Personal Expenses & Deductions

Tip!: Read all the fields before answering.

Tax Payer

First Name

Last Name

Tax Year

Medical, Dental, and Vision Expenses

Medical and dental bills you paid for yourself, spouse, and dependents

Payments to health insurance premiums

Long-term care insurance premiums

Prescription medications and medical supplies

Costs of certain medical procedures

Eyeglasses and contact lenses

Travel and Lodging

Medical miles driven

Miles driven to medical appointments

Other medical transportation cost not included above

For example: Ambulance fees

Lodging for medical purposes

Up to $50 per night per person

Other Expenses

Other medical, dental, or vision expenses

Taxes You Paid

State and local taxes

State and local income taxes

Real estate taxes

Personal property taxes

Charitable Donations

Cash Donations

Name of Charity & Amounts

Noncash Donations

Name of Charities & Amounts

Miles Driven to Perform Charitable Service

Miles Driven to Deliver noncash donations