Client Tax Information Sheet

BROOKWOOD TAX SERVICE

4 Montclair Dr., NE

Atlanta, GA 30309-1527

404-915-6268

Fax 404-892-2559

brookwoodtax@mindspring.com

NOTE: New clients please fill in all boxes in top half of page – returning clients indicate only where there are changes.

If any dependent child did not live with you, write child’s name here:

If another taxpayer can claim you or your spouse as a dependent, check this box.

IRA Contributions: Taxpayer $ Spouse $

Traditional Roth    Traditional Roth

SIMPLE/SEP/KEOGH Contributions: Taxpayer $ Spouse $

Alimony Paid $ Recipient: SSN:

Federal Estimated Tax Payments $ Job-Related Moving Expenses $

State Estimated Tax Payments $ Lodging Expenses During Move $

State Tax Due Paid with 2002 Return $ Miles Traveled to New Home:

Dependent Cared For:

Care Provider’s Name: Provider’s SSN/EIN:

Provider’s Address Amount Paid to Provider: $

Dependent Cared For:

Care Provider’s Name: Provider’s SSN/EIN:

Provider’s Address Amount Paid to Provider: $

1. Has the IRS or any state or local taxing agency notified you of any change to a prior year tax return? Yes No

2. Are any dependents claimed by you not citizens or residents of the U.S.? Yes No

3. Do you (or your spouse) wish to designate $3.00 of your taxes to the Presidential Campaign Fund? Taxpayer Yes No   Spouse Yes No

4. Did you or your spouse receive income from any source not listed elsewhere in this questionnaire? Yes No

5. Did you or your spouse barter goods or services with others? Yes No

6. Did you or your spouse receive any distributions from an IRA, pension or profit-sharing plan? Yes No

7. Do you have any children age 14 or under who have investment income? Yes No

8. Did you move during the past year? Yes No

9. Did you or your spouse start a new business in the past year or do you anticipate starting one in the current or next year? Yes No

10. Do you expect any significant changes in income, tax withholding or tax liability in the next year? Yes No

11. Did you or your spouse make gifts to any individual of more than $11,000? Yes No

12. Did you or your spouse pay premiums or receive benefits from long term care insurance? Yes No

13. Did you or your spouse receive educational benefit payments from your employer? Yes No

14. Did you, your spouse or a dependent attend post-secondary school? Yes No

15. Are you or your spouse paying off a student loan? Yes No

16. Did you pay anyone who is over age 18 $1,300 or more to work at your home during the year doing housework, yard work or other domestic help? If so, provide details and amounts. Yes No

17. Did you or your spouse become disabled during the year? Yes No

18. Are you or your spouse handicapped employees? Yes No

19. Do you or your spouse have a foreign bank or investment account? Yes No

20. Did you or your spouse have earned income and living expenses while working outside of the United States? Yes No

21. Did you or your spouse open a medical savings account during the year? Yes No

22. Did you have a casualty loss due to conditions in a Presidentially-declared disaster area? Yes No

23. Did you receive reimbursement from insurance or another source for prior year casualty losses or medical deductions? Yes No

24. If you or your spouse have reached age 70 and a half, have you begun your mandatory withdrawals from retirement savings accounts? Yes No

Write Details of Yes Answers in The Space Below – Also Any Other Information or Questions

No. Details