Form 13614-C (Ar) - Intake/interview & Quality Review Sheet (Arabic Version) Page 2
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42 ﺍﻟﺻﻔﺣﺔ
ﺍﺧﺗﺭ ﺍﻟﻣﺭﺑﻊ ﺍﻟﻣﻼﺋﻡ ﻟﻛﻝ ﺳﺅﺍﻝ ﻓﻲ ﻛﻝ ﻓﻘﺭﺓ
(ﺍﻟﺟﺯء ﺍﻟﺛﺎﻟﺙ- ﺍﻟﺩﺧﻝ-ﻓﻲ ﺍﻟﺳﻧﺔ ﺍﻟﻣﺎﺿﻳﺔ، ﻫﻝ ﺗﻠﻘﻳﺕ ﺃﻧﺕ )أو زوﺟﺘﻚ/زوﺟﻚ
ﻏﻳﺭ ﻭﺍﺛﻕ
ﻻ
ﻧﻌﻡ
( ﺇﺫﺍ ﻧﻌﻡ، ﻛﻡ ﻭﻅﻳﻔﺔ ﻛﺎﻧﺕ ﻟﺩﻳﻙ ﺍﻟﺳﻧﺔ ﺍﻟﻣﺎﺿﻳﺔ؟W-2 ( ﺃﺟﻭﺭ ﺍ ً ﺃﻭ ﺭﺍﺗﺑ ﺎ ً ؟ )ﺍﻹﺳﺗﻣﺎﺭﺓB) .1
( ﺩﺧﻼ ً ﻣﻥ ﺍﻟﺑﻘﺷﻳﺵ؟A) .2
(1098T ﻭW-2 ( ﻣﻧﺣ ﺎ ً ﺩﺭﺍﺳﻳﺔ؟ )ﺍﻹﺳﺗﻣﺎﺭﺍﺕB) .3
(1099DIV 9901 ﻭﺍﻹﺳﺗﻣﺎﺭﺓINT ( ﻓﻭﺍﺋﺩ/ﺃﻧﺻﺑﺔ ﺃﺭﺑﺎﺡ ﻣﻥ: ﺣﺳﺎﺑﺎﺕ ﺷﻳﻛﺎﺕ/ﺗﻭﻓﻳﺭ، ﺳﻧﺩﺍﺕ، ﺇﻋﺗﻣﺎﺩﺍﺕ ﻣﺳﺗﻧﺩﻳﺔ، ﻋﻣﻭﻻﺕ؟ )ﺍﻹﺳﺗﻣﺎﺭﺓB) .4
(1099G ( ﺇﺳﺗﺭﺟﺎﻉ ﺿﺭﺍﺋﺏ ﺍﻟﺩﺧﻝ ﺍﻟﻣﺣﻠﻳﺔ/ﻟﻠﻭﻻﻳﺔ؟ )ﺍﻹﺳﺗﻣﺎﺭﺓB) .5
( ﺩﺧﻝ ﻧﻔﻘﺔ ﺍﻟﺯﻭﺟﺔ ﺍﻟﻣﻁﻠﻘﺔ/ﺍﻟﺯﻭﺝ ﺍﻟﻣﻁﻠﻕ ﺃﻭ ﻣﺩﻓﻭﻋﺎﺕ ﺇﻋﺎﻟﺔ ﺍﻟﺯﻭﺟﺔ ﺍﻟﻣﻧﻔﺻﻠﺔ/ﺍﻟﺯﻭﺝ ﺍﻟﻣﻧﻔﺻﻝ؟B) .6
9901، ﻣﺑﺎﻟﻎ ﻧﻘﺩﻳﺔ(؟MISC ( ﺩﺧﻝ ﺍﻟﻌﻣﻝ ﺍﻟﺣﺭ )ﺍﻹﺳﺗﻣﺎﺭﺓA) .7
ﺃﻭ ﺍﻹﺳﺗﻣﺎﺭﺓ 9901؟W-2 ( ﻣﺩﻓﻭﻋﺎﺕ ﻧﻘﺩﻳﺔ/ﺷﻳﻛﺎﺕ ﻣﻘﺎﺑﻝ ﺃﻱ ﻋﻣﻝ ﻣﺅﺩﻯ ﻭﻏﻳﺭ ﻣﺑﻠﻎ ﻋﻧﻪ ﻋﻠﻰ ﺍﻹﺳﺗﻣﺎﺭﺓA) .8
(1099B ،1099S ( ﺍﻟﺩﺧﻝ )ﺃﻭ ﺍﻟﺧﺳﺎﺭﺓ( ﻣﻥ ﺑﻳﻊ ﺍﻷﺳﻬﻡ ﺃﻭ ﺍﻟﺳﻧﺩﺍﺕ ﺃﻭ ﺍﻟﻌﻘﺎﺭﺍﺕ )ﺑﻣﺎ ﻓﻳﻬﺎ ﻣﻧﺯﻟﻙ(؟ )ﺍﻹﺳﺗﻣﺎﺭﺍﺕA) .9
(1099R، W-2 ( ﺩﺧﻝ ﺍﻹﻋﺎﻗﺔ )ﻣﺛﻝ ﺍﻟﻣﺩﻓﻭﻋﺎﺕ ﻣﻥ ﺍﻟﺗﺄﻣﻳﻥ ﺃﻭ ﺗﻌﻭﻳﺽ ﺍﻟﻌﻣﺎﻝ(؟ )ﺍﻹﺳﺗﻣﺎﺭﺍﺕB) .10
(1099R ؟ )ﺍﻹﺳﺗﻣﺎﺭﺓIRA ( ﺍﻟﺗﻭﺯﻳﻌﺎﺕ ﻣﻥ ﻣﻌﺎﺷﺎﺕ ﺍﻟﺗﻘﺎﻋﺩ ﻭ/ﺃﻭ ﺍﻟﻌﻼﻭﺍﺕ ﺍﻟﺳﻧﻭﻳﺔ ﻭ/ﺃﻭ ﺣﺳﺎﺏA) .11
(G-1099 ( ﺗﻌﻭﻳﺽ ﺍﻟﺑﻁﺎﻟﺔ )ﺍﻹﺳﺗﻣﺎﺭﺓB) .12
(RRB1099 ،SSA1099 ( ﻣﺧﺻﺻﺎﺕ ﺍﻟﺿﻣﺎﻥ ﺍﻹﺟﺗﻣﺎﻋﻲ ﺃﻭ ﺗﻘﺎﻋﺩ ﻋﻣﺎﻝ ﺍﻟﺳﻛﻙ ﺍﻟﺣﺩﻳﺩﻳﺔ؟ )ﺍﻹﺳﺗﻣﺎﺭﺍﺕB) .13
( ﺍﻟﺩﺧﻝ )ﺃﻭ ﺍﻟﺧﺳﺎﺭﺓ( ﻣﻥ ﻣﻠﻛﻳﺔ ﻣﺅﺟﺭﺓ؟M) .14
، ﺃﺗﺎﻭﺍﺕ، ﺩﺧﻝ ﺃﺟﻧﺑﻲ، ﺇﻟﺦ.( ﻳﺭﺟﻰ ﺍﻟﺗﺣﺩﻳﺩSch K-1 ،( ﺩﺧﻝ ﺁﺧﺭ؟ )ﺍﻟﻘﻣﺎﺭ، ﺍﻟﻳﺎﻧﺻﻳﺏ، ﺍﻟﺟﻭﺍﺋﺯ، ﺍﻟﻣﻧﺢ، ﻭﺍﺟﺏ ﻫﻳﺋﺔ ﺍﻟﻣﺣﻠﻔﻳﻥB) .15
(ﺍﻟﺟﺯء ﺍﻟﺭﺍﺑﻊ-ﺍﻟﻧﻔﻘﺎﺕ- ﻓﻲ ﺍﻟﺳﻧﺔ ﺍﻟﻣﺎﺿﻳﺔ، ﻫﻝ ﺩﻓﻌﺕ ﺃﻧﺕ )أو زوﺟﺘﻚ/زوﺟﻚ
ﻏﻳﺭ ﻭﺍﺛﻕ
ﻻ
ﻧﻌﻡ
ﻻ
ﻧﻌﻡ
( ﻧﻔﻘﺔ ﺍﻟﺯﻭﺟﺔ ﺍﻟﻣﻁﻠﻘﺔ/ﺍﻟﺯﻭﺝ ﺍﻟﻣﻁﻠﻕ ﺃﻭ ﻣﺩﻓﻭﻋﺎﺕ ﺇﻋﺎﻟﺔ ﺍﻟﺯﻭﺟﺔ ﺍﻟﻣﻧﻔﺻﻠﺔ/ﺍﻟﺯﻭﺝ ﺍﻟﻣﻧﻔﺻﻝ؟ ﺇﻥ ﻧﻌﻡ، ﻫﻝ ﻟﺩﻳﻙ ﺭﻗﻡ ﺍﻟﺿﻣﺎﻥ ﺍﻹﺟﺗﻣﺎﻋﻲ ﻟﻠﻣﺳﺗﻠﻡ؟B) .1
2. ﻣﺳﺎﻫﻣﺎﺕ ﻓﻲ ﺣﺳﺎﺏ ﺗﻘﺎﻋﺩ؟
ﻏﻳﺭ ﺫﻟﻙ
(B) Roth IRA
(B) 401K
(A) IRA
(1098T ( ﻧﻔﻘﺎﺕ ﺗﻌﻠﻳﻡ ﺟﺎﻣﻌﻲ ﺃﻭ ﺑﻌﺩ ﺛﺎﻧﻭﻱ ﻣﺩﻓﻭﻋﺔ ﺑﺎﻟﻧﻳﺎﺑﺔ ﻋﻧﻙ ﺃﻭ ﻋﻥ ﺯﻭﺟﺗﻙ/ﺯﻭﺟﻙ ﺃﻭ ﻣﻥ ﺗﻌﻳﻠﻬﻡ؟ )ﺍﻹﺳﺗﻣﺎﺭﺓB) .3
( ﻧﻔﻘﺎﺕ ﺃﻋﻣﺎﻝ ﻣﻭﻅﻔﻳﻥ ﻏﻳﺭ ﻣﻌﻭﺽ ﻋﻧﻬﺎ )ﻣﺛﻝ ﺍﻟﻠﺑﺎﺱ ﺍﻟﺭﺳﻣﻲ ﺃﻭ ﺍﻷﻣﻳﺎﻝ(؟B) .4
( ﻧﻔﻘﺎﺕ ﻁﺑﻳﺔ )ﺑﻣﺎ ﻓﻳﻬﺎ ﺃﻗﺳﺎﻁ ﺍﻟﺗﺄﻣﻳﻥ ﺍﻟﺻﺣﻲ(؟B) .5
(1098 ( ﻓﻭﺍﺋﺩ ﻋﻠﻰ ﺭﻫﻥ ﺍﻟﻣﻧﺯﻝ؟ )ﺍﻹﺳﺗﻣﺎﺭﺓB) .6
( ﺍﻟﺿﺭﺍﺋﺏ ﺍﻟﻌﻘﺎﺭﻳﺔ ﻟﻣﻧﺯﻟﻙ ﺃﻭ ﺿﺭﺍﺋﺏ ﺍﻟﻣﻠﻛﻳﺔ ﺍﻟﺷﺧﺻﻳﺔ ﻟﺳﻳﺎﺭﺗﻙ؟ )ﺍﻹﺳﺗﻣﺎﺭﺓ 8901(؟B) .7
( ﺍﻟﻣﺳﺎﻫﻣﺎﺕ ﺍﻟﺗﺑﺭﻋﻳﺔ؟B) .8
( ﻧﻔﻘﺎﺕ ﺭﻋﺎﻳﺔ ﺍﻷﻁﻔﺎﻝ/ﺍﻟﻌﺎﻟﺔ، ﻣﺛﻝ ﺍﻟﺭﻋﺎﻳﺔ ﺍﻟﻳﻭﻣﻳﺔ؟B) .9
( ﻟﻠﻣﺳﺗﻠﺯﻣﺎﺕ ﺍﻟﻣﺳﺗﺧﺩﻣﺔ ﻛﺎﺧﺻﺎﺋﻲ ﺗﻌﻠﻳﻡ ﻣﺅﻫﻝ ﻣﺛﻝ ﺍﻟﻣﻌﻠﻡ، ﺃﻭ ﻣﺳﺎﻋﺩ ﺍﻟﻣﻌﻠﻡ ﺃﻭ ﺍﻟﻣﺳﺗﺷﺎﺭ ﺃﻭ ﺇﻟﺦ.؟B) .10
( ﺍﻟﻧﻔﻘﺎﺕ ﺍﻟﻣﺗﻌﻠﻘﺔ ﺑﺩﺧﻝ ﺍﻟﻌﻣﻝ ﺍﻟﺣﺭ ﺃﻭ ﺃﻱ ﺩﺧﻝ ﺁﺧﺭ ﺗﻠﻘﻳﺗﻪ؟A) .11
(1098E ( ﻓﺎﺋﺩﺓ ﻋﻠﻰ ﻗﺭﻭﺽ ﺍﻟﻁﺎﻟﺏ؟ )ﺍﻹﺳﺗﻣﺎﺭﺓB) .12
ﻻ
ﻧﻌﻡ
(ﺍﻟﺟﺯء ﺍﻟﺧﺎﻣﺱ- ﺃﺣﺩﺍﺙ ﺍﻟﺣﻳﺎﺓ- ﻓﻲ ﺍﻟﺳﻧﺔ ﺍﻟﻣﺎﺿﻳﺔ، ﻫﻝ ﺃﻧﺕ )أو زوﺟﺘﻚ/زوﺟﻚ
ﻏﻳﺭ ﻭﺍﺛﻕ
(12 ﻓﻲ ﺍﻟﻣﺭﺑﻊW ﻣﻊ ﺍﻟﺭﻣﺯW-2 9901 ﻭSA8945 ﻭSA ( ﻛﺎﻥ ﻟﺩﻳﻙ ﺣﺳﺎﺏ ﺗﻭﻓﻳﺭ ﺻﺣﻲ؟ )ﺍﻹﺳﺗﻣﺎﺭﺍﺕHSA) .1
(1099A ،1099C ( ﻛﺎﻥ ﻟﺩﻳﻙ ﺩﻳﻥ ﻣﻥ ﺭﻫﻥ ﺃﻭ ﺑﻁﺎﻗﺔ ﺇﺋﺗﻣﺎﻥ ﻣﻠﻐﻰ/ﻣﻌﻔﻰ ﻣﻥ ﻣﻘﺭﺽ ﺗﺟﺎﺭﻱ؟ )ﺍﻹﺳﺗﻣﺎﺭﺍﺕA) .2
(1099A ( ﻗﻣﺕ ﺑﺑﻳﻊ ﻣﻧﺯﻟﻙ ﺃﻭ ﺑﺷﺭﺍﺋﻪ ﺃﻭ ﺧﺿﻊ ﻟﻐﻠﻕ ﺭﻫﻧﻪ؟ )ﺍﻹﺳﺗﻣﺎﺭﺓA) .3
([ ﻏﻳﺭ ﻣﺳﻣﻭﺡ ﻓﻲ ﺳﻧﺔ ﺳﺎﺑﻘﺔ؟ ﺇﺫﺍ ﻧﻌﻡ، ﻷﻱ ﺳﻧﺔ ﺿﺭﻳﺑﻳﺔ؟Earned Income Credit (EIC] "( ﻛﺎﻥ ﻟﺩﻳﻙ "ﺇﻋﺗﻣﺎﺩ ﺩﺧﻝ ﻣﻛﺗﺳﺏB) .4
(.( ﻗﻣﺕ ﺑﺷﺭﺍء ﻭﺗﺭﻛﻳﺏ ﻣﺳﺗﻠﺯﻣﺎﺕ ﻣﻧﺯﻟﻳﺔ ﻣﻘﺗﺻﺩﺓ ﻟﻠﻁﺎﻗﺔ؟ )ﻣﺛﻝ ﻧﻭﺍﻓﺫ، ﺳﺧﺎﻥ، ﻣﻭﺍﺩ ﻋﺎﺯﻟﺔ، ﺇﻟﺦA) .5
( ﺃﻗﻣﺕ ﻓﻲ ﻣﻧﻁﻘﺔ ﺗﺄﺛﺭﺕ ﺑﻛﺎﺭﺛﺔ ﻁﺑﻳﻌﻳﺔ؟ ﺇﺫﺍ ﻧﻌﻡ، ﺃﻳﻥ؟B) .6
[ ﻓﻲ ﺳﻧﺔ 8002؟First Time Homebuyers Credit] "( ﺗﻠﻘﻳﺕ "ﺇﻋﺗﻣﺎﺩ ﻣﺷﺗﺭﻱ ﺍﻟﻣﻧﺎﺯﻝ ﻟﻠﻣﺭﺓ ﺍﻷﻭﻟﻰA) .7
( ﺩﻓﻌﺕ ﺃﻗﺳﺎﻁ ﺿﺭﺍﺋﺏ ﻣﻘﺩﺭﺓ ﺃﻭ ﻁﺑﻘﺕ ﺍﻟﻣﺑﻠﻎ ﺍﻟﻣﺳﺗﺭﺟﻊ ﻣﻥ ﺍﻟﺳﻧﺔ ﺍﻟﻣﺎﺿﻳﺔ ﻋﻠﻰ ﺿﺭﻳﺑﺗﻙ ﻟﻬﺫﻩ ﺍﻟﺳﻧﺔ؟ ﺇﻥ ﻛﺎﻧﺕ ﺍﻟﺣﺎﻟﺔ ﻛﺫﻟﻙ، ﻓﻛﻡ؟B) .8
ﻣﻥ ﺍﻹﺳﺗﻣﺎﺭﺓ 0401؟D [ ﻋﻠﻰ ﺍﻟﻣﻠﺣﻕcapital loss carryover] "( ﺭﻓﻌﺕ ﻛﺷﻑ ﺿﺭﺍﺋﺏ ﻓﺩﺭﺍﻟﻳﺔ ﻟﻠﺳﻧﺔ ﺍﻟﻣﺎﺿﻳﺔ ﻳﺣﺗﻭﻱ ﻋﻠﻰ "ﻣﺟﻣﻭﻉ ﻣﺭﺣﻝ ﻟﺧﺳﺎﺋﺭ ﺭﺃﺳﻣﺎﻟﻳﺔA) .9
13614-C (AR)
58970P ﺍﻟﻛﺗﺎﻟﻭﺝ ﺭﻗﻡ
(2017-10 )ﺗﻌﺩﻳﻝ
ﺍﻹﺳﺗﻣﺎﺭﺓ
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