Steve’s Tax Service
WORKSHEET FOR TAX YEAR -2011
Please copy and paste, then fill it out and bring it to your appointment
Please fill out as much of this worksheet as possible.
Bring all supporting documents with you.
Take your time! It’s your money that’s being taxed.
Payer Last______________________________
Payer First _____________________________ DOB _____/_____/______ SS# ______-_____-________
Spouse First ____________________________ DOB _____/_____/______ SS# ______-_____-________
Spouse Last ____________________________
Address:
______________________________________City______________________State_____Zip___________
(1) Phone Home (______)_______-_____________
(2) Phone Cell Payer (______)_______-____________
(3) Phone Cell Spouse (______)______-____________
E-mail: ____________________________________ E-mail: ____________________________________
Filing Status: Married filing joint, Head of household, Single, Married filing single
OCCUPATION of Taxpayer _____________________________Spouse_________________________
Dependents Name: DOB SS# RELATION # MONTHS
Lived in home
_________________________ ____/_____/ 19_____ ______-_____-_______ ___¬______ _____
_________________________ ____/_____/ 19_____ ______-_____-_______ ___¬______ _____
_________________________ ____/_____/ 19_____ ______-_____-_______ ___¬______ _____
_________________________ ____/_____/ 19_____ ______-_____-_______ ___¬______ _____
Additional Members on Back
Page (2)
INCOME
(ORIGINAL DOCUMENTS MUST BE ATTACHED)
DOCUMENT NUMBER OF DOCUMENTS ATTACHED
1. W-2s or W-2G _________
2. 1099 MISC _________
3. 1099 SS _________
4. 1099 DIV. _________
5. 1099 INT. _________
6. 1099-G _________
7. 1099-R _________
8. 1099-MSA _________
9. 1099 MISC. _________
10 Self-employment Income _________
11. Other income reported to IRS _________
(Tips and gifts)_______________________________________
List income that was received for tips or gifts that is to be reported.
Be sure to include all income from Bank Savings and Sales of Stocks.
FOREIGN INCOME $_______________.______
Have you ever been audited? YES NO if YES, What year? __________________
Do you owe IRS money from past years? YES NO if yes, amount $___________._____
TAXES YOU HAVE PAID IN TO IRS: 941 or 1040V
Self-Employment tax $__________.______ SS tax not reported on W-2s_$____________._____
Retirement plans, IRAs, _$__________._____Household employment Tax $_____________.______
Page 3 REAL ESTATE:
(City, State, County, M.U.D., School, Hospital, Fire, and etc).
Amount Paid for the year or attach Form 1098
Primary home Property Tax $__________._____
Second home or land $__________._____
Vacation home $__________._____
Office business taxes $__________._____
Personal Tax $__________._____
Auto registration fee $__________._____
Auto tax on purchase $__________._____
Other taxes on Rental property $__________._____
Sales Tax Paid on Special Items $___________._____
Sales Tax Paid on regular Items $___________._____
INTEREST PAID ON MORTGAGES form 1098 received from the mortgage co.
Primary home $_________________._____
Second Vacation Home $____________.____
Interest paid on business loans that were not reported on 1098. $_________._____
Interest paid on student loans $_____________._____
Interest or financial charges for business credit cards or loans. $___________._____
Page 4
MEDICAL AND DENTAL EXPENSES: Out of Pocket (NOT paid for by insurance.)
MEDICAL, DENTAL OR VISION INSURANCE PREMIUMS deducted from your check or direct payment for the
year of 2007. $_____________.______ (Pre taxes insurance is not claimed)
MEDICARE (B) PREMIUMS__$___________._______
MEDICARE B LONG TERM CARE INSURANCE $______________.______
SELF-EMPLOYMENT INSURANCE PREMIUMS _$_________________._______
CO PAYMENTS paid to the Doctors, Dentist and Vision Doctors. $___________._______
PRESCRIPTION DRUGS Co Payments total for the year. (Can be requested from your Pharmacy) for all
members of family. $_____________._______
HOSPITAL, CLINICS $______________._______
LAB, AND X-RAY __$________________._________
GLASSES or CONTACTS $____________.________
PATIENT CARE BY NURSE _$_____________._______ NURSING HOME_$_____________._____
HEARING AIDS & BATTERIES $________________.______
MEDICAL EQUIPMENT AND SUPPLIES_$__________________.________
Wheel chair, braces, crutches, blood pressure, blood sugar,
MEDICAL TRANSPORTATION EXPENSES: _$________________._______
Bus, taxi, ambulance, air fair,
LODGING FOR MEDICAL PURPOSES _$__________________.________
TOTAL MILES TRAVELED round trip from home to Pharmacy, Doctors, Dentist, Hospital, Clinics
______________________
OTHER MEDICAL EXPENSES:$___________________._______
REPAIRS OR UPGRADES MADE TO HOME FOR WHEELCHAIR ACCESS.
AIR CONDITIONERS, HUMIDIFIERS, SAUNAS, JACUZZI, SWIMMING POOL AND SPECIAL NEEDS ORDERED BY
DOCTORS. $______________.______
PAGE 5
EMPLOYEE’S JOB EXPENSES
PURCHASE OF TOOLS AND EQUIPMENT REQUIRED DOING YOUR JOB.
Taxpayer_$____________.______ Spouse _$_______________.______
REPAIR AND MAINTENANCE COST OF TOOLS AND EQUIPMENT TO DO YOUR JOB.
Taxpayer__$_____________.______ Spouse __$____________.______
Large items (179) _$_____________.______ Depreciation _$____________.______
SPECIAL CLOTHING, SHOES, PROTECTIVE GEAR _$___________._____
CLEANING OF UNIFORMS.
WORK EDUCATION (CEUs) $___________.______
UNION DUES_ $___________.______ JOB SEARCH COSTS. _$____________.______
PROFESSIONAL SUBSCRIPTIONS _$_____________._______
OTHER UN REIMBURSED EMPLOYEE BUSINESS EXPENSES
MILLAGE BETWEEN JOBS (NOT TO AND FROM HOME) UNLESS YOU WORK FROM HOME.
__________________________________
MISC. EXPENSES $________________._______
EXPENSES AS MEALS AND ENTERTAINMENT NOT REIMBURSED_$____________________
(UNDER THE DOT RULES)
REIMBURSED EXPENSES AMOUNT FOR ANY OF THE ABOVE__$_______________________
LODGING WHILE OUT OF TOWN OR STATE THAT WAS NOT REIMBURSED BY EMPLOYER.
$___________._____
REMEMBER, IF IT COST A DOLLAR TO MAKE A DOLLAR YOU NEED TO CLAIM IT AS A DEDUCTION.
PAGE 6
REMEMBER, YOU NEED TO KNOW THE NAME, ADDRESS, AND EIN NUMBER OR SS# TO FILE CHILD
CARE.
DEPENDENT / CHILD CARE SERVICES:
Dependent Name _______________________________ Amount $_____________________
Dependent Name _______________________________ Amount _$_____________________
Dependent Name _______________________________ Amount _$_____________________
Paid to: _______________________________________ Tax ID. ________________________
Address: _____________________________________________________________________
City: ______________________ State: _____ Zip: ___________ Phone: ________________
Dependent Name _______________________________ Amount $______________________
Dependent Name _______________________________ Amount _$_____________________
Dependent Name _______________________________ Amount _$_____________________
Paid to: _______________________________________ Tax ID. ________________________
Address: _____________________________________________________________________
City: ______________________ State: _____ Zip: ___________ Phone: ________________
* EDUCATION EXPEDIENCES THIS IS A VERY GOOD DEDUCTION.
TUITION, BOOKS, BACK PACKS, PAPER, PENS, COMPUTER, DISK AND ETC.
$ _____________.______ FOR (TAXPAYER) $___________.______FOR (SPOUSE)
$ ___________.______ FOR (DEPENDENT)
GIFTS TO CHARITY (CASH, CHECK, or MONEY ORDERS) / with documentation.
(CHURCHES, FOUNDATIONS, UNITED WAY, RED CROSS, JERRY’S KIDS.)
Cash, Tithes, offerings to churches and other non-profit organizations $____________._______
Page 7
NON CASH to charitable organizations
(To whom, what, and where) AND THE VALUE AT THE TIME OF DONATION.
_________________________________________________________________________________________
_________________________________________________________________________________________
__________________________________________________________________________$___________.
_____
Do you or your spouse work or hold a title in the church? Yes No if yes, describe duties (EVEN IF YOU
DON’T GET PAID FOR IT)
_________________________________________________________________________________________
_
MILES FROM HOME TO CHURCH ______________TIMES PER WEEK ATTENDED. __________
MILES TRAVELED FOR OTHER CHARITABLE CONTRIBUTIONS ____________________________
MISC. DEDUCTIONS
GAMBLING LOSSES (TO THE EXTENT OF GAMBLING INCOME) $_______________.________
CASUALTY / THEFT LOSSES OF INCOME PRODUCING PROPERTY/ BAD DEBT $__________._
Must have documents of losses. (Police report, insurance statement, or affidavit signed with the accounts, dates
and times). Bad debts must have as much information as possible, stating why, to whom, when, and all amounts.
Also what you did to try to collect what was owed.
ANY SELF-EMPLOYMENT EXPENSES
Ask for Schedule C or F package.
If you have any type of business that you work on throughout the year, that you did not get a w-2 or 1099 for,
bring all information with you, even if you didn't’t get paid for your work. (Example, ministries, home office, side
work.)
FARMING OR LIVE STOCK PRODUCTION
FOOD, VET, TRAVEL, MILEAGE, STORAGE, SUPPLIES AND ETC.
You may get better tax cuts with side jobs attached.
(HOME OFFICE, CAR, TRUCK, EQUIPMENT ETC.) Bring all information for these.
CALL FOR MORE INFORMATION ON SIDE BUSINESSES.
Chastity Lamb
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