The forms below will take approximately 30 minutes to complete. Once completed click on the submit button to send the forms to D'Alessio & Co.  Remember information submitted to us is encoded and confidential. 

*Note: Once completing the form you may want to print it out for your own records. The form must be printed before submitting it to D'Alessio & Company.

Personal Data
Taxpayer (or Single) Spouse
Last Name Last Name
First Name & Initial First Name & Initial
Occupation Occupation
Phone (Home) Phone (Home)
Phone (Work) Phone (Work)
Social Security Number Social Security Number
Mailing Address
County City State Zip Code

Dependents

Name (First, Initial, Last)

Date of birth (DOB)

Social Security No. 

Relationship

No. of mos. lived in your home
Check if post- secondary student 

Check if post- secondary student 

Check if post- secondary student 

Check if post- secondary student 

Social Security Numbers are required for all dependents.
If filing Head of Household and qualifying person is your child but not your dependent above enter child's name here .
Questions: (Yes answers, include explanations)
1. Did your name, address or marital status change during the year? Yes  No 
If Yes
2. Are you being claimed as a dependent on another tax form?        Yes  No
If Yes
3. Are you (or your spouse) blind or permanently disabled?            Yes  No 
If Yes
4. If you claim children above that don't live with you , are they allowed as a result of pre- 1985 agreement?                                                                           Yes  No 
If Yes
5. Did you carry forward or incur any adoption expenses during the year?  Yes  No 
If Yes

 

Wages / Salaries / W-2 Forms

Other Taxes Withheld 

T/S

Name of Employer

Withheld Fed. Tax

Taxable Earnings

Social Security

Medicare

State

Local

T/S/J Code: T- Taxpayer S- Spouse J- Joint      Use these codes if married filing jointly

Miscellaneous Income  

TSJ

Source of Income

(Show losses in Brackets)

Amount

Alimony (Not Child Support) (If you pay Alimony- list in misc. deductions)

Jury Duty (or Other Public Service)
Tips/Gratuities (Not reporter on W-2)
Contest/Awards/Gambling Winnings (Attach 1099-MISC forms or Explain)
Commissions/Bonuses (Not reported on W-2)
Pensions/Annuities (Furnish 1099-R Forms or Detail)
IRA/Keogh (Attach form 1099-R)
Profit Sharing Distributions (Attach Form 1099-R)
Unemployment Compensation (Attach 1099-G Form)
Partnerships/Estates/Trusts (Furnish K-1 Forms or Details)    *                                                       
Small Business Corporations/Sub Chapter S (Furnish K-1 Forms)     *                

Business/Self Employed (Furnish Schedule or Detail) *
Farm (Furnish Schedule or Details)*
Rental (Furnish Schedule or Details)*
Other (Explain):
* If you did not actively or materially participate in earning the income (or loss) listed

 

Sale of Personal Residence
Date Old Residence Acquired                                                        Cost or Basis

Improvements (Additions, Landscaping, Driveway, New Roof, etc.)

Fixing-Up Expenses (Painting, Repairs, etc., To Prepare for Sale)

Date Old Residence Sold                                                                 Selling Price

Expenses of Sale (Commissions, Legal Fees, Points, Stamps, etc.)

1. Was any part of residence rented or used for business?

Yes No
2. Was it your principal place of residence for 2 of the last 5 years?

Yes No
3. Have you deferred a gain from the sale of personal residence into the home sold? If so, please provide Form 2119 from tax return for year prior home sold.

Yes No
4. Was sale of residence required due to job transfer?

Yes No
Date New Residence Acquired (or Construction Began)

Date Of Occupancy              Cost of New Residence 

If married, do you and your spouse have the same proportionate interest in the new residence as in the old?  Yes     No

Attach copy of Real Estate Closing Papers and Form 1099-S.
 

Interest Income
TSJ

Name of Payer

Interest Amount

Exempt

 List Code Here

  • List interest income reported on all 1099-INT and 1099-OID forms.
  • Attach all 1099 forms reporting Tax Withheld.
  • Do not list IRA or Retirement Plan reported interest unless withdrawn and not redeposited in another Retirement Plan within 60 days.

Use Codes Below if from indicated sources:

  • MB Municipal Bonds
  • IN Installment Sales
  • US U.S. Bonds
  • TE Tax Exempt (explain)
  • MF Mortgage Financed By Seller (list name, address, & SSN)

If tax exempt for any of the above, Explain here:

 

Dividend Income

TSJ

Name of Payer

Dividend

Capital Gain

Check if Non Taxable

Check if State Exempt

*Related to mutual funds.  Dividends under $10 do not require a 1099.  Attach all 1099-DIV forms & explanation received.

Capital Gains and Losses

TSJ

Description 

Date Acquired MO/DA/YR

Date* Sold MO/DA/YR

Sale Price

Cost or Basis
1.

If anything above was sold on the installment basis, list line number.**
2.

If so, how much did you receive on the principal during the year?
3.

List all interest received from installment sales under Interest Income.

Sale of Property and Real Estate (Attach Form 1099-S)  Stocks and Bonds (Attach Form 1099-B)   *Enter exact date.  **If new installment sale, report selling expenses, mortgage assumed and if used in business, accumulated depreciation.

Non-Taxable Income
(Important to list even if not taxable)
Child Support/Payments/Assistance    (Not Alimony)
Veterans Benefits/Disability Income
Workman's Compensation/Loss of Time Payments
Other (Explain):

Social Security
 

Check Here

Total Received
Use amount reported on Social Security Benefit Statement (SSA-1099) Taxpayer

Spouse

Income Taxes Paid Or Refunded
  Federal State Local
Balance on last year's return (or prior years)
Refunds received from last year's return (or prior years)
       
Estimated Tax Paid Federal State Local

1st Quarter 4/15

2nd Quarter 6/15

3rd Quarter 9/15

4th Quarter 1/15
If not paid by due dates list actual dates paid.

 

 

Itemized Deductions
List only the amounts that have been paid during the year. Save all cancelled checks and receipts for a period of at least 3 years. You may round off to the nearest dollar. Please put an asterisk * next to any deduction that is a result of a disproportionate amount for only you or your spouse. It may be to your advantage to file separately. (If you need to submit additional lists use our email info@dalecpa.com


Medical
Only the amount of Unreimbursed medical expenses that exceeds 7.5% of adjusted gross income is allowed.

Amount

Prescription & Drugs  (Doctor Prescribed only)
Insulin (general drugs not allowed)
Medical Insurance Paid  Pre Tax After tax   or Unsure
Insurance - Paid by You
Group Health Plans (deducted from salary)
Medicare Premiums (From Soc. Sec. Benefits & Supplemental Ins.)
Other Insurance (Long Term Healthcare, MSA, Other)
Doctors, Dentists, Clinics, Hospitals, Nurses, etc.)
Eye Glasses/Contact Lenses
Hearing Aids & Supplies
Ambulance
X-Ray/Lab Fees
Nurses (Board & Room)

Medical Aid Rental
Equipment (Prescribed)
Nursing Home Medical Care
Other:
Lodging: While away from home
Transportation: Total miles driven for medical reasons or act. cost.


Interest 
Mortgage Interest Principal Residence
Paid to Financial Institution (Form 1098)

Paid to an Individual (List Name, Address, Soc. Sec. no. below)
Name:

Social Security No.
Address: Mortgage Interest Second Home
Paid to Financial Institution (Form 1098)

Paid to an Individual (List Name, Address, Soc. Sec. no. below)
Name:

Social Security No.
Address:

Did you acquire a new mortgage or borrow on an existing mortgage during the year? Yes No   If Yes , what is your combined mortgage debt?

Points paid to acquire new  mortgage (if not included above)
Home Equity Loan Interest (Form 1098)
Home Improvement Loan Interest (Form 1098)
Other:
Deductible Investment Interest (explain): 
Note: Personal interest form credit cards, department stores, autos, bank loans, etc., is not deductible.


Taxes

Description of Tax

 State Amount    
Real Estate Taxes (Home- do not include special assessments)
Real Estate Taxes (other) (Not if included on Rental Schedule)
Property Tax Rebates (If Any)
Personal Property Tax (IF Any)
Auto Licenses (Not a deduction in All States)                          Total Cost
State or Local Income Taxes (If not listed elsewhere) 
Other:
Note: General Sales Taxes are not deductible. This includes tax on vehicles, boats, building materials, telephone, gasoline, transportation, alcohol, etc.


Contributions 
Cash Contribution Must have receipts for single donations of $250 or more.

Amount

Church/Temple (Name)

Cancer/Heart/Easter/Christmas Seals, etc. (submit list if more than one)
Red Cross/United Way/YMCA/YWCA (submit list if more than one)
Educational TV/Radio
Veteran's Org. (Name)
Schools (Name & Describe)
Other:
Non-Cash Contribution- Property, Clothing, Furniture, Food, etc. (Submit explanation listing name and address of donee organization, items donated, date, fair market value. If total value of a single donation exceeds $500 explain method used to arrive at value).
Volunteer Work- Mileage & Parking (Submit explanation listing name & address of donee organization, activity performed, miles driven, parking fees).


Miscellaneous Deductions

Only the TOTAL amount that exceeds 2% of Adjusted Gross Income is Allowed.

Description of Misc. Deductions

Amount
Tax Preparation Fees
Safe Deposit Box
Union/ Professional Dues
Business Gifts
Subscriptions & Trade Journal
Tools/Shoes/Glasses
Telephone (business)
Uniforms and Upkeep
Job Hunting Expenses
Second Job Mileage
IRA/Keogh Fund Fees
Investment Expenses (describe)
Educational Expenses (describe)
Alimony Paid

Alimony Paid to: (Name)

Social Security Number


Casualty/ Theft Losses

Only the TOTAL NET RESULT that exceeds 10% of Adjusted Gross Income is Allowed.
Fire, Storm, Theft and Auto Damage - If more than one, provide similar detail for each.

Kind of Property or Item

Date Acquired

Cost or Basis

Insurance Paid

Describe How or What Happened:

Date of Loss

Mkt. Value before

Mkt. Value After


Child And Dependent Care
If required to be gainfully employed (or a full time student) * Asterisk next to amount if service performed in your home.
Name/Address of Provider  
Name

Soc. Sec. or ID Number
Address:

Paid
Name Soc. Sec. or ID Number
Address:

Paid
No. of Children Under Age 13 #
Form W-10 should be used to obtain provider details. If more space needed, attach list with same details.


Moving Expense
Miles from old home to old job Miles from old home to new job
Cost to pack & ship household goods and personal effects

Cost of travel and lodging from old to new residence (no meals)

Other:

Amount (if any) reimbursed by employer

 

 

IRA/KEOGH/SEP/SIMPLE RETIREMENT CONTRIBUTIONS

X 

if covered by a retirement plan at work

Date

IRA

Keogh/SEP/Simple

If you want the maximum allowable deduction - write MAX in money column. You will be informed of amount to deposit. A maximum of $2000 per spouse contribution to an IRA is permitted even if not deductible.

List total value of ALL IRAs on 12/31

Single or Taxpayer

Single taxpayer

Spouse

Spouse
   


Higher Education Expenses
Note: Many of your higher education expenses qualify for special tax credits and deductions. Others may qualify as exclusions from income for tax-free and/or penalty-free  withdrawals from your tax deferred savings accounts. Please provide information individually for each student enrolled at least half time in a qualified post-secondary institution.
  1st Student 2nd Student 3rd Student
Code (T=Taxpayer, S=Spouse, D1=Dependent 1, D2=Dependent 2)

Tuition (Tuition paid during year for at least half-time enrollment) Amount Amount Amount
Post -Secondary Years 1 and 2
Post-Secondary Years after 1 and 2
Tuition Fees
Other Expenses: (Enter amounts as these expenses may qualify for tax/penalty-free IRA withdrawals, student loan interest deduction, or U.S. Savings Bond Interest Income Exclusion)
  1st Student 2nd Student 3rd Student
Room and Board
Books and Supplies

Job Related Education
(Enter amounts only if job/career-related and only for you and your spouse)
  Taxpayer Spouse
Room and Board
Books and Supplies
Seminar Fees

Employee Business Expenses
Vehicle Info. (Check if New this year) Date Placed In Service mm/dd/yy Make Model Cost or Basis
Vehicle 1 
Vehicle 2

Furnish details on newly acquired vehicles and trade-in or disposition of old vehicle
Vehicle Mileage Detail Odometer Reading Vehicle 1 Vehicle 2
Check if another vehicle is available for personal use

End of year
No. of round-trip miles from home to work

Number of days worked last year?

Beginning of Year

Business Miles (Jan 1st - Mar 31st)
Business Miles (Apr 1st - Dec 31st)
Percent of Business Use

Vehicle Expenses (If both taxpayer & Spouse have deductions, use vehicle 1 for taxpayer, 2 for spouse)
  Vehicle 1 Vehicle 2   Vehicle 1 Vehicle 2
Gas & Oil Parking/Tolls
Washing / Lube Licenses
Repairs/Maintenance  Lease Payments
Tires/Accessories Other:
Insurance      
Travel Expenses- Away from home (Days Gone Overnight )
  Taxpayer Spouse   Taxpayer Spouse
Transportation Auto Rentals
Lodging Cabs, Bus, etc.
Reimbursement for All Expenses Above - if not reported on W-2
Other Business Expense
  Taxpayer Spouse   Taxpayer Spouse
Postage/Cards Commissions
Office Supplies Other:

Reimbursement for All Expenses Above - if not reported on W-2
Meals & Entertainment (Must have supportive records and receipts)
Meals & Tips Tickets & Events
Entertainment Gifts
Reimbursement for All Expenses Above - if not reported on W-2
Did you purchase any other business equipment during the year?  Yes    No   If Yes, Submit (email) information including: date bought, cost, description, and trade-in details.

Home Office
Type of Business:
If Justified for Business or Professional use for:   Taxpayer      Spouse       Both 
Date Acquired Home Utilities
Land Cost Interest
Home Cost Taxes
Improvement Cost Insurance
Sq. ft. of living area Rubbish & Maintenance
Sq. ft. of office (incl. inventory & sample storage) Other:

Other Tax Information

Answer the following questions. For YES answers, write the number of the question and the detailed explanation in the box following question 24, labeled "details".
1. Were you notified by the IRS or STATE of any change to any prior year tax return? Yes   No  13. Do you expect any significant changes in income, withholding taxes or your tax liability for the coming year? Yes   No 
2. Are any of your claimed dependents not residents or citizens of the U.S.? Yes   No  14. Did you (or your spouse) receive any source of income that is not listed on these forms (lottery, awards, etc.)? Yes   No 
3. Did you or your spouse make any gifts over $10,000 to any individual (no tax advantage to you)? Yes   No  15. Do you have children 14 or under with investment income? Yes   No 
4. Do you have any foreign income or foreign bank accounts? Yes   No  16. Did you pay anyone (over 18) $1,000 or more to work at your home (housecleaning, yard work or other domestic help) during the calendar year? If yes submit details.  Yes   No 
5. Did you (or your spouse) have living expenses in a foreign country as a result of income earned abroad? Yes   No  17. Do you (and/or your spouse) wish to designate $3.00 of your taxes to the Presidential Campaign Fund (no cost to you)?   

YN You

YN Spouse
6. Do you have any worthless stocks or uncollectible bad debts? Yes   No  18. Did you donate a partial interest in any goods to charitable organizations? Yes   No 
7. Did you (or your spouse) become disabled during the year? Yes   No  19. Have you opened a Medical Savings Account (MSA) during the year? Yes   No 
8. Are you (or your spouse) a handicapped employee? Yes   No  20. If you (or your spouse) reached the age of 70 1/2 do you have a plan for your mandatory retirement savings withdrawals? Yes   No 
9. Did you (or your spouse) receive any distribution from an IRA, Profit Sharing, or Pension Plan? Yes   No  21. Did you (or your spouse) receive employer provided educational assistance any time since December 31, 1994? Yes   No 
10. Have you (or your spouse) used bartering to exchange any goods or services? Yes   No  22. Did you (or your spouse) pay long term healthcare insurance premiums or receive benefits during the year? Yes   No 
11. Did you receive any insurance or other reimbursement from a prior year casualty, theft, loss or medical deduction? Yes   No  23. Are you (or your spouse) paying off a student loan? Yes   No 
12. Did you start a new business during the year or do you expect to start one this coming year? Yes   No  24. Do you have a dependent attending post secondary school? Yes   No