Questions. The following questions pertain to the 2017 tax year. For any question answered Yes, include supporting detail or documents.

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3 Questions The following questions pertain to the 2017 tax year. For any question answered Yes, include supporting detail or documents. Personal Information: Yes No Did your marital status change? Are you married? If Yes, do you and your spouse want to file separate returns? If No, are you in a domestic partnership, civil union, or other state-defined relationship? Can you or your spouse be claimed as a dependent by another taxpayer? Did you or your spouse serve in the military or were you or your spouse on active duty? Dependents: Yes No Were there any changes in dependents from the prior year? Did you or your spouse pay for child care while you or your spouse worked or looked for work? Do you have any children under age 18 with unearned income more than $1,050? Do you have any children age 18 or student children, aged 19 to 23, who did not provide more than half of their cost of support with earned income and that have unearned income of more than $1,050? Did you adopt a child or begin adoption proceedings? Are any of your dependents non-u.s. citizens or non-u.s. residents? Healthcare: Yes No Did you have healthcare coverage (health insurance, including Medicare, Medicaid, CHIP, and TRICARE) for you, your spouse, and any dependents for the entire year? If Yes, include all Forms 1095-A, 1095-B, and 1095-C. If you did not receive Forms 1095-A, 1095-B or 1095-C, attach information detailing each month you, your spouse, and your dependents had coverage. If No, how many months did you have coverage? Page 3

4 Education: Yes No Did you or your spouse pay any student loan interest? Did you or your spouse withdraw any amounts from your IRA to pay for higher education expenses incurred by you, your spouse, your children or grandchildren? Did you or your spouse withdraw any amounts from a Coverdell Education Savings Account or Qualified Education Program (Section 529) plan? If Yes, include all Forms 1099-Q. Did you, your spouse, or your dependents incur any post-secondary education expenses, such as tuition? Deductions and Credits: Yes No Did you or your spouse incur any casualty or theft losses? Did you or your spouse incur any casualty or loss attributable to a federally declared disaster? Did you or your spouse purchase a new alternative technology vehicle, including a qualified plug-in electric drive motor vehicle? Did you or your spouse install any alternative energy equipment in your residence such as solar water heaters, solar electricity equipment (photovoltaic) or fuel cells? Did you or your spouse install any energy efficiency improvement or energy property in your residence such as exterior doors or windows, insulation, heat pumps, furnaces, central air conditioners, or water heaters? Investments: Yes No Did you or your spouse have any debts canceled, forgiven or refinanced? Did you or your spouse start or purchase a business, rental property, or farm, or acquire any new interest in any partnership or S corporation? Did you or your spouse sell an existing business, rental property, farm, or any existing interest in a partnership or S corporation? If yes, please include Schedule(s) K-1 showing income from partnerships, estates, trusts, S Corporations, and limited liability companies. Did you or your spouse sell, exchange, or purchase any real estate? If Yes, include closing statements. Page 4

5 Investments (continued): Yes No Did you or your spouse receive grants of stock options from your employer, exercise any stock options granted to you or your spouse or dispose of any stock acquired under a qualified employee stock purchase plan? Did you purchase/trade/mine any cryptocurrency during 2017 (ex. Bitcoin, Ethereum, Ripple, etc.)? Retirement or Severance: Yes No Did you or your spouse contribute to a Roth IRA or convert an existing IRA into a Roth IRA? Did you or your spouse roll into a Roth IRA any distributions from a retirement plan, an annuity plan, tax shelter annuity or deferred compensation plan? Did you or your spouse turn age 70 ½ and have money in an IRA or other retirement account without taking any distribution? Did you or your spouse retire or change jobs? Personal Residence: Yes No Did your address change? If Yes, provide the new address. Sale of Your Home: Yes No Did you sell your home? Did you receive Form 1099-S? If Yes, include Form 1099-S. Gifts: Yes No Did you or your spouse make any gifts, including birthday, holiday, anniversary, graduation, education savings, etc., with a total (aggregate) value in excess of $14,000 to any individual? Did you or your spouse make any gifts to a trust (domestic or foreign) for any amount? Did you or your spouse forgive any indebtedness to any individual, trust or entity? Page 5

6 Foreign Matters: Yes No Did you or your spouse perform any work outside of the U.S., have any foreign income, or pay any foreign taxes? If yes, please provide information and foreign tax return(s). Do you have any interest in or a signature authority over a bank account, securities account, or other financial account in a foreign country? If yes, please fill out the attached FinCEN spreadsheet. Did you have power to direct activities in a foreign financial account, eve if you did not have an ownership interest or signature authority? Did you or your spouse create or transfer money or property to a foreign trust? Did you or your spouse own any foreign financial assets (i.e. stocks, bonds, life insurance, retirement accounts, real estate, etc.)? Did you own any interest in foreign entities, foreign financial instruments/contracts, etc.? Did you own any shares of foreign corporations, foreign partnerships, and/or other types of business entities in a foreign country? If you answered yes to any of the above questions in this section, please provide information. Did you have non-u.s. retirement benefits (superannuation or other foreign retirement plans)? If yes, please provide calendar year retirement account statements. Did you receive a gift of more than $15,671 from a foreign entity, or more than $100,000 from a foreign individual? Were you a beneficiary of a foreign trust? Were you an appointor, protector, or principal of a foreign trust? Were you a director of a corporate trustee of a foreign trust? Did you make a transfer (as a grantor or transferor) to a foreign trust? Did you receive a distribution from a foreign trust? Were you a beneficial owner of a foreign trust (even if you are not the grantor/settlor, and even if you did not receive a current distribution)? Did you receive any benefits from a foreign trust s assets, including use of the trust s real estate or other assets without adequate consideration? For non-u.s. Citizens, did your U.S. immigration status change during the year? For non-u.s. Citizens, did your foreign residency status change during the year? Page 6

7 For Foreign Persons Living in the U.S.: Country of Citizenship Country of Tax Residence Current U.S. Visa Status (i.e. type) (Please provide a copy of the visa) Taxpayer Spouse Miscellaneous: Yes No Did you or your spouse pay in excess of $1,000 in any quarter or $2,000 during the year for domestic services performed in or around your home to individuals who could be considered household employees? Have you or your spouse received a punitive damage award for damages other than for physical injuries or illness? Did you or your spouse engage in any bartering transactions? Were you or your spouse notified by the IRS or other taxing authority of any changes in prior year returns? For any trust that you or your spouse created or are trustee, did any beneficiaries, grantors, or trustees die or move? If You Are A Schedule C Filer Self-Employed: Yes No Do you maintain a pension plan for current or former employees (including yourself? Related Tax Filings: Yes No Place a check mark next to any of the following business-related forms you would like us to prepare for you: Annual Pension Report Form (Form 5500) Business Property Report (Form 571-L) City Business License Payroll Tax Returns Sales/Use Tax Returns Page 7

8 Authorizations (please sign below): Yes No May the IRS discuss your tax return with your tax preparer? Do you authorize your tax preparer to have (view only) access to all information associated with your social security number on the California Franchise Tax Board (FTB) website for all tax years (such as estimated tax payments made to the FTB, wage, withholding, and FTB-issued 1099 information)? Taxpayer s Signature Spouse s Signature Date Date Please type in your name if unable to sign due to electronic transmittal. A typed name will signify your consent. Additional state pages have been included at the back of the organizer and should be reviewed. Page 8

9 Foreign Asset Declaration My (Our) federal and state income tax returns will be prepared by you. You have made me (us) aware that U.S. taxpayers are required to report their worldwide income, that is, income from both U.S. and foreign sources. In addition, taxpayers who own, have an interest in, or have signature or other authority over financial assets in a foreign country may be required to report the existence of such assets. I (We) have reported to you any and all foreign financial assets in which I (we) have either ownership or signature authority. These items include, but are not limited to, funds in foreign financial institutions, rights to foreign pension plans, rights to distributions from foreign estates or trusts, life insurance policies with cash surrender values, or any other foreign financial assets. Foreign securities and other assets held by brokerage companies located in the U.S. are not required to be reported. There might be exceptions if such investments through U.S. brokerage companies are held through foreign partnerships. PLEASE NOTE: Penalties are severe for failure to report timely. If you have any doubt as to whether or not any of your foreign financial assets are reportable, please contact us. Taxpayer s Signature Date Spouse s Signature Date Page 9

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