SCHEDULE A TAX DEDUCTION WORKSHEET
[Pages:1]SCHEDULE A TAX DEDUCTION WORKSHEET
MEDICAL EXPENSES
CONTRIBUTIONS
Insurance Premiums
$
CASH CONTRIBUTIONS:
Medicare Premiums (withheld from soc. security)
$
Church (Name:_____________________________) $
Prescriptions
$
Church (Name:_____________________________) $
Long Term Care Insurance Premiums
$
Church (Name:_____________________________) $
Doctor (Name:____________________________) $
Church (Name:_____________________________) $
Doctor (Name:____________________________) $
Other (Name:_____________________________) $
Doctor (Name:____________________________) $
Other (Name:_____________________________) $
Doctor (Name:____________________________) $
Other (Name:_____________________________) $
Doctor (Name:____________________________) $
Other (Name:_____________________________) $
Dentist (Name:____________________________) $
Dentist (Name:____________________________) $
NON-CASH CONTRIBUTIONS:
Hospital Care
$
Church ( Name:_________________________Cost: $
Laboratory & X-Ray Costs
$
Desc.: _________________________)
Miles Driven for Medical Care
Other ( Name:_________________________Cost: $
Medical Travel (parking, taxis, airfare, etc.)
$
Desc.: _________________________)
Medical Travel (lodging)
$
Miles Driven for Charity
Ambulance Costs
$
Glasses, Contacts & Eye Exams
$
Please attach any and all receipts
Hearing Aids & Batteries
$
Prosthetic Appliances
$
INTEREST PAID
Sick Room Supplies & Appliances
$
In Home Attendant or Nursing Service
$
Home Mortgage Interest (attach form 1098)
$
Home Mortgage Interest (attach form 1098)
$
Insurance Reimbursements (for amounts listed above)
$
Home Mortgage Interest (attach form 1098)
$
Home Mortgage Interest (attach form 1098)
$
CASUALTY
Home Mortgage Interest (other)
$
Home Mortgage Interest (other)
$
Total Casualty Loss (attach documentation)
$
Examples: Theft, Earthquake, Fire, Flood
Mortgage Interest Paid to an Individual
$
Name:_______________________________________
ADJUSTMENTS TO INCOME
Address:_____________________________________
City, State, Zip:_______________________________
Archer MSA Deduction
$
Business Expenses (reservists, artists, & fee-based officials) $
Points Paid on Mortgage Loan
$
Moving Expenses (work related)
$
Points Paid on Mortgage Loan
$
SEP, SIMPLE & Qualified Plan Contributions
$
Alimony Paid (Name & SSN: ______________________) $
If you refinanced your primary or secondary residence
IRA Deductions
$
or sold your home, please bring the settlement sheet
Student Loan Interest Paid
$
Jury Duty Pay (Given to Your Employer)
$
MISCELLANEOUS
TAXES PAID
State Income Tax (prior year return)
$
State Income Tax (current year estimate)
$
State Income Tax Withheld (from W-2)
$
SDI Withheld (from W-2)
$
Real Estate Taxes (attach appropriate form)
$
Personal Property Tax
$
DMV Registration
$
Other (Desc.:____________________________)
$
Other (Desc.:____________________________)
$
Other (Desc.:____________________________)
$
Other (Desc.:____________________________)
$
PLEASE SIGN BELOW
Please print your name
Please sign your name
Date
UN-REIMBURSED BUSINESS EXPENSES:
Auto Expense (gas, repairs, etc.)
$
Business Miles
Business Phones
$
Business Travel
$
Commuting Miles
Meals & Entertainment
$
Other Miles
Safety Equipment
$
Small Tools
$
Teaching Expenses
$
Uniform & Cleaning Fees
$
$
MISCELLANEOUS EXPENSES
Education Fees
$
Investment Expense
$
Job Search Fees
$
Legal Fees
$
Safe Deposit Box
$
Subscriptions (trade journals)
$
Tax Preparation Fee
$
Form 914 Rev. 2 (12/06)
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