Income and Withholding Worksheet: So I can help you with Roth conversions and tax withholdings

Income and Withholding Worksheet: So I can help you with Roth conversions and tax withholdings
Client name(s)
Preferred phone number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred email
example@example.com
Current year income sources and income taxes withheld: Each income source that applies to you is required, along with the amount of income taxes withheld (do not list any monthly amounts; list the grand total for this year for each entry)
Income from employment or self-employment (both are considered "earned income"): Full-time, part-time, and seasonal should all be included
Earned income #1 total for this year
Total federal income taxes withheld this year from earned income #1
Total state income taxes withheld this year from earned income #1
Earned income #2 total for this year
Total federal income taxes withheld this year from earned income #2
Total state income taxes withheld this year from earned income #2
Income from Social Security: Be sure to enter the gross amount (before any deductions, including Medicare premiums)
Social Security income #1 total for this year
Total federal income taxes withheld this year from Social Security income #1
Social Security income #2 total for this year
Total federal income taxes withheld this year from Social Security income #2
Income from pensions: Be sure to enter the gross amount (before any deductions)
Pension income #1 total for this year
Total federal income taxes withheld this year from pension income #1
Total state income taxes withheld this year from pension income #1
Pension income #2 total for this year
Total federal income taxes withheld this year from pension income #2
Total state income taxes withheld this year from pension income #2
Income from dividends and interest: Taxable interest from bank accounts or investments that are NOT with Dale
Dividends and interest total for this year
Income from taxable IRAs: These are distributions from IRAs that are NOT with Dale
Taxable IRA #1 total distributions for this year
Total federal income taxes withheld this year from taxable IRA #1
Total state income taxes withheld this year from taxable IRA #1
Taxable IRA #2 total distributions for this year
Total federal income taxes withheld this year from taxable IRA #2
Total state income taxes withheld this year from taxable IRA #2
Any other taxable income sources for this year? If yes, please describe below.
Other income source #1 details
Other income source #1 total for this year
Total federal income taxes withheld this year from other income source #1
Total state income taxes withheld this year from other income source #1
Other income source #2 details
Other income source #2 total for this year
Total federal income taxes withheld this year from other income source #2
Total state income taxes withheld this year from other income source #2
Did you make or do you plan to make any estimated federal or state income tax payments for this year? If yes, please complete the last two fields below.
Total estimated federal income tax payments made and/or planned to be made for this year
Total estimated state income tax payments made and/or planned to be made for this year
Securities offered through Registered Representatives of Cambridge Investment Research, Inc., a broker-dealer member FINRA/SIPC. Advisory services through Cambridge Investment Research Advisors, Inc., a Registered Investment Adviser. Cambridge and Financial Independence Wealth Management, LLC are not affiliated.

Recommendations relating to this questionnaire will be based on the assumption that the answers to this questionnaire are complete, accurate, and reflect your current situation. Please notify your financial professional promptly if your financial situation or any of the information contained in your questionnaire changes. This form collects data for informational purposes only and does not supersede any data or information reported on official Cambridge forms.
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Income and Withholding Worksheet: So I can help you with Roth conversions and tax withholdings

Current year income sources and income taxes withheld: Each income source that applies to you is required, along with the amount of income taxes withheld (do not list any monthly amounts; list the grand total for this year for each entry)

Income from employment or self-employment (both are considered "earned income"): Full-time, part-time, and seasonal should all be included

Income from Social Security: Be sure to enter the gross amount (before any deductions, including Medicare premiums)

Income from pensions: Be sure to enter the gross amount (before any deductions)

Income from dividends and interest: Taxable interest from bank accounts or investments that are NOT with Dale

Income from taxable IRAs: These are distributions from IRAs that are NOT with Dale

Any other taxable income sources for this year? If yes, please describe below.

Did you make or do you plan to make any estimated federal or state income tax payments for this year? If yes, please complete the last two fields below.