Take some time to fill it out, and bring it with you when you come to the office. This will save you time and money and help us help you more effectively. Just fill out the questionnaire using the fields below. Upload your last 3 years tax returns at the bottom of this form. If you are having us do prior year returns we need a questionnaire completed for each year unless ALL of your information has remained exactly the same.
Taxpayer Information
Filing Status*
Single
Married
Head of Household
Qualifying Widow
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If you would like your tax refund to be deposited directly into your bank account please provide the following information:
Deposit of Tax Refund*
Checking
Savings
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Did you engage in any Business Activities including but not limited to S-Corp, C-Corp, LLC, last year?
Business Activities
Yes
No
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If yes, please request a Business Questionnaire form. Filing of business taxes generally results in an additional fee. Please reach out with any inquiries regarding this.
VIRTUAL CURRENCY: At any time during the previous tax year, did you receive, sell, send, exchange, or otherwise acquire any financial interest in any virtual currency?
Virtual Currency*
Yes
No
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HEALTH INSURANCE COVERAGE: Starting with the 2019 plan year, the Federal Shared Responsibility Payment no longer applies. Some states, however, have their own individual health insurance mandate, requiring you to have qualifying health coverage or pay a fee with your state taxes. Please read the following statements carefully. More than one might apply to your "tax family."
1. If you had health care coverage with a government Marketplace (Exchange) during the previous tax year. Please send us Form 1095-A, issued by the Marketplace. In some family situations you may have more than one 1095-A.
2. If you are claiming someone on your return who was included on another taxpayer’s policy with a Marketplace. If so, then you will also need a copy of that taxpayer’s 1095-A.
3. If a dependent filed a return for the previous tax year. Provide a copy of the return.
4. If you had compliant health insurance through an employer plan, private policy or with a government plan and provide Form 1095-B, 1095-C or other proof of insurance document.
5. If you were issued a hardship exemption by the Marketplace (Exchange). Provide all applicable exemption certificate numbers issued for each member of your family.
6. Complete the information below if you or any individual included in your “tax family” did NOT have insurance coverage for any month of the previous tax year. Please indicate any months that a member of your "tax family" was NOT insured.
Dependents
Provide Dependents' Details for Each of the Dependents (Name, DOB, Relationship, # of Months Lived in House, Income Over $2,200?)
Income (Include Copies of W2s)
Provide Income Details (Name, Gross Wages Withheld, Social Security Withheld, Medicare Withheld, Federal Income Tax Withheld, State Income Tax Withheld)
Did you receive any Wages or Salaries in the previous tax year? If yes, please provide a copy of the W-2(s).
Wages or Salaries*
Yes
No
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Did you receive any Interest Income in the previous tax year? If yes, please provide a copy of the 1099.
Interest Income*
Yes
No
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Did you receive interest from a Seller Financed mortgage? If yes, please include details.
Seller Financed Mortgage
Yes
No
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Did you receive and Dividend Income in the previous tax year? If yes, please provide a copy of the 1099.
Dividend Income
Yes
No
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Did you have any Capital Gains or Losses in the previous tax year? If yes, please include details.
Capital Gains or Losses
Yes
No
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Any other Gains or Losses in the previous tax year? If yes, please include details.
Other Gains or Losses
Yes
No
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Any Pensions, IRA Distributions, Annuities, or Rollovers? If yes, please provide 1099s or other related papers.
Pensions, IRA Distributions, Annuities, or Rollovers
Yes
No
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Any Rents, Royalties, Partnerships, S Corporations, Estates, or Trusts? If yes, please provide paperwork (K-1 for all partnerships/ S Corporations/Fiduciaries) (Separate schedule(s) showing receipts and expenses for each rental property).
Rents, Royalties, Partnerships, S Corporations, Estates, or Trusts
Yes
No
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Did you receive any Unemployment Compensation for the previous tax year?
Unemployment Compensation
Yes
No
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Did you receive any Social Security Benefits in the previous tax year? If yes, please attach the annual statement.
Social Security Benefits
Yes
No
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Did you receive a State or Local Tax Refund? If yes, please provide details
State or Local Tax Refund
Yes
No
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Any other Income not included in the above? If yes, please provide details
Other Income not Included in the Above
Yes
No
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Credits
Number of Qualifying Individuals. Name, address, and identification number of each provider:
Did you incur any expenses related to adoption in the previous tax year?
Expenses Related to Adoption
Yes
No
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Did you pay any tuition or related fees for higher education in the previous tax year?
Tuition or Related Fees for Higher Education
Yes
No
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Did you have any Foreign Income Taxes for the previous tax year? If Yes please attach
Foreign Income Taxes
Yes
No
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Itemized Deductions
Medical and Dental
Out of pocket costs for prescription medications, doctors, dentists, nurses, and medical and dental insurance premiums (includes Medicare Part B) paid in the previous tax year (minus insurance reimbursements)
Lodging and transportation costs incurred while obtaining medical care
Miscellaneous - hearing aids, eyeglasses, medical devices, etc.
Taxes Paid in the Previous Tax Year
State and Local income (not listed elsewhere)
Real Estate taxes (not listed elsewhere)
Personal Property taxes (include owners tax on automobile registration)
Interest Paid in the Previous Tax Year
Home Mortgage interest paid to financial institutions
Home mortgage interest paid to individual (name & address)
Points paid on purchase (provide detail) & Points paid on refinance (provide details)
Investment interest
Student Loan interest
Automobile Use in the Previous Tax Year
In order to deduct mileage for auto expenses on your tax return, you must provide a log which details mileage driven for business purposes. This log would be needed to justify the write off for the expense in the event there is an audit.
Provide Car Information (Make, Model, Year)
If the vehicle is used by the owner, please provide the following information:
Note: Moving Mileage applies to active duty members of the Armed Forces who moved due to permanent change of station
If you have more than one vehicle please attach a document showing additional information.
Contributions: (Documentation needed for all gifts of $250 or more)
Provide details of any Contributions (1. Cash - Less than $250 paid to any organization, 2. Cash - $250 or more paid to any organization (attach details), 3. Excluding Cash - Attach details)
Theft and Casualty Losses - Please provide details
Miscellaneous Deductions
Eliminated until the end 0f 2025. For more information regarding these deductions. Please visit the following link (copy and paste the link into a new tab or window)
Provide the following details related to Employee Business Expenses (Reimbursed, Not Reimbursed, Expenses for job hunting)
Provide details related to Other Expenses (Tax Preparation, Business Publications, Safety Deposit Box Rental, Telephone for Business, IRA Custodial Fees, Education Expenses)
Provide details related to Other Expenses (Union Dues, Professional Dues or Fees, Small Tools used to perform job, Uniforms and Laundering costs, Investment Expenses, Business Meals, Other (please describe))
Provide details related to Adjustments to Income and whether Maximize or Not (Your IRA deduction, Spouse’s IRA deduction, Keogh SEP deduction, Penalty for early withdrawal of savings, Alimony paid - Please describe, Self- employed health insurance premiums)
Did anyone in your household receive a scholarship in the previous tax year? If yes, please provide details.
Received Scholarship in Previous Tax Year
Yes
No
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Did you settle any notices or settle any examinations concerning your prior tax years’ returns
Notices or Settle Examinations Concerning Prior Tax Years’ Returns
Yes
No
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Did you receive any payments from a pension or profit sharing plan? If yes, please provide details
Receive Payments from a Pension or Profit Sharing Plan?
Yes
No
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Did you sell your primary residence during the previous tax year? If yes, please provide details.
Sell Primary Residence During the Previous Tax Year
Yes
No
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Did you change your state of residency during the previous tax year?
Change State of Residency During Previous Tax Year
Yes
No
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If you answered yes to changing state of residency and you are a member of the Armed Forces please provide the following information:
Previous Address, Date of Move, Distance, Costs of Move
Did your principal residence (or secondary) exceed the fair market value of the residence?
Principal Residence
Yes
No
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Do you have an equity loan of credit exceeding $100,000 or total mortgage indebted exceeding $750,000?
Equity Loan of Credit
Yes
No
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Did you exercise any stock options?
Stock Options
Yes
No
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Did you add or dispose of any fixed assets used in trade, business, rental, or farm activities? If yes, please provide details including description, date of acquisition/disposition, cost. etc.
Fixed Assets
Yes
No
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Did you sustain any non-business bad debts?
Non-Business Bad Debts
Yes
No
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Did you purchase, sell, or own any bonds? If yes, please provide details
Purchase, Sell, or Own Any Bonds
Yes
No
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Did you make or receive a “below-market” or “interest-free” loan?
“Below-Market” or “Interest-Free” loan
Yes
No
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Rental & Royalty Income and Expense
Property is Owned by
Property is Owned by
Taxpayer
Spouse
Joint
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If not owned 100% please indicate what percentage
Provide details of the property type & location
Did you occupy part of the rental as a tenant?
Occupy The Rental Income
Yes
No
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If yes, what percentage did you occupy?
If rented to a related party, please explain your relationship.
If Vacation Home:
Provide the following details (Number of days rented, Number of days used personally, Indicate what percentage if not owned 100%)
Provide the following details related to Income (Rental Income, Royalties Received)
Provide the following details related to Expenses (Advertising, Cleaning and Maintenance, Insurance, Utilities, Management Fees, Other Interest, Supplies)
Provide the following details related to Expenses (Association Dues, Commissions, Legal/ Professional Fees, Licenses and Permits, Mortgage Interest, Repairs, Property Taxes, Other (please describe))
Depreciation Details:
Provide the following details (Property, Date Acquired, Cost or Other Basis, Depreciation Method, Prior Depreciation)
Business Use of Home:
Do you use any part of your home exclusively and regularly for business?
Home is Used Exclusively and Regularly for Home
Yes
No
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Describe the work one inside and outside of home office:
Describe the total area of home and total area of office
Estimated percentage of time spent in home office compared to total time spent in the business activity
Provide the following direct costs (Benefit only business portion of home) related to your business use of home: Home Insurance, Repairs and Maintenance, Utilities, Rent, Other
Provide the following indirect costs (Others) related to your business use of home: Home Insurance, Repairs and Maintenance, Utilities, Rent, Other
Depreciation
Cost of home, improvements, and prior depreciation
Depreciation of home improvements, furniture and equipment
Provide the following details (Property, Date Acquired, Cost or Other Basis, Depreciation Method, Prior Depreciation)
If Daycare Facility
Provide the following details (Days used as a daycare facility, Prior year carryover of unallowed losses)
Household Employees
Did you pay a household employee at least $2,200 in the previous tax year? (Examples: housekeepers, nannies, nurses, gardeners)
Did you pay a household employee at least $2,200 in the previous tax year?
Yes
No
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If yes, please provide the following information for each: (Name, Wages Paid, Medicare Tax withheld, Federal Income Tax withheld, Social Security Tax withheld, State Income Tax withheld)
Your Employer Identification Number (SSN can no longer be used)
Has W-2 been filed?
Has W-2 been filed?
Yes
No
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If no, would you like to file it now?
If no, would you like to file it now?
Yes
No
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Have the necessary state employment returns been filed?
Have the necessary state employment returns been filed?
Yes
No
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If no, would you like to file it now?
If no, would you like to file it now?
Yes
No
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Was the household employee under eighteen years of age and a student?
Was the household employee under eighteen years of age and a student?
Yes
No
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By checking this box, I certify that the above information is true and correct to the best of my knowledge and belief. I understand that any false, misleading or deliberately omitted information on this form may subject me to legal action for fraudulent misrepresentation.
Certify Information is True and Correct*
Yes
No
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