| 1. Are you self-employed or do you received hobby income? |
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9. Were there any births, deaths, marriage, divorces or adoptions in your immediately family? |
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| 2. Did you receive income from raising animals or crops? |
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10. Did you give a gift of more than $11,000 to one or more people? |
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| 3. Did you receive rent from real estate or other property? |
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11. Did you go through bankruptcy proceedings? |
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| 4. Did you receive income from gravel, timber, minerals, oil, gas, copyrights, patents? |
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12. (a) If you paid rent, how much did you pay?
(b) Was heat included? |
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| 5. Did you withdraw or write checks from a mutual fund? |
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13. Did you pay interest on a student loan for yourself, your spouse, or your dependent during the year? |
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| 6. Do you have a foreign bank account, trust or business? |
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14. Did you expenses for yourself, your spouse, or your dependent to attend class beyond high school? |
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| 7. Do you provide a home for or help support anyone not listed in Section 2 above? |
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| 8. Did you receive any correspondence from the IRS or State Department of Taxation? |
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