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GERARD A STACK CTA          
CLIENT INTERVIEW WORKSHEET YEAR 2016                                                                              Page 1        						                                                                                                                                                                                                                                                                   
Appoint Date:                                               Time: 
    Name:                                                       Address:  ___________________________                  Mob Ph:
Occupation:                                                              ____________________   ________             Daytime ph:
Date of Birth:                       Tax File Number:                         Marital Status:  Single / Married / Separated / De facto               
             		 Abn:                                             Current Email: 

PLEASE CIRCLE YOUR ANSWERS TO THE FOLLOWING QUESTIONS:-
INCOME
1.  Salary and wages - PAYG payment summaries                 NO YES 
2.  Allowances, tips, director's fees etc.                                  _ NO YES    $_____      _   Type :________________( e.g. car, meals, tools, uniform)
3.  Employer lump sum payments                                             NO YES     A$__________R / T   B$____________E$________________
4.  Employment termination payments                                      NO YES   If yes attach PAYG payment summary 
5.  Newstart, sickness benefits, Austudy etc.                             NO YES    If yes attach statement from Centrelink & a list of expenses you incurred
6.  Australian Government pensions e.g. Age                             NO YES   If yes attach statement from Centrelink
7.  Australian annuities & super income streams                      NO YES   If yes attach PAYG payment summary
8.  Australian Superannuation lump sum payments                  NO YES    If yes furnish details
10.  Gross interest from banks and other institutions   _____ NO YES     $_________,
11.  Dividends                                                                           NO YES    Unfranked $__________ Franked $__________ IMP Credits $___________
12. Employee Share Schemes                                                NO YES _ Attach details
13. Income from partnerships/ trusts or managed investmts    NO YES   Attach annual tax statemt & list of any expenses relating to this income 
15. Income from a business                                                     NO YES     Attach a statement of income & list of expenses for each business
18. Capital gains or losses e.g. sale of shares/property           NO YES _ Advise purchase & sale details of each item
19. Foreign assets: Do you hold more than $50,000 overseas  NO YES
20. Foreign source income                                                     NO YES    If yes, indicate type (pension, dividend etc.) & amount of foreign tax paid
21. Gross rental income & list of exps for each property       NO YES
22. Insurance bond or life policy cashed in under 10yrs        NO YES
24. Other income e.g. Royalties Rebates                               NO YES
_____________________________________________________________________________________________
WORK RELATED EXPENSES    (Only use this section if you worked for a salary)                      
D1. Did you use your motor vehicle for work trips, other than to & from work NO YES If yes, describe nature of trips and state how many kilometers you
 Traveled on these trips     Number of kms =                        Nature of trips:  ____________________________________________________________                                                               
______________________________________________________________________________________________________________________
  Cost of Vehicle $___________ Date of purchase       /      /          & engine capacity (e.g. CC 1800)__CC______ 
  If you traveled for more than 5000 kms for work,you must have a valid log book. Based on your log book what is the business use?          %        
D2. Accom, meals etc. for domestic travel away from home 
    (More than 6 nights you must have a diary)                     NO YES 
    Overseas travel (You must have a diary)                         NO YES
__Did you receive an overtime meal allowance?                 NO YES       If so, did you spend it all on meals?   NO   YES
 D3. Protective clothing &  Uniforms with coy logo              NO YES      State whether Compulsory?  YES NO   Were they supplied?  YES   NO_                                                                                                                                                   
___What items did you purchase?                                    Overalls $         , Safety Boots $         , Coy logo items $          , Other $_           ______                  
      Hat, sun cream, sunglasses for outdoor work                   NO YES   Sunglasses $              , Hat $            _    , Sun cream $          _____      
      Dry cleaning as per receipts                                           NO YES    $______                 
      Laundry (50 cents or $1 per wash up to $150)               NO YES   $_______                 
D4. Courses undertaken at a place of education                   NO YES      Fees $_______, Stationery $__________   equipment $_            ___
      Describe how this course helped you with your day to day work duties? __ Travel costs $______ Books$_______ other $________
                                                                                                                
D5. Other work expenses:
     Refresher short courses and seminars                            NO YES       Type:                                                            Cost: $________ ____                          
     Union, registration fees & or professional subscriptions   NO YES        Name:                                                          Cost: $ ____________                             
     Light and power of home office                                        NO YES	    Number of hours per week_____ @ 48 wks. @32cents = $__    ___
     Telephone landline expenses                                          NO YES	    $_______ x Business percentage ______% = $_               _____
     Telephone mobile expenses                                            NO YES	    $_______ x Business percentage ______% = $_                  ____
    Trade books, journals and periodicals                             NO YES        $ ______                                                                                                              
     Diary, stationery, printing, photocopying etc.                    NO YES       $ ______                                                                                                              
     Replacement of tools                                                       NO YES        Attach a list
     Computer, electronic equipment & software                    NO YES         Attach a list 
     Salary packaging fees                                                     NO  YES                      
      Any other expenses for work e.g. internet access           NO YES     $                x Business percentage              % = $______             
                                                         Others specify             NO YES

GERARD A STACK CTA	
CLIENT INTERVIEW WORKSHEET YEAR 2016    	    	                                                   Page 2
Name:  

GENERAL DEDUCTIONS
D7. Expenses in respect of interest income                               NO YES    Type:                                                                            Cost $_________                               
D8 Expenses in respect of dividend income (e.g. investment advice, interest paid, seminars)   NO YES     Type:                     ___ Cost: $____  ___                                
D9. Gifts to approved charities                                                   NO YES    Attach a list $       .                 
D10. Tax agent's fees for last year's return                                NO YES     $_______& Travel to Agent kms_____x_32cents per km______= $__  ___        
D11. Deductible amount - foreign pension                                 NO YES __$_______
D12. Self-employed super contributions                     NO YES     $_______ Fund______________ Acct No.______________ABN_______________ 
                                                                                                                  If Yes:  Attach a Confirmation of Contributions letter from super fund
D15 Income protection insurance                               NO YES       Name of Insurer:                                     Pol No.:                        Cost: $________            
        Audit insurance protection                                               NO   YES     $__________                 
____Other_-_Specify________________________________NO_YES ________________                                                          $_____________

TAX OFFSETS (REBATES)
 Did you have a spouse or defacto during the year?       NO YES    If yes advise the following
Name:                                                         , DOB___/_ _/____, Assessable income$           ,RFBA $            , RECS $            ,Exempt income $       .          
List of dependent children: __Name:_______________   _     _ D of B     /      /            Name: _____________________D of B ____/__/______
                                               Name:          _________      _   __D of B      /     /           Name: ______________________D of B____/__/______
T1. Senior persons or pensioners tax offset                            NO YES 
T2 Australian superannuation income stream (10%)               NO  YES   $                   . 
T3. Super contributions on behalf of spouse                            NO YES   Name of Fund                                           Amt of contributions $_   ______                   
T5. Net Medical expenses for Disability aids, attendant care or aged care. NO YES                         
      Disability aids $            , Attendant exps $                                     , Aged care exps $                                                                                                
T6 Dependant  (invalid or carer)      NO  YES  Dates:                                           % Maintained                            
     Adjusted combined taxable incomes of taxpayer & spouse $                              . _____________________________________________________________________________________________________________________                       

ADDITIONAL INFORMATION
Did you have private health cover?                   NO YES   Fund ID______Member No___              _______    ___      
How many dependent children are on this cover?  Number:            ____  If yes, attach statement from fund
A1 Are you under 18 years as at 30/6/2016?                ___    NO  YES
A2 Did you become an Australian resident during the year?  NO  YES   If so, insert date of arrival
A3 Have you made personal super contributions that have not been claimed as a deduction?___ NO  YES
A5 PAYG instalments already paid (Item 5A on BAS's)    NO   YES      $__________ (Do not show tax deducted from salary & wages)
Have you a Higher Education Debt?                                  NO   YES     $_________     _ (An estimate will do)
Your refund will be deposited into your nominated bank account Please furnish BSB No.                           Acct No._________________&                                                           ____________________________________________________Name(s) on  Account: _______________________   _______________                                                                                                                                                                                                                                                                        
Do you want your tax return sent to you via post or emailed?     Post or Email   (Circle your choice)
Do you want to receive our free quarterly newsletter via email   NO   YES
OTHER NOTES:

Signature of Taxpayer: _____________________________   Date:                     /                        /2016