PLEASE LIST ALL INCOME OTHER THAN W-2



PLEASE LIST ALL INCOME OTHER THAN W-2

OTHERWISE WE CANNOT BE RESPONSIBLE FOR UNREPORTED INCOME

LIST ALL INCOME EXCEPT W-2 FORMS BRING IN COPIES OF ALL 1099 FORMS

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| INTEREST INCOME | DIVIDEND INCOME |

|FROM |AMOUNT |FROM |AMOUNT |

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|OTHER INCOME, UNEMPLOYMENT COMPENSATION, SOCIAL SECURITY AND RAILROAD RETIREMENT BENEFITS, CERTAIN ANNUNITIES |

|AND LUMP SUM DISTRIBUTION |

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| CHILDREN AND OTHER DEPENDENTS |

| |

|NAME |SOCIAL SECURITY NUMBER |BIRTHDATE |RELATIONSHIP |INCOME |YOUR CONTRIBUTION TO THEIR |

| | | | | |SUPPORT |

| | | | | | |

| | | | | | |

| | | | | | |

| ITEMIZED DEDUCTIONS |

|MEDICAL & DENTAL EXPENSES (LIMITED TO EXCESS OVER 7.5% OF GROSS |AMOUNT | CONTRIBUTIONS |AMOUNT |

|INCOME) | | | |

|(NOT COMPENSATED BY INSURANCE OR OTHERWISE) CHURCH OR SYNAGOGUE | |

| HOSPITAL AND SURGICAL INSURANCE PREMIUMS | |SCOUTS BOYS TOWN | |

|MEDICARE INSURANCE PREMIUMS PAID | |HEART FUND CANCER | |

|LONG TERM CARE INSURANCE PREMIUMS | |UNITED FUND EASTER SEALS | |

|PRESCRIPTIONS DRUGS AND INSULIN | |MARCH OF DIMES PTA | |

|DOCTORS, DENTIST, NURSES AND HOSPITAL FEES | |OTHER: PAYROLL DEDUCTIONS: | |

|HEARING AIDS, DENTURES, EYEGLASSES AND SURGICAL | |OUT OF POCKET EXPENSES FOR CHARITY WORK | |

|STOCKINGS | | | |

| | |CHARITABLE MILEAGE ON AUTO | |

|MEDICAL EQUIPMENT AND SUPPLIES | | | |

|MEDICAL TRANSPORTATION | |FAIR MARKET VALUE OF DONATED GOODS | |

|TOTAL NUMBER OF MILES DRIVEN TO & FROM: | |(PROVIDE DOCUMENTATION) | |

|HOSPITALS, DOCTORS SEEDING MEDICAL AID | |SALVATION ARMY; GOODWILL INDUSTRIES.,ETC | |

| BUS FARE, PARKING, AMBULANCE, OTHER | |MISCELLANEOUS DEDUCTIONS | |

|TAXES | |(SUBJECT TO 2 % LIMITATION) | |

|STATE ESTIMATED INCOME TAX PAYMENTS | | UNION AND PROFESSIONAL DUES | |

|STATE INCOME TAX PAID THIS YEAR FOR PRIOR YEAR | |TAX PREPARATION FEES | |

|REAL ESTATE TAXES PAID FOR PRIMARY HOME | |REQUIRED WORK UNIFORMS & CLEANING OF UNIFORMS | |

|REAL ESTATE TAXES PAID FOR SECOND HOME | |SMALL WORK TOOLS | |

|ADVALOREM TAXES ON AUTOS, TRAILERS, ETC. | |JOB SEEKING EXPENSES IN THE SAME FIELD(TRAVEL, EMPLOYMENT | |

| | |AGENCY, RESUME) | |

|INTEREST EXPENSES | |EMPLOYMENT RELATED SCHOOLING, BOOKS, SEMINARS, SUPPLIES, | |

| | |JOURNALS, SUBSCRIPTIONS | |

|HOME MORTGAGE (PROVIDE FORMS) | |SAFETY DEPOSIT BOX | |

|HOME IMPROVEMENT LOAN SECURED BY 1ST OR 2ND | |SAFETY EQUIPMENT: HELMETS, SHOES, ETC | |

|HOME MORTGAGE PAID TO INDIVIDUAL (PROVIDE NAME, ADDRESS AND SOCIAL | |BUSINESS TRAVEL & ENTERTAINMENT EXPENSES | |

|SECURITY NUMBER | | | |

|POINTS REPORTED ON FORM 1098 | |BUSINESS EXPENSES: INSURANCE, TELEPHONE, LONG DISTANCE CALLS, | |

| | |PROFESSIONAL PUBS AND JOURNALS | |

|POINTS NOT REPORTED ON FORM 1098 | | | |

| | |GAMBLING LOSSES LIMITED TO WINNINGS | |

|INVESTMENT INTEREST | | | |

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