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FILING STATUSCircle One:SingleMarried Filling JointMarried Filing SeparateHead of Household Qualifying Widow(er)PRIMARY TAXPAYER First Name:_______________________ Last Name: ___________________________________ M.I. _______S.S.N. ___________________________________ Birthdate: _______________________________________ Occupation: _______________________________ Are you a Dependent on another Tax Return? Y / NLegally Blind: Y / N Disabled: Y / N Taxpayer Identification PIN:__________________Home Phone: ___________________ Work Phone: _________________ Cell Phone: ____________________Email: ____________________________________________________________________________________ Drivers License: #_____________________ Issue Date: _________________ Exp. Date:_________________SPOUSE INFORMATIONFirst Name:_______________________ Last Name: ___________________________________ M.I. _______S.S.N. ___________________________________ Birthdate: _______________________________________Occupation: _______________________________ Are you a Dependent on another Tax Return? Y / NLegally Blind: Y / N Disabled: Y / N Taxpayer Identification PIN:__________________Home Phone: ___________________ Work Phone: _________________ Cell Phone: ____________________Email: ____________________________________________________________________________________ Drivers License: #_____________________ Issue Date: _________________ Exp. Date:_________________ADDRESSStreet: ___________________________________________________________ Apt #:___________________ City: _____________________________________________ State: ____________ Zip:_________________Bank Information for Direct Deposit of RefundBank Name: ______________________________________ Account Type:SavingsCheckingRouting #: _________________________________ Account #: ___________________________________Will this refund go outside of the US? Y / NDEPENDENTSFirst NameLast NameBirthdateSSNRelationship# of monthsDep. CodeEICChildren who lived with you and are being claimed on another returnPlease Circle All. No Blanks!Affordable Care Act / Did you purchase Health Insurance through the Affordable Care Act / ? (Obamacare)YESNON/A Taxpayer/Household InfoAny Personal Changes such as address, married, kids, etc?YESNON/ADid client change jobs or retire?YESNON/AChild/Dependent care expenses to claim: (Day Care)YESNON/AWages, Tips, Gambling and other IncomeAre there wages reported on FormW-2?YESNON/AIs there gambling income reported on Form W2-G?YESNON/AIs there income reported on Form 1099-G (Gov’t refund or Unemployment? YESNON/AAre there unreported tips to report? (Form 4137)YESNON/AIs there retirement income reported on Form 1099- R?YESNON/AIs there Social Security income reported on Form 1099-SSA?YESNON/AAre there Railroad Retirement benefits reported on 1099-RRB?YESNON/ADid client receive a Form 1099-C? (Cancellation of Debt)YESNON/AIs there “other income”, such as a prize, jury duty, etc.?YESNON/AIf Yes, Describe the income: ____________________________________________________Interest, Dividends and Other InvestmentsIs there Interest income reported on Form 1099-INT?YESNON/AAre there Dividends reported on form 1099-DIV?YESNON/AAre there any Capital Gains on form 1099-B?YESNON/ADid client have a financial interest in or signature authority over,Foreign Financial Accounts? (FINCEN Reporting, Schedule B)YESNON/AIs there a Schedule K-1 (1065) related to a partnership?YESNON/AIs there a Schedule K-1 (1120S) related to an S Corporation? YESNON/ABusiness Income and ExpensesAre there Rental Properties or Royalty income? (Schedule E)YESNON/AIs there a sole proprietorship business? (Schedule C)YESNON/ADid Client receive a Form 1099- Misc?YESNON/ADid client receive a Form 1099-K?YESNON/AItemized Expense Deductions (Schedule A) Miles driven to Dr./Dental office visits during year:YESNON/A Number of miles driven? ________________________Medical/Dental Expenses Paid out of pocket:YESNON/AReal Estate Property Taxes Paid:YESNON/AHome Mortgage Interest: (1098)YESNON/APoints Paid (Purchase of Principle Residence OR Qualified Refinance):YESNON/AMiles driven for Volunteer Work with Charitable Organization:YESNON/A How many? __________________________Charitable Cash or Check Contributions:YESNON/ANon-Cash Charitable Contributions:YESNON/ADid client have a loss from a theft or casualty? (Form 4684)YESNON/ADid you buy or sell any Virtual Currency? (i.e. Bitcoins)YESNON/ADeductions and CreditsResidential energy efficiency improvements? (Form 5695)YESNON/AFirst-Time Homebuyer Credit received in TY 2008?YESNON/ADid client sell a home that had a 1st time Homebuyers credit taken in 2008? YESNON/AIs the client a teacher that had educator expenses?YESNON/ADid client adopt a child? (Form 8839)YES NON/ADid client buy an electric car? (Form 8936)YESNON/AOther Tax Situations Did client make estimated tax payments? YESNON/AWhen, How Much? _________________________________________________________________IRA Contributions: YESNON/A Tax Payer Amount: $__________________________ Spouse Amount: $____________________________Alimony Received: $______________________________________YESNON/AAlimony Paid: $__________________________________________YESNON/ARecipient’s SSN:______________________ Recipient’s Name_____________________________Education CreditsAmerican Opportunity Credit:YESNON/AIf Yes, used in priors?____________ What years used?_____________________Life Time Learning qualified expenses:YESNON/ADid client receive a Form 1098-E for student loan interest?YESNON/ARefund Options:Check Mailed form IRS: YESNODirect Deposit to TP’s Bank account: YESNORefund Transfer (bank product): YESNONOTES: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________The above information is true and correct, and I/we understand that the information given on this questionnaire and your attached forms will be used to complete my/our tax return(s). I/ We agree to hold Be Prepared Tax Service LLC harmless for any errors that they may make on my / our tax return. I /We also understand that error on my/ our return will cause a delay in the processing of the return and the receipt of the refund, if any. Taxpayer Signature: __________________________________ Date: _______________Spouse Signature: ____________________________________ Date: _______________ ................
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