The Tax Coach | Ron R. Valentine, MS,CPA - Valentine CPA, A Professional Corporation
Personal Income Tax Work Sheet
© 2003 Valentine CPA, A Professional Corporation
GENERAL INFORMATION

Name:
Spouse Name:
SS No.:
Spouse SS No.:
Occupation:
Spouse Occupation:
Street:
City & Zip
Home Phone:
Work Phone:


DEPENDANTS    
 
Dependant 1
Dependant 2
Dependant 3
Dependant 4
Dependant 5
Name:
Date of Birth:
SS No.:
Relationship:
Months lived at home:

SALARIES & WAGES (W-2) [10]    
 
Employer 1
Employer 2
Employer 3
Employer 4
Employer 5
Employer Name:
[800]
[800]
[800]
[800]
[800]
Spouse's? (Y/N):
[1]
[1]
[1]
[1]
[1]
Pension Plan (Y/N):
[2]
[2]
[2]
[2]
[2]
Wages (Box 1)
[3]
[3]
[3]
[3]
[3]
Fed W/Held (Box 2)
[4]
[4]
[4]
[4]
[4]
SS W/Held (Box 4)
[6]
[6]
[6]
[6]
[6]
Med W/Held
(Box 6)
[8]
[8]
[8]
[8]
[8]
State W/Held
(Box 18)
[14]
[14]
[14]
[14]
[14]
Child Care Ben
(Box 10)
[12]
[12]
[12]
[12]
[12]


PENSIONS, IRA (1099-R) [13]     
Payer 1
Payer 2
Payer 3
Payer 4
Payer 5
Payer Name
[800]
[800]
[800]
[800]
[800]
Spouse's? (Y/N):
[1]
[1]
[1]
[1]
[1]
Is it IRA? (Y/N):
[2]
[2]
[2]
[2]
[2]
Is it a Rollover? (Y/N)
[13]
[13]
[13]
[13]
[13]
Gross Distrib
(Box 1)
[3]
[3]
[3]
[3]
[3]
Taxable Amt
(Box 2)
[4]
[4]
[4]
[4]
[4]
Fed W/Held
(Box 4)
[6]
[6]
[6]
[6]
[6]
State W/Held
(Box 10)
[9]
[9]
[9]
[9]
[9]
Rollover to Roth
[138]
[138]
[138]
[138]
[138]
Suppress Form 5329
[37]
[37]
[37]
[37]
[37]
Early withdrawl? (Y/N)
[24]
[24]
[24]
[24]
[24]
State deduction? (Y/N)
[44]
[44]
[44]
[44]
[44]

INTEREST INCOME [11] INTEREST INCOME FROM
SELLER FINANCED MORTGAGES [11]
Bank/Credit Union Name Amount
[800]
[2]
Payers Name
[800]
[800]
[2]
Amount
[3]
[800]
[2]
Social Sec. no
[801]
U.S. Bonds Amount Street address
[802]
[800]
[4]
City State Zip
[803]


DIVIDEND INCOME [12]   
Payer Name
Gross Div
Cap. Gain
US Bond Int
In-UT bonds
Out-UT bonds
[800]
[2]
[3]
[6]
[7]
[8]
[800]
[2]
[3]
[6]
[7]
[8]
[800]
[2]
[3]
[6]
[7]
[8]
[800]
[2]
[3]
[6]
[7]
[8]

S S BENEFITS RECEIVED [14.1] UNEMPLOY COMP ALIMONY RECEIVED
Taxpayer
[2]
Taxpayer
[6]
Taxpayer
[5]
Spouse
[52]
Spouse
[56]
Spouse
[55]
Medicare Prem (Taxpay.)
[13]
Medicare Prem (Sp)
[63]
 


MEDICAL AND DENTAL [24]           OTHER INCOME (PRIZES) [14.1]
  Amount Taxpayer
[11]
Prescript Medicine & Drugs
[4]
Spouse
[61]
Doctors, dentists, nurses
[5]
 
Hopitals, nursing homes
[6]
ALIMONY PAID [23]
Health Insurance premiums
[6]
Taxpayer
[18]
No of Miles to doc, hospital
[52]
Spouse
[68]
Other medical (like eyeglasses, etc.)
[10]
Recipient's SS#
LongTerm Care Premiums
[17]
S/E Health Insur
[16]


TAXES PAID [24]           EDUCATION CREDITS [35.3]
Refund from State last yr when you filed return
[14.1] [1]
Dependent Name
[11]
Payment to State last yr when you filed return
[13]
1=Hope, 2=Lifetime
[15]
Property tax on your home
[15]
Amt of tuition & fees
[16]
Property tax on investment R/E
[16]
 
Tax portion of registration on cars, boats, etc.
[18]


CHARITABLE CONTRIBUTIONS [24]  
Paid by cash or check
[32]
Volunteer Expense
[40]
No of Miles for charity
[54]
Int. not on 1098
[22]
Noncash donations (clothing, etc.)
[33]
Name, Add, SS#


INTEREST PAID [24]
Home mortgage lender Amount Investment Interest Amount
[21]
 
[24]
[21]
Points (not on Form 1098)
[21]
 
[23]


MISCELLANEOUS [24]
Union Dues [42] Unreimbursed expenses for job (list)
[43]
Prior Year Tax Prep Fee [45] Investment Exp [44]
[43]
Safe Depsit Box rental

[46]

Gambling losses [48]
[43]


CHILD CARE (While both parents worked or full time students) [32]
  Provider 1 Provider 2 Provider 3
Provider Name
[10]
[10]
[10]
Street
[11]
[11]
[11]
City, State, Zip
[12]
[12]
[12]
SS# or EIN
[13]
[13]
[13]
Amount
[14]
[14]
[14]

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