Individual Income Tax Questionnaire Page 3
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Medical and Dental Expenses
Medical Insurance…………...……..…………
Ambulance…………………………….…
Medicare Insurance……………...………...…
Medical Transportation:
Long Term Care Insurance….…..…Taxpayer
Mileage ______miles @ $ .23
Spouse
Name of Company
Policy # (s):
Parking, Bus, Taxi………………….…
Prescription Drugs………....…...…...………..
Motels……………………………….……
Glasses and Contacts………...…….......……
Other Expenses
:
(Describe)
Hearing Aids………………….…...……..…....
Doctors, Dentists, Hospitals and Clinics :
Less HSA Reimbursements
included above…………..………...…… (
)
Less Insurance Reimbursements
HSA Contributions…………………………….
included above…………..………...…… (
)
Interest Paid
Deductible Home Mortgage:
Financial Institution
Amount Paid
Interest Paid to Banks and Other Financial Institutions :
List All Mortgages and Equity Loans
(Attach all Forms 1098 received)
Deductible Mortgage Insurance:
(only applies to new mortgages)
Points paid on purchase or refinance of mortgage loans :
(Include copy of settlement statement)
Interest Paid to Individuals on a Contract For Deed : (Payee's Name, Address
and Social Security Number must be included; failure to provide is subject to a fine)
Name………………………………….……….……….
Address………………………………....….….……....
Social Security Number……….…………..……..…..
Investment Interest :
Investment Loan Relates to :
Interest Paid to
Amount Paid
Brokerage Margin Account:
Other (Describe)
Student Loan Interest :
Student's Name…………………………......…………..………
Interest Paid (Attach Forms 1098-E)………………...………..
Contributions
Only amounts given to qualified charitable organizations qualify. Examples of NON-DEDUCTIBLE amounts are to Political
Organizations and Candidates, Dues and Fees paid to lodges and fraternal orders, Raffles, Bingo, and Pull Tabs.
Please list all of your qualified charitable gifts here as you may receive a deduction on your State return even
if you do not itemize deductions on your Federal return.
Cash Contributions :
Non-Cash Contributions:
Religious Organizations...….….….………….
1) Complete the worksheet included with your organizer.
Schools……………….…….….…..…………..
2) You must have a receipt stating the amount received
United Way…………………………...……….
by the organization from the sale of a donated
Boy Scouts / Girl Scouts……...………..…….
vehicle, boat, etc.
Other
:
(Please list)
If TOTAL Non-Cash Contributions are:
Less than $250: Receipt not required if impractical.
Document donations with written description.
More than $250: Receipts required.
Volunteer Mileage : ______miles @ .14
The IRS requires proof for ALL cash contributions to qualified charitable organizations.
(receipt, cancelled check, bank statement, credit card statement, etc.)
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