FILING STATUS: (Circle One)

SINGLE   MARRIED   MARRIED FILING SEPARATE   HEAD OF HOUSEHOLD

DEPENDENTS (Add additional dependents as necessary)

	DEPENDENT #1	DEPENDENT #2
First Name & Initial
Last Name
Social Security Number
Date of Birth
Months Lived at Home

INCOME

SALARIES AND WAGES (ATTACH W-2’S)

	TAXPAYER	SPOUSE
Employer’s Name
Gross Wages
Federal Income Tax Withheld
FICA Withheld
Medicare Withheld
State Tax Withheld
TID Withheld
Other

INTEREST INCOME (ATTACH 1099-INT’S)

SOURCE	AMOUNT

DIVIDEND INCOME (ATTACH 1099-DIV’S)

SOURCE	AMOUNT

STATE TAX REFUND (ATTACH 1099-G’S)

SOURCE	AMOUNT

	Did you itemize your deductions in prior years?

BUSINESS INCOME (CONTACT Farmer and First CPA's FOR BUSINESS INCOME ORGANIZER)

CAPITAL GAINS AND LOSSES (ATTACH 1099-B’S AND BASIS DETAIL)

DESCRIPTION	PURCH DATE	SALE DATE	PROCEEDS	BASIS

IRA & PENSION DISTRIBUTIONS (ATTACH 1099-R’S)

SOURCE	ROLLOVER ?	DISTRIBUTION	TAXABLE AMOUNT

RENTAL INCOME (CONTACT Farmer and First CPA's FOR RENTAL INCOME ORGANIZER)

INCOME FROM PASS-THOUGH ENTITIES (ATTACH SCHEDULE K-1’S)

SOURCE	ACTIVE ?	AMOUNT

OTHER INCOME

	AMOUNT
ALIMONY INCOME
- If applicable, need payor’s name and social security number
UNEMPLOYMENT RECEIVED (ATTACH 1099-G)
SOCIAL SECURITY RECEIVED (ATTACH 1099-SSA)
SOCIAL SECURITY RECEIVED (ATTACH 1099-SSA)
MISCELLANEOUS INCOME
- If applicable, enter description and amount

ADJUSTMENTS TO INCOME

	TAXPAYER	SPOUSE
IRA Deduction
Keogh/SEP Deduction
SIMPLE Plan Deduction
Education IRA Deduction
Roth IRA Contribution
Student Loan Interest Paid
Penalty for Early Withdrawal of Savings
Alimony Paid – if applicable, please provide social security number of alimony recipient

ITEMIZED DEDUCTIONS

MEDICAL EXPENSES

	TAXPAYER	SPOUSE
Medical Insurance Premiums
Prescriptions
Doctors, Dentists, etc.
Hospital & Lab Charges
Other

TAXES PAID

	TAXPAYER	SPOUSE
State Income Taxes (not including W-2)
Real Estate Taxes
Personal Property Taxes
Fire Tax
Other

INTEREST PAID (ATTACH 1098’S)

	TAXPAYER	SPOUSE
First Mortgage
Second Mortgage
Equity Line
Investment Interest

CHARITABLE CONTRIBUTIONS (ATTACH ACKNOWLEDGEMENT LETTERS FOR GIFTS GREATER THAN $250)

	TAXPAYER	SPOUSE
Miscellaneous Cash or Check
Non-Cash Contributions
Charitable Mileage
- Please provide detail for all gifts > $250

MISCELLANEOUS DEDUCTIONS

	TAXPAYER	SPOUSE
Union/Professional Dues
Investment Expenses
Tax Return Preparation Fees
Safe Deposit Box
Uniforms and protective clothing
Work tools
Employee Business Expenses (not reimbursed)

TAX CREDITS

CHILD & DEPENDENT CARE CREDIT		

	DEPENDENT #1	DEPENDENT #2
Child Care Provider
Address
City State Zip
Child Care Expenses

LIFETIME LEARNING CREDIT

	TAXPAYER	SPOUSE
Educational Institution
Tuition and fees

ESTIMATED TAX PAYMENTS

	FEDERAL	STATE
Overpayment Applied from Prior Year
First Quarter – April 15, 1999
Second Quarter – June 15, 1999
Third Quarter – September 15, 1999
Fourth Quarter – January 15, 2000

MISCELLANEOUS QUESTIONS

	YES	NO
Has your marital status changed since 1998?
If you are married, do you want to file separate tax returns?
Has your mailing address changed since 1998?
Can another taxpayer claim you (or your spouse) as a dependent?
Were there any changes to your dependents during 1999?
Were child care expenses incurred while you were at work?
Do you have any children under 14 who have unearned income greater than $700?
Did you begin adoption proceedings or adopt a child in 1999?
Did you open a Roth IRA account or convert an existing IRA into a Roth IRA during 1999?
Did you convert an IRA into a Roth IRA during 1998? If yes, did you elect to spread the resulting income over four years?
Did you buy, sell or refinance your first or second home during 1999? If yes, please provide copies of the closing documents.
Did you use your car for work and incur expenses that were not reimbursed?
Does anyone owe you money that has become uncollectible?
Have you been notified by the IRS or state taxing authority of any changes to your prior year income tax returns?
Do you expect an significant changes to your income in 2000?