1. Medical & Dental Expenses

a. Medical Mileage:
b. Out of Pocket Medical & dental Expenses:
c. Description of Medical & dental Expenses:

2. Paid Taxes

a. Real Estate Taxes
b. Personal Property Taxes:
c. Car/Truck Property Taxes:
d. Car Tag:

3. Interest You Paid

a. Home Mortgage Interest:
b. Name:
c. Address:
d. ID No:
e. Mortgage Interest Premiums:
f. Investment Interest:

4. Gifts of Charity

a. Contributions by cash or cheek:
b. # of miles to make contributions:
c. Non cash contributions:
d. Description of Contributions:

5. Unreimbursed Job Expenses

a. Educator Expenses:
b. Union & Professional Dues:
c. Uniforms:
d. Tools:
e. Cell Phone:
d. Dry cleaning:
d. Upkeep & Appearance:
d. Tax Preparation Fees:
d. Casualty Theft Loss:
d. Safe Deposit Box Fees:
d. Loss on IRA:
d. Gambling Loss:

6. Employee Business Expenses:

a. Parking fees, tolls, transportation:
b. Travel Expenses for overnight trips:
c. Meal & Entertainment Expenses:
d. Other Business Expenses:
e. Total Vehicle Mileage Driven:
f. Total Business Mileage:
g. Gas, Oil, Repairs, Insurance:
h. Vehicle Rentals:

7. Child & Dependent Care Expenses

a. Care Provider Name:
b. Care Provider Address:
c. Care Provider EIN or SSN:
d. Amount Paid for Year:
e. Which dependent is the child dependent care for:
I attest that all the above information is correct and was provided voluntary. In addition, none of the above information was by any fashion, shape, or form aided by of Tax Service Atlanta (TSA) prepares. Therefore, I agree to release Tax Service Atlanta (TSA) of any liability that may incur from the above information.