CFS Income Tax Data Itemizer


* indicates a required field


Personal Data

*Taxpayer's Name Soc Sec #
Spouse's Name Spouse's Soc Sec #
Taxpayer's Occupation Birth Date: Blind?
Spouse's Occupation Birth Date: Blind?
Address
City, State, Zip ,
*Phone
Email Address
Estimated Taxes Paid Federal State Local

Dependents

  Name Soc. Sec. # Birth Date Relationship
1
2
3
4
  Income ($) Support by You ($) Support By Others ($) Months in Your Home
1
2
3
4

Note: You Must Provide a Social Security Number for All Dependents


Things to Bring

 
INTEREST INCOME (If Not On 1099-INT) DIVIDEND INCOME (If Not on 1099-DIV)
H/W/Jt Payee Amount ($) H/W/Jt Payee Amount ($)

Rental Income & Expense

Amount($)*

Total Rent Received
Expenses
Taxes
Utilities
Interest
Insurance
Auto Mileage
Repairs
Supplies
Other (Specify)

Other Income

Amount($)*

Tips
Child Care
Pensions/Annuities
Jury Duty
Strike Benefits
Unemployment (1099-G)
Alimony Received
Prizes (1099-MISC)
Farming
Self-Employment
Partnerships & S Corps
Estate & Trusts
Soc Sec Benefits
Scholarships & Fellowships
Tax Refunds
Royalties
Nontaxable Income
Gambling
Other

SALE OF STOCK OR OTHER PROPERTY Cost Sales Price
*Please Bring Supporting Documents

Deductions and Credit Items

PAYMENTS TO A TRADITIONAL IRA
Husband Date Amount $
Wife Date Amount $
PAYMENTS TO A ROTH IRA
Husband Date Amount $
Wife Date Amount $
PENALTY FOR EARLY WITHDRAWAL Amount $
ALIMONY PAID Amount $
SELF-EMPLOYMENT HEALTH INS Amount $
KEOUGH, SEP, SIMPLE CONTRIB Amount $

Medical Expenses

Amount ($)

Med. Savings Account (MSA) Contributions
Health Savings Account (HSA) Contributions
Insurance & Medicare Premiums
Prescriptions
Eyeglasses
Doctors
Dentists
Hospital
Ambulance
Other Travel Expenses
Hearing Aids & Batteries
Other Medical Expenses
Reimbursements

Taxes

Amount ($)

Real Estate Tax
State Estimated Tax
Date Pd
Date Pd
Date Pd
Date Pd
Personal Property Tax
City/County Tax
Sales Tax
Other

Interest Expense

Amount ($)

Home Mortgage - Pd to Financial Institution
Home Mortgage - Pd to Individuals
Name & SSN of
Individual(s)
Investment Interest
Interest Pd on Student Loans

Contributions

Amount ($)

Charities
Other Cash Contributions
Charitable Auto Mileage
Property Donated For Which You Have Receipts
Other

Casualty & Theft Losses

Amount ($)

Cost of Property Lost
Fair Market Value of Property
Ins Reimbursements Received

Moving Expenses

Amount ($)

Travel & Lodging
Moving Household Goods

Automobile Expenses

Amount ($)

Total Miles
Business Miles
Gas & Oil
Interest
Tolls & Local Transportation
Other
Other

Miscellaneous

Amount ($)

Dues & Subscriptions
Education
Safety Equipment
Uniforms
Job Seeking Expenses
Legal & Accounting
Tools
Business Entertainment
Investment & Tax Advice
Safe-Deposit Box
Hobby Losses
Gambling Losses
Impairment Related Work Expenses
Classroom Expenses for Teachers
Other (Specify)

Child Care Expenses - Bring List of Monthly Totals

Provider's Name Address ID# of Provider(s) Amount Pd

Education Credits

Name of Institution Tuition Pd Who Attended When Classes Began

LOANS: If you borrowed money during the year, bring a list showing the amounts, dates, and use of proceeds


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