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What We Do
Fringe Benefit Information
Please fill out a separate form for each owner
OWNER(s) HEALTH INSURANCE PAID VIA THE PRACTICE
Monthly premium for Dr’s health and dental insurance
BUSINESS AUTOMOBILE QUESTIONNAIRE
Taxpayers deducting automobile expenses are required to maintain written records that support deductions including dates, destination, mileage and business purpose.
Description of Vehicle
Date placed in Service
Was the vehicle used for commuting?
What is your average daily roundtrip commuting distance?
What is the total vehicle mileage for 2022?
What is your total business mileage for 2022?* (Do not include commuting)
*If the business mileage (not including commuting) is less than 50% of the total, please contact your account manager and do not return this form.
Is there another vehicle available for personal use?
I have completed the above to the best of my ability. By signing below, I affirm that I have written evidence to support my information.
MM slash DD slash YYYY
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