Name:                       

Company (If applicable):   

Street or P.O. Box:   

City:                          

State:                        

Telephone number:           

e-mail address:          

Please provide the following information:

           1. How many Form(s) W-2 did you receive: 

           2. How many Form(s) 1099 DIV did you receive: 

           3. How many Form(s) 1099 INT did you receive: 

           4. How many Form(s) 1099-R did you receive: 

           5. Do you have a business (sole proprietor): Yes No

                     If yes, indicate how many separate businesses: 

           6. Do you have rental real estate: Yes No

                     If yes, indicate how many rental properties:

           7. Did you operate a farm or ranch:  Yes No

                     If yes, indicate how many: 

           8. Did you have a home mortgage:  Yes No

           9. Did you pay real estate taxes:  Yes No

           10. Did you make charitable contributions:  Yes No

           11. Did you have moving expenses:  Yes No

           12. Did you sell stock, mutual funds, or bonds:  Yes No 

                     If yes, indicate how many transactions (approximate):   

           13. Were you a shareholder in an S-Corp:  Yes No

                     If yes, indicate how many S-Corp's:      

           14. Were you a member of an LLC:  Yes No     

                     If yes, indicate how many LLC's:     

           15. Were you a partner in a partnership:  Yes No

                     If yes, indicate how many partnerships: 

           16. For which state(s) do you need to file a return(s):