2016 TAX ORGANIZER

I Wel haye submitted this information for the sole purpose of preparing my tourl tax returntsl･Each item can be substantiated by receipts, canceled checks or other documents･ This

information is true, correct and complete to the best of my (oun know一edge,

TaxpayerSignature 認�FR�

SpouseSignature 認�FR�

Mai一/Presentation Sheet - to prepar釘600106　04-01-16

千 R O M

mi§ letter is to confirm and specify the terms of our engagement with

you and to clarify the nature and extent of the services we will

provide.エn order to ensure an mderstanding of our mutual

responsibilities, we ask all clients for whom returns are prepared to

confirm the following arrangements.

we will prepare your　2016　federal and requested state income tax

returns from information that you will fumish us. We will not audit or

otherwise `verify the data you submit, although it may be necessary to

ask you for clarification of some of the information. we will furnish

you with questionnaires and/Or worksheets to guide you in gathering theO

necessary information. Your use of such forms will assist in keeplng

pertinent information from being overlooked･

エt is your responsibility to provide all the information required for

the preparation of complete and accurate returns. You should retain all

the docments, canceled checks and other data that form the basis of

income and deductions･ mese may be necessary to prove the accuracy andcompleteness of the returns to a taxing authority. You have the final

responsibility for the income tax returns and, therefore, you shouldl

review them carefully before you slgn them.

our work in connection with the preparation of your income tax returns

does not include any procedures deslgned to discover defalcations orl

other irregularities, should any exist. We will render such accounting

and bookkeeping assistance as determined to be necessary for

preparation of the income tax returns･

We will use professional judgment in resolving questions where the tax

law is unclear, or where there may be conflicts between the taxing

authorities-　interpretations of the law and other supportable

positions. Unless otherwise instructed by you, we will resolve such

questions in your favor whenever possible.

me law provides various penalties that may be imposed when taxpayersunderstate their tax liability.工f you would like information on the

amount or the circumstances of these penalties, please contact us. Your

returns may be selected for review by the taxing authorities. Any

proposed adjustments by the examining agent are subject to certain

rights of appeal.工n the event of such goverment tax examination, We

will be available upon request to represent you and will render

additional invoices for the time and expenses incurred.

Our fee for these services will be based upon the amount of time

required at standard bilLing rates plus out-oi-pocket expenses. All

invoices are due and payable upon preSentation･

エf the foregoing fairly sets forth your understanding., please slgn thei

enclosed copy of this letter in the space indicated and return it to

our office. However, if there are other tax returns you expect us t°

prepare, such as gift and/or property, please inform us by noting so

〕ust below your slgnature at the end of the returned copy of this

一1

letter.

we want to express our appreciation- for this opportunity to work with

yOu･

Accepted By:

Date:

Copyright 2016 by the American Institute of Ce輔ed Pub一ic Accountants･ lnc･創rights reseNed･ Reprinted with permissi°n･

Form〇〇〇〇〇〇〇〇〇〇〇〇〇〇〇〇000

A一imony Paid or Received

Annuity Payments Received

App一ication of Refund

Business Income and Expenses

Business Use of Home:

Business

Emp一oyee Business Expenses

Itemized Deductions

Passthrough

Rentai

Ca一endar

Casualty or Theft Losses

Chi一d and Dependent Care Expenses

Conso一idated Brokerage St甜ements:

Interest Income a Foreign Information

Dividend Income a Foreign information

Sa一es of Stocks, Securities, Capita一 Assets a Misc. Income 5G

Contri butions

Dependent Information

Depreciable Propeny and Equipment:

Business

Emp一oyee Business Expenses

Renta一 and Roya一ty

Direct Deposit lnform…摘on

Dividend income

Education Expenses

Educator qeacher) Expenses

E一ectronic Filing

Emp一oyee Business Expenses

Estate Income

Farm Income and Expenses 12, 12A, 12B

Federa一, State and City Estimated Taxes.｡.……..〟.…..…　20, 20A

Foreign Assets 5C, 5D

Foreign Emp一oyment lnform的on　　　　　　　　30, 30A, 30B

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Foreign Houslng Expenses

Forelgn Taxes

Foreign Trave一 and Workdays

ForelgnWagesand αher lncome　….….……………. 31, 31A, 31B

Gamb一ing WinnlngS

Hea一th Savings Accounts

Househo一d Emp一oyment Taxes

lnstaIIment Sale Receipts

Interest income

Interest Paid

Investment Interest Expense

IRA Contributions

IRA Distributions

Keogh P一an Contributions

Medica一 and Dental Ex昨nSeS

Ministeria一 Income

Misce一laneous Income and Aqjustments

Miscellaneous itemized Deductions

Mohgage Interest Paid

Movlng Expenses

Pahnership Income

Pension Income

Persona一 Information

Rai一road Retirement Benefits

1

Form

Rea一 Estate Mongage Investment Conduit Income (REMIq … 1 1

Renta一 and Royalty income and Expenses

Both IRA Contributions/Conversions

S Corporation income

Sale of Stock, Securities and Other Capita一 Assets

Sa一e of Your Home

Savings Bond Purchases

SEP/SIMPLE Pはn Contributions

Socia一 Security Benefits

State and Local Tax Refunds

Student Loan Interest

Taxes Paid

Trust Income

Unemp一oyment Compensation

Vehicle/Other Hsted Propehy lnform如ion:

Business

Emp一oyee Business Expenses

Renta一 and Roya一ty

Pahnership/S Corporation

Wages and Sa一aries

600111 09-12-16

Questions (Page 1 of到

The fol一owing questions pehain to the 2016 tax year. For any question answered Yes, include suppo鵬ng de屯il or docments･

Personal information:

Didyourmaritaistatuschange? ‥‥‥.‥.‥‥‥.‥‥‥.‥‥‥‥‥.‥‥‥‥‥‥‥‥.‥‥‥

Are you married?

lf Yes, do you and your spouse w飢t tO fi一e separate returns?

lf No,甜e you in a domestic pahnership, civil union, or oth釘State･defined rel帥onship?

Can you or your spouse be c一aimed as a dependent by another taxpayer?

Did you or your spouse seNe in the military or w釘e you OryOur Spouse On active duty?　‥ ‥

Dependents :

Werethereanychangesindependentsfromthepr10ryear? ‥ ‥ ‥ ‥ ‥ ‥. ‥ ‥ ‥ ‥

Note: Include non-child dependents for whom you provided more than half the support.

Did you or your spouse pay for child care while you or your spouse worked or looked for work?

Do you have any ch肘ren underage 18W肌unearned income morethan $1,050? ‥ ‥. ‥.

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Do you have any children age 18 0r student children, aged 19 to 23, who dd not provide more than half of their cost of support

With eamed income and that have uneamed income of more than $1 ,050?

Did you adopt a chi一d or begin adoption proceedings?

Areanyofyourdependentsnon･U･S･citizensornon･U･S･residents? . ‥ ‥ ‥. ‥ ‥ ‥ ‥ ‥ ‥ ‥ ‥ ‥ ‥. ‥ ‥ ｡ ‥.

Heaithcare:

Did you have heaIthcare coverage小ealth insurance, including Medicare, Medicaid, CHIP,紬d TRICARB for you, your spouse,

andanydependentsfortheentireyear? .‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥.‥‥‥.‥‥‥.｡.‥

lf Yes, inc一ude ali Forms 1095"A, 1095･B,飢d lO95･C.請you did not r∞eive Forms 1095･A, 1095-B or 1095-C,徹tach information

d劇a冊g each month you, your spouse, and your dependents had coverage･

lf No, there are severa一 exemptions from the mandate requiring hea一th insurance coverage. Examples inc一ude

membership ln a healthcare sharing ministry, membership ln a federally r∞ognized Indian tribe, incarceration,

membership ln Cenain re一igious sects,飢d enrollment in cenain Medicaid and TRICARE programs that do not

provide m軸mum essentia一 coverage. lf any of these provisions app一y, provide information regarding

the exemption, the individual(S) (taxpayer, spouse, dependents) to whkIh the exemption(S) may apply, and the

month(S) for whk)h the exemption(S) apply.

Are you claiming the exem函on for someone having healthcare coverage purchased in the Mark鏡place and for●

whomyoudidnotreceiveForm1095-A? -･------ヽ---〟--･--･------･

Did you r∞eive Form 1 O95･A for50m∞ne for whom飢Other taxpayer w帥claim the persona一 exemption on their t秋r鏡urn?

Did you apply for飢eXemption through the Mark鏡place?

If Yes, provide the Exemption Ce輔icate Number.

Are any of your dependents required to f鴫a tax r鏡urn?

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600121 06-21-16

Questions (Page 2 o†劫

Healthcare (continued):

Was anyone covered on your hea一th insurance po一icy a一so covered on another health insurance policy for any pan

of the year?

Wereyoueiigibleforemployer･sponsoredhealthcarecoverage?. ‥. ‥ ‥. ‥ ‥. ‥ ‥. ‥ ‥ ‥ ‥ ‥

lf you received advance premium t秋Credit or enrolled in coverage through the Ma庇etplace, are married･飢d are

filing separately from your spouse, are you a victim of domestic abuse or spousal abandonment? ......

Did you oryourspouse have anytransactions pe佃ning to a hea一th savings account (HSA)? ‥ ‥. ‥ ‥ ‥ ‥ ‥

lf you received a distribution from飢HSA亘clude alI Forms 1099･SA･

Didyouoryourspousehaveanytransactionspertainingtoamedicalsavingsaccount(MSA)? .............

lf you received a distribution from飢MSA言nclude al一 Forms lO99･SA･

Did you oryourspouse r∞eive any distributions from bng-term care insurance contracts? ‥ ‥ ‥ ‥ ‥ ‥ ‥ ‥

請Yes, inc一ude ai一 Forms lO99･LTC.

If you or your spouse are self･employed, are you or your spouse eligible to be covered under an employer's health plan

atanotherjob? .‥‥‥.‥‥‥.‥

lf Yes, how m飢y months were you covered?

lf you or your spouse are se一f-emp一oyed, are you` or your spouse eligible to be covered under an employer's 一ong-term

careplanatanotherjob? ...................................................

If Yes, how m飢y months were you covered?

Did you or your spouse 一ose your job because of foreign Competition and pay for your own hea一th insurance?

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Education:

Didyouoryourspousepayanystudentloaninterest? . ‥ ‥ ‥. ‥ ‥ ‥ ‥ ‥ ‥ ‥ ‥ ‥ ｡ ‥.. ‥ ‥

Did you or your spouse withdraw any amounts from your IRA to pay for higher education expenses incurred by you･

yourspouse,yourch肘renorgrandchiIdren? . ‥ ‥ ‥ ‥. ‥ ‥ ‥ ‥ ‥ ‥ ‥ ‥ ‥ ‥ ‥ ‥ ‥. ‥

Did you or your spouse w肌draw any amounts from a CoverdelI Education Savings Account or Qua一ified Education

ProgramGection529plan)?.‥〟‥‥,‥.｡‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥

If Yes, inc一ude a一l Forms 1099-Q.

Did you, your spouse, Or your dependents incur any post-secondary education expenses, such as tuition?

Deductions and Credits:

Did you or your spouse contribute prope母(other than cash) wm a fair m甜k鏡value of more than $5,000 to a

charitableorganization?　‥.‥‥‥..‥.‥.‥.‥‥‥‥.‥‥.‥‥‥‥‥‥‥‥‥‥‥｡.

lf Yes, provide the appraisa一 of propehy contributed･ An appraisa一 is not r印uired for contributions of publicly

traded securities or contributions of non-publicly traded stock of $1 0,000 or k;ss.

Didyouoryourspouseincuranycasualtyorth鮒losses? . ‥ ‥ ‥ ‥ ‥ ‥. ‥ ‥ 〟 ｡ ‥ ‥ ‥ ‥ ‥ ‥. ‥ ‥ ｡ 0 ｡

Didyouoryourspousemakeanylargepurchases,suchasmotorvehiclesandboats? . ‥ ‥ ‥ ｡ ‥ ‥ ‥ ‥. ‥ ‥ ‥

Did you oryourspouse incurany casua一ty or 一oss attributableto afederally dec一ared disaster?. ‥ ‥ ‥ ‥ ‥ ‥ ‥ ‥ ‥

Did you or your spouse purchase a new a一ternative t∞hnology vehicle言ncluding a qua一ified plug･ln e一ectric drive motor vehic一e?

Did you or your spouse use gaso一ine or specia一 fuels for business or f甜m purposes (Other than for a highway vehicゆ?. ｡ ｡ ‥

lf Yes, provide the number of gallons of gaso一ine or special fuels used for o什highway business purposes･

Gallons

Did you or your spouse instaII any a一ternative energy equipment in your residence such as solar water heaters, ∞lar

electricityequipment(photovoltaic)orfuelceIIs? . ‥ ‥. ‥. ‥. ‥ ‥ ‥ ‥ ‥ ‥ ‥ ‥ ‥ ‥ ‥ ‥. ‥

Did you or your spouse install any energy e鮒ciency lmPrOVementS Or energy PrOpehy in your residence such as exterior

doors or windows言nsulation, heat pumps, furnaces, centra一 air conditioners, or w甜er heaters? ‥ ‥ ‥ ‥ ‥ ‥

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600122 10-14-16

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Questions (Page s o†劫

Investments :

Did you or your spouse have any debts canceled, forgIVen Or refinanced?

Did you or your spouse start or purchase a business, renta一 property, or farm, or鵡qulre any new interest in any

pahnershiporScorporation? ‥.‥‥.‥.‥‥‥‥‥‥‥‥‥‥.‥‥‥‥‥.‥‥

Did you or your spouse sell an existing business, renta一 propehy, farm, or飢y existing interest in a pahnership or

S corporation?

DidyouoryourspouseselI,exchange,orpurchaseanyrealestate? . ‥ ‥ ‥. ‥ ‥ ‥. ‥. ‥. ‥ ‥. ‥ ‥

lf Yes, include cioslng Statements.

Did you or your spouse receive grants of stock o函ons from your emp一oyer, exercise any stock options granted to you or

your spouse or dispose of any stock acquired under a qua一ified emp一oyee stock purchase p一an? . ‥ ‥ ‥ ‥ ‥

Did you or your spouse engage in any put or ca旧ransactions?

lf Yes, provide the transaction detai一s.

Did you or your spouse c一ose any open･shon sales?

DidyouoryourspousesellanysecuritiesnotrepohedonFormlO99･B?　‥ ‥ ‥ ‥ ‥ ‥ ‥ ‥ ‥ ‥. ‥ ‥.

Retirement or Severance:

Did youoryourspousecontributetoaRoth lRAorconvehan existing lRAintoaRoth IRA? ‥ ‥ ‥. ‥ ‥ ‥ ‥

Did you or your spouse ro旧nto a Both lRA any distributions from a retirement p一an, an annuity plan, tax she一ter amuity

ordeferredcompensationplan?.‥‥‥｡.‥‥.‥‥...‥‥.‥‥‥‥‥‥‥‥.‥‥‥.

Did you or your spouse turn age 70 1/2 and have money ln an lRA or oth釘retirement account whhout taking any

distribution?

Did you or your spouse r鏡ire or change jobs?

Did you or your spouse receive deferred, r帥rement or severance compensation?

If Yes, enter the date received (Mo/DaNr).

Persona一 Residence:

Didyouraddresschange? . ‥ ‥. ‥ ‥ 〟

If Yes, provide the new address.

lf Yes, did you move to a d暗erent home because of a change in the location of your job?

Did you or your spouse c一aim a homebuyer credit for a home purchased in 2008?

Did you or your spouse wkhdraw any amounts from your Individua一 Retirement Account (IRA) or Roth IRA to acquire

aprlnCiPalresidence? .‥‥‥.‥‥‥.‥〟‥‥‥.‥‥‥‥‥‥‥‥‥‥‥.‥.‥

Are your total mortgages on your first and/or second residence greater than $1 ,000,000?

lf Yes, provide the princiPal ba一ance and interest rate at the begimlng and end of the year.

Didyouoryourspousetakeoutahomeequityloan? ‥. ‥ ‥. ‥ ‥. ‥. ‥ ‥.. ‥

Did you or your spouse have an outstanding home equity 一oan at the end of the year? ‥ ‥

lf Yes, provide the prlnCIPal ba一ance and interest rate at the beglmlng and end of the year.

Are you claiming a deduction for mohgage interest paid to a financia一 institution and someone e一se received

the Form 1098?

Did you or your mongagee receive mohgage assistance payments?

lf Yes言nclude all Forms 1098-MA.

2C

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600123　04-01-16

Questions (Page 4 of勃

Sale of Your Home:

Did you sell your home?

Didyour∞eiveFormlO99･S?‥‥‥.‥‥‥.‥‥‥‥‥.‥.‥‥.‥‥‥‥‥.‥‥‥‥

lf Yes, inc一ude Form lO99･S.

Did you or your spouse own and occupy the home as your prlnClpal residence for甜Ieast two years of the five･year

periodprlOrtOthesale?‥‥‥‥‥‥‥.‥‥‥‥‥.‥.‥‥‥‥‥‥‥‥‥.‥‥‥

Didyouoryourspouseeverrentoutthepropehy?.‥ ‥.‥ ‥‥. ‥ ‥‥‥ ‥ ‥‥‥‥‥‥‥‥‥ ‥.‥

Did you or your spouse ever use any po面on of the home for business purposes?

HaveyouoryourspousesoldaprlnCIPalresidencew軸nthelasttwoyears?　‥ ‥ ‥. ‥ ‥ ‥ ‥ ‥ ‥

姐h｡tim｡｡fth｡saI｡,the,｡sid｡n｡｡was｡wn｡dbyth｡‥ □ Taxpay｡r　□ spouse　□ Both

Gi請S:

Did you or your spouse make any gifts, including birthday, holiday, anniversary, graduation･ education savlngS･

etc.,wmatotaieggregate)valueinexcessof$14,000to飢yindividual? . ‥ ‥ ‥ ‥ ‥ ｡ ‥ ‥. ‥

Did you or your spouse make any gifts of difficult･to･value assets (such as non･publicly traded stock)

to any person regard一ess of va一ue?

Did you or your spouse make any g請s to a trust for any amount?

Do you or your spouse have a life insurance trust?

2D

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Did you or your spouse assist whh the purchase of any asset (auto, home) for any individual?

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Didy｡u｡,y｡ursp｡us｡f｡rglV｡anyind｡bt｡dn｡sst｡anyindividual,trustorentity? … ‥. ‥ ‥ ‥ ‥ ‥ ‥ ‥. … … ‥　□　□

Forelgn MaHers:O

Did you oryourspouse pe五〇rm anywork outside of the U･S" or陶y anyforelgntaXeS? . ‥. ‥.

Were you or your spouse a grantor or tr飢Sfemr for a foreign trust, have any interest in or a slgn如u晦

authority over a bank account, securities account or other financial account in a forelgn COuntry?

Did you or your spouse create or transfer money or property to a forelgn trust?

Did you or your spouse own anyねrelgn financia一 assets?●

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600124　04-01-16

Questions (Page 5 of 5)

Miscel一aneous:

Did you or your spouse pay in excess of $1 ,000 in any quarter, or a,000 during the year for domestic services

peHormed in or around your home to individua一s who cou一d be considered househo一d emp一oyees?

Didyouoryourspousereceiveunrepohedtipincomeof$200rmoreinanymonth?　‥. ‥ ‥ ‥ ‥ ‥ ‥ ‥ ‥

Have you or your spouse r∞eived a punitive damage award or an award for damages other than for physica一 injuries or

Ⅲness?

Did you or your spouse engage活any banering transactions?

Were you or your spouse notified by the lRS or other taxlng authority of any changes in prlOr year returns?

Were you or your spouse a pahy to sp一it-dol一ar 一ife insurance po一icy?

For any trust that you or your spouse created or are trustee, did any beneficiaries, grantors or trustees die or move?

Have you or your spouse entered into any tax she一ter(S) such as a repohable transaction(S) or IRS Listed

Transaction(S)thatwould requirerep〇両ng/disciosingonyourtaxr鏡urn?　‥ ‥ ‥ ‥ ‥ ‥. ‥ ‥ ‥ ‥

Additional state pages have been included at the back of he organizer and should be reviewed･

22

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600130　07-06-16

Personal Information 3

Taxp aver:

Spouse:

comact lnforma鴫on:

First Name and lnitial

Occupation

Driver●s License or State-Issued lD Number

□ Driv徴-s License □ State-Issued ID

First Name and lnitial

Occupation

Driv徴,-s License or State-Issued lD Numbく汀

□ Driver.s License □ State-Issued lD

Last Name

Date of Birth (MdDaNr)　Date of Death (MdDaNr)

Issue Date (Mo/DaNr)　　Expirati°n Date (MdDaNr) State

No ldent綱cation

Last Name

Date of Birth (MdDaNr)　Date of Death (MdDdYr)

Issue Date (M°/DaNr)

No ldent綱cation

Expiration Date (MdDaNr) State

Street Address

City

Fαe一gn Pr〇両nce or County

Fαelgn Country

Taxpayer DaytimdWork Phone

Taxpay針CelI Phone

Spouse DaytimeNo爪Phone

Spouse CeII Phone

Socia一 Security Number

Socia一 Security Numb徴

Apartment Number

Zip or Post劃Code

Taxpay鋤Evenihg/Home Phone Taxpay針Forelgn Phone

Taxpayer Fax Number

Spouse Evming/Home Phone

Spouse Fax Numb徴

Spouse FαeIgn Phone

Taxpayer EmaiI Address

Spouse EmaりAddress

Preferred Method of Contact

May the IRS or other taxlng authority discuss the return wm the preparer?

ls the taxpayer claimed as a dependent on someone else's tax r敏urn?

Are you considered legally b一ind per IRS regu一ations?

Do you want to contribute to the Presidentia一 E一ection Campaign Fund?

Are you a U.S. citizen or Gr∞n Card ho一der?

Persona一 ldent胴cation Numbers:

Tax Organizer Legend:

日田Taxp ayer

COde-1-IssuedbV旧S2-lssuedbVStateOrC直y �｢���

TS �7F�FR�City �6�R��PIN

Throuqhout the tax organizer, you w‖l巾nd columns with the headin鋼-TSJ"-. Enter一丁'I for由xDaVer, 'S'I for spouse or "iJI'for iomt,

Worksheets: Basic Data > General and Return Options > Processing Options

Forms 1, 1Aand2

000131 09-19-16

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Dependents and Wages

Dependent information:

3A

FirstNameandlnitial 犯�7D��ﾖR�SociaISecurity 認�FV�(ｩ�F��DateofDea廿ー �&Vﾆ�F柳�6��F��Number 宥v�F��$��(Mo/DaNrI 彦����妨"�

Months Livedin 膚肪�Yes or No 薄FV蹤宥���&�V7F柳���披�

Your Home 認�6�(示VB�

Provide the name of any dependent who is not a U.S. citizen or Gr鉾n Card holder･

Provide the name of any person 一iving wm you who is c一aimed as a dependent on someone else's tax r劇urn･

List the years that a release of claim to exemption is given for a dependent ch肘not living wm you･

Wages and Sa一aries: lncI 遊FR�〟 alicopーe �6�薮W&7W'&R�ntye ��$f�&ﾒ�sW-2

Note: Use this section to report any wages and/or salaries for whbh no Form W-2 was received.

TS 之ﾗ�ﾆ�W"w4��ﾖR�TaxabーeWages 彦��友�VﾆB�Federal 播�4��廼&ﾂ�Medicare �7F�FR�Local

Worksheets: Basic Data > General and Dependents; Wages, Salaries and Tips; FleI/Flew of CIaim to ExempGon for Child (Form 83321

Forms 1, 1A IRS-W2 and S-37　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　600135 09-26-16

A

B

C

D

冒

千

G

H

A

B

C

D

E

千

G

H

E一ectronic Fiiin

Electronic Filing:

EIectronic軸ng is the means by which your r敏urn is transmitted direct一y to the IRS and state t秋authorities･ The lRS has implemented an e一ectronic

f軸g mandate r印ulrlng Cehain preparers, inc一uding this firm, to file all returns that they prepare electronicaily･ Some states a一so require Ce佃n

preparers to electronical一y fi一e state returns prepared, The iRS and some states allow t秋payerS tO elect not to file their returns eiectronically･

Do not electronically fi一e the federa一 return

Do not e一ectronically file the state r鏡urn(S)

Note: The lRS and some states that require returns to be elec廿onically制ed also impose fees anuor penalties for failure to do so. 請 you

checked either of me boxes above, you may be requred to sign an ''opt-out●- form before we can release yo山returnS. As a follow-up we

wil一 contact you to discuss these requirements and you abi1時to i'opt-out'● of elec廿onic軸ng･

The lRS requires, and many states ailow, the use of a Persona一 Identification Number (PIN) in 一ieu of mailing a signature document when

electronicaliy f軸9.

Wou一d you 一ike to use a random一y gener叡ed PIN?

Taxpayer

Spouse

lf No, enter a 5-digit self･selected PIN:

TaxpayerPIN .‥.‥.‥‥

Spouse PIN

目目口　□

4

Worksheet: Elec廿onic Fi一ing > Form捌8 - Prepar針且やIanation for Not Filing Elec廿onicalty and Pape帖ss王制e

Forms EF-1, EF-2, and EF-4

000531 10-24-16

llll lllll llll lll酬Il酬201 6

Direct De osit and Withdrawa一 4A

Direct Deposit and Elec廿onic Funds Wimdrawal Account Information:

The lRS and certain states allow refunds to be deposited to and ba一ances due to be paid directly from your financia一 institution. lf you woukl 一ike to

receive your refund or pay a balance due electronically, complete the foIIowlng information･ K you selected either of these options in 201 5, your

account infomi摘on may a一ready be inc一uded be一ow.

Wouldyouiikeanyrefundsowedtoyoudirectiydeposited? ‥. ‥. ‥ ‥ ‥ ‥. ‥

Would you 一ike to pay any amount due on your危d㈱I return using el∞tmnic wmdrawal?

lf Yes, wh甜amount wouはyou like w肌d胎Wn,譜not the entire ba一ance due?

lf Yes, when should the wbhdrawal Occur, K other than the due date of the return?

Would you like to pay any amount due on your stare retum(S) using electronic wbhdrawaI?

lf Yes, wh甜amount wou一d you 一ike wmdrawn,譜not the entire balance due?

(M o/D aNr)

lf Yes, when shou一d the w龍hdrawal occur,譜Other than the due date of the retum? (MdDaNr)

The lRS and some states allow鈴timated payments to be eiectronically w軸drawn on the due dates of the estimated payments･

Wou一d you like to pay any estim甜ed payments due for your応de胎I r鏡urn using el∞tronic wmdrawai? ‥ ‥ ‥. ‥

Would you 一ike to pay any estimated payments due'for your state return(S) using electronically w肌drawal,譜available?

Name of bank or financia一 institution

RoutingTransit Number(RTN) ....

Accountnumber . ‥. ‥ ‥ ‥ ‥

Type of account:

ls this a business account?

Account owner

Checking

Archer MSA Savings

Yes No

E目

[ユニ]

Traditiona一 Savings

Coverdell Ed. Savings

□ Yes

□ T秋payer

IRA Savings

HSA Savings

[コNo

□ spouse

I confirm that the bank account infomation and the direct deposit/electronic withdrawal options selected above are correct.

Wouldyou likeanyrefundsowedtoyoudirectlydeposited? . ‥ ‥ ‥ ‥ ‥ ‥ ‥ ‥

Would you 一ike to pay any amount due on yourねd粥I r敏urn using e一ectronic w肌drawaI?

lf Yes, wh叡amount wou一d you 一ike wmdrawn,譜∩競the飢tire ba一ance due?

□ myRA

□ Joint

□

lf Yes, when shou一d the w競hdrawal occur,譜other than the due d叡e of the r鏡urn?

Would you like to pay any amount due on your state retum(S) using electronic withdrawal?

lf Yes, what amount wou旧you 一ike w肌drawn,鷹not the entire ba一ance due?

(Mo/DaNr)

lf Yes, when shou一d the w軸drawaI occur再Other than the due date of the return? (M o/DaNr)

The IRS and some states allow estimated payments to be ,electronically withdrawn on the due dates of the estimated payments･

Would you liketo pay any estim甜ed payments due for yourねde伯Ir鏡urn using e一ectronic w柵drawaI? ‥ ‥ ‥ ‥. ‥ ‥

Would you 一ike to pay any estimated payments due for your sねte return(S) using electronically wmdrawal再available?

Name of bank or financia一 institution

Routing Transit Number (RTN) . ‥

Account number

Type of account:

ls this a business account?

Account owner

Checking

Archer MSA Savings

Yes No

E醒

[二□

醍

Traditional Savings

CoverdeII Ed. Savings

□ Yes

□ Taxpayer

IRA Savings

HSA Savings

□N｡

□ spouse

I confirm that the bank account information and the direct deposit/electronic withdrawal options selected above are correct.

□ myRA

□ J｡int

□

Worksheet: Basic Data > Direct Deposit / Electronic Funds Withdrawal 600147 04-01-16

FormBNK-1

interest lncome

interest information:

tncludeco ��ﾆU6��6ﾄf�&ﾗ3��湯ﾓ�薈�&��&F�7VﾖV蹠6f�&也FW&W7G&V6V庸VB�x��

Tax-Exemp 友也FW&W7D6�S｢�1-109 湯ﾖ泌B�2-Pri 庸�FT�7F庸��tyBond �2ﾔ&���

▼ ��

5A

TSJ 疲�ﾖV���妨"�lnterestlncome 紐�2�&�ﾇ6�襭��&ﾆ没�F柳�2�Code 彦�ぶW�ﾗ�B�也FW&W7B�2015-nterest Amount

Seller一円nanced MoHgage interest Information:

Nameoflndividual打omWrmm 免FV蹣4V6�F柳��2016-nterest �#��Vﾆ蹤W&W7B�

MortgagelnterestWasReceived 皮Vﾖ&W&�ﾆ襷庸萌V�ﾂ�Amount ��ﾖ�蹌�

Addressofl 匁F庸萌R�al廿om 婦&ﾖﾒ�Mor喝a 没Vﾆ蹤W&R�stWas �&V6V庸VB�

Enter Any Additional Information:

Note: List al一 items sold during the year on Form 7.●

Worksheet:Interest e00151 09-15-16

Form lRS-10991NT

Dividend lncome

Dividend information:

lnclude copies Of aii Forms 1099-DIV or other documents for dividends receivedO

i i TSJ 疲�ﾖV���妨"�Boxla �&�ﾆ"�Box2a 紐�2�&�Fﾆ蹤W&W7B�

TotalOrdina町 ��V�F貿坊B�TotalCapital ��ﾖ�蹤�"�

Dividends 認庸芳V襾2�GainDiStribution ��W&6V蹤紋&�ﾆ��

■■■ lTax-ExemptーlnterestCOde:1-1099-DN2-P面ateActivitVBOnds3-叡軸

↓

A B C D 冒 F G H I J K L M N �6�R�Tax-Exempt Interest �#��Tw&�72�F庸芳V襾2��ﾖ�蹌�

Total ��

Enter Any Additional information:

5B

Note: List all items sold during the year on Form 7.〃

Worksheet: Dividends

Form lRS-1㈱DIV

000152　04-01-16

A

B

C

D

管

F

G

H

_

J

K

L

M

N

Sa一es of Stocks, Securities,

ital Assets a instailment Sa一es

Gains or Losses from Sales of Stocks, Securities and Other Capital Assets:

lnc 沫VB�● eailForms1099-A,1099-B,1099-SandcopteSofmutua 免gV襾7F�FVﾖV蹠6f�'F�坊�"�

Did you have any of the foilowtng during the year?

Mutual fund transactions●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　〃　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　○　　　　●　　　　●　　　　●　　　　●

Exchangeofanysecuritiesorinvestmentsforsomethingotherthancash　‥ ‥. ‥ ‥. ‥ ‥. ‥. ‥. ‥ ‥.

Salesofinheritedpropeny　‥.‥‥‥‥‥‥‥.‥.‥.‥‥‥.‥‥‥‥‥‥‥‥‥‥‥.

Sales of any stock or stock options at a loss and purchases of the same or substantially similar stock or options 30 days

beforeor30daysa龍erthesale .‥.‥.‥‥‥‥‥‥.‥‥‥.‥‥‥‥‥.‥‥‥‥‥‥

Commoditysaies,shonsalesorstraddies .‖‥‥.‥‥‥‥‥‥‥‥‥‥‥‥.‥‥‥‥‥‥

Reinvestment of the proceeds ofthesaie ofa publiclytraded security into an SSBIC interest　‥ ‥ ‥ ‥. ‥ ‥ ‥

Reinvestment of the proceeds of the sale of qua一ified small business stock in other qua一ified sma一l business stock

Debts that became uncoilectible●　　　　○　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●

Securitiesthatbecamewonhless　‥‥‥‥‥‥‥.‥.‥‥‥‥‥.‥‥‥‥‥‥‥‥.‥‥

Saieofanypropenywhereyouwillreceivepaymentsinfutureyears　‥ ‥ ‥ ‥ ‥ ‥ ‥ ‥ ‥. ‥ ‥ ‥ ‥. ‥

7

TSJ 噺匁F��&��W'G��襯FW67&��F柳��Date Acquired (Mo/DaNr) 認�FU6�B���F�風"��GrossSates Price(Less Commissions)

Costor 杷VFW&�ﾅF���StateTax ○therBasis 夫友�VﾆB�Withheld

instailment Sales:〟 O

Do not inc一ude interest received in princlpal amount

TSJ ��&��W'G認W67&��F柳��DateSold (Mo/DaNr) �#��b��&匁6���ﾅ&V6V庸VB�2015 PrincipalReceived

一命 �� ��

Worksheets: Gains and Losses > Stocks, Securities and Other NO‖-Passive Transactions and installment Sales > Genera一 e00171 04-0十16

and Schedule of Receipts I Collections

Forms D-1, D-5 and D-6

A

B

C

D

冒

F

G

H

困□□□H目口□□□□□

回□□□□□□□□□□

A

B

C

D

管

F

G

H

individua一 Retirement Account liRAl Information

lndividuai Retirement Account (lRA):

TS

lnclude all copleS of Forms 1099-級 and 5498.置

IRA Questions for 2016:

Areyou covered by an employer's retirement p一an? . ‥ ‥ ‥.

If no, is your spouse covered by an employer's retirement p一an?

Do you want to 一imit your lRA`contribution to the maximum amount deductible on yourtax r鏡urn? . ‥ ‥ ‥ ‥

lf no, do you want to contribute the maximum allowable amount to your IRA even though you may not qua一ify

for an IRA deduction?●　　　　●　　　　〃　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　○　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　○　　　　○　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　●

Did you use any IRA as security for a 一oan this year?

Did you have any transactions w鷹h any IRA during the year?

lf Yes, exp一ain.

9

IRA Va一ues, Rollovers, and Dis廿ibutions:

TotalvalueofalltraditionaIIRAsonDecember31,2016　‥ ‥ ‥ ‥ ‥. ‥ ‥ ‥ ‥ ‥.

Note: This information or Form 5498 b required if you received a distribution during the year.

OutstandingrolloversonDecember31,2016 . ‥ ‥ ‥ ‥ ‥ ‥ ‥ ‥ ‥. ‥. ‥. ‥

Total distributions convened to Roth iRAs〟 ● ● 〟 ● 〟 ● 〟 〟 i ● 〟 〟 i ● ● ● i ● ● ● ● 〟 ● ○ 〟 〟 ● ● 〟

TotalretirementplansconvehedtoRothlRAs . ‥ ‥ ‥ ‥ ‥ ‥ ‥ ‥ ‥. ‥. ‥. ‥

Con廿ibutions:

IRA:

Contributions in 2016 for the 2016 tax r劇urn● ● 〟 ● i ● ● 〟

Contributions in 2017 for the 2016 tax r鏡urn〟 〟 〟 〟 〟 〟 ● ●

Amount for 2016 you choose to be treated as nondeductible

Roth IRA:

Contributions made for the 2016 t秋yeか

Distributions: lnc 沫VB�eallForms1099-Randanynon 友����b ���○ �'R�tionde 友���ーS ーedlS 宥'B�

NameofPayer �#��dw&�72�Taxable 杷VFW&�ﾅF���StateTax. 棉7F�6��2015Gross Distributions ��ﾖ�蹌�Withhe一d 夫友�VﾆB�Rollover? 認�9?末'WF柳�2�

Worksheets: lRAs, Pensions and Annuities e00191 05-18-16

Forms M-22 and lRS-1099R

国□□□□□□

回□□□□□□

Pension｡ Annuity and Retirement P一an Information 9A

Pensions and Annuities: lncl 遊FR�aitForm �3��湯ﾕ&��nda 也��nontaxabーe 芳��stributio 匁FWF���ｵ2�

TSJ 疲�ﾖV���妨"�2016Gross 彦���(示R�Federal.Tax �7F�FUF���lsthisa �#��Tw&�72�Dis廿ibutions ��ﾖ�蹌�Withhe一d 夫友�VﾆB�Rollover? 認�9?末'WF柳�2�

Self-Employed Retirement P一an:〟

Include copies of alI Forms 1099-R

Have you estab一ished a se一f-emp一oyed retirement or SIMPLE p一an w軸

deductib一e contributions?

Do you w飢t tO contribute the m飲imum amount al一owed?

Con廿ibutions to:

Simplified employee pension p一an

Defined benefit p一an

Defined contribution p一an

SIMPLEpian　‥‥.‥.‥

2016 ��ﾖ��nt 2016 ��ﾒ�ou 也B�

Worksheets: iRAs, Pensions and Annuities; Keogh, SEP amI Simple Plans　　　　　　　　　　　　　　　　　　　　　　　　　　000195 04-0十16

Forms M-6 and lRS-1000R

Misceiianeous income｡ Adiustments and Alimon

in° 沫VB�eForms:W-2G,1099- �� ��ｵ42ﾃ��湯ﾕ%$"ﾃ�� 涛鍔78��ﾃ��湯ﾕ4�ﾃ��湯ﾔﾅD6�襪����ﾔr�

Misce一laneous income and Adjustments:

Unemp一oyment compensation received

Unempioyment compensation repaid in 2016 .

Socia一 security benefits received　‥ ‥ ‥ ‥

Socia一 security benefits repaid in 2016 . ‥ ‥

Medicarepremiumsw鷹hheld . ‥ ‥ ‥ ‥.

Tier 1 rai一road retirement benefits received

Tier 1 ra帥Oad retirement benefits repaid in 2016

Tota一 一ump sum socia一 security received　‥ ‥

Lumpsumtaxablesocialsecurity　‥ ‥. ‥

Otherfederalw鷹hhoiding . ‥ 〟 ‥ ‥ ‥ ‥

Otherst如ew直hholding　. ‥ ‥. ‥ ‥. ‥

State and Local income Tax Refunds:

TSJ

2016Amount �#��T�ﾖ�蹌�

13

TSJ

2016Amount �#��T�ﾖ�蹌�

TSJ �7F�FR�City 彦���坊�"�IncomeTaxRefund State 犯�6�ﾂ�

Other income:

TSJ 疲�GW&V�襴6��6R�2016Amount �#��T�ﾖ�蹌�

A一imony Paid or Received:

TSJ �&V6��坊蹌w4��ﾖR�Recipient's SocialSecurityNo. ��ﾆ蒙���&V6V庸VC��2016Amount �#��T�ﾖ�蹌�

Womsheets: Other Income > MiScellaneous Income, Socia一 Secur時Benefit Statement, Cenain Government Payments, Refunds ot　　　　　　　000231 10-24-1e

State and Local Income Taxes and Alimony Received and OtherAdjustments>Alimony Paid

Forms M-2, M-3,旧S-1000G, lRS-1009MISC and lRS-SSAl㈱

Miscellaneous Adjustments

Educator Expenses: Deduction for amounts aid b educators of kinder ahen throu h Grade 12

TS �#��d�ﾖ�蹌�2015Amount

Health Savings Accounts (HSAs)

13A

TS 認W67&��F柳��2016Amount �#��T�ﾖ�蹌�

COntributionsmadefOr2016 ��

DistributiOnsreceiVedfrOm割lHSAsin2016 ��

what type ｡f ｡｡V｡rag｡ applies t｡ your high deductib一e hea一th p一an? □ se一f only　□ Fami一y

Were any HSA contributions 一isted above a一so shown on your Form W2?

Were al一 distributions什Om your HSA for unreimbursed medica一 expenses?

DidyouoryourspouseenrollinMedicare? ‥. ‥ ‥ ‥. ‥ ‥ ‥. 〟

lfYes,wh甜monthdidyouenroll? ‥ ‥ ‥ ‥ ‥ ‥ ‥. ‥. ‥ 〟

Whatmonthdidyourspouseenroli? ‥ ‥ ‥ ‥. ‥ 〟 ‥ ‥ ‥ ‥

Other Adjustments to Income: Include all Forms 1098-E for Student Loan Interest Paid

TSJ 疲�GW&V�襴6�&6R�2016Amount �#��T�ﾖ�蹌�

I ��

Worksheets: Other income > lRS 1009-MISC; Health Savings Accounts; other Adjustments > Educatα Expenses;　　　　　　　600232 10-24-1e

Student Loan Interest Statement > lRS 1008-E

Forms M-19, P-16, IFIS-1098E and IRS-1099MISC　　　　　　　　　　　　'

回JH]

国書■■

Itemized Deductions - Medica一 and Taxes

Medical and Dental Expenses:

Prescription medicines and drugs

Total medica一 insurance premiums paid ★

Long･term care expenses

Total insurance reimbursement〟 ● ● 〟 〟

Number of mi一es trave一ed for medica一 care

Lodging　‥‥.‥‥‥.‥‥‥

Doctors,dentists,鏡C. ‥. ‥ ‥ ‥.

Hospitals　‥‥.‥‥.‥‥‥‥

Lab fees●　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●

Eyeglassesandcontacts　‥. ‥ ‥.

Taxpayer 一ong-term care insurance premiums paid

Spouse long-term care insurance premiums paid

14

TSJ �#��d�ﾖ�蹌�2015Amount

2016Amount �#��T�ﾖ�蹌�

★ Do not inc一ude Medicare premiums or premiums deducted in computing taxab一e wages repohed on a W･2.

Other Medica一 Expenses:

TSJ 認W67&��F柳��2016Amount �#��T�ﾖ�蹌�

Taxes Paid: lnclude copies of your tax bil一s置

Persona一 propehy taxes paid (inc一ude vehic一e taxes)

Genera一 sa一es taxes paid on specified items

itemize rea一 estate taxes by state.

TSJ �#��d�ﾖ�蹌�2015Amount

TSJ �&V�ﾄW7F�FUF��2�2016Amount �#��T�ﾖ�蹌�

Other Taxes Paid:

TSJ 認W67&��F柳��2016Amount �#��T�ﾖ�蹌�

lf you purchased ｡r so一d you, home in 2016, did you include any taxes from your c一osing statement in the amounts above? □ Y｡S　□ N｡

Worksheet: itemized Deductions > Medica一 and Dental Expenses, Other Medica一 Expenses, Taxes Paid and Other Taxes Paid　　000241 04-01-16

Forms A-1 and A-2

1temized Deductions - Moh〇aOe interest and Points

Mohgage Questions for 2016:

If you purchased or so一d your home, did you inc一ude any mohgage interest from your closlng Statement in the amount below?

Didyourefinanceyourhome?(lfYes,enclosetheclosingstatement.) . ‥ ‥. ‥ ‥ ‥ ‥ ‥. ‥ ‥ ‥ ‥. ‥ ‥ ‥

IfYes,howm飢yyearSisyournewmohgageloan?　‥ ‥ ‥. ‥ ‥ ‥. ‥ ‥ ‥. ‥ ‥ ‥ ‥

Didyoupurchaseanewhomeorsellyourformerhomeduringtheyear? . ‥ ‥ ‥. ‥ ‥ ‥ ‥ ‥ ‥. ‥. ‥ ‥ ‥ ‥ ‥

lf Yes, enc一ose the closing Statements from the purchase and sa一e of your new and former homes.

lf Yes, a一so, did you (or your spouse再married) have an ownership interest in a principa一 residence in the US

duringthe3yearperiodprIOrtOthepurchaseofthishome?. ‥ ‥. ‥ ‥. ‥. ‥ ‥ ‥ ‥ ‥ ‥ ‥. ‥ ‥ ‥

If Yes, did you (and your spouse, B married at the time of purchase) Own and use the same home as a principal residence

in the U.S. for飢y 5 consecutive year period during the 8 year period ending on the purchase date of the new home?

Home MoHgage interest Paid To Financia一 Institutions:

14A

田田口　□

‥□ [コ

ロ　ロ

TSJ �%��胞F��DidYouReceive Forml008? �2016Amount �#��T�ﾖ�蹌�Yes 疲��

Other Home Mongage interest Paid:

TSJ ���胞F��椿ﾄD躔ﾖ&W"�2016Amount �#��T�ﾖ�蹌�

Name ��FG&W72�

Deductib一e Points:

TSJ ���胞F��DidYouReceive Form1098? �2016AmounL �#��T�ﾖ�蹌�

Yes 疲��

Mohgage Insurance Premiums:

Premiums paid or accrued for qua一ified mohgage insurance.

investment interest Expense:

Interest paid on money you borrowed that is alIocable to propeHy he一d for investment.

TSJ �#��d�ﾖ�蹌�2015Amount

TSJ ���胞F��2016Amount �#��T�ﾖ�蹌�

Worksheet: itemized Deductions > Home Mo的age Interest Paid to a Financia一 institution and Deductible Points,

Other Home Mor喝age Interest Paid, Investment lnterest Expense Deduction and Mohgage Insurance Premiums

Forms A-3, A-4 and lRS-1008MIS

600242 10-24-16

itemized Deductions - contributions

Cash Contributions: include aII Forms lO98･C or other documentation.

15

You camot deduct a cash contribution, regard一ess of the amount, un一ess you k∞p as a r∞ord of the contribution a bank r∞ord (such as a

cance一ed check, a bank copy of a cance一ed check, or a bank statement containing the name of the charity, the date, and the amount) or a w塙ten

communication from the charity. The w砧ten communication must inc一ude the name of the charity, date of the contribution, and amount of the

contribution. CIothes and household items donated must be in good, used condition or better in order to be deductible unless the item donated is

wohh more than $500 and you have the item's va一ue appraised. AH従h a copy of the appraisa一. Include any vehic一es donated to charity.

TSJ 微&v�譌ｦ�F柳踟$FW67&��F柳踐d6�?ｩlｦ'WF柳��2016Amount 冩��T�ﾖ�蹌�

TSJ �6�6W'��F柳�&V���&��W'G��2016Arhount �#��T�ﾖ�蹌�

100%limit ��

50%limit ��

TSJ 認W67&��F柳��2016Miies 售#��Tﾖ免W2�

NumberofmiiestraveledpeHOrminqvOlunteerwOrkfOrquaーifiedcharitableOrqa而zatiOns ��

Noncash Contributions Tota一ing $500or Less: lnciude all documentation.

TSJ 認W67&��F柳踐dF�FVE�&��W'G��2016Amount �#��T�ﾖ�蹌�

Include all Forms 1 098-C or other documentation.Noncash Contributions Tota一ing More Than $500:

TSJ●　　　　●　　　　●　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　〟

Descriptionofthedonatedpropehy . ‥ ‥ ‥. ‥ ‥ ‥

Donee organization name

Donee organization address

Date the property was acquired by the taxpayer .. (Mo/DaNr)

Datethepropertywasdonated ............ (Mo/DaNr)

Costorbasisofthedonatedpropeny　‥ ‥ ‥ ‥ ‥ ‥. ‥

Fairmark鏡valueofthedonatedpropehy　‥. ‥. ‥. ‥ ‥

Which of the following methods was used to determine the fair market value? CAUTION: Gmerally, contributions in excess of S,000 0f similar

property will require an appraisa一 (does not app一y to m甜ketable securities)

- App,aisaI　　　- Th,ift shopvalue　- catalog　　- compa,abI.sale

Other ･ please exp一ain

Which of the followlng describes how th恵donated property was acquired?

□ pur｡has｡　　□ G的　　　　　□ lnheritance　□ Exchange

Worksheet:鵬emized Deductions > Comibutions and鍛檎- Noncash Charitable con師butions

Forms A-5, A6 and A8

000251 04-01-16

Federa一 Tax Payments

Refund App一ication:

lf you have an overpayment of 2016 taxes, do you want the excess:

Refunded● ● 〟 〟 〟 i ● ● ● 〟 ● 〟 〟 ● ● ● ● ●

Applied to your 201 7 estim甜ed tax liabiiity

Federa一 Estimated Tax Payments:

2016 1st Quaher Estimate

2016 2nd Quaher Estim如e

201 6 3rd Quarter Estimate

2016 4th Quaher Estim如e

目濃白鷺;

201 5 0verpayment applied to 201 6 estimate

(Due O4･1 8･201 6)

(Due O6･1 5･201 6)

(Due 09-1 5･201⑩

(Due 01-17･2017)

Tax Plannlng Information for Tax Year 2017:O

Do you expect any of the foliowlng tO Occur in 2017?

Achangeinyourmaritalstatus . ‥. ‥. ‥ ‥

20

AmountDue 認�FU��烹�謀踟DF�FTGVR�Gv�F��&ﾂ�AmountPaid

A change in the number of your dependents

A substantial change in your income

A substantia一 change in your w請hholding

A substantia一 change in deductions

lf you answered Yes to any of請e above questions, prov迫e de由iis,

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Worksheet: Estimates and旬plication of Overpaymem > Estimate options e00301 10-24-16

Payments > Federa一 Estimated Tax Paymems

Forms T-1 and T-2

State and ci巾Tax Payments

State and City Estimated Tax Payments:

20161stQuanerEstimate　.‥‥.‥‥‥.‥.‥‥

20162ndQuanerEstimate　‥.‥.‥‥‥‥‥.‥.

20163rdQuaherEstimate　.‥‥‥.‥‥‥‥‥‥

20164thQuaherEstimate　.‥‥‥‥.‥‥‥‥‥

If you have an overpayment of 2016 taxes, do you

want the excess applied to your 201 7 estimated tax liab冊y?

201 5 0verpayment app一ied to 201 6 estimate

Ba一ance of prior year(S)'tax paid in 2016 p一us

amount paid w直h 2015 extensions ‥. ‥

Estimated tax payments for 2015 paid in 2016

20A

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State/City

AmountDue 認�FU��烹�謀踟DF�FTGVR����ﾄF�ﾅ�"��AmountPaid

□Yes □N｡

State and City Estimated Tax Payments:

20161stQuaherEstim叡e　.‥‥‥.‥‥‥‥‥‥

20162ndQuanerEstimate .‥‥.‥‥‥‥.‥‥.

20163rdQuaherEstimate　.｡‥.‥‥.‥‥‥‥‥

20164thQuaherEstimate　.‥‥.‥.‥.‥‥‥‥

lf you have an overpayment of 2016 taxes, do you

want the excess app一ied to your 2017 estimated tax liab冊y?

201 5 0verpayment applied to 201 6鎧timate

Balance of prior year(S)'tax paid in 2016 plus

amount paid w直h 2015 extensions ‥ ‥.

Estimated tax payments for 2015 paid in 2016

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State/City

AmountDue 認�FU��烹�謀踟DF�FTGVR�Gv�F��$｢�AmountPaid

State and Cib Estimated Tax Payments:

2016 1st Quaner Estimate

20162ndQuanerEstimate　‥‥ ‥ ‥ ‥‥‥‥‥ ‥

20163rdQuanerEstim甜e　‥‥｡,‥‥‥‥‥‥‥

20164thQuanerEstimate　.‥‥‥‥.‥‥‥‥‥

lf you have an overpayment of 2016 taxes, do you

want the excess app一ied to your 2017 estimated tax liab冊y?

2015 0verpayment applied to 2016 estimate

Ba一ance of prior year(S)号ax paid in 2016 plus

amount paid whh 2015 extensions

Estimated tax payments for 2015 paid in 2016

□Y｡S　□N｡

TSJ

StatdC吋

AmountDue 認�FU��烹�謀踟DF�FTGVR��DF��ﾅ�"��AmountPaid

□Yes　□N｡

Worksheet: Paymems > S由te Estimated Tax Paymems e00305 04-01-16

State a City Interview Forms

iiiinois Information

Genera一 information:

Enter the total propehy tax paid ,appiicable to the personal residence

Propeny index number

County name

Enterthe amount of general merchandise forwhbh you did not pay any sales tax ..

Enter the amount of qua一ifying food, non･prescription drugs and medica一 app一iances for

whichyoudidnotpayanysalestax .‥‥‥‥.‥.‥‥‥‥‥.‥‥

Residency Information:From

(M o/DaNrlTo

(M o/DaNrl

lf you did not 一ive in Il一inois for all of 2016, enter the dates you did 一ive in Illinois

Enter the state names other than lllinois where you had income

Education Savings:●

Did you or your spouse make any contributions to a Bright Stan College Savings Poo一, Coliege冊nois

Prepaid Tuition Program, or帥ght Directions College Savings Poo一 account? . ‥ ‥ ‥ ‥ ‥

lf Yes, enter the foilowlng:

TS 疲�ﾖV�FW6没��FVD&V觀f�6��'��.TypeofPbn �6�6���6V7W&宥��躔ﾖ&W"�AccountNumber �#��d�ﾖ�蹌�6�?末'WFVB�

Voluntary Contributions:

Enter the amount you wish to contribute on your 2016 tax r鏡urn to the followlng funds:

Wildlife PreseNation Fund● 〟 〟 ● 〟 ● ● 〟 〟 〟 〟 〟 i ● 〟 〟 〟 〟 ● 〟 ● 〟 〟 i 〟 ● ● i 〟 ○ ● 〟 〟

Specia1 01ympICS冊nois and Special Children's Charities Fund

AIzheimer's Disease Research Fund●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　●　　　　o O　　　　●　　　　●　　　　●　　　　●

Assistance to the Home一ess FundO　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　○　　　●　　　●　　　●　　　●

U.S.S.冊noisCommissionlngFund　‥ ‥ ‥ ‥ ‥ ‥ ‥. ‥. ‥ ‥ ‥ ‥ ‥

Autism Care Fund●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●　　　●

Diabetes Research Fund

Qua一ified Education Expense information:

DependentName 背&�FR�┫ﾓ�"��SchoolName �66��8韮�Tuition,Book/ljbFees

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Enter Any Additiona一 Ⅲinois information:

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600661 05-09-16