1



In order to help us prepare your returns, please complete these forms prior to bringing in your 2020 tax informationLehman, Hershberger & Company P.C.Client Tax Organizer(This planner can also be found on our website as a fill-in form. LHPC.us)1. Personal InformationNameSoc. Sec. No.Date of BirthOccupationWork PhoneTaxpayer FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Spouse FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Street Address:City:State:ZIPHome Phone: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Email Address(es):Cell (Taxpayer):Cell (Spouse):Fax: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????If you would like direct deposit for your refund, please provide banking information:Bank Name:Checking or savings?Routing Number:Account Number:TaxpayerSpouseMarital StatusBlind………………………………. FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX SingleDisabled………………………….Wish to donate $3 to the Pres. Campaign fund? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Married filing jointly FORMCHECKBOX Married but filing separately FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Widow(er)Can anyone else claim you as a dependent? -Date of Spouse’s Death: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????School District: FORMTEXT ?????2. Dependents (Children & Others you supported)Name(First, Last)RelationshipDate of BirthSoc. Security NumberMonths Lived with you during yearCan anyone else ever claim this person?DisabledFull Time StudentDependent’s Gross Income FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMDROPDOWN FORMTEXT ?????3. Estimated Taxes You Paid for 2020FederalStateQuarterDue DateDate PaidAmount$Check#QuarterDue DateDate PaidAmount$Check#14/15/20 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????14/15/20 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????26/15/20 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????26/15/20 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????39/15/20 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????39/15/20 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????41/15/21 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????41/15/21 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????To the best of my knowledge, this information is correct and complete.Signature:Date:4. Foreign Bank Accounts & Foreign Income (please mark “do” or “do not” for the following statements)& 5. Virtual Currency (please mark “yes” or “no” for the following statement)I(we) FORMCHECKBOX do FORMCHECKBOX do not have any foreign bank accounts.I(we) FORMCHECKBOX do FORMCHECKBOX do not have any foreign income.At any time during 2020, did you receive, sell, send, exchange, or otherwise acquire any financial interest in any virtual currency? FORMCHECKBOX YES FORMCHECKBOX NO________________________________________________________________________________________Taxpayers signature(s)6. Health Insurance (Attach any 1095 forms you have received)Did you or anyone in your tax household have health insurance through the Marketplace during 2020? If yes, please list who was covered by the Marketplace policy and include form 1095A with your tax documents. FORMCHECKBOX YES FORMCHECKBOX NOMembers of your tax household who had health insurance through the Marketplace during 2020. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????7. Economic Impact Payment – Stimulus Payment (Attach notice 1444 you received)Did you or anyone in your tax household receive an economic impact payment otherwise know as a stimulus payment? If yes, please list names and amounts received: FORMCHECKBOX YES FORMCHECKBOX NOName: FORMTEXT ?????Amount: FORMTEXT ?????Name: FORMTEXT ?????Amount: FORMTEXT ?????Name: FORMTEXT ?????Amount: FORMTEXT ?????Name: FORMTEXT ?????Amount: FORMTEXT ?????8. IncomeIf you have any of the following income sources, please mark and include forms.Form Name# of each you haveW-2s (wage, salary income) FORMTEXT ?????W-2G’s (unemployment) FORMTEXT ?????1099-INT (interest statements) FORMTEXT ?????Brokerage Statements FORMTEXT ?????1099-DIV (dividend statements) FORMTEXT ?????1099-C (cancellation of debt) FORMTEXT ?????K-1 (partnership, S-Corp, Estate, or trust income) FORMTEXT ?????SSA-1099 (social security) FORMTEXT ?????RRB-1099 (railroad retirement) FORMTEXT ?????1099-R (pension/annuity income) FORMTEXT ?????Others: FORMTEXT ????? FORMTEXT ?????9. I.R.A. (Individual Retirement Acct.)Contributions made for this tax year:AmountDateRoth?Taxpayer: FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Spouse: FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Withdrawals (Attach 1099-R or 5498):AmountReasonRolled Over?Taxpayer: FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Spouse: FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX 10. Investments Sold (Attach Documentation (1099-B, etc.))Stocks, Bonds, Mutual Funds, Gold, Silver, and Partnership Interest InvestmentDate AcquiredCostDate SoldSale Price FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????11. Real Estate Sold (Attach 1099-S and Closing Statements)Property Was this your principal residence?Date AcquiredCostImprovementsDate SoldSale Price FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????12. Other IncomeLawsuit settlements: FORMTEXT ????? Describe: FORMTEXT ?????Scholarships (Grants) FORMTEXT ?????Alimony Received FORMTEXT ?????Prizes, Bonuses, Awards FORMTEXT ?????Gambling, Lottery, Winnings FORMTEXT ????? - Gambling, Lottery Expenses( FORMTEXT ?????)Unreported Tips FORMTEXT ?????Director, Executor Fee Received FORMTEXT ?????Commissions FORMTEXT ?????Jury Duty FORMTEXT ?????Payment from Prior Installment Sale FORMTEXT ?????State Income Tax Refund FORMTEXT ?????Other: FORMTEXT ????? FORMTEXT ?????13. Taxes Paid in 2020 (attach receipts if more than one property)Real Estate on Principle Residence: FORMTEXT ?????Real Estate on 2nd Home: FORMTEXT ?????Personal Property Tax: FORMTEXT ?????Auto Excise & Wheel Tax: (not reg. fees) FORMTEXT ?????Sales Tax on Purchase of New Vehicle: FORMTEXT ????? Date Purchased: FORMTEXT ?????Sales Tax on other Big Ticket Items: FORMTEXT ?????14. Mortgage Interest Paid (attach 1098)Mortgage Interest Paid (on Principle) FORMTEXT ?????Mortgage Interest Paid (on 2nd Home or line of credit) FORMTEXT ?????Interest Paid to an individual for your home (attach amortization schedule) FORMTEXT ?????Paid to: Name FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Soc. Sec.# FORMTEXT ?????15. Rent Paid for Personal ResidenceRent Paid in 2020: FORMTEXT ?????Rent Paid To: FORMTEXT ?????Address: FORMTEXT ????? FORMTEXT ?????Address where rented: FORMTEXT ????? FORMTEXT ?????Number of months rented: FORMTEXT ?????16. Medical/Dental Expenses (unreimbursed – Out-of-Pocket)Med. Insurance Premiums (NOT on W-2) FORMTEXT ?????Long-Term Care Ins. Premiums (taxpayer) FORMTEXT ?????Long-Term Care Ins. Premiums (spouse) FORMTEXT ?????Name of Insurance Co.: FORMTEXT ?????Do not include any bills that were paid with HSA or MSA dollars in this section. Thanks!Prescription Drugs FORMTEXT ?????Eye, Glasses, Contacts FORMTEXT ?????Hearing Aids, Batteries FORMTEXT ?????Medical Equipment, Supplies FORMTEXT ?????Nursing Care, Medical Therapy FORMTEXT ?????Hospital FORMTEXT ?????Doctor, Dental, Orthodontist FORMTEXT ?????Other FORMTEXT ????? FORMTEXT ?????Health Savings Account (HSA): Distributions FORMTEXT ?????Withdrawals from HSA that were not used for medical expenses. FORMTEXT ?????Contributions by You FORMTEXT ?????Employer Contributions FORMTEXT ?????Medical Savings Account (MSA): Distributions FORMTEXT ?????Withdrawals from MSA that were not used for medical expenses. FORMTEXT ?????Contributions by You FORMTEXT ?????Employer Contributions FORMTEXT ?????Medical Miles Driven:January – December 2020 FORMTEXT ????? miles17. Charitable ContributionsYou MUST keep the receipts, but we do not need to see them. Contributions greater than $250 must have “no goods or services were received” on the receipt in order to fully qualify.Church FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????United Way FORMTEXT ?????Colleges, Universities FORMTEXT ?????Other Cash Contributions: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Non-Cash Contributions: (Bring in details) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Volunteer Miles Driven: Jan.-Dec. 2020 FORMTEXT ????? miles FORMTEXT ????? FORMTEXT ?????18. Investment Related ExpensesTax Preparation Fee FORMTEXT ?????Safe Deposit Box Rental FORMTEXT ?????Mutual Fund Fees FORMTEXT ?????Investment Counselor FORMTEXT ?????Investment Interest FORMTEXT ?????Other: FORMTEXT ????? FORMTEXT ?????19. Other DeductionsAlimony Paid to: FORMTEXT ?????Soc. Security No: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other: FORMTEXT ????? FORMTEXT ?????20. Casualty, Theft LossFor property stolen or damaged by storm, water, fire, accidentLocation of property: FORMTEXT ????? FORMTEXT ?????Date of Purchase FORMTEXT ?????Cost & Improvements: FORMTEXT ?????Description of property: FORMTEXT ?????Amt. of Damage: FORMTEXT ?????Ins. Reimburs.: FORMTEXT ?????Repair Cost: FORMTEXT ?????Fed. Grants Received: FORMTEXT ?????21. Energy Credit/Insulation (attach receipts)Alternative Fuel Vehicle Purchased:Date: FORMTEXT ?????Make: FORMTEXT ?????Model: FORMTEXT ?????Price: FORMTEXT ?????Install of solar, wind or geothermal items at your home:Item: FORMTEXT ?????Date: FORMTEXT ?????Price: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????22. Child & Dependent Care ExpensesChild orDependentName of Care ProviderAddressSoc. Sec. No. orFed. ID No.AmountPaid FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Did you receive dependent care benefits from your employer? FORMDROPDOWN 23. Education Expenses (including home school, private school, & Amish school in Indiana) Student NameYear in SchoolSchoolCampus locationType of ExpenseAmount FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Student Loan Interest Paid: (attach statements) FORMTEXT ?????Contribution(s) to Indiana College 529 Plan: (attach statements) FORMTEXT ?????24. Other Information Did any of the following apply to you in 2019? FORMCHECKBOX Marriage FORMCHECKBOX Home Foreclosure FORMCHECKBOX Births FORMCHECKBOX Income from Animals FORMCHECKBOX Divorce FORMCHECKBOX Self-employment FORMCHECKBOX Adoption FORMCHECKBOX Income from Crops FORMCHECKBOX Bankruptcy FORMCHECKBOX Hobby Income FORMCHECKBOX Job-Related Move FORMCHECKBOX Rental Income FORMCHECKBOX Give a gift of more than $15,000 to anyone FORMCHECKBOX Provide home or help support to someone not listed as a dependent on Page 1 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download