1 : Name & Address

Taxpayer

DIGITAL ASSETS:

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 2023. Please provide 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 , provide a copy of the return.

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 2023. Please indicate any months that a member of your "tax family" was NOT insured.

Please indicate any months that a member of your "tax family" was NOT insured.

Tax Return Questionnaire - 2023 Tax Year

DEPENDENTS:

INCOME:

1.Wages and Salaries (Attach W-2's)

2.Interest Income (Attach 1099's)

(List and identify as non-taxable Interest Income)

For the tax year (Provide details for any "Yes" response)

Rental & Royalty Income and Expense