Print this form out & use it to organize your documents prior to coming to our office. It will help you remember all of the things you should bring to the meeting. Tax Return Questionnaire - 2018 Tax Year Name & Address: Social Security # Occupation Taxpayer: Spouse: Address: Phone # s - Cell: Work: Home: Birth Date: Month, Day, Year Yourself: / / Spouse: / / As of December 31, 2018 your marital status was: Single Married: Did you live with your spouse during any part of the last six months of 2018? Divorced or Legally Separated: Date of final decree or separate maintenance agreement: Widowed: Date of spouse s death: DEPENDENTS: Name (First & Last) Income Less Than 4,150? (Y/N) Date of Birth Social Security Number Relationship Months Lived in Home HEALTHCARE COVERAGE: Full Coverage Part- Year Marketplace Purchased(1) Exempt Comments You Spouse Dependent # 1 Dependent # 2 Dependent # 3 Dependent # 4 (1)Please provide form 1095-A if medical insurance was purchased on the Marketplace
INCOME: 1. Wages and Salaries (Attach W-2's) Name of Payer Gross Wages Soc Security (withheld) Medicare (withheld) Fed Inc Tax (withheld) St Inc Tax (withheld) 2. Interest Income (Attach 1099-INT's) List non-taxable Interest along with taxable. Name of Payer Amount Taxable? Name of Payer Amount Taxable? 3. Dividend Income (Attach 1099-DIV's) Name of Payer Ordinary Dividends Qualified Dividends Capital Gains Distributions Foreign Tax Paid Other 5. Capital Gains and Losses (Attach 1099-B s): Investment Date Purchased Cost or Other Basis Date Sold Net Proceeds of Sale
6. Pensions, IRA Distributions, Annuities, and Rollovers (Attach 1099R s): Payer EIN # Amount Distributed Fed Tax Withheld State Tax Withheld Rolled Over? - - - 7. Rent/Royalties, Partnership, S Corporations, Estates, Trusts... (Attach K-1's for all Partnerships/S Corporations/Fiduciaries) (Attach separate schedule(s) showing receipts & expenses for each rental property) 8. Unemployment Compensation Received (Attach 1099-G) 9. Social Security Benefits Received (Attach SSA-1099) 10. State/Local Tax Refunds (Attach 1099-G) 11. Other Income: Description Amount Ex- Distributions from HSA (1099-SA), Distribution from 529 Plans (1099-Q), Alimony, Gambling Winnings, Jury Duty, SUBTRACTIONS from INCOME: Name of Institution Amount Health Savings Account Contribution (attach 5498-SA) Student Loan Interest Your IRA Deduction (attach 1098-E) Maximize? [ ] yes [ ] no Spouses IRA Deduction Maximize? [ ] yes [ ] no Alimony Paid Out - recipient S S # - - Other CREDITS: 1. Child and Dependent Care: Child s Name Amount Paid Amt Reimbursed Daycare Provider 3
Daycare Provider Name EIN or SS # Address City, State, Zip If payments were made to an individual, were the services performed in your home? If Yes, have payroll reports been filed? 2. Did you incur expenses in connection with an ADOPTION? (bring expenses to meeting with tax accountant, along with details on the child - special needs?, foreign?) 3. Tuition & Fees Paid for Higher Education (Attach 1098-T s): Student Name Amount College/University/School Name 4. First Time Home Buyer Credits - please call regarding repayment if applicable 5. Energy Credits: Item Amount Item Amount Residential Energy Property Credit: The credit applies to improvements such as adding insulation, energy efficient exterior windows and energy-efficient heating and air conditioning systems. Residential Energy Efficient Property Credit: Alternative energy equipment, such as solar hot water heaters, geothermal heat pumps and wind turbines. ITEMIZED DEDUCTIONS: 1. Medical (out of pocket expenses): Insurance Premiums Paid Dentist Prescriptions Hearing Aids Doctors Optical (glasses & contacts) Other (nursing care etc.) Travel & Lodging Relating to Medical Mileage Driven for Medical miles 4
2. Taxes Paid: State and Local Income Taxes (not listed elsewhere) Real Estate Taxes (include vacation property - do not include rental properties) Auto Registration Fees 3. Interest Paid (Attach 1098's): On all new purchases and refi s include a copy of closing statements Type Paid To Amount Home Mortgage Interest Mortgage Interest Paid to Individuals (name & address) Points Paid [ ] purchase [ ] refinance Investment Interest 4. Contributions: (written documentation is required for all cash donations of 250 or more) Non-cash donations require - value & descriptions of items donated. Name of Charity Amount CASH Donations Miles Driven for Charity X 0.14 per mile NON- CASH Address of Charity 5. Casualty & Theft Losses (must be a federally declared disaster area to deduct) Attach Details 6. Miscellaneous Deductions: (NOTE Employee Business Expenses are no longer deductible except for Armed Forces Reservists, Qualified Performing Artists, etc) Attach Details 7. Automobile Use: - Please see Auto Expense Worksheet 5
2018 ESTIMATED TAX PAYMENTS: FEDERAL Date Paid Amount STATE Date Paid Amount Qtr 1 Qtr 1 Qtr 2 Qtr 2 Qtr 3 Qtr 3 Qtr 4 Qtr 4 Extension (April 15, 2019 ) Extension (April 15, 2019 ) Applied from prior year Applied from prior year Did you buy or sell your primary residence during 2018? [ ] Yes [ ] No If yes, provide a copy of the closing statements of the sale and a copy of the closing of the purchase (if applicable). Qualified State Tuition Plans - Did you or your spouse make any contributions to a Section 529 Plan during 2018? Name of Designated Beneficiary Social Security # State Sponsoring Plan 2018 Amount Would you like your tax refund (if any) deposited directly into your bank? [ ] Yes [ ] No Account Type Bank Name Bank Routing Number Your Account Number Checking [ ] Savings [ ] Electronic Filing Electronic filing is the only filing method that provides you with acknowledgment that the IRS has received your return and is processing it. Note that not all returns qualify for electronic filing under IRS rules but by law we are required to E file your return if it qualifies unless you specifically request to file a paper return. Please provide a 5-digit self-selected Personal Identification Number (PIN). Taxpayer PIN Spouse PIN 6 digit- Identity Theft PINS provided by the IRS (if appropriate) Taxpayer Identity Theft PIN Spouse Identity Theft PIN Dependent Identity Theft PIN 6
Household Employees: (Nanny Tax) Did you pay a household employee at least 2,100 this year? [ ] Yes [ ] No (e.g., housekeepers, nannies, nurses, yard workers, health aides, babysitters - not provided by another organization) If yes, please provide the following for each household employee: Taxes Withheld Name Social Security # Wages Paid Federal Tax Social Security Tax Medicare Tax State Income Tax Has W-2 been filed? Yes [ ] No [ ] If no, do you want us to prepare them for you? Yes [ ] No [ ] Have the necessary state employment returns been filed? Yes [ ] No [ ] If no, do you want us to prepare them for you? Yes [ ] No [ ] Was the household employee under 18 yrs of age & a student? Yes [ ] No [ ] State Income Tax Questions: USE TAX Amount of Internet, mail order or other out-of-state purchases RENTERS Landlord Name &Address # of Months Rented Monthly Rent Please use these lines for any additional questions or details you would like to include. To the best of my knowledge the information enclosed in this client tax questionnaire is correct and includes all income, deductions, and other information necessary for the preparation of this year's income tax returns for which I have adequate records. Taxpayer Date Spouse Date 7
Rental & Royalty Income & Expense Property Type: [ ] Residential [ ] Commercial Location (s): (For additional properties print more copies of this page) If Vacation Home: Number of days rented Number of days used personally Property Owned by: [ ] Taxpayer [ ] Spouse [ ] Joint Percentage ownership if not 100% % Did you live in part of the rental property? [ ] Yes [ ] No If yes, what % did you occupy as a tenant? % [ ] Check if rented to a related party Explain Relation: Income Amount 1. Rental Income 2. Royalties Received Expenses Amount Amount 1. Advertising 11. Mortgage Interest (form 1098) 2. Association Dues 12. Other Interests 3. Auto Miles Driven (miles) 13. Repairs 4. Travel 14. Supplies 5. Cleaning & Maintenance 15. Property Taxes 6. Commissions 16. Utilities 7. Insurance Other (description) 8. Legal & Professional Fees 17 a. 9. Licenses & Permits 17 b. 10. Management Fees 17 c. Depreciation: Property Date Acquired Cost or Basis Depreciation Method Prior Depreciation 8
AUTO EXPENSE WORKSHEET (print additional copies if needed) In order to deduct mileage for auto expenses in a tax return, a log must be kept which details mileage driven for business purposes. A log, or something which keeps track of mileage, would be needed to justify the write-off for the expense in the event of an audit. Note: You may use either actual expenses of the all-inclusive mileage rate for your auto, whichever gives you the greater deduction. However, if you used the actual expense method in the past for a vehicle, you may not be able to use the mileage method in subsequent years. Vehicle # 1 Vehicle # 2 Year, Make, Model Driver (Taxpayer/Spouse) Total mileage for the year Business miles included above Total gas, oil, lube Total repairs, wash, anti-freeze Total tires, batteries, supplies Total Insurance Total Auto Lease payments Total licenses, tabs Parking, tolls Interest paid on loan (if applicable) NEW VEHICLE PURCHASED? (Circle one) YES or NO YES or NO Please provide sales document NEW LEASED VEHICLE? (Circle one) YES or NO YES or NO Please provide lease agreement Fair Market Value PRIOR Year Leased Vehicle (Circle one) YES or NO YES or NO Date lease began Fair Market Value 9
Business Income & Expense (Sole Proprietorship or LLC NOT an Employee with W-2) Principle business: Employer ID: Business Name: Address Business Owned by: [ ] Taxpayer [ ] Spouse City State Zip Accounting Method: [ ] Cash [ ] Accrual Did you materially participate in the business? Inventory Method: [ ] Cost [ ] Lower Cost or market [ ] Yes [ ] No [ ] Other Check if this is the first yr of the business. [ ] Income Amount Cost of Goods Sold Amount 1. Gross Receipts or Sales 1. Beginning of year inventory 2. Returns and allowances 2. Purchases 3. Other Income 3. Cost of items used personally Expenses Amount 4. Cost of Labor (do not list twice) 1. Advertising 5. Materials and supplies 2. Bad Debts (accrual acct only) 6. Other costs 3. Commissions and fees 7. End of year inventory 4. Employee benefits Expenses Amount 5. Health Insurance 16. Supplies 6. Other insurance 17. Payroll Taxes 7. Mortgage interest (not your home) 18. Other Taxes 8. Other interest bank/credit not vehicle 19. Licenses 9. Legal & Accounting fees 20. Travel 10. Office Expense 21. Meals & Entertainment (in full) 11. Pension & Profit Sharing 22. Utilities 12. Rent - Equipment 23. Wages (not listed above) 13. Rent - Building 24. Other (description) 14. Repairs & Maintenance - Equip 15. Repairs & Maintenance - Bldg Depreciation: (add additional pages for more property) Property (NOT your Home) Date Acquired Cost or Basis Depreciation Method Prior Depreciation 10
Business Use of Home (Only for Business Owners or Contract No Employees) Do you use any part of your home REGULARLY and EXCLUSIVELY for business? [ ] Yes [ ] No Do you have work space provided by the contracted company? [ ] Yes [ ] No Name of Business where you use the space in your home Home Insurance Total Area of Home Total Area of Home used regularly for business Repairs & Maintenance Rent Utilities (gas, electric only no water) Other (describe) Direct Costs (benefit only business portion of home none of the expense is personal) Indirect Costs (some portion is business some portion is personal) Total do not prorate Prior year carryover of unallowed losses (new clients only) If you run a Daycare Facility: Days used as a daycare facility Depreciation of home, improvements, furniture, and equipment: Property Date Acquired Cost or Basis Depreciation Method Prior Depreciation 11