Copyright ©​ Daniel Cullinane CPA.

Name and Address                                             Social Security Number          Birthdate                  Occupation​

Taxpayer_________________________________________________________________________________________________________________________________________________                  
Spouse____________________________________________________________________________________________________________________________________________________
Phone Numbers   Work ______________________        Home_______________________________________       Cell______________________________________________


email address ______________________________

​Do you wish $3 to go to the Presidential Election campaign          Circle     yes     no

HEALTH INSURANCE COVERAGE

YOU MUST PROVIDE PROOF OF HEALTH INSURANCE COVERAGE BEGINNING ON JANUARY 1, 2015

The IRS requires that you report certain information related to your health care coverage on your 2015 tax return. Please read the following statements carefully. More than one may apply to your tax family

​1) If you had health care coverage with a government Marketplace (Exchange) during 2015. Please provide Form 1095-A, issued by the Marketplace. In some family situations you may have more than one 1095-A

2) If you are claiming someone of your return who was included on another taxpayer's policy with a market place you will need a copy of that taxpayer's 1095-A

​3)If a dependent filed a return for 2015. Provide a copy of that return

4) If you had compliant health insurance through an employer plan, private policy or with a government plan and provide Form 1095-B, 1095-C or other proof of insurance document

​5 If you were issued a hardship exemption by the Marketplace (Exchange). Provide all applicable exemption certificate numbers issued for each member of your family.

6) Complete the information below if you or any individual included in your "tax family" did not have insurance coverage for any month of 2015.



































Please circle any months a member of your "tax family" was not insured

Name

Jan   Feb     March    April    May    June    July    August    September    October   November    December

Name
Jan    Feb    March    April    May    June    July    August    September    October    November    December

Name
Jan   Feb    March    April     May    June  July    August      September    October     November   December

Name
Jan   Feb   March    April    May     June   July   August       September     October     November    December


1 WAGES AND SALARIES    (ATTACH W-2S)


Name of payer

1_____________________________________________________
2_____________________________________________________
3_____________________________________________________
4_____________________________________________________
5_____________________________________________________


2  INTEREST INCOME           ( Attach 1099's)                              3  DIVIDEND INCOME  ( Attach 1099's)

Name of payer

1_____________________________________________________                      1_____________________________________________________


2_____________________________________________________                      2_____________________________________________________


3_____________________________________________________                      3_____________________________________________________


4_____________________________________________________                      4______________________________________________________


5_____________________________________________________                      5_______________________________________________________



4 CAPITAL GAINS AND LOSSES


Investment                                                  Date Acquired               Cost                      Date Sold                Net Proceeds

1 _________________________________________________________________________________________________________________________________

2__________________________________________________________________________________________________________________________________

3 _________________________________________________________________________________________________________________________________

4 _________________________________________________________________________________________________________________________________

5 _________________________________________________________________________________________________________________________________


5 OTHER GAINS AND LOSS


Investment                                                  Date Acquired               Cost                      Date Sold                Net Proceeds

1 ___________________________________________________________________________________________________________________________________


2 ___________________________________________________________________________________________________________________________________


3 ____________________________________________________________________________________________________________________________________

4 _____________________________________________________________________________________________________________________________________


6 PENSIONS, IRS DISTRIBUTIONS,  ANNUITIES,  AND ROLLOVERS   (Attach all 1099s)


Total Received _______________________________________________

Taxable Amount_____________________________________________ 


7 RENTS/ROYALTIES PARTNERSHIPS S CORPORATION  ESTATES TRUSTS    ( Attach all K-1s show receipts &expenes for rental property)


8 UNEMPLOYMENT COMPENSATION RECEIVED _____________________________________________________________________


9 SOCIAL SECURITY BENEFITS RECEIVED  ( Attach annual statement)

Total amount received ____________________________________________

10 STATE AND LOCAL TAX REFUND

Total amount received ______________________________________________

11 OTHER INCOME

1 Description _____________________________________________________________________  Amount Received_____________________________

2  Description _____________________________________________________________________Amount Received_____________________________

3  Description _____________________________________________________________________ Amount Received_____________________________

CREDITS

CHILD & DEPENDENT CARE

1 Number of Qualifying Individuals ( Children under age 12 or physically or mentally incapable of self care)

2 Providers Name                                                             Address                                                                                      Tax Identification number

a)_______________________________________________________________________________________________________________________________________

b)______________________________________________________________________________________________________________________________________


3 If payments were made to an individual, were the services performed in your home          Yes __________   No ____________


4 If yes were payroll reports filed                                                                                                                            Yes __________  No _____________

​5 Expenses incurred in connection with adoption                                                                                         Yes _________  No  _____________

6 Tuition and Fees


University                                                                        Address                                                                                        Tax Identification Number 

________________________________________________________________________________________________________________________________________________________



Books ______________________________________________________________   Tuition ______________________________________________________________________

ESTIMATED TAX PAYMENTS

Federal 
Date ____________    Amount ____________ Date _____________ Amount __________  Date ____________    Amount _________ Date _____________ Amount _                                                                 
State
Date ____________    Amount ____________ Date _____________ Amount __________  Date ____________    Amount _________ Date _____________ Amount 

ITEMIZED DEDUCTIONS

Medical and Dental

1 Out of pocket costs for prescription medicines, drugs, insulin, and insurance amount ________________________

TAXES

1 State and local taxes paid             Amount ____________________
2 General sales taxes paid                Amount ____________________
3 Real estate taxes paid                     Amount _____________________
4 Personal property taxes paid       Amount _____________________

INTEREST PAID

1 Home mortgage interest              Amount _____________________
2 Points                                                      Amount _____________________
3 Mortgage insurance premiums    Amount _____________________
4 Investment interest                       Amount _____________________

GIFTS TO CHARITY

1 Gifts by cash                                      Amount ______________________
2 Gifts other than cash                     Amount ______________________

CAUALTY AND THEFT LOSS  
Description                                        Amount _______________________





___________________________________________________________________________________________________________________________________________



​CLICK FOR PAGE 2



​INCOME TAX ORGANIZER

Daniel Cullinane CPA

25 Plaza 5 25th fl Jersey City NJ                                          phone 732-516-1648 fax 732-516-9778

MBA Taxation

Daniel Cullinane CPA

2500 Plaza 5 25th fl  Jersey City NJ 07311                                                          phone 732-516-1648  fax 732-516-9778

                 MBA TAXATION