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pdfﺍﻹﺳﺗﻣﺎﺭﺓ )13614-C (AR
ﻭﺯﺍﺭﺓ ﺍﻟﻣﺎﻟﻳﺔ ﺍﻷﻣﺭﻳﻛﻳﺔ – ﺩﺍﺋﺭﺓ ﺿﺭﻳﺑﺔ ﺍﻟﺩﺧﻝ
ﺭﻗﻡ ﻣﻛﺗﺏ OMB
1545-1964
ﺻﻔﺣﺔ ﺇﺳﺗﻳﻌﺎﺏ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ/ﺍﻟﻣﻘﺎﺑﻠﺔ ﻭﻣﺭﺍﺟﻌﺔ ﺍﻟﺟﻭﺩﺓ
)ﺃﻛﺗﻭﺑﺭ (2016
• ﻳﺭﺟﻰ ﺇﺳﺗﻛﻣﺎﻝ ﺍﻟﺻﻔﺣﺗﻳﻥ 3-1ﻣﻥ ﻫﺫﻩ ﺍﻹﺳﺗﻣﺎﺭﺓ.
• ﺃﻧﺕ ﻣﺳﺅﻭﻝ ﻋﻥ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ ﻋﻠﻰ ﻛﺷﻔﻙ .ﻳﺭﺟﻰ ﺗﺯﻭﻳﺩ ﻣﻌﻠﻭﻣﺎﺕ ﻛﺎﻣﻠﺔ ﻭﺻﺣﻳﺣﺔ.
• ﺇﻥ ﻛﺎﻧﺕ ﻟﺩﻳﻙ ﺃﺳﺋﻠﺔ ،ﻳﺭﺟﻰ ﻁﺭﺣﻬﺎ ﻋﻠﻰ ﺍﻟﻣﺗﻁﻭﻉ ﺍﻟﻣﻌﺩ ﻟﻛﺷﻑ ﺍﻟﺿﺭﺍﺋﺏ ﻭﺍﻟﻣﻌﺗﻣﺩ ﻣﻥ ﻣﺻﻠﺣﺔ .IRS
ﺳﺗﻛﻭﻥ ﺑﺣﺎﺟﺔ ﺇﻟﻰ:
• ﻣﻌﻠﻭﻣﺎﺕ ﺿﺭﺍﺋﺏ ﻣﺛﻝ ﺍﻹﺳﺗﻣﺎﺭﺍﺕ .W-2، 1099، 1098، 1095
• ﺑﻁﺎﻗﺎﺕ ﺍﻟﺿﻣﺎﻥ ﺍﻹﺟﺗﻣﺎﻋﻲ ﺃﻭ ﺃﺭﻗﺎﻡ ﺍﻟﻬﻭﻳﺔ ﺍﻟﻔﺭﺩﻳﺔ ﻟﺩﺍﻓﻌﻲ ﺍﻟﺿﺭﺍﺋﺏ ﻟﺟﻣﻳﻊ ﺍﻷﺷﺧﺎﺹ ﻋﻠﻰ ﻛﺷﻑ ﺿﺭﺍﺋﺑﻙ.
• ﺑﻁﺎﻗﺔ ﻫﻭﻳﺔ ﺗﺣﻣﻝ ﺻﻭﺭﺓ )ﻣﺛﻠﺔ ﺭﺧﺻﺔ ﻗﻳﺎﺩﺓ ﺻﺎﻟﺣﺔ( ﻟﻙ ﻭﻟﺯﻭﺟﺗﻙ/ﺯﻭﺟﻙ.
ﺍﻟﻣﺗﻁﻭﻋﻭﻥ ﺍﻟﻣﺳﺎﻋﺩﻭﻥ ﻓﻲ ﺇﻋﺩﺍﺩ ﻛﺷﻔﻙ ﻣﺩﺭﺑﻭﻥ ﻋﻠﻰ ﺗﺯﻭﻳﺩ ﺧﺩﻣﺔ ﻋﺎﻟﻳﺔ ﺍﻟﺟﻭﺩﺓ ﻭﺍﻹﻟﺗﺯﺍﻡ ﺑﺄﺳﻣﻰ ﺍﻟﻣﻌﺎﻳﻳﺭ ﺍﻷﺧﻼﻗﻳﺔ.
ﻹﺑﻼﻍ ﻣﺻﻠﺣﺔ IRSﻋﻥ ﺳﻠﻭﻙ ﻏﻳﺭ ﺃﺧﻼﻗﻲ ،ﻳﺭﺟﻰ ﻣﺭﺍﺳﻠﺗﻧﺎ ﻋﺑﺭ ﺍﻟﺑﺭﻳﺩ ﺍﻹﻟﻛﺗﺭﻭﻧﻲ ﻋﻠﻰ ﺍﻟﻌﻧﻭﺍﻥ [email protected]
ﺍﻟﺟﺯء ﺍﻷﻭﻝ -ﻣﻌﻠﻭﻣﺎﺗﻙ ﺍﻟﺷﺧﺻﻳﺔ )إن ﻛﻨﺖ ﺗﺮﻓﻊ ﻛﺸﻔﺎً ﻣﺸﱰﻛﺎً ،ﺳ ّﺠﻞ اﺳﺎﻤءﻛﻢ ﺑﱰﺗﻴﺐ ﻣﻄﺎﺑﻖ ﻟﱰﺗﻴﺐ ﻛﺸﻒ اﻟﺴﻨﺔ اﳌﺎﺿﻴﺔ(
.1ﺇﺳﻣﻙ ﺍﻷﻭﻝ
ﺍﻟﺣﺭﻑ ﺍﻷﻭﻝ ﻣﻥ ﺍﻷﻭﺳﻁ
ﺍﻹﺳﻡ ﺍﻷﺧﻳﺭ/ﺍﻟﻠﻘﺏ
ﺭﻗﻡ ﺍﻟﻬﺎﺗﻑ
ﻫﻝ ﺗﺣﻣﻝ ﺍﻟﺟﻧﺳﻳﺔ ﺍﻷﻣﺭﻳﻛﻳﺔ؟
ﻻ
ﻧﻌﻡ
.2ﺍﻹﺳﻡ ﺍﻷﻭﻝ ﻟﺯﻭﺟﺗﻙ/ﺯﻭﺟﻙ
ﺍﻟﺣﺭﻑ ﺍﻷﻭﻝ ﻣﻥ ﺍﻷﻭﺳﻁ
ﺍﻹﺳﻡ ﺍﻷﺧﻳﺭ/ﺍﻟﻠﻘﺏ
ﺭﻗﻡ ﺍﻟﻬﺎﺗﻑ
ﻫﻝ ﺗﺣﻣﻝ ﺍﻟﺯﻭﺟﺔ/ﺍﻟﺯﻭﺝ ﺍﻟﺟﻧﺳﻳﺔ ﺍﻷﻣﺭﻳﻛﻳﺔ؟
ﻻ
ﻧﻌﻡ
ﺍﻟﺭﻣﺯ ﺍﻟﺑﺭﻳﺩﻱ
ﺍﻟﻭﻻﻳﺔ
ﺭﻗﻡ ﺍﻟﺷﻘﺔ
.3ﺍﻟﻌﻧﻭﺍﻥ ﺍﻟﺑﺭﻳﺩﻱ
.4ﺗﺎﺭﻳﺦ ﻣﻳﻼﺩﻙ
.5ﻣﻧﺻﺑﻙ ﺍﻟﻣﻬﻧﻲ
.7ﺗﺎﺭﻳﺦ ﻣﻳﻼﺩ ﺍﻟﺯﻭﺟﺔ/ﺍﻟﺯﻭﺝ
.8ﻣﻧﺻﺏ ﺯﻭﺟﺗﻙ/ﺯﻭﺟﻙ ﺍﻟﻣﻬﻧﻲ
ﻧﻌﻡ
ﻧﻌﻡ
.10ﻫﻝ ﻳﺳﺗﻁﻳﻊ ﺃﻱ ﺷﺧﺹ ﺍﻹﺩﻋﺎء ﺑﺈﻋﺎﻟﺗﻙ ﺃﻭ ﺇﻋﺎﻟﺔ ﺯﻭﺟﺗﻙ/ﺯﻭﺟﻙ ﻋﻠﻰ ﻛﺷﻑ ﺿﺭﺍﺋﺑﻬﻡ؟
ﺃ .ﻭﻗﻌﺕ ﺿﺣﻳﺔ ﺳﺭﻗﺔ ﻫﻭﻳﺔ؟
.11ﻫﻝ ﺃﻧﺕ ﺃﻭ ﺯﻭﺟﺗﻙ/ﺯﻭﺟﻙ:
ﺍﻟﺟﺯء ﺍﻟﺛﺎﻧﻲ -ﻣﻌﻠﻭﻣﺎﺕ ﺍﻟﺣﺎﻟﺔ ﺍﻟﺯﻭﺟﻳﺔ ﻭﺍﻷﺳﺭﺓ ﺍﻟﻣﻌﻳﺷﻳﺔ
.1ﺣﺗﻰ 31ﺩﻳﺳﻣﺑﺭ/ﻛﺎﻧﻭﻥ ﺍﻷﻭﻝ ،2016ﻫﻝ ﻛﻧﺕ:
ﻏﻳﺭ ﻣﺗﺯﻭﺝ
ﻣﺗﺯﻭﺟﺎ ً
ﺍﻹﺳﻡ )ﺍﻷﻭﻝ ،ﺍﻟﻠﻘﺏ(
ﻻ ﺗﺳﺟﻝ ﺃﺩﻧﺎﻩ ﺇﺳﻣﻙ ﺃﻭ ﺇﺳﻡ ﺯﻭﺟﺗﻙ/ﺯﻭﺟﻙ
)ﺃ(
ﺍﻟﻛﺗﺎﻟﻭﺝ ﺭﻗﻡ 58970P
)ﺏ(
)ﺝ(
.6ﻓﻲ ﺍﻟﺳﻧﺔ ﺍﻟﻣﺎﺿﻳﺔ ،ﻫﻝ ﻛﻧﺕ
ﺏ .ﻣﻌﺎﻗﺎ ً ﺗﻣﺎﻣﺎ ً ﻭﺩﺍﺋﻣﺎ ً
ﻻ
ﻧﻌﻡ
.9ﻓﻲ ﺍﻟﺳﻧﺔ ﺍﻟﻣﺎﺿﻳﺔ ،ﻫﻝ ﻛﺎﻧﺕ ﺯﻭﺟﺗﻙ/ﺯﻭﺟﻙ
ﺏ .ﻣﻌﺎﻗﺎ ً ﺗﻣﺎﻣﺎ ً ﻭﺩﺍﺋﻣﺎ ً
ﻻ
ﻧﻌﻡ
ﺏ .ﺗﺑﻧﻳﺕ ً
ﻁﻔﻼ؟
ﻧﻌﻡ
ﻧﻌﻡ
ﻧﻌﻡ
ﻧﻌﻡ
ﻧﻌﻡ
ﻻ
ﻧﻌﻡ
ﻧﻌﻡ
ﺃ .ﺇﺫﺍ ﻧﻌﻡ ،ﻫﻝ ﺗﺯﻭﺟﺕ ﻓﻲ ﺳﻧﺔ 2016؟
ﺏ .ﻫﻝ ﺃﻗﻣﺕ ﻣﻊ ﺯﻭﺟﺗﻙ/ﺯﻭﺟﻙ ﺃﺛﻧﺎء ﺃﻱ ﺟﺯء ﻣﻥ ﺍﻷﺷﻬﺭ ﺍﻟﺳﺗﺔ ﺍﻷﺧﻳﺭﺓ ﻣﻥ ﻋﺎﻡ 2016؟
ﺗﺎﺭﻳﺦ ﺍﻟﻘﺭﺍﺭ ﺍﻟﻧﻬﺎﺋﻲ
ﺗﺎﺭﻳﺦ ﺇﺗﻔﺎﻕ ﺍﻹﻋﺎﻟﺔ ﺧﻼﻝ ﺍﻹﻧﻔﺻﺎﻝ
ﺳﻧﺔ ﻭﻓﺎﺓ ﺯﻭﺟﺗﻙ/ﺯﻭﺟﻙ
ﺃﺭﻣﻝ/ﺃﺭﻣﻠﺔ
ﺻﻠﺔ ﺍﻟﻘﺭﺍﺑﺔ ﺑﻙ
ﺗﺎﺭﻳﺦ
ً
)ﻣﺛﻼ ،ﺇﺑﻥ ،ﺇﺑﻧﺔ،
ﺍﻟﻣﻳﻼﺩ
)ﻳﻭﻡ/ﺷﻬﺭ /ﺃﻡ ،ﺃﺏ ،ﻻ ﺃﺣﺩ،
ﺇﻟﺦ(.
ﻋﺎﻡ(
ﻏﻳﺭ ﻭﺍﺛﻕ
ﺃ .ﻁﺎﻟﺑﺎ ً ﺑﺩﻭﺍﻡ ﻛﺎﻣﻝ
ﺝ .ﻣﻌﺎﻗﺎ ً ﻗﺎﻧﻭﻧﻳﺎ
ﺃ .ﻁﺎﻟﺑﺎ ً ﺑﺩﻭﺍﻡ ﻛﺎﻣﻝ
ﺝ .ﺃﻋﻣﻰ ﻗﺎﻧﻭﻧﻳﺎ ً
ﻻ
ﻻ
ﻻ
ﻻ
)ﺑﻣﺎ ﻓﻲ ﺫﻟﻙ ﺍﻟﺷﺭﺍﻛﺎﺕ ﺍﻟﻣﻧﺯﻟﻳﺔ ﺍﻟﻣﺳﺟﻠﺔ ﺃﻭ ﺍﻹﺗﺣﺎﺩﺍﺕ ﺍﻟﻣﺩﻧﻳﺔ ﺃﻭ ﻏﻳﺭﻫﺎ ﻣﻥ ﺍﻟﻌﻼﻗﺎﺕ ﺍﻟﺭﺳﻣﻳﺔ ﺑﻣﻭﺟﺏ ﻗﺎﻧﻭﻥ ﺍﻟﻭﻻﻳﺔ(
ﻣﻁﻠﻘﺎ ً
ً
ﻣﻧﻔﺻﻼ ﻗﺎﻧﻭﻧﻳﺎ ً
.2ﻋﺩﺩ ﺃﺩﻧﺎﻩ ﺃﺳﻣﺎء:
• ﻛﻝ ﺷﺧﺹ ﻣﻥ ﺃﻗﺎﻡ ﻣﻌﻙ ﺍﻟﺳﻧﺔ ﺍﻟﻣﺎﺿﻳﺔ )ﻏﻳﺭﻙ ﺃﻭ ﻏﻳﺭ ﺯﻭﺟﺗﻙ/ﺯﻭﺟﻙ(
• ﺃﻱ ﺷﺧﺹ ﻗﻣﺕ ﺑﺈﻋﺎﻟﺗﻪ ﻟﻛﻧﻪ ﻟﻡ ﻳﻘﻳﻡ ﻣﻌﻙ ﺍﻟﺳﻧﺔ ﺍﻟﻣﺎﺿﻳﺔ
ﻻ
ﻻ
ﺍﻟﻣﺩﻳﻧﺔ
ﺇﺫﺍ ﻛﻧﺕ ﺑﺣﺎﺟﺔ ﺇﻟﻰ ﻓﺳﺣﺔ ﺇﺿﺎﻓﻳﺔ ،ﺗﻭﺿﻊ ﺇﺷﺎﺭﺓ ﻫﻧﺎ
ﻻ
ﻻ
ﻭﻳﺗﻡ ﺍﻹﺩﺭﺍﺝ ﻋﻠﻰ ﺍﻟﺻﻔﺣﺔ .4
ﻟﻺﺳﺗﻛﻣﺎﻝ ﻋﻠﻰ ﻳﺩ ﻣﺗﻁﻭﻉ ﻣﻌﺗﻣﺩ ﻭﻣﻌﺩ ﻟﻛﺷﻑ ﺍﻟﺿﺭﺍﺋﺏ
ﻋﺩﺩ ﺃﺷﻬﺭ
ﺍﻹﻗﺎﻣﺔ ﻓﻲ
ﻣﻧﺯﻟﻙ ﺍﻟﺳﻧﺔ
ﺍﻟﻣﺎﺿﻳﺔ
)ﺩ(
ﺣﺎﻣﻝ
ﻟﻠﺟﻧﺳﻳﺔ
ﺍﻷﻣﺭﻳﻛﻳﺔ
)ﻧﻌﻡ/ﻻ(
)ﻩ(
ﻫﻝ ﺯﻭّ ﺩ ﻫﺫﺍ ﻫﻝ ﻛﺎﻥ ﺩﺧﻝ
ﻣﻘﻳﻡ ﻓﻲ ﺍﻟﻭﻻﻳﺎﺕ ﺃﻋﺯﺏ ﺃﻭ ﻣﺗﺯﻭﺝ ﻁﺎﻟﺏ ﺑﺩﻭﺍﻡ ﻣﻌﺎﻕ ﺗﻣﺎﻣﺎ ً ﻫﻝ ﻫﺫﺍ
ﺍﻟﺷﺧﺹ ً
ﻛﺎﻣﻝ ﺍﻟﺳﻧﺔ ﻭﺩﺍﺋﻣﺎ ً
ﻁﻔﻼ /ﺍﻟﺷﺧﺹ ﺃﻛﺛﺭ ﻫﺫﺍ ﺍﻟﺷﺧﺹ
ﺍﻟﻣﺗﺣﺩﺓ ﺃﻭ ﻛﻧﺩﺍ ﺃﻭ ﺣﺗﻰ
ً
ﻗﺭﻳﺑﺎ ً
ﺃﻗﻝ ﻣﻥ
ﻣﻥ %50
ﻣﺅﻫﻼ
ﺍﻟﻣﻛﺳﻳﻙ ﺍﻟﺳﻧﺔ
ﺍﻟﻣﺎﺿﻳﺔ
31/12/16
)ﻧﻌﻡ/ﻻ(
$4,050؟
ﻣﻥ ﺇﻋﺎﻟﺗﻪ
ﻷﻱ ﺷﺧﺹ
ﺍﻟﻣﺎﺿﻳﺔ )ﻧﻌﻡ/ﻻ( )ﺃﻋﺯﺏ /ﻣﺗﺯﻭﺝ( )ﻧﻌﻡ/ﻻ(
)ﻧﻌﻡ/ﻻ(
ﺁﺧﺭ؟ )ﻧﻌﻡ/ﻻ( ﺍﻟﺧﺎﺻﺔ؟
)ﻧﻌﻡ/ﻻ(
)ﻭ(
)ﺡ(
)ﺯ(
)ﻁ(
www.irs.gov
ﺍﻹﺳﺗﻣﺎﺭﺓ
ﻫﻝ ﺩﻓﻊ ﺩﺍﻓﻊ
ﻫﻝ ﺯﻭّ ﺩ ﺩﺍﻓﻊ
)ﺩﺍﻓﻌﻭ( ﺍﻟﺿﺭﺍﺋﺏ )ﺩﺍﻓﻌﻭ( ﺍﻟﺿﺭﺍﺋﺏ
ﺃﻛﺛﺭ ﻣﻥ %50ﺃﻛﺛﺭ ﻣﻥ ﻧﺻﻑ
ﻣﻥ ﺍﻹﻋﺎﻟﺔ ﻟﻬﺫﺍ ﻛﻠﻔﺔ ﺻﻳﺎﻧﺔ ﻣﺳﻛﻥ
ﻟﻬﺫﺍ ﺍﻟﺷﺧﺹ؟
ﺍﻟﺷﺧﺹ؟
)ﻧﻌﻡ/ﻻ(
)ﻧﻌﻡ/ﻻ(
)13614-C (AR
)ﺗﻌﺩﻳﻝ (2016-10
ﺍﻟﺻﻔﺣﺔ 2
ﺍﺧﺗﺭ ﺍﻟﻣﺭﺑﻊ ﺍﻟﻣﻼﺋﻡ ﻟﻛﻝ ﺳﺅﺍﻝ ﻓﻲ ﻛﻝ ﻓﻘﺭﺓ
ﻧﻌﻡ
ﻻ
ﻧﻌﻡ
ﻻ
ﻧﻌﻡ
ﻻ
ﻏﻳﺭ ﻭﺍﺛﻕ ﺍﻟﺟﺯء ﺍﻟﺛﺎﻟﺙ -ﺍﻟﺩﺧﻝ-ﻓﻲ ﺍﻟﺳﻧﺔ ﺍﻟﻣﺎﺿﻳﺔ ،ﻫﻝ ﺗﻠﻘﻳﺕ ﺃﻧﺕ )أو زوﺟﺘﻚ/زوﺟﻚ(
(B) .1ﺃﺟﻭﺭﺍً ﺃﻭ ﺭﺍﺗﺑﺎً؟ )ﺍﻹﺳﺗﻣﺎﺭﺓ (W-2ﺇﺫﺍ ﻧﻌﻡ ،ﻛﻡ ﻭﻅﻳﻔﺔ ﻛﺎﻧﺕ ﻟﺩﻳﻙ ﺍﻟﺳﻧﺔ ﺍﻟﻣﺎﺿﻳﺔ؟
ً (A) .2
ﺩﺧﻼ ﻣﻥ ﺍﻟﺑﻘﺷﻳﺵ؟
(B) .3ﻣﻧﺣﺎ ً ﺩﺭﺍﺳﻳﺔ؟ )ﺍﻹﺳﺗﻣﺎﺭﺍﺕ W-2ﻭ(1098T
(B) .4ﻓﻭﺍﺋﺩ/ﺃﻧﺻﺑﺔ ﺃﺭﺑﺎﺡ ﻣﻥ :ﺣﺳﺎﺑﺎﺕ ﺷﻳﻛﺎﺕ/ﺗﻭﻓﻳﺭ ،ﺳﻧﺩﺍﺕ ،ﺇﻋﺗﻣﺎﺩﺍﺕ ﻣﺳﺗﻧﺩﻳﺔ ،ﻋﻣﻭﻻﺕ؟ )ﺍﻹﺳﺗﻣﺎﺭﺓ 1099INTﻭﺍﻹﺳﺗﻣﺎﺭﺓ (1099DIV
(B) .5ﺇﺳﺗﺭﺟﺎﻉ ﺿﺭﺍﺋﺏ ﺍﻟﺩﺧﻝ ﺍﻟﻣﺣﻠﻳﺔ/ﻟﻠﻭﻻﻳﺔ؟ )ﺍﻹﺳﺗﻣﺎﺭﺓ (1099G
(B) .6ﺩﺧﻝ ﻧﻔﻘﺔ ﺍﻟﺯﻭﺟﺔ ﺍﻟﻣﻁﻠﻘﺔ/ﺍﻟﺯﻭﺝ ﺍﻟﻣﻁﻠﻕ ﺃﻭ ﻣﺩﻓﻭﻋﺎﺕ ﺇﻋﺎﻟﺔ ﺍﻟﺯﻭﺟﺔ ﺍﻟﻣﻧﻔﺻﻠﺔ/ﺍﻟﺯﻭﺝ ﺍﻟﻣﻧﻔﺻﻝ؟
(A) .7ﺩﺧﻝ ﺍﻟﻌﻣﻝ ﺍﻟﺣﺭ )ﺍﻹﺳﺗﻣﺎﺭﺓ ،1099MISCﻣﺑﺎﻟﻎ ﻧﻘﺩﻳﺔ(؟
(A) .8ﻣﺩﻓﻭﻋﺎﺕ ﻧﻘﺩﻳﺔ/ﺷﻳﻛﺎﺕ ﻣﻘﺎﺑﻝ ﺃﻱ ﻋﻣﻝ ﻣﺅﺩﻯ ﻭﻏﻳﺭ ﻣﺑﻠﻎ ﻋﻧﻪ ﻋﻠﻰ ﺍﻹﺳﺗﻣﺎﺭﺓ W-2ﺃﻭ ﺍﻹﺳﺗﻣﺎﺭﺓ 1099؟
(A) .9ﺍﻟﺩﺧﻝ )ﺃﻭ ﺍﻟﺧﺳﺎﺭﺓ( ﻣﻥ ﺑﻳﻊ ﺍﻷﺳﻬﻡ ﺃﻭ ﺍﻟﺳﻧﺩﺍﺕ ﺃﻭ ﺍﻟﻌﻘﺎﺭﺍﺕ )ﺑﻣﺎ ﻓﻳﻬﺎ ﻣﻧﺯﻟﻙ(؟ )ﺍﻹﺳﺗﻣﺎﺭﺍﺕ (1099B ،1099S
(B) .10ﺩﺧﻝ ﺍﻹﻋﺎﻗﺔ )ﻣﺛﻝ ﺍﻟﻣﺩﻓﻭﻋﺎﺕ ﻣﻥ ﺍﻟﺗﺄﻣﻳﻥ ﺃﻭ ﺗﻌﻭﻳﺽ ﺍﻟﻌﻣﺎﻝ(؟ )ﺍﻹﺳﺗﻣﺎﺭﺍﺕ (1099R، W-2
(A) .11ﺍﻟﺗﻭﺯﻳﻌﺎﺕ ﻣﻥ ﻣﻌﺎﺷﺎﺕ ﺍﻟﺗﻘﺎﻋﺩ ﻭ/ﺃﻭ ﺍﻟﻌﻼﻭﺍﺕ ﺍﻟﺳﻧﻭﻳﺔ ﻭ/ﺃﻭ ﺣﺳﺎﺏ IRA؟ )ﺍﻹﺳﺗﻣﺎﺭﺓ (1099R
(B) .12ﺗﻌﻭﻳﺽ ﺍﻟﺑﻁﺎﻟﺔ )ﺍﻹﺳﺗﻣﺎﺭﺓ (G-1099
(B) .13ﻣﺧﺻﺻﺎﺕ ﺍﻟﺿﻣﺎﻥ ﺍﻹﺟﺗﻣﺎﻋﻲ ﺃﻭ ﺗﻘﺎﻋﺩ ﻋﻣﺎﻝ ﺍﻟﺳﻛﻙ ﺍﻟﺣﺩﻳﺩﻳﺔ؟ )ﺍﻹﺳﺗﻣﺎﺭﺍﺕ (RRB1099 ،SSA1099
(M) .14ﺍﻟﺩﺧﻝ )ﺃﻭ ﺍﻟﺧﺳﺎﺭﺓ( ﻣﻥ ﻣﻠﻛﻳﺔ ﻣﺅﺟﺭﺓ؟
(B) .15ﺩﺧﻝ ﺁﺧﺭ؟ )ﺍﻟﻘﻣﺎﺭ ،ﺍﻟﻳﺎﻧﺻﻳﺏ ،ﺍﻟﺟﻭﺍﺋﺯ ،ﺍﻟﻣﻧﺢ ،ﻭﺍﺟﺏ ﻫﻳﺋﺔ ﺍﻟﻣﺣﻠﻔﻳﻥ ،Sch K-1 ،ﺃﺗﺎﻭﺍﺕ ،ﺩﺧﻝ ﺃﺟﻧﺑﻲ ،ﺇﻟﺦ (.ﻳﺭﺟﻰ ﺍﻟﺗﺣﺩﻳﺩ
ﻏﻳﺭ ﻭﺍﺛﻕ ﺍﻟﺟﺯء ﺍﻟﺭﺍﺑﻊ-ﺍﻟﻧﻔﻘﺎﺕ -ﻓﻲ ﺍﻟﺳﻧﺔ ﺍﻟﻣﺎﺿﻳﺔ ،ﻫﻝ ﺩﻓﻌﺕ ﺃﻧﺕ )أو زوﺟﺘﻚ/زوﺟﻚ(
(B) .1ﻧﻔﻘﺔ ﺍﻟﺯﻭﺟﺔ ﺍﻟﻣﻁﻠﻘﺔ/ﺍﻟﺯﻭﺝ ﺍﻟﻣﻁﻠﻕ ﺃﻭ ﻣﺩﻓﻭﻋﺎﺕ ﺇﻋﺎﻟﺔ ﺍﻟﺯﻭﺟﺔ ﺍﻟﻣﻧﻔﺻﻠﺔ/ﺍﻟﺯﻭﺝ ﺍﻟﻣﻧﻔﺻﻝ؟ ﺇﻥ ﻧﻌﻡ ،ﻫﻝ ﻟﺩﻳﻙ ﺭﻗﻡ ﺍﻟﺿﻣﺎﻥ ﺍﻹﺟﺗﻣﺎﻋﻲ ﻟﻠﻣﺳﺗﻠﻡ؟
(B) Roth IRA
(B) 401K
(A) IRA
.2ﻣﺳﺎﻫﻣﺎﺕ ﻓﻲ ﺣﺳﺎﺏ ﺗﻘﺎﻋﺩ؟
(B) .3ﻧﻔﻘﺎﺕ ﺗﻌﻠﻳﻡ ﺟﺎﻣﻌﻲ ﺃﻭ ﺑﻌﺩ ﺛﺎﻧﻭﻱ ﻣﺩﻓﻭﻋﺔ ﺑﺎﻟﻧﻳﺎﺑﺔ ﻋﻧﻙ ﺃﻭ ﻋﻥ ﺯﻭﺟﺗﻙ/ﺯﻭﺟﻙ ﺃﻭ ﻣﻥ ﺗﻌﻳﻠﻬﻡ؟ )ﺍﻹﺳﺗﻣﺎﺭﺓ (1098T
(B) .4ﻧﻔﻘﺎﺕ ﺃﻋﻣﺎﻝ ﻣﻭﻅﻔﻳﻥ ﻏﻳﺭ ﻣﻌﻭﺽ ﻋﻧﻬﺎ )ﻣﺛﻝ ﺍﻟﻠﺑﺎﺱ ﺍﻟﺭﺳﻣﻲ ﺃﻭ ﺍﻷﻣﻳﺎﻝ(؟
(B) .5ﻧﻔﻘﺎﺕ ﻁﺑﻳﺔ )ﺑﻣﺎ ﻓﻳﻬﺎ ﺃﻗﺳﺎﻁ ﺍﻟﺗﺄﻣﻳﻥ ﺍﻟﺻﺣﻲ(؟
(B) .6ﻓﻭﺍﺋﺩ ﻋﻠﻰ ﺭﻫﻥ ﺍﻟﻣﻧﺯﻝ؟ )ﺍﻹﺳﺗﻣﺎﺭﺓ (1098
(B) .7ﺍﻟﺿﺭﺍﺋﺏ ﺍﻟﻌﻘﺎﺭﻳﺔ ﻟﻣﻧﺯﻟﻙ ﺃﻭ ﺿﺭﺍﺋﺏ ﺍﻟﻣﻠﻛﻳﺔ ﺍﻟﺷﺧﺻﻳﺔ ﻟﺳﻳﺎﺭﺗﻙ؟ )ﺍﻹﺳﺗﻣﺎﺭﺓ (1098؟
(B) .8ﺍﻟﻣﺳﺎﻫﻣﺎﺕ ﺍﻟﺗﺑﺭﻋﻳﺔ؟
(B) .9ﻧﻔﻘﺎﺕ ﺭﻋﺎﻳﺔ ﺍﻷﻁﻔﺎﻝ/ﺍﻟﻌﺎﻟﺔ ،ﻣﺛﻝ ﺍﻟﺭﻋﺎﻳﺔ ﺍﻟﻳﻭﻣﻳﺔ؟
(B) .10ﻟﻠﻣﺳﺗﻠﺯﻣﺎﺕ ﺍﻟﻣﺳﺗﺧﺩﻣﺔ ﻛﺎﺧﺻﺎﺋﻲ ﺗﻌﻠﻳﻡ ﻣﺅﻫﻝ ﻣﺛﻝ ﺍﻟﻣﻌﻠﻡ ،ﺃﻭ ﻣﺳﺎﻋﺩ ﺍﻟﻣﻌﻠﻡ ﺃﻭ ﺍﻟﻣﺳﺗﺷﺎﺭ ﺃﻭ ﺇﻟﺦ.؟
(A) .11ﺍﻟﻧﻔﻘﺎﺕ ﺍﻟﻣﺗﻌﻠﻘﺔ ﺑﺩﺧﻝ ﺍﻟﻌﻣﻝ ﺍﻟﺣﺭ ﺃﻭ ﺃﻱ ﺩﺧﻝ ﺁﺧﺭ ﺗﻠﻘﻳﺗﻪ؟
(B) .12ﻓﺎﺋﺩﺓ ﻋﻠﻰ ﻗﺭﻭﺽ ﺍﻟﻁﺎﻟﺏ؟ )ﺍﻹﺳﺗﻣﺎﺭﺓ (1098E
ﻏﻳﺭ ﻭﺍﺛﻕ ﺍﻟﺟﺯء ﺍﻟﺧﺎﻣﺱ -ﺃﺣﺩﺍﺙ ﺍﻟﺣﻳﺎﺓ -ﻓﻲ ﺍﻟﺳﻧﺔ ﺍﻟﻣﺎﺿﻳﺔ ،ﻫﻝ ﺃﻧﺕ )أو زوﺟﺘﻚ/زوﺟﻚ(
(HSA) .1ﻛﺎﻥ ﻟﺩﻳﻙ ﺣﺳﺎﺏ ﺗﻭﻓﻳﺭ ﺻﺣﻲ؟ )ﺍﻹﺳﺗﻣﺎﺭﺍﺕ 5498SAﻭ 1099SAﻭ W-2ﻣﻊ ﺍﻟﺭﻣﺯ Wﻓﻲ ﺍﻟﻣﺭﺑﻊ (12
(A) .2ﻛﺎﻥ ﻟﺩﻳﻙ ﺩﻳﻥ ﻣﻥ ﺭﻫﻥ ﺃﻭ ﺑﻁﺎﻗﺔ ﺇﺋﺗﻣﺎﻥ ﻣﻠﻐﻰ/ﻣﻌﻔﻰ ﻣﻥ ﻣﻘﺭﺽ ﺗﺟﺎﺭﻱ؟ )ﺍﻹﺳﺗﻣﺎﺭﺍﺕ (1099A ،1099C
(A) .3ﻗﻣﺕ ﺑﺑﻳﻊ ﻣﻧﺯﻟﻙ ﺃﻭ ﺑﺷﺭﺍﺋﻪ ﺃﻭ ﺧﺿﻊ ﻟﻐﻠﻕ ﺭﻫﻧﻪ؟ )ﺍﻹﺳﺗﻣﺎﺭﺓ (1099A
(B) .4ﻛﺎﻥ ﻟﺩﻳﻙ "ﺇﻋﺗﻣﺎﺩ ﺩﺧﻝ ﻣﻛﺗﺳﺏ" ] [(Earned Income Credit (EICﻏﻳﺭ ﻣﺳﻣﻭﺡ ﻓﻲ ﺳﻧﺔ ﺳﺎﺑﻘﺔ؟ ﺇﺫﺍ ﻧﻌﻡ ،ﻷﻱ ﺳﻧﺔ ﺿﺭﻳﺑﻳﺔ؟
(A) .5ﻗﻣﺕ ﺑﺷﺭﺍء ﻭﺗﺭﻛﻳﺏ ﻣﺳﺗﻠﺯﻣﺎﺕ ﻣﻧﺯﻟﻳﺔ ﻣﻘﺗﺻﺩﺓ ﻟﻠﻁﺎﻗﺔ؟ )ﻣﺛﻝ ﻧﻭﺍﻓﺫ ،ﺳﺧﺎﻥ ،ﻣﻭﺍﺩ ﻋﺎﺯﻟﺔ ،ﺇﻟﺦ(.
(B) .6ﺃﻗﻣﺕ ﻓﻲ ﻣﻧﻁﻘﺔ ﺗﺄﺛﺭﺕ ﺑﻛﺎﺭﺛﺔ ﻁﺑﻳﻌﻳﺔ؟ ﺇﺫﺍ ﻧﻌﻡ ،ﺃﻳﻥ؟
(A) .7ﺗﻠﻘﻳﺕ "ﺇﻋﺗﻣﺎﺩ ﻣﺷﺗﺭﻱ ﺍﻟﻣﻧﺎﺯﻝ ﻟﻠﻣﺭﺓ ﺍﻷﻭﻟﻰ" ] [First Time Homebuyers Creditﻓﻲ ﺳﻧﺔ 2008؟
(B) .8ﺩﻓﻌﺕ ﺃﻗﺳﺎﻁ ﺿﺭﺍﺋﺏ ﻣﻘﺩﺭﺓ ﺃﻭ ﻁﺑﻘﺕ ﺍﻟﻣﺑﻠﻎ ﺍﻟﻣﺳﺗﺭﺟﻊ ﻣﻥ ﺍﻟﺳﻧﺔ ﺍﻟﻣﺎﺿﻳﺔ ﻋﻠﻰ ﺿﺭﻳﺑﺗﻙ ﻟﻬﺫﻩ ﺍﻟﺳﻧﺔ؟ ﺇﻥ ﻛﺎﻧﺕ ﺍﻟﺣﺎﻟﺔ ﻛﺫﻟﻙ ،ﻓﻛﻡ؟
(A) .9ﺭﻓﻌﺕ ﻛﺷﻑ ﺿﺭﺍﺋﺏ ﻓﺩﺭﺍﻟﻳﺔ ﻟﻠﺳﻧﺔ ﺍﻟﻣﺎﺿﻳﺔ ﻳﺣﺗﻭﻱ ﻋﻠﻰ "ﻣﺟﻣﻭﻉ ﻣﺭﺣﻝ ﻟﺧﺳﺎﺋﺭ ﺭﺃﺳﻣﺎﻟﻳﺔ" ] [capital loss carryoverﻋﻠﻰ ﺍﻟﻣﻠﺣﻕ Dﻣﻥ ﺍﻹﺳﺗﻣﺎﺭﺓ 1040؟
ﺍﻟﻛﺗﺎﻟﻭﺝ ﺭﻗﻡ 58970P
www.irs.gov
ﺍﻹﺳﺗﻣﺎﺭﺓ
ﻧﻌﻡ
)13614-C (AR
ﻻ
ﻏﻳﺭ ﺫﻟﻙ
)ﺗﻌﺩﻳﻝ (2016-10
ﺍﻟﺻﻔﺣﺔ 3
ﺍﺧﺗﺭ ﺍﻟﻣﺭﺑﻊ ﺍﻟﻣﻼﺋﻡ ﻟﻛﻝ ﺳﺅﺍﻝ ﻓﻲ ﻛﻝ ﻓﻘﺭﺓ
ﻧﻌﻡ
ﻻ ﻏﻳﺭ ﻭﺍﺛﻕ ﺍﻟﺟﺯء ﺍﻟﺳﺎﺩﺱ :ﺗﻐﻁﻳﺔ ﺍﻟﺭﻋﺎﻳﺔ ﺍﻟﺻﺣﻳﺔ – ﻓﻲ ﺍﻟﺳﻧﺔ ﺍﻟﻣﺎﺿﻳﺔ ،ﻫﻝ ﻛﻧﺕ ﺃﻧﺕ ﺃﻭ ﺯﻭﺟﺗﻙ/ﺯﻭﺟﻙ ﺃﻭ ﻣﻌﺎﻟﻙ )ﻣﻌﺎﻟﻳﻙ(
(B) .1ﺗﺣﻣﻝ ﺗﻐﻁﻳﺔ ﺭﻋﺎﻳﺔ ﺻﺣﻳﺔ؟
ﻹﺳﺗﻣﺎﺭﺓ 1095B
(B) .2ﺗﻠﻘﻳﺕ ﻭﺍﺣﺩﺓ ﺃﻭ ﺃﻛﺛﺭ ﻣﻥ ﻫﺫﻩ ﺍﻹﺳﺗﻣﺎﺭﺍﺕ؟ )ﺍﺧﺗﺭ ﺍﻟﻣﺭﺑﻊ(
(A) .3ﻟﺩﻳﻙ ﺗﻐﻁﻳﺔ ﻋﺑﺭ ﺳﻭﻕ ﺷﺭﺍء ﺍﻟﺗﺄﻣﻳﻥ ﺍﻟﺻﺣﻲ ﺑﻛﻠﻔﺔ ﻣﻳﺳﻭﺭﺓ ][Marketplace؟ ]ﻗﺩّﻡ ﺍﻹﺳﺗﻣﺎﺭﺓ [1095A
3ﺃ (A) .ﺇﺫﺍ ﻧﻌﻡ ،ﻫﻝ ﺗﻠﻘﻳﺕ ﻣﺩﻓﻭﻋﺎﺕ ﺇﺋﺗﻣﺎﻧﻳﺔ ﻣﺳﺑﻘﺔ ﻟﻠﻣﺳﺎﻋﺩﺓ ﻋﻠﻰ ﺩﻓﻊ ﺍﻷﻗﺳﺎﻁ ﺍﻟﺷﻬﺭﻳﺔ ﻟﺭﻋﺎﻳﺗﻙ ﺍﻟﺻﺣﻳﺔ؟
3ﺏ (A) .ﺇﺫﺍ ﻻ ،ﻫﻝ ﻛﻝ ﺷﺧﺹ ﻣﺩﺭﺝ ﻋﻠﻰ ﺍﻹﺳﺗﻣﺎﺭﺓ A-1095ﺍﻟﺧﺎﺻﺔ ﺑﻙ ﻣﻌﻠﻥ ﻋﻠﻰ ﻛﺷﻑ ﺍﻟﺿﺭﺍﺋﺏ؟
(B) .4ﺗﺣﻣﻝ ﺇﻋﻔﺎ ًء ﻣﻧﺣﺗﻪ ﺳﻭﻕ ﺷﺭﺍء ﺍﻟﺗﺄﻣﻳﻥ ﺍﻟﺻﺣﻲ ﺑﻛﻠﻔﺔ ﻣﻳﺳﻭﺭﺓ؟
ﺍﻹﺳﺗﻣﺎﺭﺓ 1095C
ﻗﻡ ﺑﺯﻳﺎﺭﺓ http://www.healthcare.gov/ﺃﻭ ﺍﻻﺗﺻﺎﻝ ﺑﺎﻟﺭﻗﻡ 1-800-318-2596ﻟﻠﺣﺻﻭﻝ ﻋﻠﻰ ﻣﺯﻳﺩ ﻣﻥ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ ﻋﻥ ﺧﻳﺎﺭﺍﺕ ﺗﻐﻁﻳﺔ ﺍﻟﺗﺄﻣﻳﻥ ﺍﻟﺻﺣﻲ ﻭﺍﻟﻣﺳﺎﻋﺩﺓ ﻓﻲ ﺷﺄﻧﻬﺎ.
ﺇﻥ ﻛﻧﺕ ﺗﺗﻠﻘﻰ ﻣﺩﻓﻭﻋﺎﺕ ﻣﺳﺑﻘﺔ ﻣﻥ ﺍﻟﺧﺻﻡ ﺍﻟﺿﺭﻳﺑﻲ ﻋﻠﻰ ﺃﻗﺳﺎﻁ ﺍﻟﺗﺄﻣﻳﻥ ﻟﻣﺳﺎﻋﺩﺗﻙ ﻋﻠﻰ ﺩﻓﻊ ﺃﻗﺳﺎﻁ ﺗﻐﻁﻳﺔ ﺗﺄﻣﻳﻧﻙ ﺍﻟﺻﺣﻲ ،ﻓﻌﻠﻳﻙ ﺇﺑﻼﻍ ﺳﻭﻕ ﺷﺭﺍء ﺍﻟﺗﺄﻣﻳﻥ ﺍﻟﺻﺣﻲ ﺑﻛﻠﻔﺔ ﻣﻳﺳﻭﺭﺓ ﻋﻥ ﺃﻱ ﺗﻐﻳﻳﺭﺍﺕ ﺣﻳﺎﺗﻳﺔ ،ﻣﺛﻝ ﺍﻟﺗﻐﻳﻳﺭﺍﺕ ﻓﻲ ﺍﻟﺩﺧﻝ ﺃﻭ
ﺍﻟﺣﺎﻟﺔ ﺍﻟﺯﻭﺟﻳﺔ ﺃﻭ ﺣﺟﻡ ﺍﻟﻌﺎﺋﻠﺔ .ﻓﺎﻹﺑﻼﻍ ﻋﻥ ﺍﻟﺗﻐﻳﻳﺭﺍﺕ ﺳﻳﺳﺎﻋﺩﻙ ﻋﻠﻰ ﺿﻣﺎﻥ ﺣﺻﻭﻟﻙ ﻋﻠﻰ ﺍﻟﻣﺑﻠﻎ ﺍﻟﻣﻼﺋﻡ ﻣﻥ ﺍﻟﻣﺩﻓﻭﻋﺎﺕ ﺍﻟﻣﺳﺑﻘﺔ.
ﻳﺳﺗﻛﻣﻠﻪ ﺍﻟﻣﺗﻁﻭﻉ ﺍﻟﻣﻌﺗﻣﺩ ﻹﻋﺩﺍﺩ ﻛﺷﻭﻑ ﺍﻟﺿﺭﺍﺋﺏ )ﺍﺳﺗﺧﺩﻡ ﺍﻟﻣﻧﺷﻭﺭ 4012ﻭﺍﺧﺗﺭ ﺍﻟﻣﺭﺑﻊ )ﺍﻟﻣﺭﺑﻌﺎﺕ( ﺍﻟﻣﻼﺋﻡ ﻟﻺﺷﺎﺭﺓ ﺇﻟﻰ "ﺍﻟﺗﻐﻁﻳﺔ ﺍﻷﺳﺎﺳﻳﺔ ﺍﻷﺩﻧﻰ" ] (Minimum Essential Coverage] (MECﻟﻛﻝ ﻣﻥ ﻫﻭ ﻣﺩﺭﺝ ﻋﻠﻰ ﻛﺷﻑ ﺍﻟﺿﺭﺍﺋﺏ(.
ﺍﻹﺳﻡ
)ﻋﺩﺩ ﺍﻟﻣﻌﺎﻟﻳﻥ ﺑﺗﺭﺗﻳﺏ ﻣﻁﺎﺑﻕ ﻟﻠﺟﺯء ﺍﻟﺛﺎﻧﻲ(
ﺗﻐﻁﻳﺔ ﺃﺳﺎﺳﻳﺔ ﺃﺩﻧﻰ
ﺃﺛﻧﺎء ﻛﺎﻣﻝ ﺍﻟﺳﻧﺔ
ﻻ ﺗﻐﻁﻳﺔ ﺃﺳﺎﺳﻳﺔ
ﺃﺩﻧﻰ
ﺩﺍﻓﻊ ﺍﻟﺿﺭﺍﺋﺏ
ﺍﻟﺯﻭﺟﺔ/ﺍﻟﺯﻭﺝ
ﺍﻟﻣﻌﺎﻝ
ﺍﻟﻣﻌﺎﻝ
ﺍﻟﻣﻌﺎﻝ
ﺍﻟﻣﻌﺎﻝ
ﺗﻐﻁﻳﺔ ﺃﺳﺎﺳﻳﺔ ﺃﺩﻧﻰ ﺃﺛﻧﺎء ﺟﺯء ﻣﻥ ﺍﻟﺳﻧﺔ
ﺍﻟﻣﺎﺿﻳﺔ )ﺳﺟّ ﻝ ﺍﻷﺷﻬﺭ ﺫﺍﺕ ﺍﻟﺗﻐﻁﻳﺔ(
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ﺇﻋﻔﺎء
ﻁﻭﺍﻝ ﺍﻟﺳﻧﺔ
إﻋﻔﺎء )ﺳ ّﺠﻞ اﻷﺷﻬﺮ اﻟﺘﻲ ﺗﴪي ﻋﻠﻴﻬﺎ إﻋﻔﺎءات(
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ﻣﻼﺣﻅﺎﺕ
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ﺍﻟﺟﺯء ﺍﻟﺳﺎﺑﻊ -ﻣﻌﻠﻭﻣﺎﺕ ﺇﺿﺎﻓﻳﺔ ﻭﺃﺳﺋﻠﺔ ﻣﺗﻌﻠﻘﺔ ﺑﺈﻋﺩﺍﺩ ﻛﺷﻑ ﺿﺭﺍﺋﺑﻙ
ً
.1ﺻﻧﺩﻭﻕ ﺣﻣﻠﺔ ﺍﻹﻧﺗﺧﺎﺑﺎﺕ ﺍﻟﺭﺋﺎﺳﻳﺔ )ﺇﻥ ﺍﺧﺗﺭﺕ ﻣﺭﺑﻌﺎً ،ﻟﻥ ﻳﺣﺩﺙ ﺗﻐﻳﻳﺭﺍ ﻓﻲ ﺿﺭﻳﺑﺗﻙ ﻭﻻ ﻓﻲ ﺍﻟﻣﺑﻠﻎ ﺍﻟﻣﺳﺗﺭﺟﻊ ﻟﻙ(.
ﺍﻟﺯﻭﺟﺔ/ﺍﻟﺯﻭﺝ
ﺍﺧﺗﺭ ﺍﻟﻣﺭﺑﻊ ﻫﻧﺎ ﺇﻥ ﻛﻧﺕ ﺃﻧﺕ ،ﺃﻭ ﺯﻭﺟﺗﻙ/ﺯﻭﺟﻙ ﻓﻲ ﺣﺎﻝ ﺭﻓﻊ ﻛﺷﻑ ﻣﺷﺗﺭﻙ ،ﺗﺭﻳﺩ ﺃﻥ ﻳﺧﺻﺹ ﻣﺑﻠﻎ $3ﻟﻬﺫﺍ ﺍﻟﺻﻧﺩﻭﻕ
ﺃﻧﺕ
.2ﺇﻥ ﻛﻧﺕ ﺗﺳﺗﺣﻕ ﻣﺑﻠﻐﺎ ً ﻣﺳﺗﺭﺟﻌﺎً ،ﻫﻝ ﺗﻭﺩ
ﺃ .ﺇﻳﺩﺍﻋﺎ ً ﻣﺑﺎﺷﺭﺍً
ﺝ .ﻗﺳﻡ ﺍﻟﻣﺑﻠﻎ ﺍﻟﻣﺳﺗﺭﺟﻊ ﻟﻙ ﺑﻳﻥ ﺣﺳﺎﺑﺎﺕ ﻣﺧﺗﻠﻔﺔ
ﺏ .ﺷﺭﺍء ﺳﻧﺩﺍﺕ ﺗﻭﻓﻳﺭ ﺃﻣﺭﻳﻛﻳﺔ
ﻻ
ﻧﻌﻡ
ﻻ
ﻧﻌﻡ
ﻻ
ﻧﻌﻡ
.3ﺇﻥ ﻛﺎﻥ ﻟﺩﻳﻙ ﺭﺻﻳﺩ ﻣﺳﺗﺣﻕ ،ﻫﻝ ﺗﻭﺩ ﺩﻓﻊ ﻣﺑﻠﻎ ﻣﻥ ﺣﺳﺎﺑﻙ ﺍﻟﻣﺻﺭﻓﻲ؟
ﻻ
ﻧﻌﻡ
.4ﺯﻭّ ﺩ ﻋﻧﻭﺍﻥ ﺑﺭﻳﺩ ﺇﻟﻛﺗﺭﻭﻧﻲ )ﺧﻳﺎﺭﻱ( )ﻟﻥ ﻳﺳﺗﺧﺩﻡ ﻋﻧﻭﺍﻥ ﻫﺫﺍ ﺍﻟﺑﺭﻳﺩ ﺍﻹﻟﻛﺗﺭﻭﻧﻲ ﻟﻺﺗﺻﺎﻻﺕ ﻣﻥ ﻣﺻﻠﺣﺔ ﺿﺭﻳﺑﺔ ﺍﻟﺩﺧﻝ(
ﺗﻌﻣﻝ ﻣﻭﺍﻗﻊ ﻋﺩﻳﺩﺓ ﻹﻋﺩﺍﺩ ﻛﺷﻭﻑ ﺍﻟﺿﺭﺍﺋﺏ ﻋﺑﺭ ﺇﺳﺗﻼﻡ ﺃﻣﻭﺍﻝ ﻣﻧﺢ .ﻭﻗﺩ ﻳﺳﺗﺧﺩﻡ ﻫﺫﺍ ﺍﻟﻣﻭﻗﻊ ﺍﻟﺑﻳﺎﻧﺎﺕ ﻣﻥ ﺍﻷﺳﺋﻠﺔ ﺍﻟﺗﺎﻟﻳﺔ ﻟﺗﻘﺩﻳﻡ ﻁﻠﺑﺎﺕ ﻟﻠﺣﺻﻭﻝ ﻋﻠﻰ ﻫﺫﻩ ﺍﻟﻣﻧﺢ .ﻭﺳﺗـُﺳﺗﺧﺩﻡ ﺃﺟﻭﺑﺗﻙ ﻷﻏﺭﺍﺽ ﺇﺣﺻﺎﺋﻳﺔ ﻓﻘﻁ.
.5ﻏﻳﺭ ﺍﻟﻠﻐﺔ ﺍﻹﻧﺟﻠﻳﺯﻳﺔ ،ﻣﺎ ﻫﻲ ﺍﻟﻠﻐﺔ ﺍﻟﻣﺣﻛﻳﺔ ﻓﻲ ﻣﻧﺯﻟﻙ؟
ﻧﻌﻡ
.6ﻫﻝ ﻟﺩﻳﻙ ﺃﻧﺕ ﺃﻭ ﺃﺣﺩ ﺃﻓﺭﺍﺩ ﺃﺳﺭﺗﻙ ﺍﻟﻣﻌﻳﺷﻳﺔ ﺇﻋﺎﻗﺔ؟
.7ﻫﻝ ﺃﻧﺕ ﺃﻭ ﺯﻭﺟﺗﻙ/ﺯﻭﺟﻙ ﻓﺭﺩ ﺳﺎﺑﻕ ﻓﻲ ﺍﻟﻘﻭﺍﺕ ﺍﻟﻣﺳﻠﺣﺔ ﺍﻷﻣﺭﻳﻛﻳﺔ
ﻻ
ﻧﻌﻡ
ﺃﻓﺿﻝ ﺍﻻﻣﺗﻧﺎﻉ ﻋﻥ ﺍﻹﺟﺎﺑﺔ
ﺃﻓﺿﻝ ﺍﻻﻣﺗﻧﺎﻉ ﻋﻥ ﺍﻹﺟﺎﺑﺔ
ﻻ
ﺃﻓﺿﻝ ﺍﻻﻣﺗﻧﺎﻉ ﻋﻥ ﺍﻹﺟﺎﺑﺔ
ﺗﻌﻠﻳﻘﺎﺕ ﺇﺿﺎﻓﻳﺔ
ﺍﻟﻛﺗﺎﻟﻭﺝ ﺭﻗﻡ 58970P
www.irs.gov
ﺍﻹﺳﺗﻣﺎﺭﺓ
)13614-C (AR
)ﺗﻌﺩﻳﻝ (2016-10
ﺍﻟﺻﻔﺣﺔ 4
ﺍﻟﺟﺯء ﺍﻟﺛﺎﻣﻥ -ﻓﻘﺭﺓ ﺍﻟﻣﺗﻁﻭﻉ ﺍﻟﻣﻌﺗﻣﺩ ﺍﻟﻣﺩﻗﻕ ﻟﻠﺟﻭﺩﺓ
ﺩﻗﻕ ﻓﻲ ﻛﺷﻑ ﺍﻟﺿﺭﺍﺋﺏ ﻣﻊ ﺩﺍﻓﻊ ﺍﻟﺿﺭﺍﺋﺏ ﻟﺿﻣﺎﻥ ﺃﻥ:
• ﺗﻡ ﺇﺛﺑﺎﺕ ﻫﻭﻳﺔ ﺩﺍﻓﻊ ﺍﻟﺿﺭﺍﺋﺏ )ﻭﺯﻭﺟﺗﻪ( ﺑﺑﻁﺎﻗﺔ ﻫﻭﻳﺔ ﺗﺣﻣﻝ ﺻﻭﺭﺓ.
• ﺍﻟﻣﺗﻁﻭﻉ ﺍﻟﻣﻌﺩ ﻟﻛﺷﻑ ﺍﻟﺿﺭﺍﺋﺏ/ﻣﺩﻗﻕ ﺟﻭﺩﺓ ﻣﻌﺗﻣﺩ ﻹﻋﺩﺍﺩ/ﺍﻟﺗﺩﻗﻳﻕ ﻓﻲ ﻫﺫﺍ ﺍﻟﻛﺷﻑ ﻭﺍﻟﻛﺷﻑ ﻫﻭ ﺿﻣﻥ ﻧﻁﺎﻕ ﺍﻟﺑﺭﻧﺎﻣﺞ.
• ﺗﻣﺕ ﺍﻹﺟﺎﺑﺔ ﻋﻠﻰ ﻛﺎﻓﺔ ﺍﻷﺳﺋﻠﺔ ﻓﻲ ﺍﻷﺟﺯﺍء ﺍﻷﻭﻟﻰ ﺣﺗﻰ ﺍﻟﺳﺎﺩﺳﺔ.
• ﺗﻣﺕ ﻣﻧﺎﻗﺷﺔ ﻛﺎﻓﺔ ﻣﺭﺑﻌﺎﺕ ﻏﻳﺭ ﻭﺍﺛﻕ ﻣﻊ ﺩﺍﻓﻊ ﺍﻟﺿﺭﺍﺋﺏ ﻭﺗﻡ ﺗﺳﺟﻳﻠﻬﺎ ﺑـ"ﻧﻌﻡ" ﺃﻭ "ﻻ" ﺑﺷﻛﻝ ﺻﺣﻳﺢ.
• ﺗﻡ ﻁﺭﺡ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ ﻋﻠﻰ ﺍﻟﺻﻔﺣﺔ ﺍﻷﻭﻟﻰ ﺣﺗﻰ ﺍﻟﺛﺎﻟﺛﺔ ﺑﺷﻛﻝ ﺻﺣﻳﺢ ﻭﻧﻘﻠﻬﺎ ﺇﻟﻰ ﺍﻟﻛﺷﻑ.
• ﺗﻡ ﺇﺛﺑﺎﺕ ﺍﻷﺳﻣﺎء ﻭﺃﺭﻗﺎﻡ ﺍﻟﺿﻣﺎﻥ ﺍﻹﺟﺗﻣﺎﻋﻲ ﻭﺃﺭﻗﺎﻡ ﺍﻟﺿﺭﻳﺑﺔ ﺍﻟﻔﺭﺩﻳﺔ ﻭﺃﺭﻗﺎﻡ ﻫﻭﻳﺔ ﺭﺏ ﺍﻟﻌﻣﻝ ﻭﻧﻘﻠﻬﺎ ﺑﺷﻛﻝ ﺻﺣﻳﺢ ﺇﻟﻰ ﺍﻟﻛﺷﻑ.
• ﺗﻡ ﺇﺛﺑﺎﺕ ﺻﺣﺔ ﻭﺿﻊ ﺭﻓﻊ ﺍﻟﻛﺷﻑ.
• ﺗﻡ ﺑﺷﻛﻝ ﺻﺣﻳﺢ ﺗﺳﺟﻳﻝ ﺍﻹﻋﻔﺎءﺍﺕ ﺍﻟﺷﺧﺻﻳﺔ ﻭﺇﻋﻔﺎءﺍﺕ ﺍﻹﻋﺎﻟﺔ ﻋﻠﻰ ﺍﻟﻛﺷﻑ.
• ﺗﻡ ﺑﺷﻛﻝ ﺻﺣﻳﺢ ﻧﻘﻝ ﻛﺎﻣﻝ ﺍﻟﺩﺧﻝ )ﺑﻣﺎ ﻓﻲ ﺫﻟﻙ ﺍﻟﺩﺧﻝ ﺍﻟﻣﺭﻓﻕ ﻭﻏﻳﺭ ﺍﻟﻣﺭﻓﻕ ﺑﻪ ﺍﻟﻭﺛﺎﺋﻕ ﺍﻷﺻﻠﻳﺔ( ﺍﻟﻣﺧﺗﺎﺭ ﻟﻪ "ﻧﻌﻡ" ﻓﻲ ﺍﻟﺟﺯء ﺍﻟﺛﺎﻟﺙ ﺇﻟﻰ ﻛﺷﻑ ﺍﻟﺿﺭﺍﺋﺏ.
• ﺗﻡ ﺍﻟﺗﺣﻘﻕ ﻣﻥ ﺻﺣﺔ ﺍﻟﺗﻌﺩﻳﻼﺕ ﻋﻠﻰ ﺍﻟﺩﺧﻝ ،ﻣﺛﻝ ﻓﺎﺋﺩﺓ ﻗﺭﺽ ﺍﻟﻁﺎﻟﺏ ،ﻭﻣﺳﺎﻫﻣﺎﺕ IRAﻭﺿﺭﻳﺑﺔ ﺍﻟﻌﻣﻝ ﺍﻟﺣﺭ ،ﻭﻫﻲ ﺻﺣﻳﺣﺔ.
• ﺍﻟﻣﻘﺗﻁﻌﺎﺕ ﺍﻟﻌﺎﺩﻳﺔ ﺃﻭ ﺍﻹﺿﺎﻓﻳﺔ ﺃﻭ ﺍﻟﻣﻔﺻﻠﺔ ﺻﺣﻳﺣﺔ.
• ﻛﺎﻓﺔ ﺍﻹﻋﺗﻣﺎﺩﺍﺕ ﻣﺑﻠﻎ ﻋﻧﻬﺎ ﺑﺷﻛﻝ ﺻﺣﻳﺢ.
• ﺗﻡ ﺇﻋﺗﺑﺎﺭ ﻛﺎﻓﺔ ﺍﻟﺑﻧﻭﺩ ﺍﻟﺳﺎﺭﻳﺔ ﻣﻥ "ﻗﺎﻧﻭﻥ ﺍﻟﺭﻋﺎﻳﺔ ﺍﻟﻣﻳﺳﻭﺭﺓ" ] [ACAﻟﻛﻝ ﺷﺧﺹ ﻣﺫﻛﻭﺭ ﻋﻠﻰ ﻛﺷﻑ ﺍﻟﺿﺭﺍﺋﺏ ﻭﺗﻡ ﺗﺳﺟﻳﻠﻬﺎ ﺑﺷﻛﻝ ﺻﺣﻳﺢ.
• ﺃﻱ ﻣﺩﻓﻭﻋﺎﺕ ﻣﺳﺅﻭﻟﻳﺔ ﻣﺷﺗﺭﻛﺔ ﻫﻲ ﺻﺣﻳﺣﺔ.
• ﺍﻟﻣﻘﺗﻁﻊ ﺍﻟﻣﺑﻳﻥ ﻋﻠﻰ ﺍﻹﺳﺗﻣﺎﺭﺍﺕ ،W-2، 1099ﻭﻣﺩﻓﻭﻋﺎﺕ ﺍﻟﺿﺭﺍﺋﺏ ﺍﻟﻣﻘﺩﺭﺓ ﻣﺑﻠﻎ ﻋﻧﻬﺎ ﺑﺷﻛﻝ ﺻﺣﻳﺢ.
• ﺃﺭﻗﺎﻡ ﺣﺳﺎﺑﺎﺕ ﺍﻹﻳﺩﺍﻉ ﺍﻟﻣﺑﺎﺷﺭ/ﺍﻟﻣﺩﻳﻥ ﻭﺍﻟﺷﻳﻛﺎﺕ/ﺍﻟﺗﻭﻓﻳﺭ ﺻﺣﻳﺣﺔ.
• ﺭﻗﻡ ﻫﻭﻳﺔ ﺍﻟﻣﻭﻗﻊ ﺻﺣﻳﺢ ﻋﻠﻰ ﺍﻟﻛﺷﻑ.
• ﺩﺍﻓﻊ )ﺩﺍﻓﻌﻭ( ﺍﻟﺿﺭﺍﺋﺏ ﺃﺣﻳﻁ ﻋﻠﻣﺎ ً ﺑﺄﻧﻬﻡ ﻣﺳﺅﻭﻟﻭﻥ ﻋﻥ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ ﻋﻠﻰ ﻛﺷﻔﻬﻡ.
ﺍﻹﺳﻡ ﺍﻟﻛﺎﻣﻝ/ﺍﻟﻣﺧﺗﺻﺭ ﻟﻠﻣﺗﻁﻭﻉ ﺍﻟﻣﻌﺗﻣﺩ ﺍﻟﻣﺩﻗﻕ ﻟﻠﺟﻭﺩﺓ )ﺧﻴﺎري(
ﺍﻹﺳﻡ ﺍﻟﻛﺎﻣﻝ/ﺍﻟﻣﺧﺗﺻﺭ ﻟﻠﻣﺗﻁﻭﻉ ﺍﻟﻣﻌﺗﻣﺩ ﺍﻟﻣﻌﺩ ﻟﻛﺷﻑ ﺍﻟﺿﺭﺍﺋﺏ )ﺧﻴﺎري(
ﻣﻼﺣﻅﺎﺕ ﺇﺿﺎﻓﻳﺔ ﻟﻣﻌﺩ ﻛﺷﻑ ﺍﻟﺿﺭﺍﺋﺏ
ﺇﺧﻁﺎﺭ ﻗﺎﻧﻭﻥ ﺍﻟﺧﺻﻭﺻﻳﺔ ﻭﻗﺎﻧﻭﻥ ﺗﺧﻔﻳﺽ ﺍﻟﻣﻌﺎﻣﻼﺕ ﺍﻟﻭﺭﻗﻳﺔ
ﻳﻠﺯﻣﻧﺎ "ﻗﺎﻧﻭﻥ ﺍﻟﺧﺻﻭﺻﻳﺔ" ] [Privacy Actﻟﻌﺎﻡ 1974ﺑﺄﻥ ﻧﻘﻭﻡ ،ﻋﻧﺩ ﻁﻠﺏ ﻣﻌﻠﻭﻣﺎﺕ ،ﺑﺈﺧﺑﺎﺭﻙ ﺑﺣﻘﻧﺎ ﻗﺎﻧﻭﻧﻳﺎ ً ﻓﻲ ﻁﻠﺏ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ ،ﻭﻟﻣﺎﺫﺍ ﻧﻁﻠﺑﻬﺎ ،ﻭﻛﻳﻑ ﺳﻳﺗﻡ ﺇﺳﺗﺧﺩﺍﻣﻬﺎ .ﻛﻣﺎ ﻋﻠﻳﻧﺎ ﺃﻥ ﻧﺧﺑﺭﻙ ﺑﻣﺎ ﻗﺩ ﻳﺣﺩﺙ ﺇﻥ ﻟﻡ ﻧﺣﺻﻝ ﻋﻠﻳﻬﺎ ،ﻭﺑﻣﺎ ﺇﺫﺍ ﻛﺎﻧﺕ ﺇﺟﺎﺑﺗﻙ ﻁﻭﻋﻳﺔ ﺃﻭ ﺇﻟﺯﺍﻣﻳﺔ ﻛﺷﺭﻁ ﻟﻠﺣﺻﻭﻝ ﻋﻠﻰ ﻓﺎﺋﺩﺓ.
ﺣﻘﻧﺎ ﻗﺎﻧﻭﻧﻳﺎ ً ﻓﻲ ﻁﻠﺏ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ ﺧﺎﺿﻊ ﻟﻠﻔﻘﺭﺓ 301ﻣﻥ ﺍﻟﻌﻧﻭﺍﻥ 5ﻣﻥ ﻗﺎﻧﻭﻥ ﺍﻟﻭﻻﻳﺎﺕ ﺍﻟﻣﺗﺣﺩﺓ ] .[U.S.C. 301 5ﻧﺣﻥ ﻧﻁﻠﺏ ﻫﺫﻩ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ ﻟﻣﺳﺎﻋﺩﺗﻧﺎ ﻋﻠﻰ ﺍﻹﺗﺻﺎﻝ ﺑﻙ ﻓﻲ ﺷﺄﻥ ﻣﺻﻠﺣﺗﻙ ﻭ/ﺃﻭ ﻣﺷﺎﺭﻛﺗﻙ ﻓﻲ ﺑﺭﺍﻣﺞ ﻣﺗﻁﻭﻋﻲ ﻣﺻﻠﺣﺔ IRSﻹﻋﺩﺍﺩ ﻛﺷﻭﻑ ﺿﺭﺍﺋﺏ ﺍﻟﺩﺧﻝ ﻭﺑﺭﺍﻣﺞ ﺍﻟﺗﻭﻋﻳﺔ ﻭﺍﻟﺗﻭﺍﺻﻝ.
ﻭﺍﻟﻣﻌﻠﻭﻣﺎﺕ ﺍﻟﺗﻲ ﺗﻌﻁﻳﻬﺎ ﻗﺩ ﻳﺗﻡ ﺗﺯﻭﻳﺩﻫﺎ ﻵﺧﺭﻳﻥ ﻳﺗﻭﻟﻭﻥ ﺗﻧﺳﻳﻕ ﺍﻷﻧﺷﻁﺔ ﻭﺇﺟﺭﺍءﺍﺕ ﺍﻟﺗﻭﻅﻳﻑ ﻓﻲ ﻣﻭﺍﻗﻊ ﻟﻣﺗﻁﻭﻋﻲ ﺇﻋﺩﺍﺩ ﺍﻟﻛﺷﻭﻑ ﺃﻭ ﺃﻧﺷﻁﺔ ﺍﻟﺗﻭﺍﺻﻝ .ﻛﻣﺎ ﻗﺩ ﻳﺗﻡ ﺇﺳﺗﺧﺩﺍﻡ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ ﻟﻭﺿﻊ ﺿﻭﺍﺑﻁ ﻓﻌﺎﻟﺔ ﻭﺇﺭﺳﺎﻝ ﻣﺭﺍﺳﻼﺕ ﻭﺍﻟﺗﻌﺭﻑ ﻋﻠﻰ ﺍﻟﻣﺗﻁﻭﻋﻳﻥ .ﺇﺟﺎﺑﺗﻙ ﻁﻭﻋﻳﺔ ،ﻟﻛﻥ ﺇﻥ ﻟﻡ ﺗﺯﻭﺩ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ ﺍﻟﻣﻁﻠﻭﺑﺔ ،ﻗﺩ ﻻ
ﺗﺗﻣﻛﻥ ﻣﺻﻠﺣﺔ IRSﻣﻥ ﺇﺳﺗﺧﺩﺍﻣﻙ ﻟﻠﻣﺳﺎﻋﺩﺓ ﻓﻲ ﻫﺫﻩ ﺍﻟﺑﺭﺍﻣﺞ.
"ﻗﺎﻧﻭﻥ ﺗﺧﻔﻳﺽ ﺍﻟﻣﻌﺎﻣﻼﺕ ﺍﻟﻭﺭﻗﻳﺔ" ] [Paperwork Reduction Actﻳﻠﺯﻡ ﻣﺻﻠﺣﺔ IRSﺑﻌﺭﺽ ﺭﻗﻡ ﻣﺭﺍﻗﺑﺔ ﻣﻛﺗﺏ OMBﻋﻠﻰ ﻛﺎﻓﺔ ﻁﻠﺑﺎﺕ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ ﺍﻟﻌﺎﻣﺔ .ﻭﺭﻗﻡ ﻣﺭﺍﻗﺑﺔ ﻣﻛﺗﺏ OMBﻟﻬﺫﻩ ﺍﻟﺩﺭﺍﺳﺔ ﻫﻭ .1964-1545 :ﺑﺎﻹﺿﺎﻓﺔ ﺇﻟﻰ ﺫﻟﻙ ،ﺇﺫﺍ ﻛﺎﻧﺕ ﻟﺩﻳﻙ ﺃﻱ ﺗﻌﻠﻳﻘﺎﺕ ﻋﻠﻰ ﺍﻟﺗﻘﺩﻳﺭﺍﺕ ﺍﻟﺯﻣﻧﻳﺔ ﺍﻟﻣﺭﺗﺑﻁﺔ
ﺑﻬﺫﻩ ﺍﻟﺩﺭﺍﺳﺔ ﺃﻭ ﺇﻗﺗﺭﺍﺣﺎﺕ ﺣﻭﻝ ﺗﺑﺳﻳﻁ ﻫﺫﻩ ﺍﻟﻌﻣﻠﻳﺔ ،ﻳﺭﺟﻰ ﻣﺭﺍﺳﻠﺔ ﻣﺻﻠﺣﺔ ﺿﺭﻳﺑﺔ ﺍﻟﺩﺧﻝ ﻋﻠﻰ ﺍﻟﻌﻧﻭﺍﻥ.Internal Revenue Service, Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, Washington, DC 20224 :
ﺍﻟﻛﺗﺎﻟﻭﺝ ﺭﻗﻡ 58970P
www.irs.gov
ﺍﻹﺳﺗﻣﺎﺭﺓ
)13614-C (AR
)ﺗﻌﺩﻳﻝ (2016-10
| File Type | application/pdf |
| File Title | Form 13614-C (AR) (Rev. 10-2016) |
| Subject | Intake/Interview & Quality Review Sheet - Arabic |
| Author | SE:W:CAR:SPEC:QPO |
| File Modified | 2016-10-24 |
| File Created | 2016-10-24 |