2022 AFBA Financial Planning Guide

15-9. INCOME TAX WORKSHEET

PERSONAL INFORMATION — YOURSELF

PERSONAL INFORMATION — YOUR SPOUSE

Full Name:

Full Name:

Address:

Address (If Not The Same):

Social Security Number:

Social Security Number:

Employer’s Name & Address:

Employer’s Name & Address:

EXEMPTIONS FOR INCOME TAX PURPOSES

Yourself: ___________ Your Spouse: ___________ Dependent Children Who Live With You: ___________ Other Exemptions As Listed Below: ___________ Total Exemptions: ___________

Single:___________ Married, Filing Separately: ___________ Married, Filing Jointly: ___________ Head of Household: ___________ Qualifying Widow(er): ___________

Income Tax Filing Status

OTHER EXEMPTIONS (DEPENDENTS)

Dependent’s Name (First, Middle Initial, and Last)

Dependent’s Age

List Dependent’s Social Security Number

Dependent’s Relationship To You

SALARY & WAGE INCOME

Social Security Tax (FICA)Withheld

Wages of Husband (H) or Wife (W)

Federal Income Tax Withheld

State Income Tax Withheld

Salary or Wages Paid By (Name of Employer)

Total Wages

Totals:

INTEREST INCOME

DIVIDEND INCOME

Interest Income Received From

Amount

Dividend Income Received From

Amount

Total:

Total:

CHAPTER 15: FEDERAL & STATE TAXES

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