Thank you for your interest in our firm. In order to better serve you, please complete the form below and indicate which areas we can assist you in. Someone will be in contact with you shortly based on the information that you provide. Thank you.   INCOME TAX QUESTIONAIRE         Your 1st Name & Initial ________________________________Last Name_________________________________________ Spouse's 1st Name & Initial ________________________________Last Name_________________________________________ Present Street Address ___________________________________________________________________________________ City_____________________________________State________________________________________Zip____________________                           Social Security# Occupation          Phone# Birth Date    Date Deceased X IF         mm-dd-yy    mm-dd-yy Blind Taxpayer ________________ _______________________ _________________ ____________ _____________ _____ Spouse ________________ _______________________ _________________ ____________ _____________ _____                 DEPENDENTS-whom you support          Birth Date Social Security # Relationship # Months Lived      Name(Include Last Name)       in Home This Year                                                           MEDICAL EXPENSES: (Do not include expenses paid CONTRIBUTIONS: (Please bring statements)                                         reimbursed or paid by others-or under a  cafeteria plan) Cash Contributions:                                                                                          Non-Cash Contributions:                                                  _____________ Medicine & Drugs                                                                            Medical Insurance                                                                   *CAPITAL GAINS & LOSSES: RATE DECREASES*   Total Doctor/Dentist/Hospital                                                   Please list below sales of Stocks, Real  Estate, Timber, Etc.: Mileage to Doctor                                                                     Please bring statements       Hearing Aid/Dentures/Eyeglasses                                          Description of Property  Date          Date Purchase     Sales   Other Medical List:                                                                    Acquired  Sold Price             Price         ___________________ ______  ______ $_______  $_______   TAXES:           State & Local                                                Alimony Received                                                                                       Property  Tax                                Alimony Paid                                                                                                  Auto Tax                           DISASTER LOSSES (Give Details) ___________________________________________________ Tuition Books & Fees   -attach documents)                                        Student Name                                                                                         Other__________________________         INTEREST EXPENSE: (Attach or enclose statements) Student Loan Interest_____________________ Home Mortgage-Bank                                                                Home Mortgage-Individuals                                                     Teacher Expense                                                                                        Name of Individual                                                                             JOB MOVING EXPENSES:             # Miles Moved                                                                                    INCOME: (Please enclose or bring statements) Cost of Moving Household Furnishings                                                      Pensions & Annuities                                                                      Social Security Benefits                                                          MISCELLANEOUS:      Unemployment Compensation                                                         Interest                                                                                      Dividends                                                                                                                                                                 Union & Professional Dues                                                                          ESTIMATED TAX PAYMENTS FOR 2011-STATE-FEDERAL Safety Deposit Box                                                                                      April 15, 2011 or___________________ $_______$_______ Small Tools/Safety Equipment on Job                                                          June 15, 2011 or___________________$_______$_______ Required Uniforms                                                                                       Sept 15, 2011  or__________________ $________$_______ Dues & Subscriptions                                                                                  Jan. 15, 2012  or___________________$________$_______ Job Hunting Expense                                                                                         Child Care                                                             www.lawlerandcole.com     Name of Provider of Child Care                                                                                LAWLER and COLE, CPAS, LLC. Address of Provider                                                                                              Certified Public Accountants Social Security # or Federal ID number of Provider                                                                                      P.O. Box 1506  Hamilton, AL 35570 Remarks/Miscellaneous                                                                                        Phone:(205)921-7801  Fax (205)921-9095                                                                                                                                                  2011 AND 2012           IRS Contact info: www.irs.gov or 800-829-1040   State of Alabama contact number 334-242-1000                     Note: Under age 50 limited to to $5,000.00                     Age 50 and over limited to $6,000.00

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