Tax Data sheet 2013
Please read the questions carefully and answer them completely. Send all correspondence forms
to gretchenbellcpa@aol.com or fax to 888-370-4231.
First time clients only: I will need a copy of last year’s tax return. If you have this on disk, or in
a *.tax file format, please email it to me in original format, PDF is OK if it is all you have.
Referral:____________________________
Your day and night time phone #’s ___________________ ____________________________
Your full name: _________________________________________Birthday_______________
SS#________-_______-__________ Occupation:_________________________
Your Spouse’s full name:__________________________________Birthday_______________
SS#________-_______-__________ Occupation:_________________________
Mailing address________________________________________________________________
E-mail address!!_____________________________________
Dependents:
Full name:___________________________ Birthday___/____/____ SS#__________________
Full name:___________________________ Birthday___/____/____ SS#__________________
Full name:___________________________ Birthday___/____/____ SS#__________________
$___________Alimony paid to: Name & SS#_______________________________________
$___________Alimony received
$___________IRA/401K distributions (1099-R) and reason for withdraw_________________
$___________All after tax money invested (IRA, Roth, rolled 401K)
$___________Student Loan Interest or 1098-E
$___________Moving expenses (u-haul, travel, storage, temp housing, paying movers/packers)
From where (city) to where:______________________________________________________
$___________Prescriptions, vitamins, over the counter medicinal items if a Dr. told you to take
$___________Medical insurance premiums (paid outside of an employer plan)
$___________ALL Dr., Dentist, hospital, clinics, health center exp. (co-pays, deductibles, etc.)
$___________Eye exams, care/wear, lab & x-ray, therapy, supplies, equipment
$___________Weight-loss, quit smoking, or any specific treatment program
$___________Mileage (how many miles) to and from Dr’s offices & drug stores
$___________Any medical expense not listed above (long term care, travel or lodging, etc)
$___________ANY and ALL money you received that is not reported as income (child
support, per diem, law suit settlements) this is for a sales tax deduction, this is not taxable
$___________ Sales tax on new or used vehicle or big ticket items (boat, ATV, jewelry,
building materials, computer or electronics etc.) OR
$___________the total sales tax you paid in 2013(I can estimate this based on your income)
$___________Property taxes if NOT on 1098 for primary residence (not rental property)
$___________Property taxes if NOT on 1098 for any additional property (not rental property)
$___________Amount paid for Vehicle Registration (tag)
Make and model of each car:
_____________________________________________________________________________
$___________Any other taxes paid and to whom __________________________
$___________Mortgage Interest NOT on 1098 (not rental property)
$___________Points, MIP, or PMI (refinance or purchase, include the settlement statement)
$___________Cash or Check Donations to Charities or Churches
$___________Non-Cash Item Donations to Charities or Churches
$___________Tax Preparation expenses (other than to me, i.e. Atty, copies, financial software)
$___________IRA custodial fees, Investment interest expenses, Safety deposit box fee
$___________Legal fees to collect taxable income, such as alimony, SSI/disability, etc
Casualties or Thefts (fire, storm, flood, robbery) _____________________________________
Date:_________________________________ Loss: $________________________________
Job-related expenses (this is not for the self-employed)
$___________Travel (hotel, air fare, and other expenses)
$___________Job Search or resume expenses (did you travel for an interview?)
$___________Union or Professional dues
$___________Continuing education, fees, books
$___________Publications, subscriptions, memberships (job related)
$___________Trade, business, or professional license or certification fees (i.e. gaming badge)
$___________Meals & Entertainment (work related or while traveling for work)
$___________Purchase and upkeep (dry cleaning & laundry) of uniforms
$___________Tools and supplies used for your job
$___________Cell phone cost per year (if your job requires you to use your phone for work)
$___________Vehicle insurance per year (if your job requires you to have upgraded insurance)
$___________ Internet cost per year (if your job requires you to do research or check email)
____________Amount of miles you drove for work related chores (not to and from office)
Vehicle make/ model ___________________________ Total miles for year _____________
Anything you can think of that cost you money for your job ___________________________
___________________________________________________________________________
___________________________________________________________________________
CREDITS:
$___________Child or dependent care expenses (nanny, babysitter, in-laws)
Name of Provider________________________________ EIN or SS# ____________________
Address______________________________________________________________________
$___________Energy efficient home improvements (water heater, A/C, new roof, solar stuff,
insulation, windows, doors etc) ___________________________________________________
$___________Higher Education expenses (1098-T) for you or a dependent (tuition, books,
supplies, dorm, gas, clothes) _____________________________________________________
Please send me all:
W-2’s, W-2G’s, 1099’s, 1098’s, K-1’s, and ALL other tax forms you have received. Please be
aware that many institutions who have paperless billing will not mail your documents. It is your
responsibility to obtain the proper documents.
**If you had a purchase, sale or refinance of a home, I need the 2 page settlement statement
If you want your refund directly deposited into your bank account (faster) please include the
bank name_________________________(___checking or ___savings)
Routing #____________________ & Account # ___________________________
The IRS now requires all Paid Preparers to E-file all returns that qualify. Payment is due upon
completion of your return PRIOR to filing. If you are unable to pay prior to receiving your
refund, we can withhold our fee from your refund for a $15 bank charge.
My fees are as follows:
$ 95 for 1040EZ & 1 State (this is VERY rare)
$190 for Federal & 1 State basic tax return w/one W-2
$250 for basic 1040X, amended returns (unless it is my fault and then it is Free)
$100 for each Schedule C, E, F, H, J, f2555
$ 75 for each education credit, Schedule D, f4684
$ 25 for each Schedule A, B, K-1, f8949, f3903, f5329, f5405, f5695
$
5 for each additional W-2, W-2G, 1099-*, 1098E
$ 35 for each additional state
$750 for Corporate/Bus returns (sending up to 3 - W-2’s, 1099’s and/or K-1’s)
$ 15 Quick Collect (mentioned above)
One dependent child or parent is free if their return is simple!
Additional fees may apply for various credits and/or schedules as well as excessive assets or entry
items. These can range from $5-$100 based on the length of time and involvement of the form.
Please be aware that there will be additional charges for extensive returns or for me having to pry the
information from you (not mentioning any names…Cooper). You may easily avoid extra fees by
having all of your information to me with a completed data sheet.
Due to the INSANE increase of AUR’s, IRS audits, and ObamaCare regulations, I am no longer able
to handle these tasks for free. The following charges will apply to IRS correspondence.
$60/hour accounting, organization, research
$125/hour consultation, advice, audits
Please feel free to call me for clarification on any of these items and add anything you feel may
be relevant. You may fill this out and return it via email to gretchenbellcpa@aol.com
Or print it and fax it to 888-370-4231, no need for a cover letter, it comes straight to me.
If you are mailing or dropping off, you can include this sheet. If you need me to pick up your
data, please call us to make arrangements at 228-331-0093.
I attest that all of the information provided here is true to the best of my knowledge.
I have read this entire data sheet and understand that I am responsible for
maintaining the records for the information submitted.
Date_______________________
Spouse
Signature_______________________________ Signature____________________________
If signing electronically, please type the last 4 didgits of your SS# and your birthday to serve
as your signature_____________________________________