE PURCHASE OF AND SELL, INCLUDING PURCHASE PRICE AND DATEOF PURCHASE ATTACH SCHEDULE FOREACHACTIVIry A K-1
R E C E IVE C O ME R OM A R TN E R S H IP S . IN F P S-CORPS, ESTATES, TRUSTS OR
RECEIVESELF-EMPLOYED, RENTAL,OR FARMINCOME
INDICATE GROSSAMOUNTRECEIVED AND DETAILOF ALL EXPENSES PAID(NCLUDEMILEAGE AND CELLPHONE USAGE) ATTACHDETATLS INCLUDING AMOUNTS
RECEIVE STATETAX REFUNDS, GAIVIBLING WINNINGS, JURY DUry PAY. PRIZES, ANY OTHERINCOI\4E OR
DEDUCTIONS
PAYMORTGAGE INTEREST YOURHOME ON PAYPROPERTY TAXON YOURHOME PAYPROPERTY TAX ON YOURAUTOMOBILES , BOATS, O R O T H ER R S O N AP R OP E R ry PE L ATTACH FORM1098FORMORTGAGE INTEREST PAID E N TE R MOU N T E RE A H ENTER AMOUNT HERE
C ON T R IB U TC AS HTO C H A R ITA B LE GA N IZA TION S E OR
E N TE R MOU N T E RE A H
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YES
NO
DURING 01,1.IDYOU..., 2 D MAKE NONCASH CONTRIBUTIONS CHARITIES TO
IFYES, LEASE.... P ATTACHRECEIPTS WITH VALUEOF DONATIONS NOTED
PAYMEDICAL (INCLUDING EXPENSES HEALTH INSURANCE, ENTER ryPE ANDAMOUNTS COPAYS, DENTISTS, EYEDOCTORS, PRESCRIPIONS, ETC.) THATEXCEED 7,5%OF YOURTOTALINCOME PAYFORJOB HUNTING EXPENSES, INVESTMENT FEES, U N R E IM BU R S ED P LOY E E X P E N S E(IN C LU D IN G EM S MILEAGE) THATEXCEED OF YOURTOTALINCOME 2% HAVEGAMBLING LOSSES
ENTER ryPE ANDAMOUNTS
E N TE R MOU N T E RE A H
CREDITS ADJUSTMENTS &
PAY FORCHILDCARE THATYOUANDYOUR SO sPousE (lF APPLTCABLE) COULD WORK ATTACH THE CHILDCAREPROVIDERS YEARENDSTATEMENT
PAYFORHIGHER EDUCATION FORYOURSELF, YOU RS POU SEO R DE P E N D E N TS ,
ATTACH FORM1098-T
CONTRIBUTE AN IRA.SEPOR SIMPLE TO PLAN PAYFORSELFEMPLOYED HEALTH INSURANCE PAYMOVING EXPENSES MOVEMORETHAN TO 5 0 M IL ES
E N TE R P EA N DA M O UNT TY HERE E N TE R MOU N T E RE A H
E N TE R MOU N T E RE A H
PAYEDUCATOR EXPENSES
E N TE R MOU N T E RE A H
PAYSTUDENT LOANINTEREST E NT E R N YQ U ES T IO NOR M AT T E R S E N E E D D IS C U S S E R E : A S W TO H
E N TE R MOU N T E RE A H
THIS TAX ORGANIZERIS NOT INTENDED TDENTIFYALL TO POSSIBLESOURCESOF INCOI\4E, DEDUCTIONS, CREDITS. OR BUT IS DESIGNED IDENTIFY TO MOST INCOME.DEDUCTIONS, AND CREDITSFOR I\4OST TAXPAYERS.COPYRIGHT 2011. LEONARDTAX & ACCOUNTING, LLC, ALL RIGHTSRESERVED
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