Yearly Tax Questionnaire by by654321

VIEWS: 15 PAGES: 7

									                                                                                                 Tax Year____
                                      Yearly Tax Questionnaire
Name:_______________________ S.S.#_____-___-_____ Birthdate:___/___/____ Occupation:________________
Spouse:______________________ S.S.#_____-___-_____ Birthdate:___/___/____ Occupation:________________
Address:______________________________________________________________________________________
City:___________________ State:_______ Zip Code:__________ County:_________________________________
Home Phone:____________________Cell Phone:__________________ Best Time to Call:____________________
School District: _______________________ Email Address (optional):_____________________________________


DEPENDENTS
Please list the names and social security numbers of all dependent children who lived with you during the tax year.
Name                                           Social Security Number                       Birthdate
_____________________________________ _____________________________ ______________________
_____________________________________ _____________________________ ______________________
_____________________________________ _____________________________ ______________________
_____________________________________ _____________________________ ______________________
_____________________________________ _____________________________ ______________________
_____________________________________ _____________________________ ______________________

Please list the names and social security numbers of all dependent children who did not live with you during the tax
year.
Name                                           Social Security Number                        Birthdate
_____________________________________ _____________________________ ______________________
_____________________________________ _____________________________ ______________________
_____________________________________ _____________________________ ______________________


INCOME
Wages
**Please Attach all W-2’s**
Did you receive unemployment?        N___ Y___ if Yes please attach 1099
Did you receive social security?     N___ Y___ if Yes please attach 1099
Did you receive a pension?           N___ Y___ if Yes please attach 1099-R
Did you receive an IRA Distribution? N___ Y___ if Yes please attach 1099-R
Did you receive any other income during the tax year? N___ Y___ if Yes please attach any 1099’s
 -Please describe any other income:
Description:________________________________________________ Amount: $_________________
Description:________________________________________________ Amount: $_________________
Description:________________________________________________ Amount: $_________________



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Interest or Dividend Income
**Please attach 1099’s received from any banks for interest or dividend income received during the tax year.**
Description:________________________________________________ Amount: $_________________
Description:________________________________________________ Amount: $_________________
Description:________________________________________________ Amount: $_________________
Description:________________________________________________ Amount: $_________________

Other Income
-Were you self-employed or had any interest in a Partnership or S-Corporation during the tax year? N___ Y___ if
Yes please attach a K-1.
-Do you own rental properties? N___ Y___ if Yes, please attach income and expense reports.
-Did you purchase or sell rental properties? N___ Y___ if Yes, please attach closing paperwork.
-Did you purchase or sell any stocks or bonds during the tax year? N___ Y___ if Yes, please attach form 1099-B
        -Please fill in chart on last page

PAYMENTS
-Did you make payments to a Traditional Individual Retirement Account? N___ Y___ if Yes, Amount $_________
-Did you make payments to a Roth IRA?                                  N___ Y___ if Yes, Amount $_________
-Did you make payments to a SEP, SIMPLE, or Keogh Retirement Plan? N___ Y___ if Yes, Amount $_________
-Did you have any interest penalties on early withdrawals of savings? N___ Y___ if Yes, Amount $_________
-Did you pay any alimony during the tax year?                          N___ Y___ if Yes, Amount $_________
        -Recipients Social Security Number: _____-____-_______
-Did you make payments to a Medical Savings Account?                   N___ Y___ if Yes, Amount $_________
-Did you make payments for a Teacher’s Classroom Expense?              N___ Y___ if Yes, Amount $_________
-Did you pay interest on Student Loans?                                N___ Y___ if Yes, Amount $_________
-Did you pay a Home Mortgage?                                          N___ Y___ if Yes, Amount $_________
        -Paid to:________________________________________________________________________________
                 (Name)                           (Address)                          (Social Security Number)
-Did you pay Home Equity Loan Interest or Equity Ease?                 N___ Y___ if Yes, Amount $_________
-Did you pay Interest on a second home?                                N___ Y___ if Yes, Amount $_________
-Did you pay interest on any investments?                              N___ Y___ if Yes, Amount $_________


ESTIMATED TAX PAYMENTS
                       Federal           State
Credit from prior
year cash payments:_____________           __________
April 15:          _____________           __________
June 15:            _____________           __________
Dec/Jan 15:        _____________           __________
Total:              _____________           __________

-Did you receive estimated tax vouchers?      State: Y______ N_______
                                            Federal: Y______ N_______



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-Did you receive an Income Tax Refund: State: Y______ N_______
                                     Federal: Y______ N_______
-Amount of Taxes Paid Last Year:       State: $_______________
                                     Federal: $_______________

REAL ESTATE
-Did you sell your residence during the tax year? N___ Y___ if Yes, please attach a copy of the closing
statement.
-Did you refinance your mortgage?               N___ Y___ if Yes, please attach a copy of the closing statement.
-Did you rent out your primary residence? N___ Y___ if Yes, Amount of rent received(heat included): $________
-Did you pay Real Estate Taxes during the year? N___ Y___ if Yes, Amount $_________
**Please attach a copy of your real estate tax bill**


VEHICLE USAGE
-Did you use your personal vehicle for business purposes or job hunting? N___ Y___ if Yes, please fill in the
following blanks:
Was your vehicle used for: Business Purposes:__________ OR Job Hunting:__________
     1. Total miles driven during the tax year:________
     2. Total number of business miles:_____________
     3. Total vehicle miles:_______________________
     4. Year of vehicle:__________________________
     5. Total miles commuting:____________________
     6. Personal miles:__________________________
     7. Do you have another vehicle for personal use? Y______ N_______
     8. Did you have job related moving expenses? N___ Y___ if Yes, Amount $_________
     9. Did you have any job search expenses?         N___ Y___ if Yes, Amount $_________
     10. Did you have an employer-provided vehicle available for personal use? Y_______ N______
     11. Do you have records showing evidence for the justification of these deductions? N___ Y___ if Yes,
           please attach written records.
     *italicized items can not be deducted on your taxes but must be included on your tax return.


CHILD AND DEPENDENT CARE
PERSON/ORGANIZATION WHO                     ADDRESS                           IDENTIFICATION            AMOUNT
PROVIDED THE CARE                       (include state, and zip)             NUMBER (SSN OR EIN)          PAID

_______________________________ ____________________________ _____________________ _______

_______________________________ ____________________________ _____________________ _______

_______________________________ ____________________________ _____________________ _______




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MEDICAL AND DENTAL EXPENSES
**These are expenses that are not reimbursed by your insurance company**
-Cost of:
Prescribed Drug: $__________
Doctors/Dentists: $__________
Hospital visits: $__________
Hearing Aids:      $__________
Dentures:         $__________
X-Rays:           $__________
Eyeglasses:       $__________
Ambulances:       $__________
Clinics/Labs:     $__________
Long-term Care: $__________
Nursing Home Insurance: $__________
Hospitalization/Dental Insurance: $__________
Lodging for Medical Care: $__________
Miles traveled to Doctors/Hospitals: __________


CHARITABLE CONTRIBUTIONS
**Receipts are required for contributions of $250 or more**
To Whom                         Amount
________________________        $___________
________________________        $___________
________________________        $___________
________________________        $___________

-Did you contribute clothes or other non-cash items to Goodwill, Salvation Army or a Church? Amount $__________
        -To Whom did you contribute?______________________
-Did you drive any miles for Non-Profit Organization Work? Miles driven:_____________
-Did you donate to a food bank, homeless shelter or community foundation? Amount$____________


EDUCATION
-Did you have any educational expenses that were required by your present employer? N___ Y___ if Yes, Tuition
Amount $_________ Book Amount:$__________ Name of University or Insitution:___________________________
-Did you or a dependent attend a college or university during the tax year?
Student                 Relation           Total            Grants          Qualifying      Institution
Name                  to Taxpayer       Tuition/Fees     Scholarships        Credit          Attended
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________




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MISCELLANEOUS DEDUCTIONS
-Did you have any Union dues? N___ Y___ if Yes, Amount $_________
-Did you purchase uniforms/shoes? N___ Y___ if Yes, Amount $_________
-Did you pay for a safety deposit box? N___ Y___ if Yes, Amount $_________
-Did you have any Professional dues and subscriptions? N___ Y___ if Yes, Amount $_________
-Did you pay a tax preparation fee? N___ Y___ if Yes, Amount $_________
-Did you have any investment expenses? N___ Y___ if Yes, Amount $_________
-Did you have any lottery expenses? N___ Y___ if Yes, Amount $_________
-Did you have any other job related expenses?
        -Business Telephone: N___ Y___ if Yes, Amount $_________
        -Supplies/equipment/tools necessary: N___ Y___ if Yes, Amount $_________
        -Trade Journals: N___ Y___ if Yes, Amount $_________
        -Automobile Expense: N___ Y___ if Yes, Amount $_________
        -Business Travel Expenses: N___ Y___ if Yes, Amount $_________
        -Business Entertainment: N___ Y___ if Yes, Amount $_________




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                                 INVESTMENT QUESTIONS
                                    *Please bring in all statements*
INTEREST RECEIVED

        From                      Amount                         From                        Amount
                         $                                                         $
                         $                                                         $
                         $                                                         $
                         $                                                         $
                         $                                                         $
                         $                                                         $
                         $                                                         $


DIVIDENDS RECEIVED

   Dividend        Total     Qualified      Total Capital                Nontaxable Withholding           Foreign
Payer/Company     Ordinary   Dividends       Gain Distr.                Distributions                       tax
                Dividends
                $            $             $                            $              $              $
                $            $             $                            $              $              $
                $            $             $                            $              $              $
                $            $             $                            $              $              $
                $            $             $                            $              $              $
                $            $             $                            $              $              $
                $            $             $                            $              $              $


CAPITAL GAINS OR LOSSES

           Name                     # of         Date Acquired         Date Sold       Sales Price        Cost
                                   Shares
                                                    /       /           /   /      $                 $
                                                    /       /           /   /      $                 $
                                                    /       /           /   /      $                 $
                                                    /       /           /   /      $                 $
                                                    /       /           /   /      $                 $
                                                    /       /           /   /      $                 $
                                                    /       /           /   /      $                 $




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                             Items to Bring to Appointment
               Appointment Date:__________ Appointment Time:___________

________ 1) All copies of W-2’s, 1099’s (including unemployment reporting and retirement
fund transfers) and K-1’s.
________ 2) All copies of 1099’s for stock sales, purchase dates and cost information.
________ 3) All escrow and property tax statements.
________ 4) Landlords name and address (if you rent a residence).
________ 5) All Social Security Numbers of all dependents.
________ 6) Year end statements for all IRA’s, pensions and brokerage accounts.
________ 7) Schedule summarizing business or rental income and expenses if applicable.
________ 8) Date and amount of each estimated tax payment.
________ 9) All copies of closing statements regarding purchase or sale of a residence.
________10) All year end lender loan statements including those refinanced or paid off
during the year.




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