Basic Household Information for TAX YEAR:
Filing Status 
__ Single

__ Married filing joint

__ Married filing separate

__ Head of household

__ Qualifying widow(er)
Taxpayer 
Full Name ____________________________Social Security No. __________________

Occupation ___________________________ Date of Birth__________________
Spouse 
Full Name ____________________________Social Security No. __________________

Occupation ___________________________ Date of Birth__________________
Address 
Street Address __________________________________________________________

City _________________________________State ________Zip Code _____________
Telephone 
Home Phone ___________________________Taxpayer Work Phone _______________

Spouse Work Phone _______________________Fax Number _____________________

E-Mail Address _______________________
DEPENDENTS
TYPE OF DEPENDENT: 1=Child at home:2=Child not at home; 3=Dependent other than child;4=HH only, not a dependent; 5=EIC only, not a dependent
EARNED INCOME CREDIT: 1=When applicable; 2=Student age 19 to 23;3=Disabled age 19 or older; 4=Force; 5=Supress
Dependent 1 
Full Name ______________________________________Date of Birth _________________

Social Security No. ______________________________Relationship ______________________

Months Lived at Home _________________Type of Dependent ____________________

Earned Income Credit _________________Claimed By: __ Taxpayer   __ Spouse
Dependent 2 
Full Name ______________________________________ Date of Birth _________________

Social Security No. _______________________________Relationship _____________________

Months Lived at Home __________________Type of Dependent ____________________

Earned Income Credit __________________Claimed By: __ Taxpayer   __ Spouse
Dependent 3 
Full Name ______________________________________Age or Date of Birth ___________

Social Security No. _______________________________Relationship _____________________

Months Lived at Home __________________Type of Dependent ____________________

Earned Income Credit __________________Claimed By: __ Taxpayer   __ Spouse
Dependent 4 
Full Name ______________________________________Age or Date of Birth __________

Social Security No. _______________________________Relationship_________________

Months Lived at Home __________________Type of Dependent ____________________

Earned Income Credit __________________Claimed By: __ Taxpayer __ Spouse
Yes No MISCELLANEOUS QUESTIONS
    Did your marital status change during the year?
    Could you be claimed as a dependent on another person's tax return for 1998?
    Did your address change since you filed your last tax return?
Yes No DEPENDENTS:
    Were there any changes in dependents?
    Were any of your unmarried children who might be claimed as dependents 19 years of age or older at the end of 1998?
    Did you have any children under age 14 on January 1, 1999 with interest and dividend income in excess of $700, or total investment income in excess of $1400?
Yes No INCOME:
    Did you receive unreported tip income of $20 or more in any month?
    Did you cash any Series EE U.S. savings bonds issued after 1989?
    Did you receive any distribution from a profit-sharing plan, retirement plan, or individual retirement arrangement?
    Did you receive any disability income?
    Did you have any foreign income or pay any foreign taxes?
Yes No PURCHASES, SALES AND DEBT:
    Did you start a business or farm, purchase rental or royalty property, or acquire an interest in a partnership, S corporation, trust, or REMIC?
    Did you purchase or dispose of any business asset (furniture, equipment, vehicles, real estate, etc.), or convert any personal assets to business use?
    Did you buy or sell any stocks, bonds or other investment property? Specify the sale of any collectibles (e.g. artworks, gems, stamps, coins) and any qualified small business stock.
    Did you purchase, sell or refinance your principal home or second home, or did you make a home equity loan?
    Did you have any debts cancelled or forgiven?
    Did you have ay debts cancelled or forgiven?
Yes No ITEMIZED DEDUCTIONS:
    Did you incur a loss because of damaged or stolen property?
    Did you work out of town for part of the year?
    Did you use your car on the job (other than to and from work)?
Yes No MISCELLANEOUS:
    Do you want to allocate $3 to the Presidential Election Campaign Fund?
    Does your spouse want to allocate $3 to the Presidential Election Campaign Fund?
    Did you have an interest in or signature or other authority over a financial account in a foreign country, such as a back account, securities account, or other financial account?
    Did you receive a distribution from, or were you the grantor or, or transferor to, a foreign trust?
    Was your home rented out or used for business?
    Did you pay interest on a higher education loan or pay tuition and related expenses for any post-secondary education?
    Did you have a medical savings accounting (MSA) or acquire an interest in an MSA because of the death of the account holder? Or, were you a policyholder who received payments under a long-term care (LTC) insurance contract or received any accelerated death benefits from a life insurance policy?
    Did you incur moving expenses due to a change of employment?
    Did you engage the services of any household employees?
    Did you make a gift of money or property to any individual?
Please use the space below to note any other matters you think could be useful in preparing your return.
     
     
     
     
     
     
     
     

WAGES, SALARIES, TIPS

Attach
W-2 Forms

 Tax Withheld
Name of Employer Wages, Tips, Other
Compensation		 Federal Social Security Medicare State Local
             
             
             
             
             
             
PENSIONS, IRA DISTRIBUTIONS - Attach Forms 1099-R

Name of Payer

 Gross
Distribution		 Taxable
Amount		 Distrib.
Code		 Federal
Withheld		 State
Withheld
.   .     .
. . .      
.   .     .
.   .     .
Attach Forms 1099-INT INTEREST INCOME Tax-Exempt Interest
Name of Payer Banks, S&Ls, C/Us, etc. Seller-
Financed Mortg.		 U.S. Bonds, T-Bills Total Munic. Bonds In-State Munic. Bonds Early
With-
drawal Penalty
             
             
             
             
             
             
             
             
             
             
             
             
             
DIVIDEND INCOME
Attach Forms 1099-DIV		 Dividend Income Tax-Exempt Interest
Name of Payer Ordinary Dividend Capital
Gain Dividend		 28% Rate Gain U.S. Bonds (% or amt.) Total Munic. Bonds In-state
Munic.
Bonds
(% or amt.)
             
             
             
             
             
             
             
             
             
             
             
             
MISCELLANEOUS INCOME
List forms 1099-G, 1099-MISC, SSA-1099, and RRB-1099. Taxpayer Spouse
State tax refund if you itemized last year . .
Social Security Benefits (SSA-1099, Box 5) . .
Medicare Premiums Paid (SSA-1099) . .
Tier 1 RR Retirement Bene. (RRB-1099, Box 5) . .
Lump-Sum Election for SS Benefits . .
Alimony Received . .
Unemployment Compensation Received . .
Unemployment Compensation Repaid . .
Taxable Scholarships and Fellowships . .
Household Employee Income Not on W-2 . .
Income Subject to S/E Tax for your own business:
(Attach Business Income & Expense Worksheet)		 . .
Rental Income
(Attach Rental Income & Expense Worksheet)		 . .
     
Other Income:
(Attach all K-1 Schedules for Partnerships, S-Corps, Estates, & Trusts)		 . .
TAX WITHHELD ON 1099 FORMS Taxpayer Spouse
Federal Income Tax Withheld . .
State Income Tax Withheld . .

ITEMIZED DEDUCTIONS

MEDICAL AND DENTAL EXPENSES Taxpayer Spouse
Prescription Medicines and Drugs .  
Doctors, Dentists, and Nurses .  
Hospitals and Nursing Homes .  
Insurance Premiums (excluding long-term care) .  
Long-Term Care Premiums .  
Insurance Reimbursement (enter as a positive number) .  
Transportation and Lodging (.10/mile) .  
Eye Care & Glasses .  
Other Medical and Dental Expenses:    
     
     
     
     

STATE, PROPERTY, & FOREIGN TAXES PAID (Not on W-2's)

 Taxpayer Spouse
State & Local Income Taxes - 1/99 payment on 1998 State estimate .  
State & Local Income Taxes - Paid with 1998 state extension .  
State & Local Income Taxes - Paid with 1998 state return .  
State & Local Income Taxes - Paid for prior yrs. and/or to other state .  
Real Estate Taxes - Principal Residence .  
Real Estate Taxes - Property Held for Investment .  
Personal Property Taxes (including automobile) .  
Foreign Income Taxes .  
Other Taxes: .  
     
     
INTEREST PAID Taxpayer Spouse
Home mortgage interest and points reported on Form 1098: (Attach all 1098 Forms) .  
     
     
     
Home mortgage interest not reported on Form 1098
(if paid to the home seller, enter the seller's name, SSN or EIN, and address):		 .  
     
     
     
Points not reported on Form 1098:    
     
     
     
Investment Interest: .  
     
     
     
Passive Interest .  
Certain home mortgage interest included above (6251) .  
CONTRIBUTIONS Taxpayer Spouse
Volunteer Expenses and Travel (.14/mile) .  
Contributions by Cash, Check, or Credit Card:    
     
     
     
     
     
     
Contributions Other Than Cash or Check (List in detail if over $500 this year with name & address of the organization, date given, & value on a separate schedule.) .  
Contributions entered above limited to 30% of AGI .  
Contributions entered above limited to 20% of AGI .  
MISCELLANEOUS DEDUCTIONS(subject to 2% AGI limit) Taxpayer Spouse
Union and Professional Dues .  
Other Unreimbursed Employee Expenses: .  
     
     
     
     
Investment Expense: .  
     
     
     
Tax Return Preparation Fee .  
Union and Professional Dues .  
Miscellaneous Deductions (2% AGI): .  
     
     
     
OTHER MISCELLANEOUS DEDUCTIONS Taxpayer Spouse
Gambling Losses to extent of winnings .  
Estate tax, Section 691(C) .  
Other Miscellaneous Deductions: .  
     
     
     

Copyright ©2008. All Rights Reserved    Larry D. Giles, EA, ATA, ABA
,P.O.Box 2051, Chapel Hill, NC 27515-2051, Phone: (919) 768-0349 Fax: (866) 843-1384