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


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



TAX RETURN QUESTIONAIRE  2016 TAX YEAR




OUR

 GOAL IS                                                  SMOOTH  

​     SAILING

               DANIEL CULLINANE CPA                                                              Phone:          732-516-1648

                           Certified Public Accountants                                                                                        FAX               732-516-9778

                               328 Amboy Ave, Metuchen NJ   08840                                                              

                                                                                                                                     


​                            

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










































DEPENDENTS

Full Name________________________________________________________________________________________                                                                              

 Income                     Social Security #                               Relationship                        Months lived in home            Date of Birth

________________________________________________________________________________________________________

Full Name  _____________________________________________________________________________                                                                             
 Income                     Social Security #                               Relationship                        Months lived in home             Date of Birth

________________________________________________________________________________________________________

Full Name ____________________________________________________________________________________                                                                              
 Income                     Social Security #                               Relationship                        Months lived in home             Date of Birth

________________________________________________________________________________________________________

Full Name  ___________________________________________________________________________________                                                                             
 Income                     Social Security #                               Relationship                        Months lived in home             Date of Birth

________________________________________________________________________________________________________

​Full Name  __________________________________________________________________________________                                                                             
 Income                     Social Security #                               Relationship                        Months lived in home             Date of Birth

____________________________________________________________________________________________