Client Information Form Accountants Page 2
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1
2ITEMIZED DEDUCTIONS
MEDICAL EXPENSES (MUST EXCEED 7.5%)
CHARITABLE CONTRIBUTIONS
Medical/dental insurance premiums _______________________________
Church__________________________
Medical insurance premiums (w/held from SS) ______________________
Payroll deduction _________________
Prescription drugs (no over the counter drugs) ______________________
Cancer __________________________
Doctor/dentists _______________________________________________
Scouts __________________________
Hospitals/nursing home/nursing care ______________________________
Others __________________________
Psychotherapy, psychology counseling ___________________________
Others __________________________
Glasses, hearing aids, batteries __________________________________
Others __________________________
Auto travel & parking (medical purposes) _________________________
Others __________________________
Insurance reimbursement (only for amounts listed above) _____________
Travel for charitable purposes ________
TAXES PAID
MISCELLANEOUS DEDUCTIONS
Real estate – home & other property ______________________________
Attorney fees (to protect taxable income) ____
State income tax paid
Business gifts _________________________
Balance due on last year’s return __________________________
Dues: unions and professional ____________
th
Prior year’s 4
qtr. Est. paid in Jan. this year _________________
Employment related education ____________
Business insurance _____________________
HOME MORTGAGE INTEREST PAID
Investment expenses ____________________
TO A FINANCIAL INSTITUTION:
Job seeking expenses ___________________
Licenses, fees, etc. _____________________
st
Primary residence – 1
mortgage _________________________________
Safe deposit box ______________________
nd
Primary residence – 2
mortgage _________________________________
Tax prep fees _________________________
st
Second home – 1
mortgage _____________________________________
nd
Second home – 2
mortgage _____________________________________
Uniforms ____________________________
Professional books ____________________
TO AN INDIVISUAL:
Other _______________________________
Name:
_______________________________________________________
Other _______________________________
Address:
_____________________________________________________
Other _______________________________
Amount:
______________________________________________________
CHILD CARE EXPENSES
OFFICE-IN-HOME
Name __________________________ SS#____________________________
Square footage of Home _______________
Address __________________________________ Amount______________
Total square footage of home _________
Name___________________________ SS# ____________________________
Utilities ____________________________
Address __________________________________ Amount______________
Repairs ____________________________
Name ___________________________SS#____________________________
Insurance___________________________
Address __________________________________ Amount_______________
Other ______________________________
Any questions you may have:
THE INFORMATION ON THIS TWO PAGE QUESTIONNAIRE IS TO THE BEST OF MY KNOWLEDGE
AND BELIEF, TRUE, CORRECT, AND COMPLETE.
YOUR SIGNATURE:_____________________________ SPOUSE:_________________________________
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