Valley Professional Services

Payroll, Bookkeeping, Tax Preparation, Incorporation

Online Tax Form

STATE/LOCAL

T for Taxpayer
S for
Spouse

Employer's state ID number

State wages, tips, etc.

State income tax

Local wages, tips, etc.

Locality name

**We STRONGLY suggest you have all the information for this form available before you fill it out.**
If you click the "RESET" button, you will have to start over from the beginning.
This Form does NO calculations. Please verify all information before submitting.

Name
Address
City
State
Zip
Telephone
Fax
Email
Taxpayer's Social Security #
Age
Occupation
Birthdate
Spouse's Social Security #
Age
Spouse's Occupation
Spouse's Birthdate

W-2 Income Form

FEDERAL

T for Taxpayer
S for Spouse

Employer
ID# (EIN)

Employer's
name, address, and ZIP code

Wages

Federal
Income Tax
Withheld

Social
Security wages

Social Security
Tax Withheld

Medicare
wages and tips

Medicare
tax withheld

Social security
tips

Allocated
tips

Advance
EIC payment

Dependent
care benefits

Nonqualified
plans

2006 Totals

12a Code

12b Code

12c Code

12d Code

Statutory employee

Retirement plan

Third-party sick pay

Other

Interest Income

Name of Payor (Please fax all Forms 1099-INT and 1099-OID)	Banks, Credit Unions, etc.	U.S. Government Obligations	Other State Municipal Bonds	Home State Municipal Bonds	2001 Gross Amount

	Taxpayer	Spouse
Penalty paid for early withdrawal of savings
Total Federal Income Tax withheld from all Forms 1099

Interest Income listed above received on behalf of another
Did you cash any Series EE U.S. Savings Bonds (issued after 1989) to pay for education expenses?	Yes No

Dividend Income

Form 1099-R

(Please fax all Forms 1099-R)
PAYER'S name, street address, city, state, and ZIP code	PAYER'S Federal ID#	RECIPIENT'S ID#	RECIPIENT'S Name	RECIPIENT'S Street address (including apt. no.)	RECIPIENT'S City, state, and ZIP code	Account #
Gross distribution	2a Taxable amount	2b Taxable amount not determined Total distribution	Capital gain (included in box 2a)	Federal income tax withheld	Employee contributions or insurance premiums	Net unrealized appreciation in employer's securities
	Distribution code(s) IRA/SEP/SIMPLE	Other %	Your percentage of total distribution %	Total employee contributions	State tax withheld	State/Payer's state no.
	State distribution	Local tax withheld	Name of locality	Local distribution

Alimony Paid

Name	Social Security Number	Amount

Student Loan

Taxpayer		Dependent Taxpayer
Spouse		Dependent Spouse

Seller-Financed Mortgage Interest

Payor's Name
City
State
Zip
Social Security #
Amount Received

Do you have authority or an interest in a foreign bank?	Yes No
If YES, identify foreign country
Did you have tax withheld by a foreign country on interest or dividends?	Yes No

Miscellaneous Income

Code

1 = Business Income & SE Applies	2 = Business Income & SE Does Not Apply
6 = Gambling Winnings	10 = Jury Pay

TSJ	Misc Income Source	Code	Amount

Dependents, Child Care, and Education Credit

Dependent Information

C = Child at Home (default)	S = Student under 24 /EIC
N = Child NOT at home	X = No Dependent /EIC
D = Disabled child at home /EIC	P = Parent
Q = Nondependent Qualifier	O = Other

Enter Name(s) of child/children listed above who are:

Earning more than $2,900
Living with you but claimed dependent by another
Receiving more than 50% support from another source
Are deaf, blind or disabled

Child Care Expenses

Child 1

First Name
Last Name (if Diff)
Soc. Sec. #
Birth Date
Relationship
% CA Phys Custody
Care Provider:
Name
Address
City
State
Zip
Phone #
SSN
Employer ID
Amount

Child 2

First Name
Last Name (if Diff)
Soc. Sec. #
Birth Date
Relationship
% CA Phys Custody
Care Provider:
Name
Address
City
State
Zip
Phone #
SSN
Employer ID
Amount

Number of Months that you or your spouse were a full-time student or disabled

Taxpayer

Spouse

Education Credits

Indicate which type of credit is being claimed. Also enter the amount of expenses (does not include Room, Board, Insurance, Transportation or other similar living expenses) incurred- tuition, enrollment/attendance fees -for the student. Indicate whether the taxpayer, spouse or a dependent was a student at an accredited Post-Secondary Institution such as a college or university. If the student is your dependent, also enter their first and last name and social security number.

Student 1
Check if:	Hope Credit Lifetime Earning Credit
Qualified Expenses
Check if student is:	TP SP Dependent
If student is a dependent enter:
First Name
Last Name
Social Security #

Student 2
Check if:	Hope Credit Lifetime Earning Credit
Qualified Expenses
Check if student is:	TP SP Dependent
If student is a dependent enter:
First Name
Last Name
Social Security #

Itemized Deductions

Medical Expenses

Hospitals/ Nursing Homes
Doctors, Dentists, etc.
Insurance Premiums

Long Term Care Provider:	Taxpayer
	Spouse
	Other

Prescription Medicine
Glasses, Hearing Aids, etc.
Automobile:
-miles traveled; OR
-actual expenses
Insurance Reimbursements
Other (description and amount)

Taxes Paid

Real Estate Taxes
Personal Residence
Investment Property
Vehicle License Fee (does not include registration fee portion)
Personal Property Tax
Taxes Paid to Another State
Name of State
Prior Year State/Local Taxes
State, Local WH and Estimates
Foreign Taxes Paid
Other Taxes (list)

Mortgage Interest

Paid to Financial Institutions
Name		Amount
Name		Amount
Name		Amount

-form 1098 in anothers name (list name address, S.S.N., & amount below)

Name
City
State
Zip
S.S.N.
E.I.N.
Amount

-Paid to an Individual (list name address, S.S.N., & amount below)

Name
City
State
Zip
S.S.N.
E.I.N.
Amount

Points from Form 1098
Points NOT on Form 1098

Investment Interest

Margin Accounts
Real Estate
Other Interest (list)

Contributions

Cash:
Church / Temple
Payroll Deductions
Micellaneous
Auto Use:
miles used; OR
Actual Expenses
Other Cash Contributions (list)
Noncash (Complete noncash information if over $500)
Thrift Shops
Other Noncash Contributions (list)

Miscellaneous Deductions

Union and Professional Dues
Tax Preparation Fees
Supplies
Investment Expense
Miscellaneous
Other Miscellaneous Deductions (list)

Other Deductions

Casualty Loss
Gambling Loss
State Lottery Losses
Political Contributions (HI)
Estate Tax Deduction
Other (list)

Retirement Plans, Moving Expenses & Other Deductions

Contributions Made During the Year:

Taxpayer

Date

Amount

Spouse

Date

Amount

Simple Plan
Compute the Maximum SEP or Keogh*
15% Keogh or SEP Plan
25% Keogh Plan
Defined Benefit Plan
Traditional IRA
Roth IRA
Education IRA**

* Maximum Code 1 = 15% Plan, 2 = 25% Plan, 3 = Both Plans
** Contributions to an Educational IRA - Bring Name and Social Security Number of each person

	Yes	No
Are you or your spouse covered by a retirement plan at work?
If contributions have not yet been made, limit your contribution to a deductible amount?
Do you wish to make a nondeductible contribution?
If you maintain a Keogh plan, specify type:
Did you receive any plan distribution?
Specify type:
Did you make contributions to a Roth IRA?
Did you make contributions to an Educational IRA?
Did you rollover any fund from one type of IRA plan to another type of plan?
Specify type:

Note: If you have received any IRA distributions in 2001 or opened or transferred funds to a new type of plan (Keogh, Traditional IRA, Roth IRA, Simple IRA, or Educational IRA), please fax any documentation.

Moving Expenses

Date moved from old residence
Date arrived at new residence
Miles from old home to new work place
Miles from old home to old work place
Expenses incurred:
Transportation/household goods
Travel and lodging expenses (no meals)

Employer reimbursement from (W-2, Box 13, Code P)
Check if Qualified Armed Forces Move

Old Employer:	Name
	Address
New Employer:	Name
	Address

Other Information, Comments or Questions:

42171-1/2 B Big Bear Blvd.
Big Bear Lake, CA 92315
Voice: 909.878.5188 * Fax: 909.878.3826

We are located in the Stater Brothers shopping center.