LOCH, ELSENBAUMER, NEWTON & CO. A PROFESSIONAL CORPORATION

ACCOUNTANTS AND CONSULTANTS INDIVIDUAL INCOME TAX ORGANIZER

2017 Taxpayer Name: Spouse's Name: Day Time Phone Number: Cell Phone Number: Email Address: Address (if different from last year): Local Municipality: Date Moved:

PLEASE ANSWER THE FOLLOWING QUESTIONS - Y(YES)/N(NO) IF THE ANSWER IS YES, PLEASE: 1. Did you receive any income from:

Wages and salary ___ Submit all Form W-2's

Interest income ___ Submit Forms 1099-INT

Dividend income ___ Submit Forms 1099-DIV

Sale of stock or securities ___ See summary on page 3

Installment sales ___ See summary on page 4

Sale of other property ___ See summary on page 3

Sale of principal residence ___ Call us prior to your appointment

IRA, pension or annuity distributions ___ Submit Form(s) 1099R and see page 3

Unemployment compensation ___ Submit Form(s) 1099-G

Did you receive COBRA assistance payments ___

Social security benefits ___ Submit Form(s) SSA - 1099

Refund of state or local income taxes ___ Submit Form(s) 1099-G

Alimony ___ Enter amount received $

Business or farm activities ___ See summary on pages 4 & 5

Rents ___ See summary on page 6

Partnerships ___ Please submit all Form K-1's

Estates or trusts ___ Please submit all Form K-1's

"S" corporations ___ Please submit all Form K-1's

2. Are you required to file a Business Privilege Tax Return? ___ Would you like us to prepare the tax return for you? ___

3. Are you required to issue Forms 1099? ___ Would you like us to prepare them for you? ___ (due by January 31st)

4. Did you pay any of the following:

Penalty on early withdrawal of savings ___ Enter amount $________________

Alimony ___ Enter amount paid $____________

Enter recipient's Soc. Sec. No. ________-_____-________

Education expenses ___ Describe on page 7

5. Do you have any securities or loans which became Describe _____________, and enter date of purchase

worthless during the year? ___ and original cost $_____________

6. Did you have any debts cancelled or forgiven? ___ Describe and submit applicable forms. 7. Did you purchase a new vehicle, hybrid vehicle or make Describe_____________________________

energy-saving home improvements? ___ Date of purchase, cost and sales tax:

_____________________________________

Attach invoice 8. Did you receive any Incentive Stock Options? ___ If so, please provide us with any information that you

received. -1-

PLEASE ANSWER THE FOLLOWING QUESTIONS - Y(YES)/N(NO) IF THE ANSWER IS YES, PLEASE:

9. Do you expect a significant change in your 2018 income? ___ Please describe ___________________________

10. Did you make gifts of more than $14,000 to an individual Please describe ___________________________

during the year? ___ ________________________________________

11. Did you pay any household employees during the year? ___ Enter amount paid $________________________

12. Did you have an interest in, signature or other authority If so, please provide us with details of accounts

over a financial account in a foreign country or have any and amounts.

relationship with a foreign trust? ___

13. Do you have any other foreign asset or investments? ___ If so, please describe _______________________

_________________________________________

14. Did you make any contributions to a Section 529 If so, please provide us with the names and

Tuition account? ___ social security numbers of each beneficiary and

the amounts.

15. Sales and Use tax is now required to be reported on If so, describe _________________________ and

your state income tax return. Did you purchase items enter date of purchase and original cost.

or services subject to sales tax for which the seller

did not charge or collect sales tax? ___

16. Would you like us to help you determine if you are in

compliance with the sales and use tax laws and

regulations? ___

DEPENDENTS

Please list all social security numbers of dependents not previously submitted:

Name Social Security Number Birth Date

______________________________________________ _______-_____-_________ ____________

______________________________________________ _______-_____-_________ ____________

______________________________________________ _______-_____-_________ ____________

HEALTH INSURANCE

PLEASE SUBMIT ALL FORMS 1095 YOU RECEIVED. Does every member of your household have health insurance for the entire year? _____ Have you received any advance health care credits? _____

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INCOME TAX PAYMENTS MADE

FEDERAL STATE LOCAL Date Amount Date Amount Date Amount

Prior year taxes paid in 2017 $ $ Prior year overpayment applied $ 4th Qtr – 2016 1st Qtr – 2017 2nd Qtr – 2017 3rd Qtr – 2017 4th Qtr – 2017

MOVING EXPENSES

Mileage from former residence to: New business ________________ Former business _________________

Expenses to transport household property $_______________

Traveling expenses & lodging incurred during move $_______________

Reimbursement not reported on W-2 $_______________

IRA DISTRIBUTIONS

For IRA distributions received during 2017, please enter amount used for:

Medical expenses $__________ General living expenses/other $___________

First-time home purchase __________ Rolled into a Roth IRA ___________

Post secondary education expenses Rolled into another qualified (tuition, books, supplies, etc.) __________ retirement account/IRA ___________

GAIN OR LOSS FROM SALE OF STOCKS, SECURITIES AND OTHER PROPERTY Please submit all 1099-B's and 1099-S's received and the following information for each item sold. Date Date Gross Selling Description Acquired Sold Sales Price Expense Cost _________________________ _________ ________ $__________ $__________ $________

(This is an example of the information required for each transaction.)

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INSTALLMENT SALES

2017 Sales Only Prior Year Sales Only

Description ________________________________ Description__________________________________

Total sales price $__________

Downpayment __________

Mortgage or note assumed __________ Principal received in 2017 $__________

Note received __________

Principal received in 2017 __________ Interest received in 2017 $__________

Interest received in 2017 __________

BUSINESS INCOME - TAXPAYER( ) SPOUSE ( )

Business Name ______________________________________ Federal I.D. #

Gross receipts $_____________ Office supplies $_____________

(Please submit all 1099-Misc Postage _____________

AND 1099-R Forms _____________ Printing _____________

Other Income _____________ Payroll processing _____________

__________________________ _____________ Outside services _____________

Cost of goods sold: Employee retirement plan

Beginning inventory _____________ contributions _____________

Purchases _____________ Legal & accounting _____________

Materials and supplies _____________ Equipment rent _____________

Freight _____________ Real estate rent _____________

Subcontract costs _____________ Repairs & maint. _____________

Other costs _____________ Supplies _____________

Ending inventory _____________ Licenses & permits _____________

Advertising _____________ _____________

Bank service charges _____________ Travel _____________

Commissions _____________ Meals and entertainment _____________

Vehicle expenses _____________ Utilities _____________

Employee medical & disability insurance _____________ Telephone _____________

Employer medical insurance _____________ Gross wages _____________

Business insurance _____________ Payroll taxes _____________

Interest expense - Business priv. tax _____________

Business loan #1 _____________ Real estate taxes _____________

Business loan #2 _____________ Dues/publications _____________

Mortgage interest Other expenses:

Business only (Form 1098) _____________ ___________________ _____________

___________________ _____________

___________________ _____________ -4-

EQUIPMENT, VEHICLES AND OTHER CAPITAL EXPENDITURES DURING 2017

Date Total Cost (Including Acquired Description Taxes, Fees, Etc.)

__________ ______________________________________________ $______________ __________ ______________________________________________ $______________ __________ ______________________________________________ $______________

BUSINESS USE OF HOME Area used regularly and exclusively for business or for inventory storage _________ sq. ft. Total area of home _________ sq. ft. Insurance $__________ Security costs $__________ Repairs & maint. __________ Utilities __________

BUSINESS RELATED VEHICLE EXPENSES Vehicle #1 Vehicle #2 Vehicle description ____________________ ____________________

Date vehicle placed in service ____________________ ____________________

Total miles driven during year ____________________ ____________________

Business miles driven during year ____________________ ____________________

Gas, oil, lube, insurance, tags $___________________ $___________________

Interest $___________________ $___________________

Lease payments $___________________ $___________________

Parking fees and tolls $___________________ $___________________

Amount reimbursed - not included in W-2 $___________________ $___________________

Average daily round trip commuting distance $___________________ $___________________

Miles that vehicle was used for commuting $___________________ $___________________

IF A BUSINESS AUTOMOBILE WAS PURCHASED IN 2017, PLEASE SUBMIT THE PURCHASE INVOICE. EMPLOYEE BUSINESS EXPENSES (FORM 2106 ONLY) TOTAL DESCRIPTION EXPENSES Travel (away from home overnight) $__________

Lodging (away from home overnight) __________

Meals and entertainment __________

Fares for airplane, boat, bus __________

Education costs __________

Dues and fees __________

Telephone __________

Work clothes, safety equipment __________

Other __________ -5-

RENTAL INCOME AND EXPENSES Residential Commercial

Property #1 Address: _______________________________________________ ( ) ( ) Property #2 Address: _______________________________________________ ( ) ( ) Property #3 Address: _______________________________________________ ( ) ( ) Property #1 Property #2 Property #3 Rental income $__________ $__________ $__________ Rental expenses:

Advertising __________ __________ __________ Auto and travel __________ __________ __________ Cleaning and maintenance __________ __________ __________ Commissions __________ __________ __________ Insurance __________ __________ __________ Legal and accounting __________ __________ __________ Interest expense - mortgage __________ __________ __________ Interest expense - other __________ __________ __________ Repairs __________ __________ __________ Supplies __________ __________ __________ Real estate taxes __________ __________ __________ Business privilege tax __________ __________ __________ Utilities __________ __________ __________ Heat __________ __________ __________ Water and sewer __________ __________ __________ Bank service charges __________ __________ __________

_____________________________________ __________ __________ __________ _____________________________________ __________ __________ __________ _____________________________________ __________ __________ __________ FURNITURE, FIXTURES, EQUIPMENT AND OTHER CAPITAL EXPENDITURES DURING 2017

Cost Date Acquired Description Property #1 Property #2 Property #3 _____________ ______________________________ __________ __________ ___________ _____________ ______________________________ __________ __________ ___________ _____________ ______________________________ __________ __________ ___________ UNREIMBURSED MEDICAL DEDUCTIONS (i.e. medicine, doctors, hospitals, hearing aids, eyeglasses, ambulance, equipment used for illness, additional costs of special diets, medical or long term care insurance)

Description Amount Amount Other medical deductions $__________ Medical Insurance $__________ Total miles traveled __________ Long Term Care Insurance __________ TAXES Real Estate $____________ Occupation Privilege/EMST $__________ Personal Property ____________ Other Taxes: _____________________ __________

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INTEREST EXPENSE Interest Paid Original home mortgage interest (Form 1098) $___________ Home equity loan (Form 1098) $___________ Margin account interest $___________ Education loans $___________ CHARITABLE CONTRIBUTIONS Miles driven for charitable purposes miles Cash contributions: Description Amount ____________________________________ $__________ ____________________________________ __________ ____________________________________ __________ Non cash contributions (clothing, furnishings, etc): Description Amount ____________________________________ $__________ ____________________________________ __________ ____________________________________ __________ If over $250, please submit receipt and/or description of donation. DEPENDENT AND CHILD CARE EXPENSES Provider Name ________________________________________________ E.I.N.: _____________________ Address ____________________________________________________________________________________ Amount of dependent and child care expenses paid in 2017 $______________ INVESTMENT AND OTHER INCOME RELATED EXPENSES Tax preparation fees $____________ Professional dues $____________ Business publications ____________ Safe deposit box ____________ Investment expenses ____________ Union dues - Name: ____________ Legal fees ____________ - Amount: ____________ Employment agency fees ____________ Special tools & uniform ____________ IRA Taxpayer Spouse 2017 contribution made in 2017 SEP,Simple __ Reg __ Roth __ $___________ $___________ 2017 contribution made in 2018 SEP,Simple __ Reg __ Roth __ ___________ ___________

EDUCATION EXPENSES Please enter below the tuition and other fees required for enrollment at an eligible education institution for courses. Please submit Form 1098-T received from the education institution. Year Student Name Institution of School Amount Paid Date Paid ____________________________ __________________________ ________ __________ __________ ____________________________ __________________________ ________ __________ __________

CASUALTY, THEFT, MEDICAL SAVINGS AND OTHER IMPORTANT TAX INFORMATION

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