If any of the following items pertain to you or your spouse for ,
please check the appropriate box and include all pertinent details.
Attach additional schedules if necessary.

First Name:
Last Name:
Phone:
 
 
 
 
 
     
 
 
 
 
 
PERSONAL INFORMATION
 
YES
 
 NO
 
 
 
 
 
Did your marital status change during the year?
 
 
 
Did your address change during the year?
 
 
 
Could you be claimed as a dependant on another person's tax return for
 
 
 
 
 
 
 
 
 
 
 
DEPENDENTS 
 
 YES
 
 NO
 
 
 
 
 
Were there any changes in dependents?
 
 
 
Were any of your unmarried children who might be claimed as dependents 19 years of age or older at the end of ?
 
 
 
Did you have any children under age 14 on January 1, 2002 with interest and dividend income in excess of $750, or total investment income in excess of $1500?
 
 
 
 
 
 
 
 
 
 
 
TAX REBATE/ADVANCE PAYMENT 
 
 YES
 
 NO
 
 
 
 
 
Did you receive a tax rebate/advance payment from the Internal Revenue Service?
If yes, specify the amount. $
 
 
 
 
 
 
 
 
 
 
 
INCOME
 
 YES
 
 NO
 
 
 
 
 
Did you receive unreported tip income of $20 or more in any month?
 
 
 
Did you cash any Series EE U.S. savings bonds issued after 1989 and pay qualified higher education expenses for yourself, your spouse, or your dependents?
 
 
 
Did you receive any disability income?
 
 
 
Did you have any foreign income or pay any foreign taxes?
 
 
 
 
 
 
 
 
 
 
 
PURCHASES, SALES AND DEBT
 
 YES
 
 NO
 
 
 
 
 
Did you start a business or farm, purchase rental or royalty property, or acquire an interest in a partnership, S corporation, trust, or REMIC?
 
 
 
Did you purchase or dispose of any business assets (furniture, equipment, vehicles, real estate, etc.), or convert any personal assets to business use?
 
 
 
Did you buy or sell any stocks, bonds or other investment property? Specify the date of any collectibles (e.g., artwork, gems, stamps, coins) and any qualified small business stock.
 
 
 
Did you purchase, sell, or refinance your principal home or second home, or did you take a home equity loan?
 
 
 
Did you have any debts cancelled or forgiven?
 
 
 
Did anyone owe you money which had become uncollectible?
 
 
 
 
 
 
 
 
 
 
 
RETIREMENT PLANS
 
 YES
 
 NO
 
 
 
 
 
Did you receive a distribution from a profit-sharing plan, retirement plan, or individual retirement arrangement (including Traditional IRA, Roth IRA, and Education Savings Account)?
 
 
 
Did you convert from a Traditional IRA to a Roth IRA?
 
 
 
Did you contribute to a Traditional IRA, Roth IRA, or Education Savings Account?
 
 
 
 
 
 
 
 
 
 
 
ITEMIZED DEDUCTIONS
 
 YES
 
 NO
 
 
 
 
 
Did you incur a loss because of damaged or stolen property?
 
 
 
Did you work out of town for part of the year?
 
 
 
Did you use your car on the job (other than to and from work)?
 
 
 
 
 
 
 
 
 
 
 

MISCELLANEOUS

 
 YES
 
 NO
 
 
 
 
 
Do you want to allocate $3 to the Presidential Election Campaign Fund?
 
 
 
Does your spouse want to allocate $3 to the Presidential Election Campaign Fund?
 
 
 
May the IRS discuss this return with the preparer?
 
 
 
Did you have an interest in or signature of other authority over a financial account in a foreign country, such as a bank account, securities account, or other financial account?
 
 
 
Did you receive a distribution from, or were you the grantor of, or transferor to, a foreign trust?
 
 
 
Was your home rented out or used for business?
 
 
 
Did you have a medical savings account (MSA), a Medicare + Choice MSA, or acquire an interest in and MSA or a Medicare + Choice MSA because of the death of the account holder? Or, were you a policyholder who received payments under a long-term care (LTC) insurance contract or received any accelerated death benefits from a life insurance policy?
 
 
 
Did you incur moving expenses due to a change of employment?
 
 
 
Did you incur any adoption expenses?
 
 
 
Did you engage the services of any household employees?
 
 
 
Were you notified or audited by either the Internal Revenue Service or the State taxing agency?
 
 
 
Did you or your spouse make any gifts to and individual that total more than $10,000, or any gifts to a trust?