Dependent / Qualified Children

2017TAX CHECKLISTQUESTIONNAIRE

Your Name: / SSN: / DOB: / Occupation:
Spouse’s Name: / SSN: / DOB: / Occupation:
Mailing Address: / Cell Phone: / Daytime Phone: / Other:
E-mail Address:

DEPENDENT / QUALIFIED CHILDREN:

Name: / SSN: / Birthdate: / Age: / Relationship: / Mos. Lived w/ You: / Full-Time Student: / Gross Income:

Can and / or have you been claimed on someone else’s tax return as a dependent? Yes

Did your marital status change due to divorce, separation, death of a spouse, etc. in 2017? Yes

2017Filing Status?  Single  Married filing jointly  Head of household  Qualifying widower

INCOME: (Please check “” all that apply)

 Wages, salary, tips, etc. (W-2s)

 Tipsnotreported on W-2s

 Interest (1099-INT, Year-end Bank Statements)

 Stock or mutual fund dividends (1099-DIV)

 Sale of stocks, mutual funds, etc.(1099-COMP)

 Previous year state tax refund

 Alimonyreceived

 Business or hobby income / loss(Schedule C)

 IRA withdrawals, rolloveror transfer (1099-R)

 Pensionor annuity income (1099-R)

 Unemploymentordisabilityincome(1099-G)

 Social Security Benefits (SSA-1099)

 Foreign income

 Partnership or estateincome (K-1)

 Gambling/lottery winnings (W-2G)

 Payments from education accounts (1099-Q)

 Rental property income

 Other:

ADJUSTMENTS TO INCOME: (Please check “” yes to all that apply)

Everyone within your household covered by health insurance the entire year? Yes

Did youreceive a Health Insurance Marketplace Statement (1095-A, B or C) in 2017? Yes

Did you incur any expense as a direct result of teaching(Educator Expense Deduction)? Yes

Did you contribute to a Health Savings Account(HSA) individually or through work? Yes

Did you move from your primary residence in 2017(Moving Expense Deduction)? Yes

Did you pay alimony(Alimony Adjustment)? Yes

Did you contribute to an Individual Retirement Account (IRA) or Roth IRA in 2017? Yes

Did you withdrawal funds from an IRA, 401(k), etc. prior to 59½(Early Withdrawal Penalty)? Yes

Did you pay interest on a student loan(Student Loan Interest Deduction)?  Yes

ITEMIZED TAX DEDUCTIONS: (Please check “” all that apply)

 Medical and Dental Expenses

 Health Insurance / Medicare Part B

 State and Local Taxes

 Real Estate Property Taxes

 New Motor Vehicle Tax

 Home Mortgage Interest / Points Paid

 Mortgage Insurance

 Gifts to Charity(Documented)

 Casualty or Theft Losses

 Tax Preparation Fees

 Investment Related Expenses

 Safe Deposit Box Dues

 Union Dues

 Work Tools / Safety Equipment

 Unreimbursed work mileage

 Other:

Did you itemize your tax deductions last year? Yes

Did you pay quarterly estimated taxes last year? Yes

TAX CREDITS: (Please check “” yes to all that apply)

Did you purchase a home in 2017? Yes

Did you install energy efficient windows, insulation, furnace, etc. in your primary residence? Yes

Did you make any payments to a licensed dependent daycare provider in 2017? Yes

Did you adopt a child in 2017 or have adoption credit carried over to 2017? Yes

Did you pay education tuition and fees for you, your spouse or dependent child in 2017? Yes

Did you pay foreign income or investment tax? Yes

Did you contribute to a 401(k), 403(b), Simple IRA or other company retirement plan in 2017? Yes

STATE RETURN: (Please check “” yes to all that apply)

Did you purchase / renew a WI special tax-deductible license plate in 2017? Yes

Did you purchase (through internet, etc.) items where WI sales tax is due but not paid? Yes

Did you work in or receive income from a state other than WI?  Yes

Did you pay rent in 2017?(Heat included/ Heat notincluded) $/ mo. x Yes

Did you contribute to WI’s 529 college savings program (Tomorrow’s Scholar or EdVest)?  Yes

OTHER: (Please check “” yes to all that apply)

Were you ever audited or received correspondenceby the IRS? Yes

Were you ever delinquent in paying your taxes or ever modified your tax return after it was filed? Yes

Do you have any dependent children who must file? Yes

As a courtesy, dependent children’s tax returns are prepared free of charge.

Do you have childrenwith investment income greater than $2,100(Kiddie Tax)? Yes

Did you provide over half the support for any other person during 2017? Yes

Did you or your spouse make or receive gifts of over $14,000 in 2017? Yes

Did you file bankruptcy or haveany debt (credit cards, etc.) forgiven or cancelled in 2017? Yes

Did you turn 70½ prior to December 31st of 2017(RMD)?  Yes

Do you want direct deposit of your refund? (If so please supply voided check or deposit slip)? Yes

Did your direct deposit account change from what is on file from last year? (Circle One)Same Changed

2018 TAX PLANNING: (Please check “” yes to all that apply)

Do you plan to enroll in the Affordable Care Act health exchanges 2018? Yes

Will you file bankruptcy, have any lender forgive / cancel debts (credit cards, etc.) in 2018? Yes

Do you and / or your spouse plan to retire or have significant life / income changes in 2018? Yes

Do you expect to undergo any major-medical expenses in 2018?  Yes

Will any dependent children turn 17 in 2018?  Yes

Do you plan on contributing to your IRA, Roth IRA, 401(k), etc. in 2018? Yes

Will you turn 70½ prior to December 31st of 2018? (RMD) Yes

Will any dependent children be entering college or vocational school in 2018?  Yes

Notes:

Required Documents / Supporting Paperwork Needed to Complete Tax Returns:

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