For Your Tax Advisor 1

FOR YOUR TAX ADVISOR Your Name Sec. Sec. No Spouse's Name Sec. Sec. No Home Address City or Town State Zip DEPENDENTS Name Relationship No of Months Lived with you On December 31 st were you Married? On December 31 st was your spouse Blind? Did your wife (or husband) die recently? Did your spouse have income? Are you a Citizen or a resident Alien Blind? 65 or over? 65 or over? Date of death Deductions? Did you file a return last year? To which Collector's Office was it sent? Do you owe any federal taxes? AUTO FACTS Date Purchased Make of Car Cost 0dometer (Jan 1st - Dec 31st) Data Paid ESTIMATED TAX PAYMENTS Amount Date Paid Amount AFFIDAVIT I hereby certify that I have maintained adequate records as required by IRS (Return Preparer's Name) to rules and regulations re: travel, meals, entertainment, auto expenses and cellular telephone expenses for one calendar year. . Signature Data American LegalNet, Inc. www.FormsWorkFlow.com 2001 © American LegalNet, Inc.