Client Questionnaire Form Step 1 of 28 3% NEW CLIENT?(Required) YES NO NEW CLIENTS PROVIDE PRIOR TWO YEAR’S RETURNSTAXPAYER INFORMATIONTAXPAYER FULL NAME(Required) SOCIAL SECURITY NUMBER(Required) DATE OF BIRTH MM slash DD slash YYYY (If New)OCCUPATION(Required) SPOUSE FULL NAME SOCIAL SECURITY NUMBER DATE OF BIRTH MM slash DD slash YYYY (If New)OCCUPATION FILING STATUS(Required) SINGLE MFJ MFS HOH RETIREMENT DATE? MM slash DD slash YYYY (Can impact taxability) MAILING ADDRESS(Required) SCHOOL DISTRICT(Required) TOWNSHIP / BOROUGH(Required) IF YOU MOVED - PROVIDE PRIOR ADDRESS MOVE DATE MM slash DD slash YYYY PHONE(S)(Required) EMAIL(S)(Required) INCOME (Fill In All That Apply) - (# Means Number of Forms)WAGES W-2 #TAXPAYERSPOUSEW-2 G (GAMBLING) #TAXPAYERSPOUSEINTEREST-1099 INT #TAXPAYERSPOUSEDIVIDEND 1099 DIV #TAXPAYERSPOUSESTOCK/BONDS 1099B #TAXPAYERSPOUSEPENSION/IRA #TAXPAYERSPOUSEPENSION/IRA W/HTAXPAYER W/H $SPOUSE W/H $SOCIAL SECURITYTAXPAYERSPOUSESOCIAL SECURITY W/HTAXPAYER W/H $SPOUSE W/H $ALIMONY RECEIVEDTAXPAYER $SPOUSE $ INCOME (Fill In All That Apply)SALE OF (Home, Land, Properties) UNEMPLOYMENT - TAXPAYER YES NO UNEMPLOYMENT - SPOUSE YES NO TAXES WITHHELD? STATE REFUND - TAXPAYER YES NO STATE REFUND - SPOUSE YES NO LOCAL REFUND - TAXPAYER YES NO LOCAL REFUND - SPOUSE YES NO DEBT 1099C / 1099A $ DEBT FORGIVEN? TAX EXEMPT INT - TAXPAYER YES NO TAX EXEMPT INT - SPOUSE YES NO WORKERS COMP - TAXPAYER YES NO WORKERS COMP - SPOUSE YES NO K-1 # JURY PRIZE, LOTTERY, OTHER ANY OTHER INCOME FROM OTHER SOURCES? YES NO (Tips, Raffles, Rentals, Etc.) IF YES EXPLAIN ADJUSTMENTS TO INCOMEEARLY WITHDRAWAL PENALTYTAXPAYERSPOUSESTUDENT LOAN INTERESTTAXPAYERSPOUSEALIMONY PAID $ DIVORCE DATE MM slash DD slash YYYY EX NAME (Include Divorce Decree Copy)SSN SEPTP $SP $(Do Not Include Employer Contributions) IRA CONTRIBUTIONTAXPAYERSPOUSEROTH CONTRIBUTIONTAXPAYERSPOUSECONVERTED ROTHTAXPAYERSPOUSEEDUCATION IRATAXPAYERSPOUSE# OF CHILDERNCOLLEGE 529 PLANTAXPAYERSPOUSE1099-QTAXPAYERSPOUSEUNION DUESTAXPAYERSPOUSE CONTINUED - ADJUSTMENTS TO INCOMESELF EMPLOYEDTAXPAYERSPOUSEFARMTAXPAYERSPOUSERENTALSTAXPAYERSPOUSEHOME OFFICETAXPAYERSPOUSEMILAGEBUSINESSPERSONALTOTAL MILEAGELOG YES NO 3RD PARTY YES NO MILAGEBUSINESSPERSONALTOTAL MILEAGELOG YES NO 3RD PARTY YES NO MILAGEBUSINESSPERSONALTOTAL MILEAGELOG YES NO 3RD PARTY YES NO MODEL PLACED IN SERVICE DATE PLACED IN SERVICE MM slash DD slash YYYY FBAR/DIGITAL ASSET/CRYPTOCURRENCYDO YOU HAVE PROPERTY IN A FOREIGN COUNTRY? - TAXPAYER YES NO DO YOU HAVE PROPERTY IN A FOREIGN COUNTRY? - SPOUSE YES NO DO YOU HAVE BANK ACCTS IN A FOREIGN COUNTRY? - TAXPAYER YES NO DO YOU HAVE BANK ACCTS IN A FOREIGN COUNTRY? - SPOUSE YES NO DO YOU HAVE BANK ACCTS IN A FOREIGN COUNTRY? - SPOUSE YES NO DO YOU HAVE A PENSION IN A FOREIGN COUNTRY? - SPOUSE YES NO ARE YOU DEALING IN ANY CRYPTOCURRENCY? - TAXPAYER YES NO ARE YOU DEALING IN ANY CRYPTOCURRENCY? - SPOUSE YES NO AT ANY TIME DURING 2022, DID YOU: (A) RECEIVE (AS A REWARD, AWARD OR PAYMENT FOR PROPERTY OR SERVICES); OR (B) SELL, EXCHANGE, GIFT OR OTHERWISE DISPOSE OF A DIGITAL ASSET (OR A FINANCIAL INTEREST IN A DIGITAL ASSET)? - TAXPAYER YES NO AT ANY TIME DURING 2022, DID YOU: (A) RECEIVE (AS A REWARD, AWARD OR PAYMENT FOR PROPERTY OR SERVICES); OR (B) SELL, EXCHANGE, GIFT OR OTHERWISE DISPOSE OF A DIGITAL ASSET (OR A FINANCIAL INTEREST IN A DIGITAL ASSET)? - SPOUSE YES NO CREDITSAMERICAN OPP CREDITTAXPAYERSPOUSEYEARS TAKENEDUCATION CREDITTAXPAYERSPOUSEYEARS TAKENSTUDENT LOAN PAYMTTAXPAYERSPOUSEYEARS TAKENACCOUNT HISTORY - TAXPAYER YES NO 1098-T,BOOKS, ETC. - TAXPAYER YES NO ENERGY CREDITS YES NO SOLAR ENERGY IMPROVEMENTS YES NO windows,doors, heating/AC, hot water heator improvemnets) Receipts NeededDID YOU PURCHASE AN EV (Electronic Vehicle)? - VIN # AND COPIES OF BILL OF SALE REQUIRED ITEMIZED DEDUCTIONSHSA USED FOR MEDICAL EXPENSES? YES NO MEDICAL INSURANCE (PAID FOR) RX OTHER MEDICAL BILLS MEDICAL MILES STATE TAXES PAID LOCAL TAXES PAID CASH CHARITY/CHURCH DONATIONS (Documentation Required)NON-CASH DONATIONS (Documentation Required)CHARITY MILES LARGE ITEM SALES TAX (Auto, Etc.)DONATED LARGE ITEMS (Make, Model, & Year) 1098 # MORTGAGE INTEREST IF HOME EQUITY, WHAT WAS USED AS COLLATERAL? WHAT WERE THE MORTGAGE/HOME EQUITY FUNDS USED FOR? SECOND HOME SECURED BY? LUXURY VEHICLE SALES TAX PD? CAMPER SECURED BY? BOAT SALES TAX PD? RV SECURED BY? FIRST TIME HOME BUYER REPAYMENT YES NO HEALTH SAVINGS ACCOUNTH.S.A. DISTRIBUTIONS - FULL AMOUNT WAS USED FOR QUALIFIED MEDICAL EXPENSES: YES NO H.S.A. CONTRIBUTIONS EMPLOYER (AMOUNT) H.S.A. CONTRIBUTIONS EMPLOYEE (PRE-TAX) H.S.A. CONTRIBUTIONS SELF CONTRIBUTION (POST-TAX) MARKETPLACE INSURANCEDID YOU HAVE MARKETPLACE INSURANCE? YES NO DID YOU RECEIVE A PREMIUM TAX CREDIT? YES NO PART YEAR RESIDENCE - (Did You Move During the Year? If Yes, Fill Out Below)FROM: MM slash DD slash YYYY TO: MM slash DD slash YYYY TOWNSHIP SCHOOL DISTRICT FROM: MM slash DD slash YYYY TO: MM slash DD slash YYYY TOWNSHIP SCHOOL DISTRICT FROM: MM slash DD slash YYYY TO: MM slash DD slash YYYY TOWNSHIP SCHOOL DISTRICT ESTIMATED PAYMENTS (Did You Make Estimated Payments? If Yes, Fill Out Below)FEDERAL1ST QUARTER $:2ND QUARTER $:3RD QUARTER $:4TH QUARTER $:STATE1ST QUARTER $:2ND QUARTER $:3RD QUARTER $:4TH QUARTER $:LOCAL1ST QUARTER $:2ND QUARTER $:3RD QUARTER $:4TH QUARTER $: DIRECT DEPOSITIF A REFUND IS DUE, DO YOU WANT DIRECT DEPOSIT? YES NO BANK NAME Please provide a voided check for routing and account numbers, and a driver’s license to photocopy. ELECTRONIC COPYIF YOU WOULD PREFER AN ELECTRONIC COPY TO A PAPER COPY PLEASE CHECK HERE YES (ONE CAN BE UPLOADED TO A SECURE PORTAL THAT YOU CAN ACCESS WITH A PASSWORD YOU CREATE THROUGH A LINK THAT WE SEND YOU.) SIGNATURES REQUIRED FOR INCOME TAX COMPLETIONTAX PAYER: TYPE FULL NAME TO DIGITALLY SIGN Date MM slash DD slash YYYY TAX PAYER: TYPE FULL NAME TO DIGITALLY SIGN Date MM slash DD slash YYYY DEPENDENTSLIST DEPENDENTSDEPENDENT NAMERELATIONSHIP (son, daughter, etc.)D.O.BS.S.N.LIVES WITH? YES NO # OF MONTHS LIST DEPENDENTSDEPENDENT NAMERELATIONSHIP (son, daughter, etc.)D.O.BS.S.N.LIVES WITH? YES NO # OF MONTHS LIST DEPENDENTSDEPENDENT NAMERELATIONSHIP (son, daughter, etc.)D.O.BS.S.N.LIVES WITH? YES NO # OF MONTHS LIST DEPENDENTSDEPENDENT NAMERELATIONSHIP (son, daughter, etc.)D.O.BS.S.N.LIVES WITH? YES NO # OF MONTHS DEPENDENTS CREDITSDAYCARE NAME DAY CARE EIN # PAID $ STREET ADDRESS CITY, STATE, ZIP GROSS INCOME OF OTHER PERSON $(TIE BREAKER RULES)HOW MANY OVERNIGHTS DID YOUR DEPENDENT STAY WITH YOU THIS TAX YEAR? HOW MANY OVERNIGHTS WITH THE OTHER PERSON? DO YOU HAVE AN 8332 ON FILE FOR ANY YEARS? YES NO IF SO, PLEASE PROVIDE A COPY OF IT. HEAD OF HOUSEHOLD FILING STATUSIF YOU WERE ASKED BY THE IRS, CAN YOU PROVIDE PROOF OF KEEPING UP HOUSEHOLD FOR YOU & YOUR DEPENDENT? (EXAMPLES: RENT, MORTGAGE, GROCERY RECEIPTS, UTILITIES) YES NO DID ANYONE ELSE LIVE WITH YOU? YES NO ListNAME?RELATIONSHIPListNAME?RELATIONSHIPListNAME?RELATIONSHIPDID ANYONE HELP PAY FOR THE ABOVE LIVING EXPENSES? YES NO IF SO WHAT PORTION / PERCENTAGE? DEPENDENTS NOTESUntitled NOT REQUIRED FOR TAX RETURN PREPLIFE INSURANCE - TAXPAYER YES NO LIFE INSURANCE - SPOUSE YES NO LIFE INSURANCE - COPY ON FILE YES NO DURABLE POA - TAXPAYER YES NO DURABLE POA - SPOUSE YES NO DURABLE POA - COPY ON FILE YES NO NAME OF POA MEDICAL POA - TAXPAYER YES NO MEDICAL POA - SPOUSE YES NO MEDICAL POA - COPY ON FILE YES NO NAME OF POA LIVING WILL - TAXPAYER YES NO LIVING WILL - SPOUSE YES NO LIVING WILL - COPY ON FILE YES NO TRUSTEE REGULAR WILL - TAXPAYER YES NO REGULAR WILL - SPOUSE YES NO REGULAR WILL - COPY ON FILE YES NO EXECUTOR RETIREMENT ACCTS - TAXPAYER YES NO RETIREMENT ACCTS - SPOUSE YES NO RETIREMENT ACCTS - COPY ON FILE YES NO LIVING TRUST - TAXPAYER YES NO LIVING TRUST - SPOUSE YES NO LIVING TRUST - COPY ON FILE YES NO TRUSTEE NAME STOCKS - TAXPAYER YES NO STOCKS - SPOUSE YES NO STOCKS - COPY ON FILE YES NO IRE-TRADITIONAL - TAXPAYER YES NO IRE-TRADITIONAL - SPOUSE YES NO IRE-TRADITIONAL - COPY ON FILE YES NO IRA-ROTH - TAXPAYER YES NO IRA-ROTH - SPOUSE YES NO IRA-ROTH - COPY ON FILE YES NO BONDS - TAXPAYER YES NO (When Mature)BONDS - SPOUSE YES NO (When Mature)BONDS - COPY ON FILE YES NO (When Mature)WHEN MATURE MM slash DD slash YYYY ATTORNEY - TAXPAYER YES NO ATTORNEY - SPOUSE YES NO ATTORNEY - COPY ON FILE YES NO NAME BROKERAGE FIRM - TAXPAYER YES NO BROKERAGE FIRM - SPOUSE YES NO BROKERAGE FIRM - COPY ON FILE YES NO NAME PERSON WE GO TO IF TAXPAYER DIES OR BECOMES MENTALLY UNABLE TO MAKE DECISIONSNAME PHONE ANYONE YOU DO NOT WANT US TO CONTACT? YES NO IF YES, WHO? NOTES (Please write Notes or Questions.)
