T A X   D A T A   W O R K S H E E T
1 9 9 1    I N F O R M A T I O N
________________________________________________________________________________
Over 65   Blind
Name _________________      ( )       ( )                             Check
Filing Status       one:
Spouse________________      ( )       ( )     _____________________________
Married filing jointly   ( )
Married filing seperate  ( )
Total Exemptions _________                     Single                   ( )
Head of household        ( )
W2 Information
______________
Husband   Wife                Federal        State
Company                  Gross     Gross      FICA    Withholding   Withholding
______________________  _________  _________ _______  ____________  ___________
Totals
=========  ========= =======  ============  ===========
Interest and Dividend Income
____________________________
Interest                                Dividends
___________________________________     ___________________________________
Name of Payer              Amount       Name of Payer              Amount
____________________   ____________     ____________________   ____________
Totals                                  Totals
============                            ============
EJECT
-------------------------------------------------------------- Page 2 ----
Medical Expenses
________________
Medicine and Drugs                 Doctors and Dentists
_____________________________      _______________________________________
Paid to                 Amount          Paid to                   Amount
______________________  ___________     _______________________   ___________
Total
______________________  ___________                               ===========
______________________  ___________
Other Medical
______________________  ___________    _______________________________________
Description                   Amount
______________________  ___________    __________________________  ___________
Health Insurance
Medical Travel
Eye Glasses
______________________  ___________    __________________________  __________
Total                                      Total
===========                                ===========
-------------------------------------------------------------- Page 3 ---
Taxes You Paid                          Gifts to Charity (Under $3000 ea)
______________                          _________________________________
Paid to              Amount
Real Estate Taxes       _____________    ___________________  ____________
Personal Property Tax   _____________    ___________________  ____________
Other Taxes             _____________    ___________________  ____________
_____________    ___________________  ____________
Subtotal           _____________    ___________________  ____________
___________________  ____________
State and Local Income Taxes
_____________________________________    ___________________  ____________
Withheld From Income    _____________    ___________________  ____________
Paid w/last Yr's return _____________    ___________________  ____________
Est. paid this year     _____________
Total Gifts Less
Total Taxes                        Than $3000 Per Donee
=============                         ____________
Interest You Paid                        Gifts Greater Than
_____________________________________    $3000 Per Donee
Home Mortgage Interest             _______________________________
Paid to             Amount               Paid to             Amount
__________________  ___________          __________________  ___________
Total Mortgage Int                      Total Gifts Greater
___________          Than $3000 Per Donee
___________
Total Charity Gifts
===========
T A X   D A T A  W O R K S H E E T
-------------------------------------------------------------- Page 4 ---
Miscellaneous Deductions  (Job Expenses and Most Other Misc Deductions)
________________________________________________________________________
Description        Amount             Description         Amount
____________________  ___________        __________________  ___________
Job Travel (Meals)                       Safe Deposit Box
Job Travel (Lodging)
Job Travel (Auto)
Job Travel (Other)
Job Supplies
Union Dues
Publications
Uniform Cost
Uniform Cleaning
Tax Preparation Fee
Total Job Related
Misc Deductions
Miscellaneous Deductions not Subject to 2% Floor
(Primarily for Handicapped persons with Job related expenses)
_____________________________________________________________
Total Misc Deductions
Not Subject to 2% FLR
A D D I T I O N A L   I N F O R M A T I O N
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Employers are required to send W2 forms to all employees showing the amount
of gross wages and taxes withheld for the year.  Also anyone who paid you $600
or more for contract labor, rent, interest or dividends is required to send
you a form 1099 indicating the amount paid to you.  You should receive all W2
and 1099 forms by January 31, 1992.
You may owe self-employment income if you were paid on a contract labor basis.
Self-employment income is applied to your net business income, which is the
amount you earned less all of your business expenses.
Interest and dividends are reported to you on a form 1099.  A copy of these
forms is also sent to the IRS.
Mortgage companies are required to send you a form 1098 for interest you paid
to them on loans.  These year-end statements frequently have information about
deductible property taxes paid from your escrow account during the year.
Tax practitioners recommend you keep copies of all receipts and informational
forms for at least 5 years.