DAY CARE EXPENSE
Provider #1Address City/State/Zip
EIN/SS# (Mandatory) Amount Paid:
Provider #2 Address City/State/Zip
EIN/SS# Amount Paid:
Children cared for
Medical/Dental Expenses
Medical insurance premiums (paid by you) Medical equipment
Long Term Care insurance Nursing Care
Prescription drugs Medical Therapy
Glasses, contacts Hospital
Hearing aids, batteries Doctor/Dental/Orthodontist
Braces Mileage (no. of miles)
Taxes Paid
Real property tax (attach bills) Personal property tax
Vehicle Tax (license, registration) Other
Interest Expense
Mortgage interest paid -
attach Form-1098(s)Interest paid to individual for your home (attach amortization schedule).
Paid to:
Name: Address:
Social Security No: Interest paid
11211 Taylor Draper Ln., Suite 300 Austin TX 78759 - (p) 512-833-5829 - (f) 512-582-8590- taxhelp@fivestonetax.com
CASUALTY / THEFT LOSS -
For property damaged by storm, water, fire, accident, or theft.Location of property Insurance reimbursement
Description of property Repair costs
Amount of damage Federal grants received
ESTIMATED TAX PAYMENTS
Federal Amount
State Amount
LY – Jan 15 LY – Jan 15
Q1 – Apr 15 Q1 – Apr 15
Q2 – Jun 15 Q2 – Jun 15
Q3 – Sep 15 Q3 – Sep 15
Q4 – Jan 15 Q4 – Jan 15
CHARITABLE CONTRIBUTIONS – (receipts required)
Church Salvation Army, Goodwill
United Way Other:
Scouts Non-Cash (household items, clothes, etc.)
Telethons Address
University, Public TV Radio City/State/Zip
Heart, Lung, Cancer, etc. Value of goods (attach list if more than one)
Wildlife Fund, Humane Society Volunteer Mileage
MISCELLANEOUS / UNREIMBURSED EMPLOYEE EXPENSES
(Self Employed see next page) Dues – union, professionalBooks, subscriptions, supplies Licenses
Tools, equipment, safety equipment Uniforms (including cleaning) Sales expense, gifts
Tuition, Books (work related) Entertainment
Tax preparation fee Safe deposit box IRA custodial fees
Investment periodical, advisory fees Job search expense
Moving of household goods (job related) Other:
Other:
SELF EMPLOYMENT INFORMATION
Business Name:
Industry Type:
Gross Sales
Business owned by: TP
SP
Self-Employment Expenses:
Advertising Repairs Expense
Commissions / Fees Supplies Expense
Dues & Publications Taxes and Licenses
Interest Expense (include auto loan) Travel Expense
Insurance (non-health, non-auto) Meals & Entertainment
Health Insurance Telephone
Legal & Professional Fees Utilities (non-home)
Office Supplies (paper, ink, etc.) Contract Labor
Rent (office space) Materials & Supplies
Auto Expense: Postage
Purchase Price
Bank chargesMake Model Tools & Equipment (below $1K)
Date auto placed in service Uniforms
Auto (business miles) PLEASE SEE HELP Dues & Subscriptions Auto (personal miles) PLEASE SEE HELP Equipment Rental Expense
Gas, repairs, tolls, taxes Other:
Auto Insurance Other:
COST OF GOODS SOLD
(only if inventory kept from prior year)Inventory at beginning of year Inventory at end of year
Purchases Other:
Cost of items for personal use Other:
Cost of labor Other:
HOME OFFICE EXPENSE
BUSINESS ASSETS PURCHASED
Number of Rooms (bedroom, living room, diningroom)
Asset
(equipment, computer, cars, etc.) Date Acquired Amount PaidExpenses:
Monthly rent
( if applicable)Annual mortgage interest paid
( if applicable)Annual repairs/maintenance
Annual utilities
(electric, gas, water, etc.) Annual home/rental insurance Real Estate TaxesRENTAL INCOME: Property 1
Property 2
Property 3
Property 4
Basis (Purchase Price) Date Purchased Address City / State Rent Income Expenses Advertising Auto & Travel Auto Miles
Cleaning & Maintenance Commissions Paid Grounds & Gardening Insurance
Interest Expense Legal & Professional Management Fees Repairs & Maintenance Supplies Taxes Utilities Association Dues Pest Control Other:
Privacy Policy
The nature of our work requires us to collect certain nonpublic information. We collect financial and personal information from
applications, worksheets, reporting statements, and other forms, as well as interviews and conversations with our clients and
affiliates. We may also review banking and credit card information about our clients in the performance of receipt of payment.
Under our policy, all information we obtain about you will be provided by you or obtained with your permission.
Our firm adheres to procedures and policies in place to protect your confidential information. We restrict access to your confidential
information to those within our firm who need to know in order to provide you with services. We will not disclose your personal
information to a third party without your permission, except where required to by law. We maintain physical, electronic, and
procedural safeguards in compliance with federal regulations that protect your personal information from unauthorized access.
11211 Taylor Draper Ln., Suite 300 Austin TX 78759 - (p) 512-833-5829 - (f) 512-582-8590- taxhelp@fivestonetax.com Prior Depreciation (if any)
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11211 Taylor Draper Ln., Suite 300 Austin TX 78759 - (p) 512-833-5829 - (f) 512-582-8590- taxhelp@fivestonetax.com
