2013 Income Tax Information Organizer Template (Page 2 of 2) in pdf

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Medical & Dental

Miscellaneous Deductions

Name:_______________________ SS # _____________ Birth Date:________ Occupation:____________

Spouse:______________________ SS # _____________ Birth Date:________ Occupation:____________

O NOT include amounts paid for or reimbursed by

Health Insurance or premiums paid with pre-tax income.

Tax Preparation:____________________________

Address:_______________________________________________________________________________

Medical Insurance: _________________________

Safe Deposit Box:___________________________

County of Residence:__________________________ School District of Residence:___________________

Medicare Premium: _________________________

IRA Custodial Fees:_________________________

Email Address:___________________________________ Best Contact#___________________________

Long Term Care Insurance: ___________________

Direct Deposit of Refunds ________Yes (Please attach a deposit ticket marked for savings or checking.)

Investment Fees:____________________________

Doctor, Dentist, Nurse: ______________________

Second Job Mileage:_________________________

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Hospitals, Lab Fees:_________________________

Union Dues:_______________________________

Prescription Drugs:__________________________

Prof. Dues & Journals:_______________________

Eye Glasses, Hearing Aids: ___________________

Job Hunting Expense:________________________

Name (First, Initial):

Social Security Number:

Relationship:

Date of Birth:

Braces, Dentures: ___________________________

Education Expense:__________________________

___________________________________ ____________________ _____________ _____________

Equipment (Prescribed):______________________

Job Supplies:_______________________________

___________________________________ ____________________ _____________ _____________

Medical Travel (miles): ______________________

Small Tools:_______________________________

___________________________________ ____________________ _____________ _____________

Medical Lodging:___________________________

Safety Equipment:___________________________

___________________________________ ____________________ _____________ _____________

Nursing or Long Term Care :__________________

Uniforms & Laundry:________________________

___________________________________ ____________________ _____________ _____________

HSA Expenses:____________________________

Gambling/Lottery Losses (Limited to Gambling/

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Other: ____________________________________

Lottery Winnings): _________________________

Taxes

Other:_____________________________________

Real Estate (Home):_________________________

_____________________________________

Wages & Salaries: (W-2 Forms)

Unemployment: (Form 1099-G)

Real Estate (Non-Home):_____________________

Interest & Dividends: (1099-INT & 1099-DIV Forms, including Tax-Exempt & Municipal Interest)

Car License (IA Only):_______________________

Employee Business Expense

Gambling or Lottery Winnings: (All Forms W-2G)

IRA’s, Pensions, Annuities: (Form 1099-R)

Sales Tax on Major Purchases:_________________

-Travel Away from Home-

Social Security Income: (Form SSA-1099 for Taxpayer & Spouse)IRA’s, Pensions

-Days Away from Home:_____________________

Other Income:________________________________________________________________________

Interest Paid

-Lodging Expense:__________________________

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Home Mortgage Paid to Financial Institutions-

-Total Business Miles:_______________________

(Please bring 1098 Forms):____________________

-Meal Expense:_____________________________

Home Mortgage Paid to Individuals:____________

-Auto Expense-

IRA Deduction: Taxpayer:____________________ Spouse:______________________________

(List Name, Address, SS #):___________________

-Total Miles Driven:_________________________

Payment to Keogh Plan, SEP or SIMPLE:_____________________________________

__________________________________________

-Parking Fees:______________________________

Moving Expenses (Work Related over 35 Miles):_______________________________

Points:____________________________________

-Other:____________________________________

Student Loan Interest (Please provide Form 1098-E)

Alimony paid:____________________________

Investment Interest:__________________________

Health Savings Account (HSA) Contributions: _____________ Educator Expenses:__________________

Vacation or Second Home, Camper, Houseboat

Tuition

Mortgage:__________________________________

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-Grades K-12-

Home Equity Loans:_________________________

Iowa Residents

Contributions

Tuition, Fees, Textbooks, Materials Required for Ex-

Name of Provider:_________________________________________ ID#___________________________

Church:___________________________________

tra Curricular Activities:_____________________

Address:_______________________________________________________________________________

United Way:_______________________________

Illinois Residents

Amount Paid:_____________________________ (If more than one provider, please list on separate sheet.)

Red Cross, MDA, Cancer:____________________

Tuition, Fees, Textbooks:_____________________

Misc. Door-to-Door:_________________________

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(IL Residents please provide Education Credit Form)

Non-Cash* (clothing, food, misc.):______________

-Post-Secondary Education -

Date

Federal Amount

State Amount

*Itemized receipts are required if over $500*

(Please provide Form 1098-T)

1st Quarter Payments

Other Miscellaneous:________________________

Tuition & Course Materials (Paid in 2013):________

Expenses for Charitable Work:________________

2nd Quarter Payments

__________________________________________

Volunteer Mileage (miles):____________________

3rd Quarter Payments

IRS Regulations require that you sign & date this worksheet when provided to a Tax Preparer.

Economic Stimulus Package

4th Quarter Payments

We will again make out your Estimated Income Tax Payments for 2014 based on your 2013 tax.

Information provided by:___________________________________________ Date:_________________

If you expect a significant change in your income for 2014, please discuss this with us.

Payment Amount Received:_________________________________________________________

2013 Income Tax Information Organizer Template Page 2

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