Every Tax Payer: Fill in STEPS 1 and 2

STEP 1

Filing Status:

Married Filing Jointly

Surviving Widow(er) with dependent child

Head of House Hold1

Married and Separate Return

Spouse's Name___________________

Spouse's SSN__________________

In year 2004 only:

Married (date:___________)

Divorced (date:__________)

Spouse Died (date:___________)

DEPENDENTS

Children living with you age 18 or younger. If the child is age 19-23 and attends school full time for at least five months during the year, place "S" after name.

Birthdate:______________

Grade:______

SSN:___________________

Birthdate:______________

Grade:______

SSN:___________________

Birthdate:______________

Grade:______

SSN:___________________

Birthdate:______________

Grade:______

SSN:___________________

Birthdate:______________

Grade:______

SSN:___________________

OTHER DEPENDENTS²

Name

Relationship

Birthdate

Social Security #

Gross Income

# Months Resided in Your Home

% Support Rcvd. From You

Check if you are a noncustodial parent claiming an exemption(s) for a child(ren) not living with you but which the custodial parent

has released the exemption to you. (Provide Form 8332).

Check if any of your dependent children have unearned income over $800.00. Unearned income consists of interest, dividends, capital gains, etc.

Check if any of your dependent children (whom you have listed above) will be filing his or her own tax return this year

Check if your exemptions changed since last year. Examples: Births, deaths, children you can no long claim.

Check if you or your spouse is legally blind or disabled.

If you were unmarried (or considered unmarried) at the end of the t ax year, and you contributed over half of the cost of maintaining a household for your child or other dependent, you may be eligible for Head of Household filing status. If you are married, you may be considered unmarried for this purpose if your spouse did not live in your home during the last six months of the tax year. If maintaining the household of a parent, the parent does not necessarily need to live with you to qualify.

If you pay over half the support for a relative, that person does not necessarily have to live with you to qualify as a dependent.

STEP 2

The Following items may affect your tax return. Please answer carefully.

YES

Did you contribute to an IRA , Roth IRA or self-employed retirement plan for 2004? (Circle one.) Self$_________ Spouse$________

Did you have a retirement plan withdrawal, rollover or lump-sum distribution in 2004? If yes, provide Forms 1099-R

If either you or your spouse attained age 70 1/2 during the year, are you taking required minimum retirement plan distributions?

Did you incur educational expenses on behalf of yourself or your spouse or dependent?

Did you pay any education loan interest in 2004? Amount $____________

Did you pay child care costs for a dependent child under age 13, or costs of caring for a handicapped individual, so you could

work, attend school or look for a job? If yes, provide the amounts paid for each dependent and the names, addresses and

taxpayer identification numbers of the care providers.

If you answered yes to question 6, did you claim any amount through an employer's dependent care reimbursement plan?

Did you incur any expenses in 2004 or prior years associated with the adoption of a child?

Did you sell stock, securities, real estate or other property? If yes, provide all Forms 1099-B and 1099-S. Also provide: (1)

a description of the property, (2) date of purchase, (3) date of sale, (4) purchase price, (5) selling price, (7) improvements or

other cost/basis additions and (8) closing statements for purchase and/or sale. If you sold a personal residence.

Did you refinance your home mortgage during 204? Provide closing papers.

Are you making payments on a recreational vehicle or boat that has basic living accommodations?

Do you own any securities or hold an bad debts that became worthless during the year? Provide details.

Were any stock options granted to you by your employer, or did you e exercise any stock options in 2004?

Did you pay alimony during 2004? Name__________________Social Security Number_______________Amount $___________

Are you a teacher? If yes, a special deduction of up to $250 is allowed for classroom expenses

Are you a National Guard member or an Armed Forces reservist and travel more than 100 miles and stay overnight to fulfill

duty? If yes, your travel costs are deductible.

Did you move at least 50 miles because of a job change? Provide details for a possible moving expense deduction.

During 2004, were there any changes to federal or state returns filed in prior years? Provide details?

Do you and/or your spouse want to designate $3 of your tax to the Presidential Election Campaign Fund? (Does not change

amount due or refund.)

If you are due a refund, would you like the refund electronically deposited into your bank account? If yes, provide the

following: Type: Checking___ or Savings____ Routing #_______________________ Account #______________________

(For a checking account, your preparer can transfer the information from a voided check. Do not use a deposit slip.)

Do you expect a substantial change in income or deductions next year?

Did your marital status change during 2004?

Do you have dependents who must file?

If yes, do you want us to prepare the return(s)?

Do you have children under the age 14 with investment income greater than $1,500?

Did you provide over half the support for any other person during the year?

Did you receive payments from an IRA, 401K, pension or profit-sharing plan?

Did you receive a distribution from an IRA or other qualified plan that was rolled over into another IRA or qualified plan?

Did you convert a traditional IRA into a Roth IRA?

Did you contribute to an Education Savings Account, 529 plan or prepaid tuition plan?

Did you receive any disability payments this year?

Did you pay sales tax on a large purchase? (i.e.: boat, auto, rv, etc.)

Did you sell or purchase a home in 2004?

Did you contributed to a health Savings Account?

Were you notified by the Internal Revenue Service or state/city taxing authority of changes to a prior year's return?

If yes, provide notice of change.

Were there changes to a prior year's income, deductions or credits which would require filing an amended return?

Did you make gifts of over $11,000 to an individual?

Do you have any other income not provided to us?

Did you buy or sell any stocks or bonds during the year?

Did you start a business, purchase a rental property, or acquire interests in partnerships or S corporations?

Do you have records, as described below, to support expenses?

Tax laws and regulations allow deductions for travel, entertainment, computers and cell phones only if adequate records

can be presented. Information must include amount, time and place, date, business purpose, description and business

relationship of recipient.

Please provide birthdates: Taxpayer________________, Spouse__________________, Child________________