Rukosky & Associates Financial Group, Inc. © Page 1 of 2

Rukosky & Associates Financial Group, Inc. Tax Organizer

Please complete this form and fax, email, or drop if off at least three full days before your scheduled appointment, along with applicable forms listed in Section 4.

1. Personal Information – IF any of the information below has changed, please update in the appropriate fields

Name Social Security # Date of Birth Occupation

Taxpayer

Spouse

Address City State Zip

Home Email Cell #

Work Email Work #

Taxpayer Spouse Marital Status

Blind Yes No Blind Yes No Married

Disabled Yes No Disabled Yes No Single

Pres. Campaign Fund Yes No Pres. Campaign Fund Yes No Legally Separated

2. Dependents (Children and Others) – list ONLY new additions or deletions

Name (First, Last)

Relationship To You

DOB SSN Months Lived

With You Disabled?

Full Time Student?

Gross Income

3. Miscellaneous Income and Expense – please answer ALL questions

1. Are you self-employed or do you receive hobbyincome?

Yes 7. Were there any births, deaths, marriages, divorces, or adoptions in your immediate family?

Yes

2. Did you receive rent from real estate or other property?

Yes 8. Did you give a gift of more than $14,000 to one or more people?

Yes

3. Did you make any withdrawals from a mutual fund or did you sell stocks/bonds?

Yes 9. Did you have any debts cancelled, forgiven, or refinanced? Was your home foreclosed on?

Yes

4. Do you have a foreign bank account, trust, or business?

Yes 10. Did you go through bankruptcy proceedings? Yes

5. Did you provide a home for or help support anyone not listed in Section 2?

Yes 11. Did you pay interest on a student loan for you, your spouse, or a dependent during the year?

Yes

6. Did you pay expenses or tuition for you, your spouse, or your dependent(s) to attend classes

Yes 12. Did you receive correspondence in 2015 from theIRS or your State Revenue Dept?

Yes

beyond high school this past year?

Rukosky & Associates Financial Group, Inc. © Page 2 of 2

13. Did you have any children under the age of 19, or

a student age 19-23, with unearned income Yes 18. Did you receive an inheritance in 2015? Yes

(stocks, dividends) of more than $2,100? 14. Did you refinance your home in 2015? Yes 19. To your main residence, did you install a solar

water heater, solar panels, generator, or energy Yes

efficient home improvements such as exterior doors, windows, insulation, heat furnaces, central

air conditioners, or water heaters? 15. Were you required to take a Required Minimum

Distribution in 2015? Yes 20. Were you on active military duty in 2015? Yes

16. Did you incur job search expenses in 2015? Yes 21. Did all members of your household have health

insurance for all of 2015? Yes

17. Did you or your spouse purchase health insurance

in 2015 and receive a subsidy from the Federal Yes

government to help pay for the insurance?

4. Forms Checklist – please collect all forms BEFORE making an appointment

W-2 forms Bank interest income (Form 1099-INT) Dividend income (Form 1099-DIV) Stock reports (Form 1099-B) Partnership income (schedule K-1) Pension distributions (Form 1099-R) Mortgage interest (Form 1098) Tuition (Form 1099-T) Self-employed income (Form 1099-MISC) Spreadsheets, QB file(s), bank statements (for self-employed) Vehicle property tax Home property tax IRS contribution (Form 5498) Other

5. Business Owners Only – please be sure to bring this information with you!

Date, cost, and description of new equipment (or auto) purchased

Date, cost, and description of any equipment (or auto) sold

Auto mileage: total miles driven on each vehicle and business miles driven on each vehicle

S Corp owners: the balance in your checking account on 12/31/2015 and if you took out business loans, we need the original

amount of the loan, the amount of interest paid on the loan, and the loan balance on 12/31/2015

Please thoroughly review this form and gather your documents before scheduling an appointment. Should you have questions, please contact us.

Thank You!

Office: (919)781-9319

Fax: (919)791-0990

Email: mytaxdocs@rafginc.com

Address: 4904 Professional Court, Suite 102 Raleigh, NC 27609

Rukosky & Associates Financial Group, Inc. Is Focused On Your Financial Well-Being

Rukosky & Associates Financial Group, Inc. ©

If you aren’t already aware, the future pensions, Social Security, and 401(k) employer-matching is poised for

change. You come here for our tax expertise; however, did you know that we also prepare over 25 Retirement,

Debt Elimination, and College Education plans for our clients each year?

This tax season, look after your future … at no cost to you! You can either provide us with your retirement savings

reports when you come in (401(k), 457, 403(b), IRA, annuities, stock reports, etc.) or fill out the form below. You

will receive a tailored Retirement Plan as well as have the option to receive a 40 minute consultation at no cost to

you.

Click or cut and paste this link to see an example Retirement Report http://myifinplan.com/wp-content/uploads/2015/04/New-Retirement-Report.pdf

Current Balance Investment Type Yours or

Your Spouses?

Work or Personal

Investment

To Be Used For …

Example $10,000 Roth IRA Spouse Personal Mortgage Payoff

Example $35,000 IRA Mine Personal Retirement

Example $15,000 Certificate of Deposit Spouse Personal Home Repairs

Example $25,000 Stocks Mine Personal Second Home

Example $65,000 Annuity Spouse Personal Grandchildren

Example $25,000 Savings Account Mine Personal Emergencies

Example $100,000 401(k)/403(b)/457 Mine Work Retirement

Example $5,000 Bonds Mine Personal Child Education

At What Age Will You Retire?

At What Age Will Your Spouse Retire?

Current Balance Investment Type Yours or

Your Spouses?

Work or Personal

Investment

To Be Used For …

Investment #1

Investment #2

Investment #3

Investment #4

Investment #5

Investment #6

Investment #7

Investment #8

Investment #9

Investment #10

VALUATION GUIDE FOR DONATED PROPERTY

Rukosky & Associates Financial Group, Inc. © Page 1 of 2

Merchandise Donated By:

Last Name First Name

Name of Charity Date of Donation

Street Address City/State/Zip

The following price ranges are provided for your convenience in recording your donation(s). The values are obtained from annual surveys of consignment and/or thrift stores, conforming to IRS requirements for valuing donated items.

ASSIGNING VALUES FOR TAX PURPOSES IS THE DONOR’S RESPONSIBILTY

CHILDREN’S CLOTHING MEN’S CLOTHING

Description Good Condition Fair Condition Total Description Good Condition Fair Condition Total

Qty. Price Qty. Price Qty. Price Qty. Price

Blouses 8.00 2.00 Jackets 25.00 7.50

Boots 20.00 3.00 Overcoats 60.00 15.00

Coats 20.00 4.50 Pajamas 8.00 2.00

Dresses 12.00 3.50 Pants/Shorts 10.00 3.50

Jackets 25.00 3.00 Raincoat 20.00 5.00

Jeans 12.00 3.50 Suits 60.00 15.00

Pants 12.00 2.50 Slacks 12.00 5.00

Snowsuits 19.00 4.00 Shirts 12.00 2.50

Shoes 8.75 2.50 Sweaters 12.00 2.50

Skirts 6.00 1.50 Shoes 25.00 3.50

Sweaters 8.00 2.50 Swim Trunks 8.00 2.50

Slacks 8.00 2.00 Tuxedo 60.00 10.00

Shirts 6.00 2.00 Undershirts 3.00 1.00

Socks 1.50 .50 Undershorts 3.00 1.00

Underwear 3.50 1.00 Belts/Ties 8.00 3.00

Misc. Misc.

Misc. Misc.

Total Total

VALUATION GUIDE FOR DONATED PROPERTY

Rukosky & Associates Financial Group, Inc. © Page 2 of 2

LADIES CLOTHING HOUSEHOLD ITEMS AND FURNITURE

Description Good Condition Fair Condition Total Description Good Condition Fair Condition Total

Qty. Price Qty. Price Qty. Price Qty. Price

Blouses 12.00 2.50 Bedroom Sets 1000.00 250.00

Bathrobes 12.00 2.50 Dining Rooms 900.00 150.00

Boots 5.00 2.00 Kitchen Sets 170.00 35.00

Bras 3.00 1.00 Double Beds 170.00 50.00

Bathing Suits 12.00 4.00 Single Beds 100.00 35.00

Coats 40.00 10.00 Air Condition Units

90.00 20.00

Dresses 19.00 4.00 Bars 75.00 30.00

Evening Dresses

60.00 10.00 Bar Stools 20.00 10.00

Fur Hats 15.00 7.00 Bicycles 65.00 15.00

Fur Coats 400.00 25.00 Conventional Sofas

300.00 85.00

Undergarments 8.00 3.00 Cribs 100.00 25.00

Hats 8.00 1.00 Strollers 100.00 5.00

Jackets 12.00 4.00 Coffee Tables 65.00 15.00

Nightgowns 12.00 4.00 Dressers/ Mirrors

100.00 20.00

Pant Suits 25.00 6.50 Desks 140.00 25.00

Socks 1.25 .40 Dryers 90.00 45.00

Suits 25.00 6.00 Stoves 150.00 75.00

Shoes 25.00 2.00 End Tables 50.00 10.00

Skirts 8.00 3.00 Lamps 40.00 7.50

Sweaters 15.00 3.00 Heaters 22.00 7.50

Slips 6.00 1.00 High Chairs 50.00 10.00

Slacks 12.00 3.50 Kitchen Tables 60.00 25.00

Handbags 20.00 2.00 Pianos 200.00 75.00

Misc. Paintings 200.00 5.00

Total Pool Tables 75.00 20.00

MISCELLANEOUS Play Pens 30.00 15.00

Description Good Condition Fair Condition Total Stereo Equip. 90.00 30.00

Qty. Price Qty. Price Rugs 90.00 20.00

Blankets/ Comforters

24.00 3.00

Refrigerators 250.00 75.00

Computers 500.00 150.00 Sofas 200.00 35.00

Lawn Mowers 250.00 100.00 Televisions 225.00 75.00

Sewing Machines

75.00 15.00 Washer/

Dryers 150.00 50.00

Vacuum Cleaners

60.00 20.00

Misc.

Misc. Misc.

Total Total

UNREIMBURSED MEDICAL EXPENSE WORKSHEET

Rukosky & Associates Financial Group, Inc. © Page 1 of 2

Last Name First Name Tax Year

Note: It may be POSSIBLE to deduct these expenses; however, your ability to deduct these items depends on your

personal situation. ONLY your tax advisor can assist you in making the proper determination.

Out of Pocket Medical Expense Taxpayer Spouse

Prescription medications $ $

Health insurance premiums (NOT out of paycheck)

$ $

Gross LTC premiums $ $

Dependent and/or child under 27 health insurance $ $

Doctor and/or dentist (expenses and/or co-pays) $ $

Hospitals and/or clinics (expenses and/or co-pays) $ $

Labs and/or x-rays $ $

Long-Term Care $ $

Eyeglasses and/or contacts $ $

Medical equipment and/or supplies $ $

Other medical expense (ambulance, etc.) $ $

Lodging for medical purpose $ $

Birth Control $ $

Legal Abortion $ $

Acupuncture $ $

Alcoholism for inpatient’s treatment at a therapeutic center, INCLUDING meals/lodging

$ $

Amounts paid for transportation to/from REQUIRED Alcoholics Anonymous meetings (not mileage expense, see below)

$ $

Annual physical examination $ $

Artificial teeth $ $

Bandages $ $

Electronic body scans $ $

Breast pump and/or supplies (that assist lactation) $ $

Breast reconstructive surgery and/or breast prosthesis, FOLLOWING a mastectomy due to cancer.

$ $

Home construction pertaining to medical needs (e.g. installation of entrance/exit ramps, installing railings, support bars, modifying stairs, installing porch lifts and other forms of lifts, etc.)

$ $

Car modifications for special hand controls and/or other special equipment for MEDICAL reasons

$ $

Chiropractor $ $

Crutches $ $

Diagnostic devices $ $

UNREIMBURSED MEDICAL EXPENSE WORKSHEET

Rukosky & Associates Financial Group, Inc. © Page 2 of 2

Drug addiction for an inpatient’s treatment at a therapeutic center for drug addiction, INCLUDING meals/lodging

$ $

Eye surgery $ $

Fertility Enhancement (e.g. procedures such as in vitro fertilization, INLCUDING temporary storage or eggs/sperm and surgery, INCLUDING operation to reverse prior surgery that prevented that person from having children

$ $

“Founder’s Fee” you pay monthly or as a lump sum under an agreement with a retirement home

$ $

Guide Dog expense including buying, training, and maintaining a guide dog or other service animal (e.g. vet bills, food, grooming, etc.)

$ $

HMO expense you pay to entitle you, your spouse, and/or dependent to receive medical care

$ $

Hearing aids $ $

Nursing services (e.g. services connected with caring for the patient’s condition, giving medication or changing dressings, and bathing/grooming for the patient)

$ $

Lead-based paint removal from surfaces in the home to prevent a child who has or has had lead poisoning (paint MUST be in poor repair - e.g. cracked walls)

$ $

Special education expense paid for a child’s tutoring by a specially trained learning disabilities teacher

$ $

Cost of legal sterilization $ $

Stop-smoking programs (e.g. REQUIRED referral from doctor) $ $

Cost of therapy as a medical treatment $ $

Cost of transplants (e.g. a possible donor of a kidney or other organ, INCLUDING transportation)

$ $

Tuition expense for a special education (e.g. special needs) $ $

A legal vasectomy $ $

Weight-Loss program for a disease diagnosed by a physician (e.g. you CANNOT DEDUCT gym fees, health clubs, or spas)

$ $

An autoette and/or wheelchair $ $

A wig expense upon advice of a physician (e.g. a patient that has lost all of his/her hair from disease)

$ $

Other $ $

Other $ $

Other $ $

Other $ $

Other $ $

Total $ $

Total medical mileage (e.g. doctor visits, going to the pharmacy, etc.)

THESE WORKSHEETS ARE USEFUL FOR SELF-EMPLOYED INDIVIDUALS, CLIENTS WHO RECEIVE 1099-MISC

FORMS FROM “SIDE-JOBS,” OR S CORPORATION OWNERS

Rukosky & Associates Financial Group, Inc. © Page 1 of 3

Last Name First Name Tax Year

Note: It may be POSSIBLE to deduct these expenses; however, your ability to deduct these items depends on your

personal situation. ONLY your tax advisor can assist you in making the proper determination.

EXPENSES PAID EXAMPLES

Equipment/Computer Repairs $ Did you have to repair any equipment?

Maintenance $ Did you buy anything to maintain equipment?

Rent $ Do you pay rent for an office or storage space to conduct

business?

Taxes and Licenses $ Did you have to obtain any licenses or pay any taxes to perform

your job?

Interest $ Do you pay credit card interest or other loan interest?

Advertising $ Did you pay someone or do any advertising for your business?

Accounting $ Did someone charge you to perform accounting duties?

Bank Fees $ Did the bank charge you any fees?

Cleaning Supplies $ Did you pay for cleaning supplies?

Commissions $ Did you have to pay anyone commissions for buying or selling

something?

Computer Services $ Did you need an IT person to perform services on your

computer equipment?

Office Supplies $ Pens, paper, ink cartridges

Credit and Collection Costs $ Did you incur any fees to collect outstanding invoices owed to

you?

Delivery and Freight $ Did you have any shipping, postage, or receiving expenses?

Discounts $ Did you have to discount something to get it off your shelf?

Dues and Subscription Expense $ Did you have any professional dues, magazine, or computer

service subscriptions? Total Small Equipment Expense (Under $500/per item)

$ Did you buy any small equipment that is under $500 each?

Equipment Rental Fees $ Did you have to rent any equipment (e.g.

machinery/computers)?

Gifts Expense $ Did you buy any gifts for your clients to perform business?

Insurance Costs $ Do you have to obtain insurance to perform your job?

Job Materials $ Did you have to buy any materials to complete a job?

Janitorial Costs $ Did you perform or pay for any janitorial fees or supplies?

Laundry and Dry Cleaning $ Did you wash laundry at your home (e.g. laundry detergent

costs) for business attire?

Legal and Professional Expense $ Did you have to pay any legal, accounting or professional fees?

Meals and Entertainment 50% Limit $ Did you take existing or potential clients our for meals or

entertainment?

Outside Services/Independent Contractors $ Did you pay for any outside services or pay for independent

contractors?

Parking Fees and Tolls $ Highway tolls, parking garage fees

Permits and Fees $ Did you pay for any permits?

Postage $ Sending letters/packages

Printing $ Kinko’s, Office Depot, UPS Store, etc.

Security $ Security system monthly or installation fee

Supplies $ File folders, envelopes, ink, paper, etc.

THESE WORKSHEETS ARE USEFUL FOR SELF-EMPLOYED INDIVIDUALS, CLIENTS WHO RECEIVE 1099-MISC

FORMS FROM “SIDE-JOBS,” OR S CORPORATION OWNERS

Rukosky & Associates Financial Group, Inc. © Page 2 of 3

Telephone Expense $ Mobile phone or office phone

Internet Expense $ Internet access

Training/Continuing Education $ CE fees, training classes

Travel (lodging/airfare) $ Plane tickets, train tickets, hotel/motel expenses. Separate into

categories, please!

Uniforms Expense $ Did you buy any work-related uniforms or dedicated work

clothing (jeans, shirts)

Uniform Cleaning $ Did you have to pay to clean the uniforms you have or

purchased (either you or an outside service)?

Utilities Expense $ Electric/Gas for your home office. Separate charges, please!

Other $

Other $

Other $

Other $

Other $

HOME OFFICE AND STORAGE DAYCARE OUT-OF-HOUSE

Date you began using your home office for this business

Number of weeks used for daycare

Square footage of your home regularly used for your business OR for storage of business items, or both

Number of days used for daycare each week

Total square footage of your home Number of days closed during the year

Number of hours office used during the year Number of hours used for daycare each day

DIRECT EXPENSE INDIRECT EXPENSE SQUARE FOOTAGE FOR DAYCARE

These expenses are specifically for the office part of your home office

These expense affect the entire house

Area used exclusively for daycare

Real Estate Taxes $

Real Estate Taxes $ Area used only partly for

daycare

Insurance $

Insurance $ Total square footage of

home

Rent $

Rent $ Total hours available for

use during the year

Repairs/Maint. $ Repairs/Maint. $ UTILITIES

Home Phone $ Home Phone $ DIRECT EXPENSE INDIRECT EXPENSE

Internet $ Internet $ Electric $ Electric $

Security $ Security $ Gas $ Gas $

HOA Dues $ HOA Dues $ Water $ Water $

Other $ Other $ Other $ Other $

Total $ Total $ Other $ Other $

LARGE EQUIPMENT (Items costing over $500 for EACH piece of equipment)

Purchase Date Description Cost

VEHICLE WORKSHEET

Rukosky & Associates Financial Group, Inc. © Page 3 of 3

Last Name First Name Tax Year

This worksheet is only to be filled out if you use your vehicle(s) for BUSINESS purposes. This worksheet applies to the following:

Self-employed individuals, clients who receive 1099-MISC forms for “side-jobs,” or S Corporation owners, ow W-2 workers who have a second (or third) job and incur mileage going from their first job to their second job (and their second job to their third job) in the same day.

VEHICLE INFORMATION CAR INFORMATION Vehicle 1 Vehicle 2 Vehicle 3

Year/Make/Model

Date you began using vehicle for business

Ending mileage reading

Beginning mileage reading

TOTAL miles put on the vehicle for the year

BUSINESS miles put on the vehicle for the year

Is another vehicle available for personal use?

Yes No

Yes No

Yes No

Was the vehicle available for personal use during off-duty hours?

Yes No

Yes No

Yes No

Was the vehicle used primarily by a more than 5% owner or related individual?

Yes No

Yes No

Yes No

Was the vehicle leased?

Yes No

Yes No

Yes No

ACTUAL EXPENSES Vehicle 1 Vehicle 2 Vehicle 3

Gasoline, Oil, Repairs, Insurance, etc.

$ $ $

Vehicle Registration, License (excluding property taxes)

$ $ $

BUY OR SELL INFORMATION Vehicle 1 Vehicle 2 Vehicle 3

Cost of your old vehicle

$ $ $

Did you trade-in or sell this vehicle during this year?

Yes No

Yes No

Yes No

If you bought a vehicle, is your recently purchased vehicle a new model (2015)?

Yes No

Yes No

Yes No

Did you trade-in or sell a vehicle that was previously listed for business use?

Yes No

Yes No

Yes No

Did your employer reimburse you for any auto expenses?

Yes No

Yes No

Yes No

If your employer did, how much were you reimbursed?

$ $ $