Taxpayer Information:

Taxpayer's Name:		Tax Year:
Family size1:		Zip Code:

¹ Family size refers to the number of dependents plus taxpayer, and spouse if filing MFJ

Income:
(Enter all numbers as positive numbers)

Income Description	Source	±	Amount
AGI	Form 1040	+
Tax-exempt Interest	Form 1040	+
Total IRA Distributions    SUBTRACT any rollover amounts included in the line above.2    SUBTRACT Taxable IRA Distributions2	Form 1040 Form 1099-R Form 1040	+ - -
Total Pensions and Annuities    SUBTRACT any rollover amounts included in the line above.2    SUBTRACT Taxable Pensions and Annuities2	Form 1040 Form 1099-R Form 1040	+ - -
Total Social Security Benefits    SUBTRACT Taxable Social Security Benefits	Form 1040 Form 1040	+ -
Nontaxable Medicaid Waiver payments3	Form W-2 or 1099-Misc	+
Nontaxable Combat Pay	From W-2	+
Child Support and Nontaxable Alimony	Taxpayer	+
Workers Compensation Payments	Taxpayer	+
Disability Insurance Payments	Taxpayer	+
Veterans Benefits (VA not DFAS)	Taxpayer	+
Public Assistance Payments	Taxpayer	+
Insurance Proceeds (Life, Accident, etc)	Taxpayer	+
Cash gifts and bequests	Taxpayer	+
Residential Rental (less than 15 days)	Taxpayer	+
Prior Year Federal Tax Refund	Prior Year 1040	+
Prior Year State Tax Refund    SUBTRACT taxable portion of Prior Year State Tax Refund	Form 1099-G Form 1040	+ -
Supplemental Social Security Benefits	Taxpayer	+
2021 Economic Impact Payments	Taxpayer	+
Any Other Nontaxable Income4	Taxpayer	+
Income for IRS Sales Tax Calculator

The entry above shown as        may be an error.
² Do not include rollovers
² Entry not required (and will be ignored) if the total amount is 0.
³ If not included in AGI
⁴ See Publication 4012, Table B for additional examples of non-taxable income.

Large Item Sales Tax Paid:

Sales Tax on Large Item Purchases	Source	Tax
Motor Vehicle (including RVs, ATVs, etc.)	Taxpayer
Watercraft or Aircraft	Taxpayer
Building Materials for home construction or remodel (if identified separately)	Taxpayer
House (if general sales tax applies)	Taxpayer
Additional Sales Tax on Specified Items for IRS Sales Tax Calculator

Record result from IRS Calculator here and print for taxpayer records:

	Total Sales Tax:
Local Tax Rate (%):	State Tax Rate (%):