Individual Tax Questionnaire ALL FIELDS MARKED WITH AN ASTERISK (*) ARE REQUIRED. If you cannot attach a document to this form, please DO NOT EMAIL IT. We will provide you access to a secure portal for any additional documents that are required. Tax Return Information What tax year is this submission for? (Please do not attach documents that are not for the tax year you selected. If you need to file returns for more than one year, please submit each year separately through this form.) 20232022202120202019 Is this an amendment? YesNo Taxpayer Information First Name Middle Name Last Name Suffix Date of Birth Social Security Number IRS Identity Protection PIN (IP PIN) Occupation Email Address Telephone Number Home Address Address Line 1 Address Line 2 City State ZIP Code Are you legally blind? YesNo Are you disabled? YesNo Would you like to donate to the Presidential Election Campaign Fund? YesNo Please upload a scan or photograph of your Social Security card Please upload a scan or photograph of your Driver's License or State ID Card What is your income tax filing status? SingleMarried Filing JointlyMarried Filing SeparatelyHead of HouseholdQualifying Surviving Spouse Year of Spouse's Death Would you like to take the standard deduction or itemize your deductions? Standard DeductionItemize DeductionsI'm Not Sure Spouse Information Full Name Date of Birth Social Security Number IRS Identity Protection PIN (IP PIN) Email Address Telephone Number Home Address Address Line 1 Address Line 2 City State ZIP Code Is your spouse legally blind? YesNo Is your spouse disabled? YesNo Would your spouse like to donate to the Presidential Election Campaign Fund? YesNo Please upload a scan or photograph of your spouse's Social Security card Please upload a scan or photograph of your spouse's Driver's License or State ID Card Dependent Information Do you have any dependents? YesNo Dependent 1 Full Name Date of Birth Social Security Number Dependent’s Gross Income Number of months dependent lived in the taxpayer’s home in 2022? — select an option — Entire Year1110987654321 Relationship — select an option — SonDaughterNieceNephewParentGrandparentGrandchildFoster ChildAuntUncleSisterBrotherOther Is this dependent disabled? YesNo Is this dependent a full-time student? YesNo Please upload a scan or photograph of this dependent's Social Security card Dependent 2 Full Name Date of Birth Social Security Number Dependent’s Gross Income Number of months dependent lived in the taxpayer’s home in 2022? — select an option — Entire Year1110987654321 Relationship — select an option — SonDaughterNieceNephewParentGrandparentGrandchildFoster ChildAuntUncleSisterBrotherOther Is this dependent disabled? YesNo Is this dependent a full-time student? YesNo Please upload a scan or photograph of this dependent's Social Security card Dependent 3 Full Name Date of Birth Social Security Number Dependent’s Gross Income Number of months dependent lived in the taxpayer’s home in 2022? — select an option — Entire Year1110987654321 Relationship — select an option — SonDaughterNieceNephewParentGrandparentGrandchildFoster ChildAuntUncleSisterBrotherOther Is this dependent disabled? YesNo Is this dependent a full-time student? YesNo Please upload a scan or photograph of this dependent's Social Security card Dependent 4 Full Name Date of Birth Social Security Number Dependent’s Gross Income Number of months dependent lived in the taxpayer’s home in 2022? — select an option — Entire Year1110987654321 Relationship — select an option — SonDaughterNieceNephewParentGrandparentGrandchildFoster ChildAuntUncleSisterBrotherOther Is this dependent disabled? YesNo Is this dependent a full-time student? YesNo Please upload a scan or photograph of this dependent's Social Security card Dependent 5 Full Name Date of Birth Social Security Number Dependent’s Gross Income Number of months dependent lived in the taxpayer’s home in 2022? — select an option — Entire Year1110987654321 Relationship — select an option — SonDaughterNieceNephewParentGrandparentGrandchildFoster ChildAuntUncleSisterBrotherOther Is this dependent disabled? YesNo Is this dependent a full-time student? YesNo Please upload a scan or photograph of this dependent's Social Security card Dependent 6 Full Name Date of Birth Social Security Number Dependent’s Gross Income Number of months dependent lived in the taxpayer’s home in 2022? — select an option — Entire Year1110987654321 Relationship — select an option — SonDaughterNieceNephewParentGrandparentGrandchildFoster ChildAuntUncleSisterBrotherOther Is this dependent disabled? YesNo Is this dependent a full-time student? YesNo Please upload a scan or photograph of this dependent's Social Security card Other Tax Information Did your marital status change during the year? YesNo Did your address change during the year? YesNo Did your dependents change during the year? YesNo Can another taxpayer claim you as a dependent on their tax return? YesNo Did you have unreported tip income of $20 or more in any month? YesNo Did you receive unemployment or disability income? YesNo Did you buy or sell any stocks, bonds, or investment property? YesNo Description of Property Sold Please upload a list of all property sold with the date it was purchased, the purchase price, the sale price, and the cost of any improvements made. Did you buy, sell, exchange, or dispose of any cryptocurrency or digital asset? YesNo Did you purchase, sell, or refinance a home or take out a home equity loan? YesNo Did you convert part or all of your traditional/SEP/SIMPLE IRA to a Roth IRA? YesNo Did you pay anyone for domestic services in your home? YesNo Did you purchase an energy-efficent, hybrid, or electric car, truck or van? YesNo Did you pay childcare expenses for any dependent listed above? YesNo Childcare Expenses Please upload a list of your childcare expenses, including who was paid and the amount paid. Did you receive a distribution from or contribute to a retirement plan such as a 401(k) or IRA? YesNo Did you give anyone a gift of more than $14,000? YesNo Did you go through bankruptcy, foreclosure, or repossession proceedings? YesNo Did you incur a loss due to damaged or stolen property? YesNo Casualty/Theft Loss Please upload details of the damaged or stolen property, including a description, its location, the amount of damage, repair costs, and any grants or reimbursments received. Were you notified or audited by the IRS or a state taxing agency? YesNo Were you a citizen of, have income from, or live in a foreign country? YesNo Did you buy any internet merchandise for which you did not pay sales/use tax? YesNo Did you have ACA compliant health insurance during the year? YesNo Did you make estimated tax payments during the year? YesNo Are you self-employed or a business owner? YesNo Do you have rental income? YesNo Other Income Please enter below any income you received from sources not reported on a Form W-2, 1099-R, or other document that will be attached below. Alimony Received Jury Duty State Income Tax Refund Gambling Winnings Disability Income Other Income Adjustments to Income Did you pay alimony? YesNo Alimony Paid Alimony Recipient Social Security Number of Alimony Recipient Amount of Alimony Paid Did you pay tuition or educational fees? YesNo Tuition or Educational Fees Paid For whom was the tuition or educational fees paid? Amount of Tuition and Educational Fees Paid Educator Expenses Health Savings Account IRA/SEP Contributions IRA/SEP Contributions (Spouse) Student Loan Interest Medical and Dental Expenses Medical Insurance Premiums Long-Term Care Insurance Medical Equipment and Supplies Nursing Care Medical Therapy Hospital Care Prescription Drugs Glasses and Contact Lenses Hearing Aids and Batteries Doctors, Dentists, and Orthodontists Braces Mileage Taxes Paid Real Estate Taxes Personal Property Taxes Foreign Taxes Paid Other Taxes Paid Interest Expense If you received a Form 1098 that documents an interest expense, please attach it below. Investment Interest Did you pay interest to an individual for your home? YesNo Interest Paid to an Individual for Your Home Amount of Interest Paid to an Individual for Your Home Name of Individual Paid Interest for Your Home Social Security Number of Individual Paid Interest for Your Home Address of Individual Paid Interest for Your Home Amortization Schedule for Interest Paid to an Individual for Your Home Charitable Contributions Total Cash Contributions Total Non-Cash Contributions Charitable Mileage Miscellaneous and Unreimbursed Expenses Dues (Union, Professional, Etc.) Books, Subscriptions, and Supplies Licenses Tools and Equipment Uniforms Work-related Tuition and Books Entertainment Tax Preparation Safe Deposit Box IRA Custodial Fees Investment Periodicals and Advisory Fees Job Search Expenses Work-related Moving Expenses Other Expenses Estimated Tax Payments Federal 1st Quarter 2st Quarter 3st Quarter 4st Quarter State 1st Quarter 2st Quarter 3st Quarter 4st Quarter Health Insurance Taxpayer What was the source of your health insurance? — select an option — Health Insurance MarketplacePrivate, Employer, or MedicaidNot Insured Upload Form 1095-A, 1095-B, or 1095-C Number of months you had health insurance? — select an option — Entire Year1110987654321 Were you exempt from the health care mandate? YesNo Exemption Certificate Number (if you have one) Spouse What was the source of your spouse’s health insurance? — select an option — Health Insurance MarketplacePrivate, Employer, or MedicaidNot Insured Upload Form 1095-A, 1095-B, or 1095-C Number of months your spouse had health insurance? — select an option — Entire Year1110987654321 Was your spouse exempt from the health care mandate? YesNo Exemption Certificate Number (if they had one) Dependent 1 What was the source of your dependent’s health insurance? — select an option — Health Insurance MarketplacePrivate, Employer, or MedicaidNot Insured Upload Form 1095-A, 1095-B, or 1095-C Number of months your dependent had health insurance? — select an option — Entire Year1110987654321 Was your dependent exempt from the health care mandate? YesNo Exemption Certificate Number (if they had one) Dependent 2 What was the source of your dependent’s health insurance? — select an option — Health Insurance MarketplacePrivate, Employer, or MedicaidNot Insured Upload Form 1095-A, 1095-B, or 1095-C Number of months your dependent had health insurance? — select an option — Entire Year1110987654321 Was your dependent exempt from the health care mandate? YesNo Exemption Certificate Number (if they had one) Dependent 3 What was the source of your dependent’s health insurance? — select an option — Health Insurance MarketplacePrivate, Employer, or MedicaidNot Insured Upload Form 1095-A, 1095-B, or 1095-C Number of months your dependent had health insurance? — select an option — Entire Year1110987654321 Was your dependent exempt from the health care mandate? YesNo Exemption Certificate Number (if they had one) Dependent 4 What was the source of your dependent’s health insurance? — select an option — Health Insurance MarketplacePrivate, Employer, or MedicaidNot Insured Upload Form 1095-A, 1095-B, or 1095-C Number of months your dependent had health insurance? — select an option — Entire Year1110987654321 Was your dependent exempt from the health care mandate? YesNo Exemption Certificate Number (if they had one) Dependent 5 What was the source of your dependent’s health insurance? — select an option — Health Insurance MarketplacePrivate, Employer, or MedicaidNot Insured Upload Form 1095-A, 1095-B, or 1095-C Number of months your dependent had health insurance? — select an option — Entire Year1110987654321 Was your dependent exempt from the health care mandate? YesNo Exemption Certificate Number (if they had one) Dependent 6 What was the source of your dependent’s health insurance? — select an option — Health Insurance MarketplacePrivate, Employer, or MedicaidNot Insured Upload Form 1095-A, 1095-B, or 1095-C Number of months your dependent had health insurance? — select an option — Entire Year1110987654321 Was your dependent exempt from the health care mandate? YesNo Exemption Certificate Number (if they had one) Self-Employment Information Business Name Who owns this busines? TaxpayerSpouseBoth Total Sales Expenses Advertising Commissions and Fees Dues and Publications Interest Expense Insurance Expense Legal and Professional Fees Office Expense Office Rent Equipment Rental Repairs Supplies Taxes Travel Meals and Entertainment Telephone Utilities Wages (gross W-2) Postage Bank Charges Tools and Equipment Uniforms Auto Expense Auto Mileage Other Expenses Assets Purchased Did you purchase any business assets? YesNo Assets Purchased Please upload details of all assets purchased, including the type of asset, the purchase date, and the purchase price. Cost of Goods Sold Inventory at Beginning of Year Purchases Cost of Items for Personal Use Cost of Labor Materials and Supplies Other Inventory at End of Year Automobile Used for Business Do you have an automobile that you use for this business? YesNo Vehicle Description Date Vehicle Placed in Service Was the vehicle available for personal use? YesNo Was the vehicle available for use during off-duty hours? YesNo Was type of evidence do you have to support these deductions? Written EvidenceOther EvidenceNone Business Miles Driven During the Year Commuting Miles Driven During the Year Total Miles Driven During the Year Automotive Business Expenses Garage Rent Insurance Licenses Parking Fees Property Taxes Repairs Tolls Interest Gas Tires Oil Lease Payments Other Business Use of Home Do you use a portion of your home for this business? YesNo What is the square footage of your home that was used regularly and exclusively for business? What is the total square footage of your home? Does your business provide daycare services in your home? YesNo Daycare Facilities How many days during the year was the area used? How many hours per day was the area used? Was the daycare facility in operation for the entire year? YesNo Office Expenses Enter here any expenses that pertain exclusively to your office. Mortgage Interest Real Estate Taxes Insurance Rent Repairs and Maintenance Utilities Other Expenses Home Expenses Enter here any expenses that pertain to the entire home. Mortgage Interest Real Estate Taxes Insurance Rent Repairs and Maintenance Utilities Other Expenses Rental Income Please enter information for all income producing property rentals. If additional space is needed, add the information to a document and upload it below. Property 1 Property Address Rent Received Number of Days the Property Was Rented Number of Days the Property Was Used for Personal Use Expenses Advertising Auto and Travel Mileage Cleaning and Maintenance Commissions Paid Grounds and Gardening Insurance Interest Expense Legal and Professional Fees Management Fees Repairs Supplies Taxes Utilities Association Dues Pest Control Other Property 2 Property Address Rent Received Number of Days the Property Was Rented Number of Days the Property Was Used for Personal Use Expenses Advertising Auto and Travel Mileage Cleaning and Maintenance Commissions Paid Grounds and Gardening Insurance Interest Expense Legal and Professional Management Fees Repairs Supplies Taxes Utilities Association Dues Pest Control Other Property 3 Property Address Rent Received Number of Days the Property Was Rented Number of Days the Property Was Used for Personal Use Expenses Advertising Auto and Travel Mileage Cleaning and Maintenance Commissions Paid Grounds and Gardening Insurance Interest Expense Legal and Professional Management Fees Repairs Supplies Taxes Utilities Association Dues Pest Control Other Property 4 Property Address Rent Received Number of Days the Property Was Rented Number of Days the Property Was Used for Personal Use Expenses Advertising Auto and Travel Mileage Cleaning and Maintenance Commissions Paid Grounds and Gardening Insurance Interest Expense Legal and Professional Management Fees Repairs Supplies Taxes Utilities Association Dues Pest Control Other Other Tax Document Uploads Please attach additional documents below. If you received an electronic document from the issuer, please upload it. If you received a paper document, please scan the document or take a photograph of the document with your smartphone. Make sure the entire page can be read. If the document has multiple pages, please upload it as a pdf. Tax Document 1 Tax Document 2 Tax Document 3 Tax Document 4 Tax Document 5 Tax Document 6 Tax Document 7 Tax Document 8 Tax Document 9 Tax Document 10 Tax Document 11 Tax Document 12 Tax Document 13 Tax Document 14 Tax Document 15 Tax Document 16 Tax Document 17 Tax Document 18 Tax Document 19 Tax Document 20 Filing and Refund Information Would you like to electronically file your return? YesNo May the IRS discuss your tax return with your preparer? YesNo How would you like to receive your refund? Direct DepositCheck Direct Deposit Information Bank Account Number Bank Account Number (repeat to confirm) Account numbers do not match Routing Number Routing Number (repeat to confirm) Routing numbers do not match Additional Comments Is there anything you would like us to know when preparing your tax return? Signature I (We, if filing Jointly) acknowledge that the above information provided is true and accurate to the best of my/our knowledge. I/We hereby relieve this tax preparer, its agents and affiliates, from any liability whatsoever, regarding the preparation of this/these tax returns, and agree to hold them harmless from any damages I/We may suffer and understand that my/our sole relief is limited to the return of any fee paid for the preparation of these tax documents. I/we guarantee payment of the preparation fee and any related charges. Sign this form by typing your name below. Taxpayer Signature X Spouse Signature X Direct deposit account numbers do not match Direct deposit routing numbers do not match
