Please answer the following questions as they relate to the year 2013.
While this form is NOT required to be completed, you may be eligible for a 5% discount if this checklist is filled out completely and all required information is provided.
Please note: For any return that is prepared while you wait, payment is expected at the time of completion. If you answer "yes" to any question, please provide the requested information so we can prepare a complete and accurate return in a timely manner. If you are unsure of the question or how to answer, you can leave it blank.
YES NO 1) Did your marital or tax filing status change during 2013? _____ _____
If yes, provide new status.
2) If you are married and filing a join return, is there a cause for an "injured spouse
claim (such as back child support, unpaid student loans, tax liens, etc.)? _____ _____ If yes, provide details.
3) Did your address or phone numbers change during 2013? _____ _____ If yes, provide new address, new phone numbers and/or date of move.
4) Are you, and/or your spouse if married, legally blind for 2013? _____ _____ 5) Do you have any NEW dependents that you can claim for 2013? _____ _____
If yes, provide their name(s), social security number(s), date of birth(s), relationship to you, and how long they lived with you during 2013.
6) Do you have any dependents you can no longer claim for 2013? _____ _____ If yes, provide their name(s).
7) Did you work during 2013? _____ _____
If yes, provide W-2's.
8) Did you receive income from Social Security, a pension, an annuity, or an IRA,
including "rollovers" from one plan into another? _____ _____ If yes, provide statements (1099-R, SSA-1099, or RRB-1099).
9) Are you, and/or spouse if married, a retired public safety officer (police, fire, rescue, ambulance or chaplain) AND had your accident, health or long term care insurance
premiums paid directly from your pension? _____ _____
If yes, provide details of premiums paid.
10) Did you receive any interest, tax-exempt interest, or dividends? _____ _____ If yes, provide statements (1099-INT and 1099-DIV).
11) Did you receive income, have financial assets, or have signature power in a bank
or brokerage account in a foreign country? _____ _____
If yes, provide details of amounts and countries.
12) Did you sell any stocks, bonds, mutual funds or own a stock that became worthless? _____ _____ If yes, provide sales price, sales date, purchase date, and purchase price.
13) Did you LOAN someone money that is no longer collectable? _____ _____ If yes, you MUST provide WRITTEN details of amounts loaned, when, why and
WRITTEN PROOF why it is no longer collectable.
14) Did you sell any real estate (including land, personal residences, or rental property)? _____ _____ If yes, provide closing or HUD settlement statement. If not a personal residence,
also provide purchase date, price and cost of improvements.
15) Did you receive TAA (trade adjustment assistance) benefits or a Pension Benefit
Guarantee Corp (PBGC) pension AND pay health insurance premiums in 2013? _____ _____ If yes, provide details and amounts paid (For 8887).
16)Did you receive any rental income in 2013? _____ _____
If yes, provide records of income and expenses paid.
If yes, did you make any payments that would require you to file Form(s) 1099? _____ _____ If yes, did you or will you file required Forms 1099? _____ _____ If yes, did you use your vehicle to collect rent and make repairs? _____ _____
If yes, provide details of mileage driven.
17)Did you receive any income from self-employment in 2013? _____ _____ If yes, provide records of income and expenses paid.
If yes, did you make any payments that would require you to file Form(s) 1099? _____ _____ If yes, did you or will you file required Forms 1099? _____ _____ If yes, did you use any part of your home for business purposes? _____ _____
If yes, provide amounts paid for insurance, repairs and utilities.
If yes, did you use your vehicle for business purposes? _____ _____ If yes, provide total miles driven and miles drive for business.
If yes, did you pay health insurance premiums for a child under age 26? _____ _____ If yes, provide amounts paid.
18)Did you receive any other income not mentioned above (alimony, unemployment benefits, education savings account, distributions from a H.S.A., gambling, lottery,
prizes & awards, partnerships, S-corporations, etc.)? _____ _____ If yes, please provide 1099’s, K-1’s and/or amounts received.
19)Were you (or your spouse) an educator (principal, teacher, etc.) in 2013 AND did
you spend more than 900 hours in the classroom? _____ _____
If yes, provide amounts paid for related expenses (supplies, books, equipment, etc.) 20)Did you incur travel expenses as a member of the military (as part of your service
obligations) for travel that was more than 100 miles (one way) from your home? _____ _____ If yes, provide details of expenses paid.
21)Did you incur any business expenses related to being a performing artist or a
fee-based government official? _____ _____
If yes, provide details and amounts paid.
22)Did you make a contribution to a traditional or Roth IRA? _____ _____ If yes, provide form 5498 or details and amounts paid.
23)Did you pay any interest on a student loan for you, your spouse (if married), or
a dependent (if the loan is in your name)? _____ _____
24)Did you pay any college tuition for yourself, spouse (if married), or dependent? _____ _____ If yes, provide amounts of expenses paid. (Form 1098-T)
25)Did you make a contribution to a health savings account? _____ _____ If yes, provide amounts paid.
26)Did you pay any job related moving expenses for a move that was greater
than 50 miles? _____ _____
If yes, provide details and amount of expenses paid.
27)Did you pay alimony (not child support) during 2013? _____ _____ If yes, provide amount paid, ex-spouse's name and social security number.
If you are able to itemize (file long form), questions 28 - 39 apply to you. If you are unsure, please answer questions 28 - 39 to the best of your ability.
28)Did you pay any medical expenses that were NOT reimbursed (including POST-tax health insurance premiums, co-pays, prescriptions, doctors, dentists, hospitals,
glasses, therapy, nursing home care, etc.)? _____ _____
If yes, provide details of amounts paid.
29)Did you purchase a new home in 2013? _____ _____
If yes, provide a copy of the HUD settlement or closing statement. 30)Did you pay any taxes, mortgage interest, home equity interest, or
mortgage insurance premiums (PMI) for a contracted issued after 12/31/06? _____ _____ If yes, provide statements. (Form 1098 and/or property tax receipts)
31)Did you make any charitable contributions by check and/or cash in 2013? _____ _____ If yes, provide details of amounts paid.
32)Did you donate property (such as clothing for furniture) to a charitable organization? _____ _____ If yes, provide description and value of items donated.
33)Did you donate a car, truck, vehicle, boat or aircraft to a charitable organization? _____ _____ If yes, provide Form 1098-C
34)Did you make any major purchases or start a new lease (such as car, boat,
mobile home, RV, etc.) during 2013 for which you paid sales tax? _____ _____ If yes, provide details of purchase/lease and sales tax paid.
35)Did you pay any miscellaneous expenses (including union dues, tools, supplies, tax preparation fees, safe deposit box, continuing education, uniforms, working out
of town, IRA custodial fees, professional license, military expenses, etc.)? _____ _____ If yes, provide details of amounts paid and for which expense.
36)Did you use any part of your home OR your personal vehicle (other than commuting)
on behalf of your employer? _____ _____
If home office, provide amounts paid for insurance, repairs and utilities.
If you had mileage, provide business miles driven as well as total miles driven.
37)Did you re-finance your mortgage during 2013? _____ _____
38)Are you an individual with a disability and have impairment related work expenses? _____ _____ If yes, provide details of amounts paid.
39)Did you incur a substantial loss (more than 10% of your income) due to damaged
or stolen property during 2013 that was NOT reimbursed by insurance? _____ _____ If yes, provide details of loss and dollar amount of loss.
(End of questions for long form or itemization. Please continue below.)
40)Did you make any gifts to any one person in 2013 in excess of $14,000? _____ _____ If yes, provide dates of gifts and to whom.
41)Did you claim the first-time home buyer credit in 2008? _____ _____ If yes, provide amount of credit claimed.
42)Did you claim the first-time home buyer credit in 2008 AND did you SELL
that same home OR did that home stop being your primary home in 2013? _____ _____ If yes, provide the amount of credit claimed.
43)Did you purchase or lease a “fuel cell” vehicle or install alternative fuel vehicle
refueling property during 2013? (Also a valid credit for NYS in 2013.) _____ _____ If yes, provide date purchased and cost of vehicle or property installed.
44)Did you pay any child care expenses, daycare, after school, pre-k, etc.)? _____ _____ If yes, include the provider's name and tax ID number, amount
paid, and for which child the expenses were paid for.
If yes, did you receive dependent care benefits from your employer? _____ _____ 45)Did you pay any adoption expenses for an adoption that was finalized in 2013? _____ _____
If yes, provide details of expenses paid.
46)Did you make any energy saving improvements to your home in 2013? (This would
include solar, insulation, exterior windows and doors, certain furnaces or A/C, etc.) _____ _____ If yes, provide details of improvements and amounts paid.
Questions 47 - 56 are for New York State Residents only. If you are a NYS resident, please answer questions 47 - 56 to the best of your ability. If you are NOT a NY resident, you can skip to question #57. 47)Credit for NYS residents: Did you buy an automated external defibrillator in 2013? _____ _____
If yes, provide details of amounts paid.
48)Credit for NYS residents: Did you pay for long-term care insurance in 2013? _____ _____ If yes, provide details of amount paid.
49)Credit for NYS residents: Were you a volunteer firefighter or ambulance
worker for the entire year during 2013? _____ _____
If yes, provide name and address of company or department.
50)Credit for NYS residents: Did you rehabilitate a historic property or make improvements
to a certified "Green Building" during 2013 that was located in New York State? _____ _____ If yes, provide details of expenses paid.
51)Credit for NYS residents: Did you purchase bioheat to be used for space heating or
for hot water production for residential purposes? _____ _____ If yes, provide details of amounts paid.
52)Credit for NYS residents: Did you directly pay the NY nursing home assessment tax
to a residential health care facility located in NY state? _____ _____ 53)Credit for NYS Residents: Do you purchase and install a solar energy system for
your personal residence? _____ _____
If yes, provide date and cost of the solar equipment.
54)NYS residents: Did you buy anything via the Internet, through a catalog, from a television shopping channel or on an Indian reservation for which you
DID NOT PAY NY State sales tax? _____ _____
If yes, provide details of amounts purchased.
55)NYS residents: Is your TOTAL income less than $18,000 for the year 2013? _____ _____ If yes, provide amount of rent paid or property taxes paid.
56)NYS residents: Did you make a contribution to the NY College Savings Program? _____ _____ If yes, provide details of amount paid.
57)Did you make any estimated tax payments for the tax year 2013? _____ _____ If yes, provide dates and amounts paid.
58)If you are entitled to a refund, do you want the refund direct deposited into a
checking or savings account? (NY is also offering a debit card at no charge.) _____ _____ If yes, provide bank routing number and bank account number or a voided
check (not a deposit slip), if different from 2012, for up to three accounts. 59)If you are entitled to a refund, do you want to purchase U.S. Series I Savings bonds with your refund (up to $5,000, in $50 increments) or direct deposit the
refund to your Treasury Direct online account? _____ _____ 60)If you have a balance due, do you want to pay by direct debit from a checking
or savings account on a date designated by you or by credit card? (Additional fee
charged by the IRS applies to credit cards only) _____ _____ If yes, bring a voided check or credit card information, if different from 2012.
61)We are required by law to give you a copy of your tax return. This copy can be _____ Paper copy either paper or electronic. We highly recommend putting your copy on _____ CD (PDF) CD in PDF format. It is easier to store the CD and you can print as many _____ Both ($6 fee) copies as needed throughout the year. If you bring back the CD, we can simply
add the current year to the same CD. Please check which format you prefer. For everyone who takes a CD copy instead of a paper copy, $1 will be donated to the 2014 Ride For Roswell. ($396 was donated in 2013! Thank you!)
62)Would you be interested in receiving our FREE newsletter via e-mail? _____ _____ If yes, and NOT already on our mailing list, enter your e-mail address below:
_________________________________________________. (The newsletter can be canceled at any time.)
63)If you are interested in receiving other correspondence via email throughout the year (such as electronic verification of acceptance of your federal tax return), please provide an email address below:
____________________________________________________ (optional) ADDITIONAL INFORMATION / QUESTIONS / COMMENTS:
