2011 TAX RETURN PREPARATION QUESTIONNAIRE

2011 PIN Applicant Spouse To be filled in by Tax Preparer Office ONLY

PERSONAL INFORMATION
Primary Applicant: LastName FirstName: Middle/Initial Name: Date of Birth: Current Address: Phone Occupation: Spouse: LastName FirstName: Middle/Initial Name: Spouse DOB Have you changed your name since your last return? (circle) (Yes/No): If yes, what was your previous Surname? Home Email Address Work Email Address

SSN #: Mobile:

SSN#/ITIN #:

DEPENDANT CHILDREN
Child's Name SSN/ITIN Date of Birth Relationship How long lived with you

WAGES INFORMATION: (Please send copies of W2/1099)

Company Name Title From To W2/1099

INTEREST INCOME: (Please send copies of Bank interest document 1099-INT)

Financial Institution (Police Credit Union, Bank etc) Amount

DIVIDEND INCOME (If unsure, enclose Statement from Company)

Name of Public Company Unfranked Amount Franked Amount Imputation Credit

STOCK GAIN/LOSS (If unsure, enclose Statement from Company)

Name of stock Purchase Date Purchase Value Number of Stocks Sale Date Sale Value

CHILD CARE EXPENSES: (Please send copies if received from care provider)
Care Provider Name Address EIN or SSN or ITIN of the provider From To Amount

DEPENDENT CARE EXPENSES

Expense Type Name From To Amount

SELF EDUCATION EXPENSES. ( Course taken at educational institution and connected to your current job)
Course Name Amount

Student Union Fees Course Fees ( Not HECS Contributions) Travel (use of private vehicle, taxi, public transport ) Reference Books/Stationery Equipment

Commuting Expenses:
Commuting Type Mileage: Distance from working place and home If by Train, please provide per day travel expenses If by Air, please provide details on air, rental car expenses.

DEPRECIABLE EQUIPMENT (Computer, Office furniture, printers, library, GPS, camera etc over $300 in value)
Description Date of Purchase Purchase Price Private Use Portion (%)

OTHER WORK RELATED DEDUCTIONS:

Amount Laundering of Uniform/Corporate Ware Max $150 without receipts Dry Cleaning of Uniform/Wardrobe Purchase of Protective Clothing Purchase of Protective Footwear Uniform Sewing and Medal Expenses Purchase of Corporate Wardrobe Use of Private Telephone for Employment Computer Stationery for Employment Use of Private Mobile Phone for Employment Internet Expenses (work only) Journals and Periodicals Seminars and Courses Union Fees/Subscriptions Sunglasses, sunhats and sunscreens Legal Fees OSG Fitness Expenses ID Wallet (Police) Reference Books Teaching Aids Parking and Toll Expense. Carrybag. OSG Equipment Portable Radio Holder (Police only ) Leather man Tool or similar (Police) Knife, Torch and Batteries Excursion Expenses (Teachers) Stationery Street Directory Tools and Equipment First Aid Course Amount

PROPERTY In US/India:
Property name on: Last Name: Property Address: Date of Purchase (MM/DD/YYYY) Interest paid from 1st Jan - 31st Dec, 2011 (In $$) First Name :

Apartment Rent in US: Rental Office Address in US:

Ownership % Last Name First Name/s

Date of Purchase Gross Rental Income $ Depreciation. Loan Interest On Borrowed Monies Land Rates Water Rates Commission to Real Estate Strata Fees (Body Corporate Expense) Borrowing Expenses Pest Control. Leasing/Letting Fees/Advertising Travel Expenses (Kilometres or $ airfare please) Accommodation Expenses (if long distance) Gardening/Lawn Mowing Landlord Insurance Postage Expenses Repairs & Maintenance Bank Charges Depreciation Inspection Report. Amount

Date of 1 st Rental

No of Weeks Rented

Note. If you have an annual financial report from your real estate, please enclose.

PRIVATE HEALTH INSURANCE.

Do you have private medical cover the entire year. If you have no private health insurance and your income is over 70K (140K for family) you will be charged an extra 1% Medicare levy. What was your spouses income if a family? No. (see next question)

DONATIONS

AMOUNT

EDUCATION OFFSET EXPENSES (Primary School Max $375, High School Max $750 per child)
School Stationery and textbooks etc Computer ComputerRelated Equipment Home Internet School Stationery and textbooks etc Tools of Trade Amount

DIRECT DEBITING: If you would like your tax refund direct debited to your nominated account please provide me the following
a. Account Name b. Account Number c. Routing Number d. Type of Account: