Usa Income Tax Return Page 2

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USA INCOME TAX RETURN
US SOURCE INCOME AND DEDUCTIONS
US SOURCE INCOME AND EXPENSES INFORMATION
Did you earn income from employment? Yes
No
If yes, send us photocopies of your W-2 forms, showing your employment income
Did you earn self-employment income? Yes
No
If yes, send us 1099-MISC forms, showing your self-employment income.
Did you have income from investments, capital or property gains? Yes
No
If yes, send us 1099-INT, 1099-DIV, 1099-B forms or similar statements showing your income.
Did you receive retirement income and Governmental payments? Yes
No
If yes, send us 1099-R, 1099-G or similar statements showing your income.
Other US Source Income (including prizes, awards, etc.)? Yes
No
If yes, give type and amounts and provide statements if available.
ADDITIONAL INCOME INFORMATION FROM ALL SOURCES
Did you receive alimony during the tax year?
Amount:
__________
Currency:
__________
Do you have any rental income from property you owned?
Amount:
__________
Currency:
__________
Did you receive a scholarship or fellowship grants?
Amount:
__________
Currency:
__________
Did you receive income from partnerships, trusts or estates?
Amount:
__________
Currency:
__________
If yes, send us 1099-R, 1099-G or similar statements showing your income.
Other Income (including prizes, awards, etc.)?
Amount:
__________
Currency:
__________
If yes, give amount: $ ________________ and provide documentation showing the type and amount of the income received
INCOME DEDUCTIONS AND MODIFICATIONS
Did you pay alimony? Yes
No
Currency:
__________
If yes, please provide the amount and enter the recipient’s SSN here
-
-
Amount:
__________
Currency:
__________
Did you move during the tax year? Yes
No
If yes, provide the following information
Miles from your old home to your new home:
miles
__________
Amount paid for travel and lodging from old home to new home:
Amount:
__________
Currency:
__________
Amount paid for transportation and storage of household goods from old home to new home:
Amount:
__________
Currency:
__________
Did you incur any child care expenses? Yes
No
If yes, state the amount here
__________
Currency:
__________
Name of Care Provider
__________________________________________________________________
Address and Phone
____________________________________________________________________
ID number (SSN or EIN if known)
__________________________________________________________
Did you give cash or non-cash gifts to charities?
Amount:
__________
Currency:
__________
Do you have unreimbursed medical expenses?
Amount:
__________
Currency:
__________
Provide all entry and exit dates to and from the foreign country.
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Destination and purpose of visit:
___________________________________________________
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Destination and purpose of visit:
___________________________________________________
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Destination and purpose of visit:
___________________________________________________
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Destination and purpose of visit:
___________________________________________________
, IDA Business & Technology Park, Ring Road, Kilkenny, Ireland

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