Fringe Benefit – Rosen & Associates, LLP

Please fill out a separate form for each owner

OWNER(s) HEALTH INSURANCE PAID VIA THE PRACTICE
Dr’s Name:*
Monthly premium for Dr’s health and dental insurance*
Annual premium*
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*
Month
Day
Year
Was the vehicle used for commuting?*
- Yes
- No
What is your average daily roundtrip commuting distance?
What is the total vehicle mileage for 2023?*
What is your total business mileage for 2023?* (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?
- Yes
- No
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.
Name*
Email*
Date*
MM slash DD slash YYYY
E-Signature*
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