Gabriel Daniel & Associates, Inc.

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Data Sheet for Self Employed Filers

Fields marked with asteriks(*) are required.

Client Information
First Name:*
Middle Name:
Last Name:*
DOB:*
S.S. Number:*
Telephone#:*
Address1:*
Address2:
City:*
State:*
Zip Code:*
Occupation:
Email Address:
Sex:	Male Female

Martial Status
Choose One:

Spouse Full Name:
Spouse S.S. Number:
Spouse Occupation:

Dependents
	Name	SS#	DOB
1.
2.
3.
4.

Income & Expenses Report

Business Name or Activity:

Expense Date: From: To:

Expense Type Expense Amount

Rent

Advertising

Insurance

Taxes/Licenses

Travel/Entertainment

Repairs/Maintainance

Vehicle/Truck Exp

Supplies

Legal/Prof. Expenses

Office Expenses

Utilities

Gasoline

Misc Expenses

CPNC/Stand Dues

Printing and Copy

Postages

Depreciation

Lease Payment

Other Expenses

Total Expenses for the Year

Total Income for the Year

Contribution of $3.00 to Presidential Election Campaign fund ?

No Yes

Declaration

I attest that the above information and documentation provided to

Gabriel Daniel & Associates for "INCOME TAX PREPARATION"

is accurate and correct to the best of my knowledge.

Date:

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