Tax Organizer Long

ORG02012 Tax Organizer

This Tax Organizer is designed to help you collect and report the information needed to prepare your 2012 income tax return. The attached worksheets cover income, deductions, and credits, and will help in the preparation of your tax return by focusing attention on your special needs.

Please enter your 2012 information in the designated areas on the worksheets. If you need to include additional information, you may use the back of a worksheet or an additional page.

When possible, 2011 information is included for your reference. You do not need to make any 2011 entries.

Note: The General Questions and Business/Investment Questions worksheets include a variety of questions designed to assist in completing your tax return. If you answer yes to any of the questions, be sure to provide the applicable details.

Please provide the following information:

A copy of your 2011 tax return (if not in our possession).

Original Form(s) W-2.

Schedule(s) K-1 showing income or loss from partnerships, S corporations or estates or trusts.

Copies of other compensation or pension documentation, such as Form 1099-MISC or Form 1099-R.

Form(s) 1099 or statements reporting dividend and interest income.

Brokerage statements showing transactions for stocks, bonds, etc.

Form(s) 1098 reporting interest paid, copies of real estate tax bills and other information relating to real property holdings.

Copies of closing statements regarding the sale or purchase of real property.

All other information notices you received, or any items you have questions about.

Thank you for taking the time to complete this Tax Organizer.

ORG0OGMW0101 07/09/12

ExactCPA14 S Pierson RoadMaplewood, NJ 07040Telephone: (973)996-2284 Fax: (646)929-5562E-mail: [email protected]

Table of Contents ORG1

OGMW8201 07/01/11 ORG1

Description Page

Cover Sheet ORG0

Topic Index ORG2

General Questions ORG3

Business/Investment Questions ORG4

Additional Information ORG5

Basic Taxpayer Information ORG6

W-2, W-2G, 1099-R Income ORG7

1099-MISC Income ORG8

Social Security Benefits/Form 1099-G/Other Income ORG10

Interest and Dividend Income ORG11

Seller Financed Interest/Child’s Interest and Dividends ORG12

Medical and Tax Expenses ORG13

Interest Paid and Cash Contributions ORG14

Non-Cash Charitable Contributions ORG14A

Miscellaneous Itemized Deductions ORG15

Moving Expenses ORG16

Employee Business Expenses ORG17

Employee Home Office Expense ORG17A

Car and Truck Expenses ORG18

Business Income and Expenses ORG19

Business Use of Home ORG20

Sales of Stocks and Securities ORG21

Sale of Your Home ORG22

Installment Sales Income ORG23

Sales of Business Property ORG24

Rental and Royalty Income and Expenses ORG25

Farm Rental Income and Expenses ORG26

Farm Income and Expenses ORG27

Adjustments to Income ORG28

Dependent Care Expenses ORG35

Education ORG36

Tax Payments ORG40

Household Employment Taxes ORG41

K-1 Partnership ' Partner’s Questions ORG45

K-1 S-Corporation ' Shareholder’s Questions ORG46

K-1 Estate & Trust ' Beneficiary’s Questions ORG47

K-1 Partnership Supplemental Business Expense ORG48

Transferred Assets ORG50

Additional Assets ORG51

Foreign Earned Income ORG52

State Information Worksheet ORG60

OGMW0201 07/01/11 ORG2

Topic Index ORG2

Alimony paid ORG28

Alimony received ORG10

Annuity payments received ORG7

Business income and expenses ORG19

Car and truck expenses ORG18

Casualties and thefts ORG3

Charitable contributions ORG14

Child and dependent care expenses ORG35

Dependent information ORG6

Depreciable property ' additions ORG51

Depreciable property ' deletions ORG50

Dividend income ORG11

Education ORG36

Employee business expense ORG17

Estate income ORG47

Estimated and other tax payments ORG40

Farm income and expenses ORG27

Farm rental income and expenses ORG26

Foreign earned income ORG52

Gambling and lottery winnings ORG7

Household employees ORG41

Installment sales ORG23

Interest income ORG11

Interest paid (mortgage, etc) ORG14

Investment interest expense ORG14

IRA contributions ORG28

IRA distributions and rollovers ORG7

Keogh plan contributions ORG28

Medical and dental expenses ORG13

Miscellaneous income reported on 1099-MISC ORG8

Miscellaneous income not from 1099-MISC ORG10

Miscellaneous itemized deductions ORG15

Moving expenses ORG16

Office in home expenses ORG20

Partnership income ORG45

Pension payments received ORG7

Personal information ORG6

Railroad retirement benefits ORG10

Rental income and expenses ORG25

Royalty income and expenses ORG25

S corporation income ORG46

Sale of home ORG22

Sales of business property ORG24

Sales of stock, securities ORG21

Self-employed health insurance ORG19

SEP plan contributions ORG28

SIMPLE plan contributions ORG28

Social security benefits ORG10

State and local tax refunds ORG10

Taxes paid ORG13

Trust income ORG47

Unemployment compensation ORG10

Wages and salaries ORG7

General Questions ORG3

PERSONAL INFORMATION

Yes No

Did your marital status change during 2012?1

If yes, explain

Do you want to allow your tax preparer to discuss this year’s return with the IRS?2

If no, enter another person (if desired) to be allowed to discuss this return with the IRS. Caution: Review any transferred information for accuracy.

GDesignee’s NameG GPhone Number Personal Identification Number (5 digit PIN)

Do you or your spouse plan to retire in 2013?3

Were you or your spouse permanently and totally disabled in 2012?4

Enter date of death for taxpayer or spouse (if during 2012 or 2013): Taxpayer: Spouse:5

Were you or your spouse a member of the U.S. Armed Forces during 2012?6

DEPENDENT INFORMATION

Yes No

Do you have dependents who must file?7 a

If yes, do you want us to prepare the return(s)?b

Do you have children who are under age 19 or a full time student under age 24 with investment income greater 8 athan $1,900?If yes, do you want to include your child’s income on your return?b

Are any of your dependents not U.S. citizens or residents?9

Did you provide over half the support for any other person during 2012?10

Did you incur adoption expenses during 2012?11

IRA, PENSION AND EDUCATION SAVINGS PLANS

Yes No

Did you receive payments from a pension or profit-sharing plan?12

Did you receive a total distribution from an IRA or other qualified plan that was partially or totally rolled over into another 13IRA or qualified plan within 60 days of the distribution?

Did you convert all or part of a regular IRA into a Roth IRA?14a

Did you roll over all or part of a qualified plan into a Roth IRA?b

Did you contribute to a Coverdell Education Savings Account?15

ITEMS RELATED TO INCOME/LOSSES

Yes No

Did you receive any disability payments in 2012?16

Did you receive tip income not reported to your employer?17

Did you buy, sell, refinance, or abandon a principal residence or other real property in 2012? 18a(Attach copies of any escrow statements or Forms 1099.)

If you sold or abandoned a home, did you claim the First-Time Homebuyer Credit when you purchased the home?b

Are you planning to purchase a home soon?c

Did you incur any casualty or theft losses during 2012?19

Did you incur any non-business bad debts?20

PRIOR YEAR TAX RETURNS

Yes No

Were you notified by the Internal Revenue Service or state taxing authority of changes to a prior year’s return?21

If yes, enclose agent’s report or notice of change.

Were there changes to a prior year’s income, deductions, credits, etc which would require filing an amended return?22

OGMW0312 07/10/12 ORG3

ORG3General Questions (continued)

FOREIGN BANK ACCOUNTS, FOREIGN ASSETS AND FOREIGN TAXESYes No

Did you have foreign income or pay any foreign taxes in 2012?23

a At any time during 2012, did you have an interest in or a signature or other authority over a bank account, or 24other financial account in a foreign country?

Did the aggregate value of all your foreign accounts exceed $10,000 at any time during 2012? Report all interest income bon Org 11Were you the grantor of or transferor to a foreign trust which existed during the tax year, whether or not you have any 25beneficial interest in the trust?Did you at any time during 2012, have an interest in or any authority over any foreign accounts or assets (i.e. stocks, 26bonds, mutual funds, partnership interests, etc.) held in foreign financial institutions that exceeded $50,000 in value at any time during the year?

HEALTH AND LIFE INSURANCEYes No

Did you or your spouse have self-employed health insurance?27If you or your spouse are self-employed, are either of you eligible to participate in an employer’s health plan at 28another job?Did your employer pay premiums on life insurance in excess of $50,000 where the proceeds are payable to beneficiaries 29named by you?

Did you contribute to or receive distributions from a Health Savings Account (HSA)?30

MISCELLANEOUSYes No

Did you make energy efficient improvements to your home or purchase any energy-saving property during 2012? If yes, 31please attach details

Did you start paying mortgage insurance premiums in 2012? If yes, please attach details32

Did you purchase a motor vehicle or boat during 2012?33If yes, attach documentation showing sales tax paid.Did you purchase a hybrid or electric vehicle in 2012?34If yes, enter year, make, model, and date purchased:Did you donate a vehicle in 2012? If yes, attach Form 1098C35

%What was the sales tax rate in your locality in 2012? State ID36

Did you or your spouse make gifts of over $13,000 to an individual or contribute to a prepaid tuition plan?37

Did you make gifts to a trust?38If there were dues paid to an association, was any portion required to be non-deductible due to political lobbying by 39the association?

If yes, please attach details.

Did you or your spouse participate in a medical savings account in 2012?40

If yes, please attach Form 1099-SA (Distributions from an HSA, Archer MSA or Medicare+Choice MSA.)

Did you make a loan at an interest rate below market rate?41

Did you pay any individual for domestic services in 2012?42Did you pay interest on a student loan for yourself, your spouse, or your dependents?43Did you, your spouse, or your dependents attend post-secondary school in 2012?44Did a lender cancel any of your debt in 2012? (Attach any Forms 1099-A or 1099-C)45Did you receive any income not included in this Tax Organizer?46

If yes, please attach information.

ELECTRONIC FILING AND DIRECT DEPOSIT OF REFUNDYes No

If your tax return is eligible for Electronic Filing, would you like to file electronically?D47

The Internal Revenue Service is able to deposit many refunds directly into taxpayers’ accounts. If you receive a refund, 48would you like direct deposit?

Caution: Review transferred information for accuracy.If yes, please provide the following information:49Name of your financial institutionaRouting Transit Number (must begin with 01 through 12 or 21 through 32)bAccount numbercWhat type of account is this? Checking Savingsd

GPlease attach a voided check (not a deposit slip) if your bank account information has changed.-

OGMW0312 09/07/12 ORG3

Business/Investment Questions ORG4

Yes No

Did you receive stock from a stock bonus plan with your employer?1

(Do not include stock sales included on your W-2.)

Did you buy or sell any stocks or bonds in 2012?2

If yes, attach broker’s information (such as Form 1099-Bs and broker annual statements) related to the transactions.

Did you surrender any U.S. savings bonds during 2012?3

Did you use the proceeds from Series EE or I U.S. savings bonds purchased after 1989 to pay for higher4

education expenses?

Did you realize a gain or loss on property which was taken from you by destruction, theft, seizure, or condemnation?5

Did you start a business, purchase a rental property or farm, or acquire interests in partnerships or S corporations?6

7 Do you have any investments for which you were not personally ’at risk’ (other than sole proprietorship or farm)?

Did you own an interest in a Real Estate Mortgage Investment Conduit (REMIC) during 2012?8

Did you sell property or equipment on installment in 2012?9

Did you have any business related educational expenses?10

Did you do a ’like-kind’ exchange of property in 2012?11

Do you have records, as described below, to support expenses?12

Tax law and IRS regulations allow deductions for travel and entertainment if adequate records can be presented.

Information must include: 1 Amount; 2 Time and place; 3 Date; 4 Business purpose; 5 Description of gift(s); and

6 Business relationship of recipient.

Did you purchase special fuels for non-highway use?13

If yes, please list the type of use and the number of gallons for each fuel.

Was Form 8903 (Domestic Production Activities Deduction) included in your 2011 federal income tax return?14

ORG4OGMW8601 07/10/12

Additional Information ORG5

OGMW0401 05/08/08 ORG5

Basic Taxpayer Information ORG6

PERSONAL INFORMATION

TAXPAYER SPOUSE

Last name

First name

Middle initial and suffix MI Suffix MI Suffix

Social security number

Occupation

Work phone/extension

Cell phone

E-mail address

MM/DD/YYYY MM/DD/YYYYBirthdate

Blind Yes No Yes No

Contribute to Presidential Election Yes No Yes NoCampaign Fund

Eligible to be claimed as a Yes No Yes Nodependent on another return

Street address Apartment number

City State ZIP code

Home phone Foreign country

Fax Foreign phone

FILING STATUS

Single1

Married filing jointly2

Married filing separately3GCheck this box if you did not live with spouse at any time during the yearGCheck this box if you are eligible to claim spouse’s exemptionGCheck this box if your spouse itemizes deductions

Head of household4

If the qualifying person is a child but not your dependent, enter

Child’s name Child’s social security number

Qualifying widow(er)5G 2010 2011Check the box for the year the spouse died

DEPENDENT INFORMATION2012 Child CareSocial Security Number **Code Date of BirthFull Name Expense

(first name, middle initial, last name, suffix) +Months 2011 Child CareRelationship *Not Citizenin U.S. Expense

** For the Dependent Code, enter the following: L = dependent child who lived with youN = dependent child who didn’t live with you due to divorce or separationO = other dependentQ = not a dependent (but is a person who qualifies your client for the earned income credit and/or the credit for

child and dependent care expenses)+ Enter the number of months dependent lived with you, and/or your spouse if married filing jointly, in the U.S.* Check this box if dependent child is not a U.S. citizen or resident alien

ORG6OGMW0501 08/9/12

W-2, 1099-R, and W-2G Income ORG7

W-2 ' WAGES, SALARIES, TIPS, AND OTHER COMPENSATION

- Attach all copies of your W-2 forms here.GEmployer’s name Check if not applicable for 2012

Employer’s name Check if for spouse

Check if this employer hired an on-staff care provider or furnished dependent care at your workplace1

1 Enter any amounts forfeited from a flexible spending account2

Check if the income reported is from a foreign source3

Clergy: Enter your designated housing or parsonage allowance4a

Clergy: Enter smallest of (a) the designated housing or parsonage allowance, (b) amount spent on bqualifying housing expenses, or (c) fair rental value

c Check SE tax on: (a) housing or parsonage allowance (b) W-2 wages (c) both

Employer’s name Check if not applicable for 2012

Employer’s name Check if for spouse

Check if this employer hired an on-staff care provider or furnished dependent care at your workplace1

2 Enter any amounts forfeited from a flexible spending account2

Check if the income reported is from a foreign source3

Clergy: Enter your designated housing or parsonage allowance4a

Clergy: Enter smallest of (a) the designated housing or parsonage allowance, (b) amount spent on bqualifying housing expenses, or (c) fair rental value

c Check SE tax on: (a) housing or parsonage allowance (b) W-2 wages (c) both

1099-R ' DISTRIBUTIONS FROM PENSIONS, ANNUITIES, RETIREMENT OR PROFIT-SHARING PLANS, IRAS, INSURANCE CONTRACTS, ETC

- Attach all copies of your 1099-R forms here.GPayer’s name Check if not applicable for 2012

Payer’s name Check if for spouse

Check if either box applies: Rollover Conversion to Roth IRA1

2 a If a partial rollover, enter the amount rolled over1

b If a partial conversion to a Roth IRA, enter the amount converted to Roth IRA

Health insurance premiums deductible on Schedule A3

GIf entire distribution is a Required Minimum Distribution (RMD), check this box4 a

b If only part of distribution is RMD, enter the part that is RMD

Payer’s name Check if not applicable for 2012

Payer’s name Check if for spouse

Check if either box applies: Rollover Conversion to Roth IRA1

2 2 a If a partial rollover, enter the amount rolled over

b If a partial conversion to a Roth IRA, enter the amount converted to Roth IRA

Health insurance premiums deductible on Schedule A3

GIf entire distribution is a Required Minimum Distribution (RMD), check this box4 a

b If only part of distribution is RMD, enter the part that is RMD

W-2G ' GAMBLING OR LOTTERY WINNINGS

- Attach all copies of your W-2G forms here.GStateCheck if Federal Tax Withheld State Tax Withheld Gross Winnings Name of Payer CodeSpouse (Box 2) (Box 14)(Box 1) (Box 13)

ORG7OGMW9401 07/11/12

1099-MISC Income ORG8

MISCELLANEOUS INCOME

- Attach all copies of 1099-MISC forms here.G

Box Description Payer 1 Payer 2 Payer 3

Check if spouse

Check if you did not receive income from this payer in 2012

Payer’s name

Payer’s federal identification number or

Payer’s social security number

Rents1

Royalties2

Other income3

Federal income tax withheld4

Fishing boat proceeds5

Medical/health care payments6

Nonemployee compensation7

Substitute payments8

Crop insurance proceeds10

Excess golden parachute payments13

Gross proceeds paid to an attorney14

Section 409A deferrals15a

Section 409A income15b

State tax withheld ' 1st state16

State name ' two letters ' 1st state17

Payer’s state number ' 1st state

State income ' 1st state18

State tax withheld ' 2nd state16

State name ' two letters ' 2nd state17

Payer’s state number ' 2nd state

State income ' 2nd state18

OGMW0701 07/10/12 ORG8

Copy 1

Social Security Benefits/Form 1099-G/Other Income ORG10

SOCIAL SECURITY BENEFITS

Attach all copies of SSA and RRB forms. Taxpayer Spouse-GSocial Security Benefits from Form SSA-10991

Federal income tax withheld from Form SSA-10992

Medicare B premiums withheld from Form SSA-10993Medicare C premiums withheld from Form SSA-10994

Medicare D premiums withheld from Form SSA-10995Railroad Retirement Benefits from Form RRB-10996Federal income tax withheld from Form RRB-10997

Medicare premiums withheld from Form RRB-10998

FORM 1099-G

Attach all copies of 1099-G forms.-G

Box Description Payer 1 Payer 2 Payer 3

Check if Spouse

Check if Joint

Payer’s name

Unemployment compensation1

Unemployment benefits you repaid in 2012a

State and local income tax refunds2

Enter the tax year from 1099-G box 33

If tax year is 2010 or prior, enter the taxable portion of the aamount reported in box 2

Federal income tax withheld4

ATAA/RTAA payments5

Taxable grants6

Agriculture payments7

Check if box 2 amount is from trade or business8

Market gain9

Two-letter state abbreviation10a

Two or three-letter local abbreviation

State identification numberb

State income tax withheld11

OTHER INCOME

2012 2012 2011 Nature and Source Taxpayer Spouse Combined

Alimony received1

Recovery of bad debts previously deducted2

Jury duty pay3

Gambling winnings not reported on W2G/10994

Income from not for profit activities (hobbies)5

Income from the rental of personal property6

Other miscellaneous income items:7

Description:

ORG10OGMW0901 08/03/12

Interest and Dividend Income ORG11

T = Taxpayer, S = Spouse, J = Joint

INTEREST INCOME

- Attach all copies of your Form 1099-INTs here.G**Type of Interest

MA1 = MA bank interest OK1 = OK bank interestblank = Regular taxable interestNH1 = NH nontaxable interest ' taxable federal TN1 = TN nontaxable interest ' taxable federalME1 = ME bond interest in federal income

MD1 = MD nontaxable interest ' taxable federal NJ1 = NJ nontaxable interest ' taxable federal WV1 = WV bond interest in federal income

2012 2012 2012 2011 Box Box 1 Box 3 Box 8 1 + 3

TSJ X* Payer Name Interest Tax Exempt StateUS/Treasury Type of InterestInterest**

X* Check if you did not receive income from this account in 2012.

DIVIDEND INCOME

- Attach all copies of your Form 1099-DIVs here.

G 2012 2012 2012 Box 1a Box 1b Box 2a 2011

Ordinary Qualified Capital TSJ X* Payer Name State Box 1a + 2aDividends Dividends Gains

X* Check if you did not receive income from this account in 2012.

OGMW1001 07/10/12 ORG11

ORG12Seller-Financed Interest/Child’s Interest and DividendsT = Taxpayer, S = Spouse, J = Joint

SELLER-FINANCED MORTGAGE INTEREST

TSJ *X Name of Payer Address SSN or EIN Amount

*X Check if you did not receive interest from this payer in 2012.

CHILD’S INTEREST AND DIVIDENDS (greater than $950)

*X Child’s Name 2012 2011

First name MI

Last name Suffix SSN

Child’s taxable interest

Child’s tax-exempt interest

Child’s ordinary dividends

Child’s capital gain distributions

First name MI






First name MI






*X Check if this child did not receive interest or dividend income in 2012.

ORG12OGMW4101 07/12/12

Medical and Tax Expenses ORG13

MEDICAL AND DENTAL EXPENSES 2012 2011

Prescription medications1

Health insurance premiums (enter Medicare B on ORG10)2

Qualified long-term care premiums3

Taxpayer’s gross long-term care premiumsa

Spouse’s gross long-term care premiumsb

Dependent’s gross long-term care premiumsc

Enter self-employed health insurance premiums on ORG19, ORG27, ORG45A, or ORG46A 4for the appropriate activity

Insurance reimbursement5

Doctors, dentists, etc6

Hospitals, clinics, etc7

Lab and X-ray fees8

Expenses for qualified long-term care9

Eyeglasses and contact lenses10

Medical equipment and supplies11

Miles driven for medical purposes12

Ambulance fees and other medical transportation costs13

Lodging14

Other medical and dental expenses:15

a

b

c

d

e

f

g

h

i

j

TAXES 2012 2011

Enter state and local income taxes on ORG7, ORG8, ORG10, and ORG40.

Real estate taxes paid on principal residence16

Real estate taxes paid on additional homes or land17

Auto registration fees based on the value of the vehicle18

Other personal property taxes19

Other taxes:20

OMGW1101 10/03/12 ORG13

Interest Paid and Cash Contributions ORG14

HOME MORTGAGE INTEREST PAID

Check if NOT Lender’s Name 2012 2011on Form 1098

POINTS PAID ON LOAN TO BUY, BUILD, OR IMPROVE MAIN HOME

Check if NOT Lender’s Name 2012on Form 1098

SELLER FINANCED MORTGAGE

Identifying Individual’s Name AddressNumber

OTHER PERSON RECEIVING FORM 1098

Form 1098 Recipient’s Name Address

OTHER POINTS

Enter below any points paid on a home equity loan (other than to improve your main home), a loan for a second home, or a refinanced mortgage.

Loan Loan Length 2011 Points Lender’s Name Points Paid Date of LoanDeductedOver (years)

INVESTMENT INTEREST

2012 2011Investment interest (for example: margin interest, interest paid on loans used for property held for investment, etc)

OGMW4901 07/20/12 ORG14

Interest Paid and Cash Contributions (continued) ORG14

LIMITED HOME MORTGAGE DEDUCTIONIf your mortgage balance exceeded $1 million ($500,000 for married filing separately) or your home equity debt exceeded $100,000 ($50,000 for married filing separately) during 2012 complete the following:

Loan 1 Loan 2 Loan 3 Loan 4 Loan 51 Interest paid in 2012

Points paid in 2012Months loan outstanding

Principal pd on loan in 2012

2 Home acquisition debt:Beginning of year balanceAdditional borrowed in 2012

3 Home equity debt:Beginning of year balanceAdditional borrowed in 2012

4 Grandfathered debt: (before 10/14/1987)Beginning of year balanceAdditional borrowed in 2012

5 Fair market value of homes on date debt was last secured by home

6 Home acquisition and grandfathered debt on date last secured by home

CASH CONTRIBUTIONS

Check if Statement Name of Donee Organization 2012 2011

Exists for Gifts $250 or More

Charitable miles driven

Miles driven to deliver noncash contributions

Parking fees, tolls, and local transportation

OGMW4901 07/20/12 ORG14

Noncash Contributions ORG14A

OGMW1201 10/19/10 ORG14A

Name of Donee OrganizationCheck if

StatementExists for Giftsof $250 or More

Fair MarketValue

Prior Year FairMarket Value

A

B

C

D

E

F

G

H

I

Note: Complete sections below only if the total noncash contributions are more than $500.

Complete these columns only for each contribution over $500* Method for

Fair Market ValueDate of

Contribution Date Acquired(month, year)

HowAcquired***

YourCost

A

B

C

D

E

F

G

H

I

* Methods of determining FMV:Appraisal Capitalization of income Present value Thrift shopAverage share Comparative sales Replacement costCatalog Consignment shop Reproduction cost

** Type of Donated PropertyHousehold/clothing items Business equipment Intellectual propertyMotor vehicle, boat or airplane Business inventory Real property, conservation propertyArt, other than self-created Stock, publicly traded Real property, other than conservationArt, self-created Stock, other than publicly traded Other personal propertyCollectibles Securities, other than stock Other intangible property

***How Property was Acquired: Purchase, Gift, Inheritance, Exchange

Description of Donated Property Type** Address of Donee Organization

A

B

C

D

E

F

G

H

I

Copy 1

Miscellaneous Itemized Deductions ORG15

MISCELLANEOUS DEDUCTIONS (2% LIMITATION) 2012 2011

Employee Business ExpensesNote: If you have any travel, transportation, meals or entertainment expenses or your

employer reimbursed you for any of your job-related expenses, complete ORG17 for all your employee expenses.

Union and professional dues1

Professional subscriptions2

Uniforms and protective clothing3

Job search costs4

Other unreimbursed employee expenses:5

a

b

c

d

e

Other Expenses Subject to the 2% Limitation

Treat all MACRS assets for this activity as qualified Indian Yes Noreservation property?

Treat all assets acquired after August 27, 2005 as qualified GO Zone property? Regular Extension No

Treat all assets acquired after May 4, 2007 as qualified Kansas Yes NoDisaster Zone property?

Was this property located in a Qualified Disaster Area? Yes No

Check to code assets as Investment Expense

Use ORG50 to record dispositions.

Use ORG51A to enter additional assets.

Use ORG11a for investment expenses related to interest income.

Use ORG11b for investment interest related to dividend income.

Tax return preparation fees6

Investment counsel and advisory fees7

Certain attorney and accounting fees8

Safe deposit box rental9

IRA custodial fees10

Other expenses (list):11

a

b

c

d

e

OTHER MISCELLANEOUS DEDUCTIONS 2012 2011

Federal estate tax paid on income in respect of a decedent12

Amortizable bond premiums (acquired before 10/23/86)13

Gambling losses (to the extent of gambling income)14

Unrecovered investment in annuity15

Other miscellaneous deductions:16

OGMW1102 07/23/12 ORG15

Moving Expenses ORG16

If you sold your principal residence during 2012, also complete Sale of Your Home (ORG22).

FIRST MOVE

If you moved your residence because of a change in job location (taxpayer or spouse), please complete the following information.

Check here only if all of the following apply? You moved in an earlier year? You are claiming only storage fees while you are away from the United States? Any amount your employer paid for the storage fees is included as wages in box 1 of your W-2

Enter the new principal place of work for this move:

New workplace:

Enter mileage if required to meet Distance Test:

Number of miles from your old home to new workplace

Number of miles from your old home to old workplace

Are you a member of the armed forces? Yes No

Yes NoIf Yes, did you move due to a permanent change of station?

If Yes, enter the allowances or reimbursements received from the government

If No, enter the total amount your employer paid for your move. Do not enter amounts already reported in Form W-2 Box 12

Description of Expense Amount

Expenses of transport and storage of household goods and personal effects:

Transportation expenses

Storage expenses

Expenses of moving from old to new home:

Travel not including meals

Lodging not including meals

SECOND MOVE

If you moved your residence because of a change in job location (taxpayer or spouse), please complete the following information.

Check here only if all of the following apply? You moved in an earlier year? You are claiming only storage fees while you are away from the United States? Any amount your employer paid for the storage fees is included as wages in box 1 of your W-2

Enter the new principal place of work for this move:

New workplace:

Enter mileage if required to meet Distance Test:

Number of miles from your old home to new workplace

Number of miles from your old home to old workplace

Are you a member of the armed forces? Yes No

Yes NoIf Yes, did you move due to a permanent change of station?

If Yes, enter the allowances or reimbursements received from the government

If No, enter the total amount your employer paid for your move. Do not enter amounts already reported in Form W-2 Box 12

Description of Expense Amount

Expenses of transport and storage of household goods and personal effects:

Transportation expenses

Storage expenses

Expenses of moving from old to new home:

Travel not including meals

Lodging not including meals

ORG16OGMW1401 07/10/12

Employee Business Expenses ORG17

Occupation in which expenses were incurred

Check box if spouse’s employee expenses. If blank, taxpayer assumed

Check box if a fee-basis state or local government official

Check box if subject to Department of Transportation (DOT) hours of service limits

Treat all MACRS assets for activity as qualified Indian reservation property? Yes No

Treat all assets acquired after August 27, 2005 as qualified GO Zone property? Regular Extension No

Treat all assets acquired after May 4, 2007 as qualified Kansas Disaster Zone property? Yes No

Was this activity located in a Qualified Disaster Area Yes No

2012 2011EXPENSES

Parking fees, tolls, and local transportation1

Travel expenses while away from home (excluding meals/entertainment expenses)2

Meals and entertainment expenses3

Business gifts4

Education5

6 Home office expenses (Preparer Use Only ' complete ORG17A)

Trade publications7

8 Depreciation expense other than vehicle (Preparer Use Only)

Carryover of Section 179 expense from prior year9

Other:10

2012 2011EMPLOYER REIMBURSEMENTS

Enter amounts not reported in Box 1 on Form W-2 (include amounts reported under code ’L’ in Box 12 of Form W-2).

Reimbursements for other than meals and entertainment11

Reimbursements for meals and entertainment12

2012 2011QUALIFIED PERFORMING ARTIST

Did you perform services in the performing arts as an employee for at least two employers 13during the year, and receive from at least two of those employers wages of $200 or more per employer? Yes No Yes No

2012 2011IMPAIRMENT-RELATED WORK EXPENSES

If you are disabled, were any of your expenses for attendant care at your place of 14employment, or were any of your expenses in connection with your place of employment that enabled you to work? Yes No Yes No

If any property or equipment other than a vehicle was acquired during 2012, please complete ORG51 ' Additional Assets. For vehicles, see page 2.

If any property or equipment other than a vehicle was disposed of during 2012, please complete the disposition information on ORG50 ' Existing Assets. For vehicles, see page 2.

ORG17OGMW1512 07/10/12

Employee Business Expenses (continued) ORG17

Vehicle 1 Vehicle 2GENERAL VEHICLE INFORMATION

Description of vehicle15

Date placed in service16

Enter detail on lines 17a and 17b, or total on line 17c:17

Ending mileage readinga

Beginning mileage readingb

c Total miles for the year (line 17a less line 17b)

Business miles18

Total commuting miles19

Average daily commuting miles20

STANDARD MILEAGE RATE Vehicle 1 Vehicle 2

21 Yes No Yes NoDo you qualify for standard mileage? (Preparer Use Only)

Is this a leased vehicle?22 Yes No Yes No

ACTUAL EXPENSES Vehicle 1 Vehicle 2

Gasoline, oil, repairs, insurance, etc23

Vehicle registration fee (excluding property tax)24

Vehicle lease or rental fee25

26 Inclusion amount (Preparer Use Only)

Value of employer provided vehicle (only if 100% of annual lease value was included 27on Form W-2)

28 Depreciation (Preparer Use Only)

Vehicle 1 Vehicle 2VEHICLE DEPRECIATION/DISPOSITIONS

Cost or basis29

Is this an electric vehicle?30 Yes No Yes No

Is this qualified Indian reservation property?31 Yes No Yes No

32 Type of vehicle (Preparer Use Only)

33 Section 179 expense (Preparer Use Only)

34 Yes No Yes NoQualified Property for Economic Stimulus? (Preparer Use)

35 Yes No Yes NoQualified Property for Qualified Disaster Area? (Preparer Use)

36 Yes No Yes NoQualified Property for Kansas Disaster Zone (Preparer Use)

37 Reg Ext N/A Reg Ext N/AQualified property for GO Zone? (Preparer Use Only)100%/ 100%/

38 30% N/A 30% N/APercentage for Special Depreciation Allowance? (Preparer Use) 50% 50%

39 Yes No Yes NoElect OUT of Special Depreciation Allowance? (Preparer Use)

Yes No Yes No40 Elect 30% in place of 50% Allowance? (Preparer Use)

Date sold41

Date acquired, if different from line 1642

Sales price43

Expense of sale44

45 Gain/loss basis, if different (Preparer Use Only)

46 AMT gain/loss basis, if different (Preparer Use Only)

VEHICLE QUESTIONS

Was your vehicle available for personal use during off-duty hours?47 Yes No

Is another vehicle available for personal use?48 Yes No

Do you have evidence to support the business use claimed?49 Yes No

50 Yes NoIf yes, is the evidence written?

ORG17OGMW1512 07/10/12

Employee Home Office Expense ORG17A

for:

copy:

GENERAL INFORMATION 2012 2011

Area used regularly and exclusively for business, regularly and exclusively for day care, 1or regularly for inventory storage (square footage)

Area used only partly for day care (square footage)2

Total area of home (square footage)3

Daycare hours4

Number of weeks used for daycare, if less than full yeara

Number of days used for day care each weekb

Number of days closed for holidays, vacations, etcc

Number of hours used for daycare each dayd

Total wages from this business5

Enter the percent of wages above that are from the business use of this home6

7 Gain from business use of home shown on Schedule D or Form 4797 (Preparer Use Only)

8 Any losses from this business shown on Schedule D or Form 4797 (Preparer Use Only)

Enter expenses that benefit only your business area in the ’Direct’ column and expenses that benefit your entire home in the ’Indirect’ column.

EXPENSES 2012 2011Direct Indirect Direct Indirect

9 Casualty losses (Preparer Use Only)

Mortgage interest/points on Form 109810

Interest not on Form 109811

Points not of Form 109812

Real estate taxes13

Qualified mortgage insurance14

Other insurance15

Rent16

Repairs and maintenance17

Utilities18

Other expenses (e.g., rent)19

Carryover of operating expenses20

21 Excess casualty losses (Preparer Use Only)

22 Depreciation of your home (Preparer Use Only)

Carryover of excess casualty losses and depreciation23

DEPRECIATIONIf your home and any additions or improvements to your home are not already listed on ORG50 for this occupation, please complete the following information.

24 Date Date Placed Cost Description Acquired in Service (include land

(MM/DD/YY) (MM/DD/YY) for residence only)

Residence

Addition/Improvement




Enter the land value included in cost for residence25

ORG17AOGMW9901 07/11/12

ORG17 1

Car And Truck Expenses ORG18(Employees use ORG17 ' Employee Business Expenses)

for:

GENERAL INFORMATION- Vehicle 1 Vehicle 2 Vehicle 3







Business miles4Total commuting miles5

STANDARD MILEAGE RATE Vehicle 1 Vehicle 2 Vehicle 3

6 Yes No Yes No Yes NoDo you qualify for standard mileage? (Preparer Use)

Is this a leased vehicle?7 Yes No Yes No Yes No

ACTUAL EXPENSES Vehicle 1 Vehicle 2 Vehicle 3







Portion of vehicle registration fee based on value14

Interest on vehicle15

DEPRECIATION/DISPOSITIONS Vehicle 1 Vehicle 2 Vehicle 3

Cost or basis16

Is this an electric vehicle?17 Yes No Yes No Yes No

Is this qualified Indian reservation property?18 Yes No Yes No Yes No

19 Type of vehicle (Preparer Use)

20 Section 179 expense (Preparer Use)

21 Yes No Yes No Yes NoQualified Property for Economic Stimulus? (Preparer Use)

22 Yes No Yes No Yes NoQualified Property for Qualified Disaster Area? (Preparer Use)

23 Yes No Yes No Yes NoKansas Disaster Zone? (Preparer Use)

24 Reg Ext N/A Reg Ext N/A Reg Ext N/AQualified GO Zone Property (Preparer Use)100%/ 100%/ 100%/

30% No 30% No 30% No25 Percentage for SDA? (Preparer Use) 50% 50% 50%

26 Yes No Yes No Yes NoElect OUT of SDA? (Preparer Use)

27 Yes No Yes No Yes NoElect 30% in place of 50% SDA (Preparer Use)

Date sold28


Sales price30

Expense of sale31

32 Gain/loss basis, if different (Preparer Use)

33 AMT gain/loss basis, if different (Preparer Use)

VEHICLE QUESTIONS Vehicle 1 Vehicle 2 Vehicle 3

Is another vehicle available for personal use?34 Yes No Yes No Yes No

Was vehicle available during off duty hours?35 Yes No Yes No Yes No

Was vehicle used primarily by a greater than 5% owner or 36related person? Yes No Yes No Yes No



OGMW1601 07/10/12 ORG18

ORG19


for:






















Cost or basis16












Date sold28


Sales price30

Expense of sale31









OGMW1601 07/10/12 ORG18

ORG25


for:






















Cost or basis16












Date sold28


Sales price30

Expense of sale31









OGMW1601 07/10/12 ORG18

ORG27


for:






















Cost or basis16












Date sold28


Sales price30

Expense of sale31









OGMW1601 07/10/12 ORG18

ORG26


for:






















Cost or basis16












Date sold28


Sales price30

Expense of sale31









OGMW1601 07/10/12 ORG18

ORG48P

Business Income and Expenses ORG19

GENERAL INFORMATION

Check ownership1 Taxpayer Spouse Joint

Business name2

Business street address3a

b 1 City, State and Zip Code, or

Foreign country2

Principal business/profession4

Employer ID number5

6 Business code (Preparer Use Only)Yes No

Was this business fully disposed of in a fully taxable transaction during 2012?7

Accounting method:8

Cash Accrual Other (specify)

Method used to value closing inventory:9

Lower of Cost Other (explain)cost or market

Yes No

Was there a change in determining quantities, costs, or valuations between opening/closing inventory?10

(If yes, attach explanation)

Did you materially participate in the operation of this business during 2012?11

Did you start or acquire this business during 2012?12

Did you make any payments in 2012 that require you to file Forms 1099?13a

If yes, did you or will you file all the required Forms 1099?b

At-risk determination:14

Is all of the investment in this activity at risk?a

Is some of the investment in this activity not at risk?b

Did you have unallowed passive losses in 2011?15

Treat all MACRS assets for this activity as qualified Indian reservation property?16a

Treat all assets acquired after August 27, 2005 as qualified GO Zone property? Regular Extension Nob

Treat all assets acquired after May 4, 2007 as qualified Kansas Disaster Zone property?c

Was this business located in a Qualified Disaster Area?d

Complete ORG51 for Asset Acquisitions and ORG50 for Dispositions.

INCOME 2012 2011

Gross receipts or sales17

Returns and allowances plus other adjustments18

Other income (include federal/state gas tax credit/refund)19

2012 2011COST OF GOODS SOLD ' IF APPLICABLE

Inventory at beginning of year20

Purchases21

Items withdrawn for personal use22

Cost of labor (do not include your salary)23

Materials and supplies24

Other costs25

Inventory at end of year26

ORG19OGMW1712 07/09/12

Business Income and Expenses (continued) ORG19

EXPENSES 2012 2011

Business name

Advertising27

Car and truck expenses (complete ORG18)28

Commissions and fees29

Contract labor30

Depletion31

32 Depreciation and Section 179 deduction (Preparer Use Only)

Employee benefit programs:33

Employee health insurance premiumsa

Other employee benefit programsb

Insurance (other than health)34

Self-employed health insurance attributable to this business35

Interest:36

Mortgage paid to banks not reported to you on Form 1098a

Otherb

Legal and professional services37

Office expenses38

Pension and profit-sharing plans39

Rent or lease:40

Machinery and equipment (enter vehicle lease on ORG18)a

Other business propertyb


Supplies (not included in cost of goods sold)42

Taxes and licenses not reported to you on Form 109843

Travel, meals, and entertainment:44

Travela

Meals and entertainment subject to 50% limitb

Meals subject to 80% limitc

Meals and entertainment not subject to limitd

Utilities45

Gross wages46

Other expenses:47

48 Expenses for business use of your home (Preparer Use Only)

Complete ORG20 for Business Use of Home.

Qualified pension plan start-up costs49

ORG19OGMW1712 07/09/12

Business Use of Home ORG20

for:

copy:

2012 2011GENERAL INFORMATION

1 Area used regularly and exclusively for business, regularly and exclusively for day care, or regularly for inventory storage (square footage)

Area used only partly for day care (square footage)2

Total area of home (square footage)3

Daycare hours4

Number of weeks used for daycare, if less than full yeara

Number of days used for day care each weekb

Number of days closed for holidays, vacations, etcc

Number of hours used for daycare each dayd

Enter the date you began using this home office for this business5

6 If part of your income is from a place of business other than this home, enter % of gross income from business use of this home

7 Adjustment to gain from business use of home shown on Schedule D or Form 4797 (Preparer Use Only)

8 Adjustment to losses from this business shown on Schedule D or Form 4797 (Preparer Use Only)

Enter expenses that benefit only your business area in the ’Direct’ column and expenses that benefit your entire home in the ’Indirect’ column.

2012 2011EXPENSESDirect Indirect Direct Indirect

Casualty losses (Preparer Use Only)9

Total mortgage interest/points10

Mortgage interest/points on Form 109811

Interest not on Form 109812

Points not of Form 109813

Real estate taxes14

Excess mortgage interest (Preparer Use)15

Qualified mortgage insurance16

Other insurance17

Rent18


Utilities20

Other expenses (e.g., rent)21

Carryover of operating expenses22

Excess casualty losses (Preparer Use Only)23

Depreciation of your home (Preparer Use Only)24

Carryover of excess casualty losses and depreciation25

DEPRECIATIONIf your home and any additions or improvements to your home are not already listed on ORG50 for this business, please complete the following information.

26 Cost Date Date Placed Description (include land Acquired in Service

for residence only)(MM/DD/YY) (MM/DD/YY)

Residence





Enter the land value included in cost for residence27

OGMW1801 07/10/12 ORG20

ORG19 1

Sales of Stocks and Securities ORG21

- Attach all copies of Forms 1099-B and/or 1099-S here.G Yes No

Did you exchange any securities for other securities or any other property held for investment?1

Did you acquire stock identical to stock sold at a loss within a period beginning 30 days prior to and ending 30 days2

after the date of the sale?

Did you engage in any transactions involving traded options?3

Did you engage in any transactions involving commodity future contracts and straddle positions?4

Did you engage in any transactions involving employee stock options?5

Do not include installment sales transactions here. Complete information on Installment Sales Income (ORG23) instead.See notes below for entries to be made on lines 1d, 4a, 4b and 5

FORMS 1099-B, 1099-S ' SALES OF STOCKS, BONDS, REAL ESTATE, ETC.

Transaction number

Check if this sale was reported to you on Form 1099-B or substitute statement1 GaIf so, check if Box 6a is marked (i.e., this is the sale of noncovered security) GbIf so, check if Box 6b is marked (i.e., the basis amount was reported to the IRS) GcIf so, select type of gain (loss) indicated in Box 1c * GdDescription of property2

3a bDate acquired Date sold

4a bType of transaction *** Property ownership **

5 Holding period *

6 Sales price

7 Cost or other basis

8 Wash sale loss disallowed9 Federal Tax withheld (if any)

10a b cState State identification State tax withheld

Transaction number

Check if this sale was reported to you on Form 1099-B or substitute statement1 Ga

If so, check if Box 6a is marked (i.e., this is the sale of noncovered security) GbIf so, check if Box 6b is marked (i.e., the basis amount was reported to the IRS) GcIf so, select type of gain (loss) indicated in Box 1c * Gd

Description of property23a bDate acquired Date sold4a bType of transaction *** Property ownership **5 Holding period *

6 Sales price

7 Cost or other basis

8 Wash sale loss disallowed

9 Federal Tax withheld (if any)10a b cState State identification State tax withheld

* Type of Holding Period *** Type of Transaction

SS = Short-term (one year or less) = Regular Sale of Socks, Bonds, etc O = Worthless SecuritiesL = Long-term (more than one year) W = Wash Sale K = Bankrupt

M = Collectible (28% Rate) N = Nonbusiness Bad Debt** Type of Ownership P = Personal Loss on Noninvestment Property E = Stock sales to ESOP’s or EWOC’s

Taxpayer OwnershipT = X = Expired (options, etc)Spouse OwnershipS =Joint OwnershipJ =

OGMW1901 08/21/12

ORG21

Sale of Your Home ORG22

GENERAL INFORMATION

- Attach copies of your original purchase and the current sale settlement sheets here.G

Complete if the sale of your home occurred in the current year (2012). Yes No

Was the sale amount of your residence $250,000 or less ($500,000 or less if married filing a joint return)?1 a

Did you acquire this home in a like-kind (Section 1031) exchange and sell it within 5 years of acquiring it?bDid you use this home partially or completely in a trade or business or hold it for investment AND dispose of it in a like-kind c(Section 1031) exchange?

Did you claim the First-Time Homebuyer Credit when you purchased this home?dDid you live in your home as a principal residence for a total of at least 2 years during the 5-year period ending 2 aon the date of sale?If married filing a joint return, did your spouse live in your home as a principal residence for a total of at least 2 years during bthe 5-year period ending on the date of sale?Did you receive a Form 1099-S?3

4 a Have you sold and excluded gain from another principal residence within 2 years before the sale of this home?

If married filing a joint return, has your spouse sold and excluded gain from another principal residence within 2 years before bthe sale of this home?

5 Did you sell this home due to a change of health, place of employment or other unforeseen circumstances? (If this is a joint sale, answer both questions the same. Otherwise, answer as applicable.)

a Youb Your spouse

Did you or your spouse use any part of your residence for business or rental purposes after May 6, 1997?6 aWas the home used as investment or rental property after December 31, 2008?b

Will you be receiving periodic payments of principal or interest from this sale?7 ab If Yes, what is the amount of the financial instrument?

Address of former home sold8

Date former home was sold9 a

Date former home was boughtb

Sales price of the home sold10

COST BASIS OF HOME SOLD

Description Amount

Original cost of home sold:Purchase price of home sold11a

Postponed gain on the sale of your previous home (from Form 2119 for the year this home was bought)b

Additions and increases to basis:Settlement fees or closing costs when home was purchased. Do not include amounts previously deducted 12aas moving expenses

Cost of capital improvementsb

Additions, including costs of materials and laborc

Other additions and increases to basisd

Decreases to basis:Seller-paid points (for old home bought after 1990)13a

Other decreases to basisb

COMMISSIONS AND OTHER EXPENSES OF SALE

Description Amount

14a

b

c

d

ORG22OGMW2001 07/10/12

Installment Sale Income ORG23

- Attach all closing documents if this is the year of sale.G

Was the property sold in this installment sale a rental or used in a trade or business? Yes No

Was the final installment received this year? Yes No

Description of property1Date acquired Date sold2 a 2 b

Check this box if ordinary gain from non-capital assetc

GROSS PROFIT INFORMATION(Complete for year of sale only.)

Selling price, including mortgages and other debts3Mortgages and other debts buyer assumed or took property subject to4Cost or other basis of property sold5Depreciation allowed or allowable6Commissions and other expenses of sale7

Was this property your main home?8 Yes No

CURRENT TAXABLE PORTION

Gross profit percentage9Payments received in current year10aInterest received in current yearb

Seller Financed Mortgage InformationPayer’s Name Address SSN or EIN11

Payments received in prior years (do not include interest)12

SALES TO RELATED PARTIES

Was the property sold to a related party after May 14, 1980?13a Yes No

b Yes NoIf yes, was the property a marketable security?

If yes, complete the rest of this form. If no, complete for year of sale and for 2 years after the sale.

If you received the final installment payment this year, do not complete the rest of this form.

Give the name, address, and taxpayer identification number of related party:cNameAddress

StateCity ZIP codeIdentifying number

Did the related party, during this tax year, resell or dispose of the property?14 Yes No

If no, do not complete the rest of this form.

Answer yes to no more than one of the following questions.

Was the second disposition more than two years after the first disposition (other than dispositions of15amarketable securities)? Yes No

If yes, give date of disposition

Was the first disposition a sale or exchange of stock to the issuing corporation?b Yes No

Was the second disposition an involuntary conversion where the threat of conversion occurred after thecfirst disposition? Yes No

Did the second disposition occur after the death of the original seller or buyer?d Yes No

Can it be established to the satisfaction of the IRS that tax avoidance was not a principal purpose foreeither disposition? Yes No

If yes, give explanation

If you answered no to all questions 15a through 15e, enter sales price of the property sold by related party16(attach Form 6252 for year of first sale)

OGMW2101 09/10/12 ORG23

Sales of Business Property ORG24

T = Taxpayer, S = Spouse, J = Joint

- Attach all copies of 1099-S and 1099-B forms here.

Note: Enter asset dispositions here or on ORG50 (Transferred Assets), but not both.

SALE OF PROPERTY USED IN A TRADE OR BUSINESS AND HELD MORE THAN 1 YEAR(Include in this table asset dispositions which resulted in long-term loss,

and dispositions of raised livestock for long-term gain)

TSJ Description of Property DateAcquired

DateSold

SalesPrice

Cost PlusExpense of Sale

SALE OF PROPERTY USED IN A TRADE OR BUSINESS AND HELD 1 YEAR OR LESS(Include in this table asset dispositions which resulted in short-term gain or loss)


DateSold

SalesPrice


GAIN FROM THE SALE OF PROPERTY HELD MORE THAN 1 YEAR(Include in this table dispositions of depreciable trade, business, or residential rental assets

which resulted in long-term gain)


DateSold

SalesPrice


OGMW2201 08/17/11 ORG24

G

Rent and Royalty Income and Expenses ORG25

BASIC PROPERTY INFORMATION

Property description:

If type is other, enter a description:Property type: *

Location (street address):

City: State: Zip:

If a foreign address: Foreign province or state:Foreign postal code: Foreign Country:

Check property owner1 Taxpayer Spouse Joint

Yes NoDid you make any payments that would require you to file Form(s) 1099?2 a

b If yes, did you or will you file all required Forms(s) 1099?

Enter the ownership percentage (if not 100%)3 a

If not 100%, are you reporting 100% of the income and expenses?b

4 Is this a rental property? (If yes, answer questions 5 through 11; if no, skip to question 12.)

Did you have personal use of this property or rent it for part of the year at less than fair rental value?56 For all rental properties, enter the number of days during 2012 that:

The property was rented at fair rental valueaThe property was used personally or rented at less than fair rental valuebYou owned the property, if not the entire yearc

Does this rental have multiple living units and you live in one of the units?7 a

b If yes, enter percentage of rental useDid you actively participate in this property’s management during 2012?8

Did you materially participate in this property’s management during 2012?9

Do you want to treat this property as non-passive?10Did this property have unallowed passive losses in 2011?11

Did you dispose of this property in a fully taxable transaction?1213 Check this box if some of this investment was not at-risk

Treat all MACRS assets for this activity as qualified Indian reservation property?14aTreat all assets acquired after August 27, 2005 as qualified GO Zone property?b Regular Extension No

Treat all assets acquired after May 4, 2007 as qualified Kansas Disaster Zone property?cWas this activity located in a Qualified Disaster Area?d


INCOME 2012 201115 Rents or royalties received

5 LandSingle family residence* Property Types: 16 RoyaltiesMulti-family residence27 Self-rentalVacation/short-term rental38 OtherCommercial4

ORG25OGMW2301 08/16/12

Rent and Royalty Income and Expenses (continued) ORG25

EXPENSES 2012 2011

Property location

Advertising16

Automobile (complete ORG18 for autos)a17

Travelb

Cleaning and maintenance18

Commissions19

Mortgage insurance premiums ' qualifieda20

Other insuranceb

Legal and professional fees21

Management fees22

Mortgage interest paid to banks ' qualifieda23

Mortgage interest paid to banks ' otherb

Other interest24

Repairs25

Supplies26

Real estate taxesa27

Other taxesb

Utilities28

Other expenses:29

a b c d e a30 Depreciation and Section 179 deduction (Preparer Use Only)

b Depletion (Preparer Use Only)

ORG25OGMW2301 08/16/12

Farm Rental Income and Expenses ORG26

GENERAL INFORMATION

Name of this activity

Check ownership1 Taxpayer Spouse Joint

Employer identification number2

Yes No

Was this farm fully disposed of in a fully taxable transaction during 2012?3

Did you actively participate in the operation of this business during 2012?4

Real estate professionals:5

Did you materially participate in the operation of this business during 2012?

At-risk determination:6

Is all of the investment in this activity at risk?a


Did you receive a subsidy in 2012?c


Treat all MACRS assets for this activity as qualified Indian reservation property?8 a

Treat all assets acquired after August 27, 2005 as qualified GO Zone property?b Regular Extension No


Was this farm rental located in a Qualified Disaster Area?d


2012 2011FARM RENTAL INCOME ' BASED ON PRODUCTION

Income from production of livestock, produce, grains and crops9

Total distributions received from cooperatives10

Taxable amount of distributions from cooperatives11

Total agricultural program payments12

Taxable amount of agricultural program payments13

Commodity Credit Corporation (CCC) loans under election14

CCC loans forfeited/repaid with certificates15

Taxable amount of CCC loans forfeited/repaid16

Crop insurance proceeds/federal crop disaster payments received in 201217

Taxable crop insurance proceeds/federal crop disaster payments18

Crop insurance proceeds/federal crop disaster deferred from 201119

Other income ' include federal/state gas tax credit/refund20

ORG26OGMW2412 08/03/12

Farm Rental Income and Expenses (continued) ORG26

2012 2011EXPENSES ' FARM RENTAL PROPERTY

Name of this activity

Car and truck expense (complete ORG18)21

Chemicals22

Conservation expenses23

Custom hire (machine work)24

25 Depreciation and Section 179 deduction (Preparer Use Only)

Employee benefit programs other than pension and profit-sharing plans26

Feed27

Fertilizers and lime28

Freight and trucking29

Gasoline, fuel, and oil30

Insurance (other than health)31

Interest:32

Mortgage (paid to banks, etc)a

Otherb

Labor hired33


Rent or lease:35

Machinery, equipment, etc (for vehicle rent or lease, see ORG18)a

Other (land, animals, etc)b


Seeds and plants37

Storage and warehousing38

Supplies39

Taxes40

Utilities41

Veterinary fees and medicine42

Other expenses (specify):43


ORG26OGMW2412 08/03/12

Farm Income and Expenses ORG27

GENERAL INFORMATION

Name of this farm

Check ownership Taxpayer Spouse Joint1Principal product2Employer identification number3Agricultural activity code (Preparer Use Only)4Accounting method Cash Accrual5

Yes No

Was this farm fully disposed of in a fully taxable transaction during 2012?6

Did you materially participate in the operation of this business during 2012?7

Did you make any payments in 2012 that would require you to file Form(s) 10998

If ’Yes,’ did you or will you file all required Forms 1099?9At-risk determination:10Is all of the investment in this activity at risk?a


Did you receive a subsidy in 2012?c


Treat all MACRS assets for this activity as qualified Indian reservation property?12a

Treat all assets acquired after August 27, 2005 as qualified GO Zone property?b Regular Extension No


Was this farm located in a Qualified Disaster Area?d

2012 2011FARM INCOME ' CASH METHOD

Sales of livestock, etc purchased for resale13

Cost/Basis of livestock, etc purchased for resale14Sales of livestock, produce, grains, etc raised15

16a Total distributions received from cooperativesTaxable amount of distributions from cooperativesbTotal agricultural program payments17aTaxable amount of agricultural program paymentsbIf you received social security retirement or disability benefits, enter any Conservation cReserve Program payments included on line 15Commodity Credit Corporation (CCC) loans under election18aCCC loans forfeited/repaid with certificatesbTaxable amount of CCC loans forfeited/repaidcCrop insurance proceeds/federal crop disaster payments received in 201219aTaxable crop insurance proceeds/federal crop disaster paymentsbCrop insurance proceeds/federal crop disaster payments deferred from 2011cCustom hire (machine work) income20

21 Other income ' include federal/state gas tax credit/refund

2012 2011FARM INCOME ' ACCRUAL METHOD

Sales ' livestock, produce, grain, other products22Total distributions received from cooperatives23aTaxable amount of distributions from cooperativesbTotal agricultural program payments24aTaxable amount of agricultural program paymentsbCommodity Credit Corporation (CCC) loans under election25aCCC loans forfeited/repaid with certificatesbTaxable amount of CCC loans forfeited/repaidcCrop insurance proceeds and certain disaster payments26

27 Custom hire (machine work) income

Other income include federal/state gas tax credit/refund28OGMW2512 09/07/12 ORG27

Farm Income and Expenses (continued) ORG27

2012 2011FARM INCOME ' ACCRUAL METHOD (continued)

Cost of Goods Sold:29

Beginning inventory ' livestock, produce, etca

Cost of livestock, produce, etc purchasedb

Ending inventory ' livestock, produce, etcc

Check if you used the unit-livestock price method or 30farm-price method to value inventory

Complete ORG51 for acquisitions and ORG50 for dispositions.

2012 2011FARM EXPENSES ' CASH AND ACCRUAL METHODS

Name of this farm

Car and truck expense (complete ORG18)31

Chemicals32

Conservation expenses33

Custom hire (machine work)34

Depreciation and Section 179 deduction (Preparer Use Only)35

Employee benefit programs other than pension and profit-sharing plans36

Feed37

Fertilizers and lime38

Freight and trucking39

Gasoline, fuel and oil40

Insurance (other than health)41a

Self-employed health insurance attributable to this farm businessb

Interest:42

Mortgage (paid to banks, etc)a

Otherb

Labor hired43


Rent or lease:45

Machinery, equipment, etc (for vehicle rent or lease, see ORG18)a

Other (land, animals, etc)b


Seeds and plants purchased47

Storage and warehousing48

Supplies purchased49

Taxes50

Utilities51

Veterinary, breeding and medicine52

Other expenses (specify):53


OGMW2512 09/07/12 ORG27

Adjustments to Income ORG28

TRADITIONAL IRA CONTRIBUTIONS Taxpayer Spouse

Traditional IRA contributions made for 20121

Check if you were covered by a retirement plan at work2

Check if you wish to make an additional contribution to your traditional IRA before the 3due date of your return

If line 3 is checked, check this box to contribute the maximum allowable amount4

Or enter the amount you wish to contribute5

If you (a) received traditional IRA distributions during 2012 and you have made nondeductible IRA contributions to any of your traditional IRAs, including SIMPLE IRAs, OR (b) choose to make any nondeductible traditional IRA contributions for 2012, please provide this information:

6 Enter the value of all of your IRAs on 12/31/2012

7 Enter the value of all recharacterizations after 12/31/2012

Enter the amount of any outstanding rollovers as of 1/1/20138

If you received IRA distributions during 2012, please complete ORG7.

ROTH IRA CONTRIBUTIONS Taxpayer Spouse

Roth IRA contributions made for 20121

Check if you wish to make an additional contribution to your Roth IRA before the 2due date of your return

If line 2 is checked, check this box to contribute the maximum allowable amount3

Or enter the amount you wish to contribute4

SELF-EMPLOYED PENSION CONTRIBUTIONS Taxpayer Spouse

Money Purchase Plan Keogh and Multiple Plans:

Payments made and/or expected to be made to a money purchase Keogh plan for 20121a

Check this box if you wish to contribute the maximum amount to your money purchase bKeogh for 2012

Profit Sharing Plan Keogh:

Payments made and/or expected to be made to a profit sharing Keogh for 20122 a

Check this box if you wish to contribute the maximum amount to your profit sharing bKeogh for 2012

Defined Benefit Plan Keogh:

Payments made and/or expected to be made to a defined benefit Keogh plan for 20123

SEP:

Payments made and/or expected to be made to a SEP for 20124 a

Check this box if you wish to contribute the maximum amount to your SEP for 2012b

Self-Employed SIMPLE Plan:

Payments made and/or expected to be made to a self-employed SIMPLE plan for 20125a

Enter matching contributions only to report on Form 1040 to a self-employed SIMPLE bplan for 2012

Individual 401(k):

Elective deferrals made and/or expected to be made to an Individual 401(k) plan 6afor 2012

Catch-up contributions made and/or expected to be made to an Individual 401(k) bfor 2012

Employer matching profit-sharing contribution made and/or expected to be made to an cIndividual 401(k) plan for 2012

Check this box if you wish to contribute the maximum amount to your Individual 401(k) dfor 2012

Roth 401(k):

Elective deferrals made or expected to be made to a designated Roth 401(k) plan for 20127a

Catch-up contributions made or expected to be made to a designated Roth 401(k) plan for 2012b

ALIMONY PAID

Recipient’s name Recipient’s SSN Alimony paid

1

2ORG28OGMW2601 06/27/12

Child and Dependent Care Expenses ORG35

CHILD AND DEPENDENT CARE EXPENSES

Enter below the persons or organizations who provided the child and dependent care.

First Name (if person) ID NumberLast Name (if person)

OR SSN on first Provider Business Name line Additional Business Name Amount PaidProvider Address

OR EIN on second

lineProvider Phone

1

Care at above address? Tax-Exempt Foreign

2


3


4


EXPENSES 2012 2011

Total employment taxes paid on wages for child care expenses1

Total expenses paid in 2012 but not incurred in 20122

Total expenses incurred in 2012 but not paid in 20123

Medical expenses paid for qualifying persons unable to care for themselves4

STUDENT/DISABLED PERSON INFORMATION FOR 2012 Taxpayer Spouse

If taxpayer or spouse was a full-time student or disabled in 2012, answer the 5following questions:

Number of months that taxpayer/spouse was a full-time student or disableda

Did taxpayer or spouse work and earn less than $250/$500 during the months entered on bline 5a? If No, leave line 5b blank. If Yes, multiply the number of months working and earning less by either $250/$500 and enter that amount here

OGMW8712 10/12/12 ORG35

Education Information ORG36

Education expenses were paid in 2011

EDUCATION TUITION AND FEES

Attach all Form 1098-Ts and a list of your qualified expenses.

EDUCATOR EXPENSES 2012 2011

Taxpayer educator expenses1 a

Spouse educator expensesb

STUDENT LOAN INTEREST PAID

Student Loan Interest Reported on a 1098-E in 2012

Enter detail below or total interest in Part 2b2 a

Lender’s Name 2012 2011

Total Student Loan Interest 2012 2011

Enter the total interest paid on qualified student loans2 b

FORM 1099-Q

Enter 1099-Q detail below.3

Earnings *State Name of Payer or Program Gross Code Distribution Type

Box 1 Box 2 Box 5

* For the Type Code, enter the following:

P = Private Qualified Tuition ProgramS = State Qualified Tuition ProgramE = Coverdell ESA

OGMW3901 10/05/12 ORG36

Tax Payments ORG40

2012 ESTIMATED TAX PAYMENTS

Federal State LocalDate Amount Date Amount ID Date Amount ID

1 Qtr 1 due by 04/17/12

2 Qtr 2 due by 06/15/12

3 Qtr 3 due by 09/17/12

4 Qtr 4 due by 01/15/13

Additional payments5a

Additional paymentsb

Additional paymentsc

Additional paymentsd

OTHER TAX PAYMENTS

Federal State Local

2011 overpayment applied to 20126

Balance due paid with 2011 return7

2011 Quarter 4 payments paid in 20128a

2011 extension payments paid in 2012b

Other taxes paid in 2012 for prior years (include explanation)9

2013 ESTIMATED TAX WORKSHEET

If you expect any significant change in your income or expenses in 2013, please enter the increase or decrease below.

Income

Wages Taxpayer10

Spouse

Self-Employment Income Taxpayer11

Spouse

Capital Gains (sale of stock, real estate, etc)12

Other Income:13

Description

Deductions

Allowable Itemized Deductions14

Other deductions (such as alimony paid, early withdrawal penalties, etc):15

Description

Federal Withholding16

Number of personal exemptions expected for 201317

ADDITIONAL INFORMATION

Check to use your 2012 tax amount for your 2013 estimate18

If you have an overpayment of 2012 taxes, check the box to indicate how you want your overpayment applied.19

Apply entire overpayment to next year and refund excessa

Apply entire overpayment to first quarter and refund excessb

Amount to apply if not entire overpayment20

Number of installments for estimated tax (1 - 4)21

ORG40OGMW2701 07/09/12


GENERAL INFORMATION

Attach copies of your state payroll returns and other payroll forms.-G

Enter your employer identification number1

Yes No

2 Did you pay any one household employee cash wages of $1,800 or more in 2012?

Did you withhold federal income tax during 2012 for any household employee?3

4 Did you pay total cash wages of $1,000 or more in any calendar quarter of 2011 or 2012 to all household employees?

COMPLETE IF YOU ANSWERED ’YES’ TO QUESTION 2 OR 3 ABOVE 2012 2011

Enter total cash wages paid during 2012 that were:5

Subject to social security taxesa

Subject to Medicare taxesb

c Subject to FUTA taxes

Enter federal income tax withheld during 20126

COMPLETE IF YOU ANSWERED ’YES’ TO QUESTION 4 ABOVE

Yes NoFederal Unemployment Tax (FUTA) Questions:

Did you pay unemployment contributions to only one state?7

Did you pay all state unemployment contributions for 2012 by April 15, 2013?8

Were all wages that are taxable for FUTA tax also taxable for your state’s unemployment tax?9

Enter any unemployment compensation you paid for 2012:10

Contributions Paid to State Taxable Wages Unemployment FundState State Reporting

Name Number 2012 2011 2012 2011

a

b

State State Complete the following if you know your state experience rate:11 A B

State experience rate (e.g., enter 5.5 for 5.5%)a

State experience rate period ' starting date (e.g., 01/01/12)b

State experience rate period ' ending date (e.g., 12/31/12)c

ORG41OGMW9801 07/18/12

Taxpayer Copy


GENERAL INFORMATION

Attach copies of your state payroll returns and other payroll forms.-G

Enter your employer identification number1

Yes No

2 Did you pay any one household employee cash wages of $1,800 or more in 2012?

Did you withhold federal income tax during 2012 for any household employee?3

4 Did you pay total cash wages of $1,000 or more in any calendar quarter of 2011 or 2012 to all household employees?

COMPLETE IF YOU ANSWERED ’YES’ TO QUESTION 2 OR 3 ABOVE 2012 2011

Enter total cash wages paid during 2012 that were:5

Subject to social security taxesa

Subject to Medicare taxesb

c Subject to FUTA taxes

Enter federal income tax withheld during 20126

COMPLETE IF YOU ANSWERED ’YES’ TO QUESTION 4 ABOVE

Yes NoFederal Unemployment Tax (FUTA) Questions:

Did you pay unemployment contributions to only one state?7

Did you pay all state unemployment contributions for 2012 by April 15, 2013?8

Were all wages that are taxable for FUTA tax also taxable for your state’s unemployment tax?9

Enter any unemployment compensation you paid for 2012:10

Contributions Paid to State Taxable Wages Unemployment FundState State Reporting

Name Number 2012 2011 2012 2011

a

b

State State Complete the following if you know your state experience rate:11 A B

State experience rate (e.g., enter 5.5 for 5.5%)a

State experience rate period ' starting date (e.g., 01/01/12)b

State experience rate period ' ending date (e.g., 12/31/12)c

ORG41OGMW9801 07/18/12

Spouse Copy

OGMW2901 05/08/08 ORG45

K-1 Partnership ' Partner’s Questions ORG45

Attach all copies of K-1s from partnerships.-

Name of partnership

Partnership identification number Tax shelter registration number

1 Ownership Taxpayer Spouse Joint

2 Is this the final K-1 for this partnership? Yes No

Name of partnership




Name of partnership




Name of partnership




Name of partnership




Name of partnership




G

1

2

3

4

5

6

OGMW3001 05/08/08 ORG46

K-1 S Corporation ' Shareholder’s Questions ORG46

Name of S Corporation

S Corporation identification number Tax shelter registration number


2 Is this the final K-1 for this S Corporation? Yes No





















Attach all copies of K-1s from S Corporations.-G

1

3

4

5

6

2

OGMW3101 08/25/10 ORG47

K-1 Estate & Trust ' Beneficiary’s Questions ORG47

- Attach all copies of K-1’s from estates and trusts.G

Name of estate or trust

Estate or trust identification no. Tax shelter registration number

1 Beneficiary Taxpayer Spouse Joint

2 Is this the final K-1 for this estate or trust? Yes No





















1

2

3

4

5

6

ORG48K-1 Supplemental Business Expenses

Partnership

EXPENSES 2012 2011

Use ORG18 to enter vehicle expenses.

Vehicle expenses1

Vehicle rentals2

Travel expenses while away from home (excluding meals/entertainment expenses)3

Business gifts4

Education5

Office supplies and expenses6

Telephone, fax, pager, etc7

Trade publications8

Depreciation and amortization (Preparer Use Only)9

Use ORG50 to record dispositions.Use ORG51 to enter additional assets.

Treat all MACRS assets for activity as qualified Indian Yes Noreservation property?

Treat all assets acquired after August 27, 2005 Regular Extension Noas qualified GO Zone property?

Treat all assets acquired after May 4, 2007 as qualified Kansas Disaster Yes NoZone property?

Was this activity located in a Qualified Disaster Area? Yes No

Carryover of Section 179 expense from prior year10

Meals and entertainment expenses11

Other:12

2012 2011REIMBURSEMENTS

Reimbursements for other than meals and entertainment13

Reimbursements for meals and entertainment14

OGMW4001 07/10/12 ORG48

OGMW2801 05/08/08 ORG50

Description Date inService

Costor Basis

DateSold

SalesPrice

Expenseof Sale

Transferred Assets ORG50(Transferred assets only. To enter assets, use ORG51 ' Additional Assets)

for:

Complete for any assets sold

Total

ORG17

OGMW2801 05/08/08 ORG50


Costor Basis

DateSold

SalesPrice

Expenseof Sale


for:


Total

ORG15 Itemized Deductions

OGMW2801 05/08/08 ORG50


Costor Basis

DateSold

SalesPrice

Expenseof Sale


for:


Total

ORG19

OGMW2801 05/08/08 ORG50


Costor Basis

DateSold

SalesPrice

Expenseof Sale


for:


Total

ORG25

OGMW2801 05/08/08 ORG50


Costor Basis

DateSold

SalesPrice

Expenseof Sale


for:


Total

ORG27

OGMW2801 05/08/08 ORG50


Costor Basis

DateSold

SalesPrice

Expenseof Sale


for:


Total

ORG26

OGMW2801 05/08/08 ORG50


Costor Basis

DateSold

SalesPrice

Expenseof Sale


for:


Total

ORG48P

Additional Assets ORG51(Enter vehicles on ORG 18 ' Car and Truck Expenses or

ORG 17 ' Employee Business Expenses)

for:


Costor Basis

BusinessUse %

Land Includedin Cost

OGMW3201 05/08/08 ORG51

ORG17



for:


Costor Basis

BusinessUse %


OGMW3201 05/08/08 ORG51

ORG15 Itemized Deductions



for:


Costor Basis

BusinessUse %


OGMW3201 05/08/08 ORG51

ORG19



for:


Costor Basis

BusinessUse %


OGMW3201 05/08/08 ORG51

ORG25



for:


Costor Basis

BusinessUse %


OGMW3201 05/08/08 ORG51

ORG27



for:


Costor Basis

BusinessUse %


OGMW3201 05/08/08 ORG51

ORG26



for:


Costor Basis

BusinessUse %


OGMW3201 05/08/08 ORG51

ORG48P

11 Kind of living quarters in foreign country.

a Purchased house

b Rented house or apartment

c Rented room

d Quarters furnished by employer

12a Did any of your family live with you abroad during any part of the tax year? Yes No

b If ’Yes,’ who and for what period?

G13aHave you submitted a statement to the authorities of the foreign country where you claim bona fide residence

that you are not a resident of that country? Yes No

b Are you required to pay income tax to the country where you claim bona fide residence? Yes No

If you answered ’Yes’ to 13a and ’No’ to 13b, you do not qualify as a bona fide resident. Do not complete the rest of this part.

14a List any contractual terms or other conditions relating to the length of your employment abroad.

G

b Enter the type of visa under which you entered the foreign country.

G

c Did your visa limit the length of your stay or employment in a foreign country? Yes No

d Did you maintain a home in the United States while living abroad? Yes No

e If ’Yes,’ enter address of your home, whether it was rented, and the names of the occupants, and their relationship to you.

G

7 Citizen/national of which country?

8 a Maintained a separate foreign residence for family due to adverse conditions? Yes No

b If ’Yes,’ city and country of the separate foreign residence. Also, enter the number of days during the tax year

that a second household maintained at the address.

G

9 Tax home(s) during tax year and dates(s) established.

G

Taxpayers Qualifying Under Bona Fide Residence Test

10 Date bona fide residence began G , and ended G

OGMW3701 09/30/11 OMG52


1 Foreign address (including country) and POD

2 Occupation

3 Employer’s name G

4 a Employer’s U.S. Address G

b Employer’s Foreign Address G

5 Employer is (Check any that apply):

a A foreign entity

b A U.S. entity

c Self

d A foreign affiliate of a U.S. company

e Other (specify) G

6 a Last year 2555 or 2555-EZ filed G

b Check if Form 2555 or 2555-EZ not filed after 1981 to claim either of the exclusions G

c Either exclusion ever revoked? G Yes No

d Enter type of exclusion and enter year for whichthe revocation was effective: Exclusion Year

15 Qualified housing expenses for the tax year

For use with Form 8801 Information

Prior year Form 2555, line 45 and line 50

16 TP ' Foreign Earned Income a Taxpayer (Form 2555, line 45) 16a

TP ' Housing b Taxpayer (Form 2555, line 50) b

SP ' FEI c Spouse (Form 2555, line 45) c

SP ' Housing d Spouse (Form 2555, line 50) d

Taxpayer Copy

11 Kind of living quarters in foreign country.

a Purchased house

b Rented house or apartment

c Rented room

d Quarters furnished by employer

12a Did any of your family live with you abroad during any part of the tax year? Yes No

b If ’Yes,’ who and for what period?

G13aHave you submitted a statement to the authorities of the foreign country where you claim bona fide residence

that you are not a resident of that country? Yes No

b Are you required to pay income tax to the country where you claim bona fide residence? Yes No

If you answered ’Yes’ to 13a and ’No’ to 13b, you do not qualify as a bona fide resident. Do not complete the rest of this part.

14a List any contractual terms or other conditions relating to the length of your employment abroad.

G

b Enter the type of visa under which you entered the foreign country.

G

c Did your visa limit the length of your stay or employment in a foreign country? Yes No

d Did you maintain a home in the United States while living abroad? Yes No

e If ’Yes,’ enter address of your home, whether it was rented, and the names of the occupants, and their relationship to you.

G

7 Citizen/national of which country?

8 a Maintained a separate foreign residence for family due to adverse conditions? Yes No

b If ’Yes,’ city and country of the separate foreign residence. Also, enter the number of days during the tax year

that a second household maintained at the address.

G

9 Tax home(s) during tax year and dates(s) established.

G

Taxpayers Qualifying Under Bona Fide Residence Test

10 Date bona fide residence began G , and ended G

OGMW3701 09/30/11 OMG52


1 Foreign address (including country) and POD

2 Occupation

3 Employer’s name G

4 a Employer’s U.S. Address G

b Employer’s Foreign Address G

5 Employer is (Check any that apply):

a A foreign entity

b A U.S. entity

c Self

d A foreign affiliate of a U.S. company

e Other (specify) G

6 a Last year 2555 or 2555-EZ filed G

b Check if Form 2555 or 2555-EZ not filed after 1981 to claim either of the exclusions G

c Either exclusion ever revoked? G Yes No

d Enter type of exclusion and enter year for whichthe revocation was effective: Exclusion Year

15 Qualified housing expenses for the tax year

For use with Form 8801 Information

Prior year Form 2555, line 45 and line 50

16 TP ' Foreign Earned Income a Taxpayer (Form 2555, line 45) 16a

TP ' Housing b Taxpayer (Form 2555, line 50) b

SP ' FEI c Spouse (Form 2555, line 45) c

SP ' Housing d Spouse (Form 2555, line 50) d

Spouse Copy

State Information Worksheet ORG60

GENERAL INFORMATION

Taxpayer Spouse

Enter your state of residence1

Check the appropriate box if:2 Taxpayer Spouse

Full year residenta

Part year resident Date of entry: Date of exit:b

Nonresidentc

Resident locality:3

County: School district: School district number:4

Taxpayer Spouse

Check if disabled5

STATE CREDITS

(for example, solar energy, carpool)6 Description/type of credit Code Amount

a

b

c

d

e

VOLUNTARY STATE CONTRIBUTIONS

(for example, wildlife, cancer)7 Description/type of contribution Code Amount

a

b

c

d

e

MISCELLANEOUS QUESTIONS

Yes No

Did you file a state return for 2011?8

Do you want state forms and instructions sent to you next year?9

Do you want any applicable penalty and interest calculated and added to the return?10

How do you want your state refund (if any) applied?11

Refunded Apply to 2013 estimates Apply to 2013 taxesa b c

Additional state information:12

ORG60OGMW8501 07/10/12

Tax Organizer Long

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