Address Service Requested

IMPORTANTTax Questionnaire

Enclosed

INCOME TAX GUIDEAND

ORGANIZERThis booklet is provided to assist you in compiling the necessary information to prepare your tax return accurately. Given thesubstantial changes in tax laws thisyear, please include as much requested information as possible. This will help maximize your deductions in the event late taxlaw changesare adopted.

Please include your lastyear's return (only if you are a newclient), all W-2 and 1099 forms, and name &address labels provided by the government, if available.

Upon completing this Tax Organizer, please read and sign belowIhavegathered andsubmittedthe information contained inthis questionnaire andto the best of my knowledge it is true,correct, andcomplete.

(Please Sign)

T PERSONAL DATA ]TAXPAYER AND SPOUSE DEPENDENTS

TAXPAYER (OR SINGLE) SPOUSE Name

(First, Initial and Last)(noa)

Xifpost-secondary student #ofmos. lived inyour homeLast Name Last Name L Social Security No. Relationship :

First Name & Initial First Name & Initial

Occupation Occupation

Phone (Home) (Work) Phone (Home) (Work)Social Security Numbers arerequired for all dependents.If filing Head of Household and qualifying person isyour child but not your dependent above

Soc. Sec. Number Date of Birth Soc. Sec. Number Date ol Birth enter child's name here

QUESTIONS: (Yes answers, include explanations)Mailing Address • Check ifaddressis new County 1. Did your name, address ormarital status change during the year? • Yes • No

2. Can you beclaimed as a dependent onanother tax return? DYes DNoCity, State &Zip

V

E-Mail Address 3. Are you (oryour spouse) blind or4. Did youclaim children abovetha5. Did youcarryforward or incur an

permj

don't

I'adop

ner

ive

ion

By disabled?with you?expenses during the)

DYes DNc

DYes DNc

ear? DYes DNc/

DEDUCTIONS

List only amounts that have actually been paid during theyear. Save all cancelled checks and receipts for a period ofatleast 3years.You may round offto thenearest dollar.Please circle any deduction that isadisproportionate amount for only you oronly your spouse(It may beto your advantage to file separately).

MEDICALOnly theamount ofun-reimbursed medical expenses thatexceeds 10% ofAdjustedGross Incomeis allowed.

Description of Medical Expenses

Doctors, Dentists, Clinics, Hospitals, Nurses,Etc.

Prescriptions &Drugs (Doctor Prescribed Only)

Insulin (General Drugs Not Allowed)

EyeGlasses/Contact Lenses

Hearing Aids,Supplies, &Other MedicalAids

X-Ray/Lab Fees

Ambulance, Paramedics

Nurses (Board&Room)

Equipment (Prescribed &Rented)

Nursing HomeMedical Care

Medicare Part B Service Pmts

Smoking Cessation Program

Other:

Medical Insurance Code:Pre-Tax = P After Tax =A Unsure = U

Important: Provide proof of Health Insurance (Form 1095 orEquiv.)

Insurance-Paid byYou

Group Health Plans (Deducted from Salary)

Medicare Premiums (From Soc. Sec. Benefits &Supplemental Ins.)

Other Insurance jlongTeim Healthcare, MSA, Other)

SummaryTotal (Optional)

Lodging: While away from home

Transportation: Total miles driven for medical reasons oractual cost.

TAXESDescription ofTax

Real EstateTaxes (Home) (Include if you plan toitemize ornot)

RealEstateTaxes (Other) (Not if included onRental Schedule)

Property Tax Rebates (If Any)

Personal Property Tax (If Any)

Auto Licenses (Not a Deduction inAll States)

State or Local IncomeTaxes (II Not Listed Elsewhere)Sales Tax/Other:!,'fzj padanyspecial assessments orsubstantial satestax. pleaseattach supporting documents.

State

Amount

Amount

INTERESTAmounts, names,and socialsecurity numbers mustmatchForm 1098issued byfinancial institutions.

MortgageInterest

PrincipalResidence

MortgageInterest

Second

Home

Paid to Financial Institution (Form 1098)

Paid to an Individual (List name,address, Soc.Sec.No. below)So. Sec. No.

Paid to Financial Institution (Form 1098)

Paid to an Individual (Listname,address, Soc.Sec.No. below)Name So. Sec. No.

Did you acquire a new mortgage orborrow on anexisting mortgage during the year?^YesD NoD If yes, what isyour combined mortgage debt?Points paid to acquire new mortgage (it not included above)

HomeEquity Loan Interest (Form 1098)

HomeImprovement Loan Interest (Form 1038)

Student Loan Interest (Attach lorm 1098-E +details: who for, loan date, loan purpose)

Other:

Other:

Deductible Investment Interest (explain ie:Margin Interest).NOTE: Personal interest from credit cards, department stores, autos, bank loans, etc., isnot deductible.

CONTRIBUTIONSReceipts/canceled checks arenow required forall cash donations.

Cash Contribution Must havereceipts or bankrecords for alldonations.

Church/Temple (Name)

Cancer/Heart/Easter/Christmas Seals, etc. (attach list if more than one)

Red Cross/United Way/YMCA/YWCA (attach list if more than one)

Public TV/Radio

Veteran's Org. (Name)

Schools (Name &Describe)

Other:

SummaryTotal Optional - Asummary total lor caslVchock con&ijuoons may beusedPolitical contributions arenotdeductible. Deduct value olgift received toranycontributions.

Non-CashContributions- Property, Clothing, Furniture, Food. etc.Attach explanation listing name&addressofdoneeorganization, items donated, dateofdonation, andfair market value. Iftotal value ofa single donation exceeds $500explain melhod used toarrive atvalue (Items over $5,000 require anappraisal). Ifyoudonateda vehicle, pleaseattachyourcharity's form 1098-C.

Volunteer Work- Mileage &Parking Attach explanation listing date, name&address oldonee organization.activity performed, miles driven, andparking fees.

MISC. ITEMIZED DEDUCTIONSOnlythe TOTAL amount that exceeds 2% of Adjusted Gross Income is Allowed.

Description of Miscellaneous Deductions

Tax Preparation Fees

Safe DepositBox

Union / Professional Dues

Business Gifts

Subscriptions&TradeJournals

Tools/Shoes/Glasses

Telephone (business)

Uniforms and Upkeep

Job Hunting Expenses (Detail)

SecondJob Mileage

IRA/Keogh Fund Fees

Investment Expenses (Describe):

Gambling Losses:(Not subject to 2% limit but limited to Gambling Winnings)

Alimony Paid: (Notsubject to2% limit)

Amount

Amount

Alimony Paidto: (Name) Soc. Sec. No.

CASUALTY/THEFT LOSSES D/"KSS2Only the TOTAL NET RESULT that exceeds 10% ofAdjusted Gross Income isAllowed

Fire, Storm, Theftand Auto Damage - If more than one, provide similar detail for each.Kind of Propertyor Item Date Acquired Cost or Basis

Insurance Paid

DescribeHow or WhatHappened: Date of Loss MM. Value Before

MM.Value After

CHILD AHD DEPENDENT CARE SiXSSX:If required to be gainfully employed (or a full time student) • if service performed in your home (Nanny)

Name/Address ofProvider |Soc. Sec.orID Number Paid

Total PaidDuring Year SFederal ID No. ifrequired to file IRSwages reports. No. of Children UnderAge 13 #UseForm W-10 for provider details. Allocate expenses bydependent. Attach details if more space isneeded.

MOVING EXPENSE

Miles from oldhome to old job Miles from oldhome to newjob

Cost to pack &ship household goods andpersonal items

Cost of travel and lodging from old tonew residence (no meals) $

Other:

Amount (if any) reimbursed byemployer

INCOME

WAGES/SALARIES/W-2 FORMS

TaxableWages

WithheldFed. Tax

Other Taxes Withheld

T/S Nameof Employer Soc. Sec. Medicare State Local

T/S/J Code: T — Taxpayer S — Spouse J —Joint Use these codes Ifmarried filingjointly

MISCELLANEOUS INCOME

T/S/J Source of Income

Alimony (NotChildSupport) (If you payAlimony - list inmisc. deductions)

Jury Duty (Or Other Public Service)

Tips/Gratuities (Not Reported onW-2)

Contest/Awards/Gambling Winnings (Attach 1099-MISC, W2G orExplain)

Commissions/Bonuses (Not Reported onW-2)

Pensions/Annuities (Furnish 1099-R Forms)

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)

SmallBusiness Corporations/SubChapter S (Furnish K-1 Forms)

Business/Self-Employed (Furnish Schedule or Details)

Farm (Furnish Schedule or Details)

Rental (Furnish Schedule orDetails)

Forgiven Debt (Attach Form 1099-A orC)

Other (Explain):

(Show Lossesin Brackets)

Amount

1̂ ifyou did not actively ormaterially participate inearning theincome (or loss) listed

SALE OF PERSONAL RESIDENCE

DateOldResidenceAcquired 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 anypartofresidence rented or usedfor business? Yes • No EJ2. Did you own and use the home as your principal residence for You: Yes D No D

at least2 ofthe lastfive years? Spouse: YesQ NoD3.Have you rolled overa gainfrom the sale ofa priorresidence into thehome

sold? If so,please provide Form 2119 from tax return for year prior home sold. YesD NoLI

4.Was sale required due tojobtransfer, medical or unforeseen circumstance? Yes D No D

DateNewResidence Acquired (Or Construction Began)

Date OfOccupancy Cost of New Residence

If married, doyouand yourspouse have the same proportionateinterest in the new residence as in the old? YesD NoU

AttachCopyof RealEstate Closing Papers for both the sale and purchase.

INTEREST INCOME (always use payer name listed on 1099)

TfS/J Name of Payer

Penalty forearlywithdrawal ofsavings

InterestAmount

Exempt

List interestincomereportedonall1099-INT and 1099-OID forms.

Attachall 1099formsreportingTaxWithheld.

Donot listIRAor ReliremenlPlan reported interestunlesswithdrawn and not redeposited inanother RetirementPlanwithin 60 days.

Use Codes below iffrom indMB MUNICIPAL BONDS

IN INSTALLMENT SALES

US U.S.BONOS

TE TAX EXEMPT (explain)

MF MORTGAGE FINANCED BY SELLER (liftname,address S SSN)

LISTCODE

HERE

Li

DIVIDEND INCOME (please attach all 1099 DIV forms)

T/S/J Nameof Payer Total OrdinaryDividends

Qualified

Dividends

CapitalGains'

Non

Taxable

• List GrossDividends aboveas reportedon 1099DIV forms received.•Attach all 1099 DIV forms.

• Related lo mutual tends.

• ifthis 1099 DIVhas information not listedaboveplease checkhere JCAPITAL GAINS AND LOSSESStocks. Bonds andMutual Funds(Attach Form 1099-B) SaleofProperty andRealEstate(Attach Form 1099-S)

4.

Description(#shares, name or stock symbol)

NOTE: Record ALLfund transactionsincluding mutual funds.

DateAcquiredrnm/dd/yy

DateSold

mm/dd/yy

SalePrice

Cost orBasis'

Use These Codes below if from indicated sourcesA 1099-B Received; Box 3 basis (cost)B 1099-B Received; NoBox 3 basis (cost)C No1099-B Received; basisis mycost

1. List line# ifitemssold on installment basis.' #_• Note interest above.

• Principal Received: thisyear$ prior year$2. Ifanythingabove was inheritedand sold, listline number(s). #

3. If1099-B stated basis(cost) iswrong, mark next to the incorrect value with the codesabove and providethe correct cost on an attached sheet.

' Fornewinstallment sale,also reportselling expenses,mortgage assumedand ifusedinbusiness,accumulateddepreciation and include copyol settlement papers.

h

NON-TAXABLE INCOME(Important to listeven ifnot taxable)

Child Support/Payments/Assistance (Not Alimony)

Veterans Benefits/Disability Income

Workmen's Compensation/Loss ofTime Payments

Other (Explain)

SOCIAL SECURITY

IMPORTANT:

provide SSA-1099

Taxpayer

Spouse

Benefits(from box 5) Federal tax withheld

/ INCOME TAXES PAID OR REFUNDED \

//someone else preparedyourtaxes lastyear,pleaseprovide a copy. Federal State Local

ESTIMATEDTAX PAID Federal State Local

Ifnotpaidbydue dates,list actual

dates paid.

IstQtr. 4/15Balancepaidon last year's return

(or prioryears) 2nd Qtr. 6/15

Refunds received from lastyear's return\v (orprior years)

3rd Qtr. 9/15

4th Qtr. 1/15 J

r RETIREMENT CONTRIBUTIONS 1/ ifcoveredby a retirement plan at work Date Traditional IRA SEP/SIMPLE Roth IRA If youwant the maximum allowable deduc

tion - write MAX in money column(s). Youwill be informed ofamount to deposit.

List total value of ALL IRAs on 12/31

Single orTaxpayer / / SingleorTaxpayer

V Spouse / / Spouse Jr HIGHER EDUCATION EXPENSES *]

Note:Manyofyourhighereducationexpenses qualify forspecial tax creditsand deductions.Others mayqualify asexclusionstromincomefortax-freeand/or penalty-freewithdrawals fromyourtax deferredsavings accounts.Pleaseprovideinformalion individually foreach student enrolledin a qualified institution.

Other Expenses (Enter amounts as theseexpenses may qualify for tax/penalty-free IRA withdrawals, student loan interestdeduction,or U.S.Savings BondInterest Income Exclusion)

1st Student 2nd Student 3rd Student

Room and Board

Note:V Ifstudent is attending less than 1/2 Time 1st Student 2nd Student 3rd Student Amount ofany Grants,ScholarshipsCode flVTaxpayer, S-Spouse, D1= Dependent 1,D2=Dependent 2)

JOB RELATED EDUCATION(Enter amounts only it job/career-related and only lor you and your spouse)Amount Amount Amount

SpouseTuition

Room and BoardFees,Books, Supplies

Booksand Supplies

V Seminar Fees JEMPLOYEE BUSINESS EXPENSES

Vehicle Info.

Vehicle 1

Vehicle 2

Date PlacedIn Service

/ /

/ /

Make Year Model Cost or Basis Yr? </

Furnish details on newlyacquired vehicles and trade-in or disposition of old vehicle

Vehicle Mileage Detail

J X If another vehicle is

available forpersonaluse

No.of round-trip milesfrom home to work

Number otdaysworked last year?

Odometer Reading

End of Year

Beginning ofYear

Business Miles

Personal Miles

Vehicle Vehicle 2

VehicleExpenses (If both taxpayer &spousehave deductions, use vehicle 1for taxpayer, 2 for spouse)Vehicle 1 Vehicle 2 Vehicle 1 Vehicle 2

Gas & Oil Parking/Tolls

Washing/Lube Licenses

Repairs/Maint. Lease Payments

Tires/Accessories Other

Insurance

Travel Expenses — Away from Home(DaysGone Overnight)Taxpayer Spouse Taxpayer Spouse

Transportation Auto Rentals

Lodging Cabs, Bus, etc.

\iReimbursement for AllExpenses Above— if not reported onW-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 (Musthave supportiverecords and receipts)

Meals&Tips Tickets & Events

Entertainment Gifts

Reimbursementfor Meals&Entertainmentonly - if not reported on W-2

Did youpurchaseanyotherbusinessequipmentduring the year? Yes • NoIfyes, attach information including: date bought, cost, description and trade-in details.

I have sufficient written evidence to supportuse of vehicles and deductions listed.

(Please Sign)

HOME OFFICEType of Business:

Justified for Businessor Professional Usefor: Taxpayer D Spouse D Both CDate Acquired Home Utilities

Land Cost Interest (Mortgage, Home Equity)

Home Cost Taxes

Improvement Cost Insurance

Sq. ft. of living area Rubbish & Maintenance

sample storage) Other:

I OTHER INFORMATION (youorspouse) For yes answers, attach detailed explanation. |1. Wereyou notifiedby the IRS or STATE of a change to any prioryear tax return? Yes • No D 18. Did you receive any source of income that is not listed in this booklet? Yes • NoD

2. Are any of your claimed dependents not residents or citizens of the U.S.? Yes • No • 19. Do you wish to designate S3.00 of your taxes to the Presidential You Yes • No •

3. Didyou make any gifts of over S14,000 to any individual? Yes D No • Campaign Fund (no cost to you)? Spouse Yes • No •

4. Do you have any foreign income or foreign bank accounts? Yes D No 20. Do you have a Medical or Health Savings Account (MSAor HSA)? Yes • No D

5. Didyou have living expenses ina foreigncountry as a result 21. Are you a same-sex couple considered legally married? Yes • No •

of income earned abroad? Yes D No • 22. Ifyou reached the age of 70^, have you begun your mandatory retirement

6. Do you have any worthless stocks, uncollectible bad debts, or were a victim saving withdrawals ? Yes • No a

of a ponzi scheme? Yes • No • 23. Did you receive employer provided educational assistance or

7. Didyou become disabled during (he year? YesD No • transportation benefits? Yes • No •

8. Are you a handicapped employee? Yes • No a 24. Did you pay long term healthcare insurance premiums or receivebenetits during the year? Yes ! : No •

9. Didyoureceiveznj distribution troman IRA, PiolitSharingor PensionPlan? Yes • No •Vh

10. Have you used bartering to exchange any goods or services? Yes D No • reimbursement? Please provide a recap of expenses for potential deduction. Yes • No •11. Have you or your dependents taken a distribution from a Qualified

TuitionProgram (QTP) or 529 program during the year? Yes D NoD26. Ifyou wouldlikeyour refund deposited directlyinto your bank account,

please attached a voided check or deposit slip, (up to 3 accounts)Yes • No •

12. Didyou receiveany insurance or other reimbursement froma prioryearcasualty, theft loss or medical deduction? Yes D No •

27. Didyou purchase any energy efficientequipment (hybridcar, AC,furnace, etc.)? Yes D NoD

13. Didyou start a new business during the year or do you expect to start one28. Didyou or yourspouse have qualifiedmilitary combat pay? Yes • NoD

this comingyear? Yes • No a 29. Doyouownbondsthatqualify forthe Gulf, Renewable EnergyorYes • NoD

14. Didyou pay anyone (over 18) $2,000 or more to workat your homeduring the calendar year? Yes D No a 30. Didyou purchase a new home this year? Yes • No •

15. Didyoudonate a partialinterest inany goods to charitableorganizations? Yes • No • 31. Ifoverage 708, didyoumakea directcontribution to a charityfroman IRA? Yes • No •

16. Do you have children under age 19 with investment income 32. Didyou make any major purchases during the year requiringpayment of

(age 24 if dependent student)? Yes • No • sales tax (including any new vehicles)? Yes • No D

17. Doyouexpectany significant changes in income,withholding taxes or your 33. Do all yourfamilymembers have health insurance? Yes • No •

V tax liability for the coming year? Yes D No a 34. Didyou receive any premium health insurance credits during the year? Yes • No •\t

>2017 Tenenz, Inc. • 800.888.5803 • www.tenenz.com |tax-ak>WM