Fringe Benefits
 
There are many other types of taxable fringe benefits. Please call our office to discuss which ones may apply to you.
 
 
Company leased/owned vehicle:
 
Company Name: ____________________
Phone #: ____________________
Contact Name: ____________________
 
 
Vehicle 1
Vehicle 2
Vehicle 3
Date acquired/leased
__________
__________
__________
Year/Model
__________
__________
__________
Cost (if leased, what would cost if purchased)
__________
__________
__________
Commute-round trip __________ Total for year
__________
__________
__________
Other personal mileage
__________
__________
__________
Business mileage
__________
__________
__________
Total mileage
__________
__________
__________
 
Life Insurance - Only if company is not beneficiary:
 
 
Is it a group policy?
 
__________
 
If so, is face amount greater than $50,000?
 
__________
 
If so, please provide the following for each member of the group:  
 
 
Employee Name
Face Amount
Age
 
_________________________
_______________
__________
 
_________________________
_______________
__________
 
_________________________
_______________
__________
 
 
If you have individual life policies, we need the employee's name and the amount of premium paid from January 1 through December 31:
 
 
Employee Name
Amount Paid
 
_________________________
_______________
 
_________________________
_______________
 
_________________________
_______________
 
Accident and Health Insurance - For stockholder of S Corporations only:
 
 
Amount of premium paid from January 1 through December 31:
 
Name
Amount Paid
 
_________________________
_______________
 
_________________________
_______________