The top of the questionnaire provides spaces for entering name of Taxpayer, Taxpayer Identification Number and Tax Period Ending. This is followed by fields in adjacent columns for 3 items. The text in the columns follows.For each item, and in row order: Item being repaired _____________________________Date of original purchase ______/____/______ Original cost of the item $ ________________ Cost of Repairs $ ________________ Date of Repairs ______/____/______ Nature of Repairs _____________________________