Other Income
Interest: Attach 1099 Forms
| Payor |
Amount |
| 1 |
$ |
| 2 |
$ |
| 3 |
$ |
| 4 |
$ | |
Dividends: Attach 1099 Forms
| Payor |
Total |
Capital
Gain |
Ordinary
Dividend |
| 1 |
$ |
$ |
$ |
| 2 |
$ |
$ |
$ |
| 3 |
$ |
$ |
$ |
| 4 |
$ |
$ |
$ | |
|
|
Capital Gains
| Description |
Date
Acquired |
Date
Sold |
Sales
Price |
Cost or
Basis |
| 1 |
$ |
|
|
$ |
| 2 |
$ |
|
|
$ |
| 3 |
$ |
|
|
$ |
| 4 |
$ |
|
|
$ | |
Pensions/IRA Distributions - Attach Form
1099 / W-2s
| Payor |
Gross
Distribution |
Taxable
Amount |
| 1 |
$ |
$ |
| 2 |
$ |
$ | Check box if Federal or State Tax was
withheld |
| Alimony
Received |
| Payor______________________ Amount
$___________ |
| Payor's Social
Security #__________________________
| |
| Unemployment
Received |
| Taxpayer Amount
$________________ |
| Spouse Amount
$__________________
| |
| Social Security
Received |
| Taxpayer Amount
$________________ |
| Spouse Amount
$__________________
| |
| Miscellaneous
Income |
| Description:
_______________________________________________ |
| _________________________________________________________ | |
Deductions
| Medical and Dental
Expense |
| Insurance Premiums
(Net)________________ |
| Doctors, Dentists,
etc.__________________
| |
| Taxes
Paid |
| State & Local
Income Tax________________ |
| Real Estate Taxes -
Residence__________________ |
| Real Estate Taxes -
Other Property__________________ |
| Auto
License: |
| No. of Cars Fees
Paid__________________ |
| Personal Property
Taxes__________________ |
| Other
Taxes__________________
| |
| Interest Paid
- Attach 1098 Forms |
| Home Mortgage Interest
Paid (1st)________________ |
| Home Mortgage Interest
Paid (2nd)__________________
| |
| Contributions
- Attach Details |
| Contributions by Cash
or Check________________ |
| Contributions other
than Cash__________________
| |
| Miscellaneous
Deductions |
| Unreimbursed Employee
Business Expenses__________________ |
| Union/Professional
Dues__________________ |
| Investment
Expense__________________ |
| Tax Return Preparation
Fees__________________ |
| Safe Deposit Box
Rental__________________
| |