Individual Income Tax Questionnaire Page 2
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Wage and Salary Income
(Attach all W-2's Received)
Employer
Gross Wages (Box 1)
Federal Tax
State Tax
Retirement Income
(Attach all 1099's Received)
Payor
Gross
Taxable
Federal
State
Distribution
Distribution
Tax
Tax
Social Security …….………………………………………………
Social Security ……….……………………………………………
Railroad Retirement …….………….…………………………….
IRA's……...…..….. …….………….…………………………….
Pensions…..………………………………………..……….……
Interest Income
(Attach All 1099 Forms Received including All Tax-Exempt Interest Received)
(If Interest is Received on a Contract For Deed, The Payor's Name, Address and Social Security # are Required)
Payor
Amount
Payor
Amount
Dividend Income
(Attach All 1099 Forms Received including All Tax-Exempt Dividends)
Payor
Dividends
Qualified
Capital
Tax
Foreign
Dividends
Gains
Exempt
Tax
Miscellaneous Income
(Attach relevant forms)
Unemployment Compensation…………...
Estates or Trusts….………………………..….
Alimony……………….……….…………….
Royalties…………….………………….……....
VA Pension………………...……………….
Welfare Assistance……….……..…………….
VA Disability……….………….………….…
Partnership or S-Corp (provide K-1)……………
Tips and Gratuities…….…………………..
Lawsuit Recoveries……………………..……..
Directors Fees………….….……………….
Cancellation of debt…………………………..
Prizes and Awards……………..……………
Other
:
(Describe)
Worker's Compensation….……….……….
Security and Real Estate Sales
Foreclosures, abandonments, Ponzi scheme losses and other property transactions need to be listed here.
Description
Date Bought
Date Sold
Sales Price
Cost
Expenses
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