New Tax Client Form

Name

First Last

Social

Phone

Employer

Spouse Name

First Last

Social

Phone

Employer

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Dependents:

Name

Social Security #

Date of Birth

Name

Social Security #

Date of Birth

Name

Social Security #

Date of Birth

Name

Social Security #

Date of Birth

Income:

Company

Select One

1099

Select One

Self

Spouse

Company

Select One

1099

Select One

Self

Spouse

Company

Select One

1099

Select One

Self

Spouse

Tax Return Questionnaire

Taxpayer Name:

First Last

Taxpayer Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Occupation

Phone Number

Email Address

Spouse Name

First Last

Spouse Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Spouse Occupation:

Spouse Phone Number

Spouse Email Address

Filing Status:

Single

Married

Head of Household

Qualifying Widow

If you would like your tax refund (if any) deposited directly into your bank:

Account Type:

Checking

Savings

Account Number:

Bank Routing Number:

If we have not previously prepared your return, please provide a copy of your previous tax return and driver's license.

Dependents

Name

First Last

Income over $2200?

Yes

Date of Birth

Relationship

Months Lived in Home

Name

First Last

Income over $2200?

Yes

Date of Birth

Relationship

Months Lived in Home

Name

First Last

Income over $2200?

Yes

Date of Birth

Relationship

Months Lived in Home

Virtual Currency: Did you receive, sell, send, exchange, or otherwise acquire any financial interest in any virtual currency?

Yes

Health Insurance Coverage: Did you have health care coverage with a government marketplace?

Yes

If yes, please provide form 1095-A issued by marketplace.

Income

1. Wages & Salaries - Include W-2's

Name of Payer

Please select one

Taxpayer

Spouse

Name of Payer

Please select one

Taxpayer

Spouse

Name of Payer

Please select one

Taxpayer

Spouse

Name of Payer

Please select one

Taxpayer

Spouse

Name of Payer

Please select one

Taxpayer

Spouse

2. Interest / Dividend Income - Include 1099's

Name of Payer

Please select one

Taxpayer

Spouse

Name of Payer

Please select one

Taxpayer

Spouse

Name of Payer

Please select one

Taxpayer

Spouse

Name of Payer

Please select one

Taxpayer

Spouse

3. Capital Gain & Losses

Name of Payer

Please select one

Taxpayer

Spouse

Name of Payer

Please select one

Taxpayer

Spouse

Name of Payer

Please select one

Taxpayer

Spouse

Name of Payer

Please select one

Taxpayer

Spouse

4. Other Gains & Losses

Name of Payer

Please select one

Taxpayer

Spouse

Name of Payer

Please select one

Taxpayer

Spouse

Name of Payer

Please select one

Taxpayer

Spouse

Name of Payer

Please select one

Taxpayer

Spouse

5. Pensions, IRA Distributions, Annuitites, and Rollovers - Include 1099 K

Name of Payer

Please select one

Taxpayer

Spouse

Name of Payer

Please select one

Taxpayer

Spouse

Name of Payer

Please select one

Taxpayer

Spouse

Name of Payer

Please select one

Taxpayer

Spouse

6. Rents/ Royalties, Partnerships, S Corporations, Estates, Trusts

Rents/ Royalties, Partnerships, S Corporations, Estates, Trusts

7. Unemployment Compensation Received - Include 1099 G

Name of Payer

Please select one

Taxpayer

Spouse

Name of Payer

Please select one

Taxpayer

Spouse

Name of Payer

Please select one

Taxpayer

Spouse

Name of Payer

Please select one

Taxpayer

Spouse

8. Social Security Benefits Received

Social Security Benefits Received

9. Other Income

Description

Please select one

Taxpayer

Spouse

Description

Please select one

Taxpayer

Spouse

Description

Please select one

Taxpayer

Spouse

Description

Please select one

Taxpayer

Spouse

Credits

Child & Dependent Care

Number of Qualifying Individuals

Name, address, and Identification Number of each Provider:

Name

Address

Id Number

Amount Paid

If payments were made to an individual, were the services performed in your home?

Yes

If yes, have reports been filed?

Yes

Special Needs Child

Yes

Adoption Expenses

Tuition & Fees Paid for higher education

Foreign Tax Credits (attach details)

Estimated Tax Payments

Federal

Amount

State

Amount

Other Payments (Child Tax Credit Received)

Date

Amount

Date

Amount

Other payments or credits - attach schedule & explain

Third Stimulus: enter the amount from IRS notice 1444-C, Your Economic Impact Payment (if any)

Itemized Deductions:

Medical & Dental - Amount

1. Out of pocket costs for prescription medicines, drugs, insulin, doctors, dentists, nurses, and medical and dental insurance premiums (including Medicare B) paid (reduce any insurance reimbursements)

2. Transportation and loding incurred to obtain medical care

3. Other - Hearing aids, eyeglasses, medical devices, etc.

Adjustments to Income

1. Your IRA deduction amount

Maximize?

Yes

2. Spouse's IRA deduction amount

Maximize?

Yes

Keogh SEP deduction amount

Maximize?

Yes

4. Penalty for early withdrawal of savings amount

5. Alimony paid?

6. Self-employed health insurance premiums amount

Did anyone in your family receive a scholarship of any kind?

Yes

If, yes please supply details.

If you have added or disposed of any fixed assets used in trade or business or rental or farm activities, please provide the following:

Addition:

Description:

Date Acquired

Cost

Trade In (if any)

List

Dispositions:

Description

Date of disposition

Amount realized

Did you settle any notices or settle any tax examinations concerning your prior tax year's returns? (if yes, please provide copy of notes, settlement reports, etc.)

Yes

Did you sell your primary residence?

Yes

Did you change your state residency?

Yes

If yes, and you were a member of the armed forces on active duty who moved because of a permanent change of station, please provide the following:

Previous Address:

Distance:

Date of Move:

Cost of Move:

Describe:

For the Year: (provide details for any "yes" responses)

Did your principal residence (and second residence, if any) loan(s) exceed the fair makred value of the residence(s)?

Yes

Do you have a balance borrowed against a home (equity line of credit) in excess of $100,000, or total mortgage indebtedness in excess of $750,000?

Yes

Did you exercise any stock options?

Yes

Did you purchase, sell, or own any bonds you paid more or less than the face amount?

Yes

Did you sustance any non-business bad debts?

Yes

Did you or your spouse make any gifts in excess of $15,000 to any one donee?

Yes

Were you the recipient of, or did you make a "below market" or interest-free" loan?

Yes

Do you have a child under the age of 18 as of Dec 31, who has earned an income (interest, dividends, etc.) of more than $1,100?

Yes

Did you lease a car in which you used for business purposes?

Yes

- If "yes", provide (1) fair market value or capitalized cost of the car on the 1st day of the lease or rental agreement, (2) term of the lease, (3) number of payments made, (4) number of days the car was leased, (5) percentage of business use, (6) business or work the car was used in, (7) amount of expenses reported by you to your employer on Form W2.

Rental and Royalty Income and Expense

Property Type:

Residence

Commercial

Location Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

If Vacation Home:

Number of days rented

Number of days used personally

Property is owned by:

Taxpayer

Spouse

Joint

Percentage Ownership

Did you live in part of the rental property?

Yes

If yes, what percentage did you occupy as a tenant?

Did you rent this property to a relative?

Yes

If yes, relation?

Fill out only if you don't have a Profit & Loss Statement:

Rental Income Amount

Royalties Received Amount

Expenses and Amount

1. Advertising

2. Association Dues

3. Auto Miles Driven

4. Travel

5. Cleaning &. Maintenance

6. Commissions

7. Insurance

8. Legal & Professional Fees

9. Allocated Tax Preparation Fees

10. Licenses and permits

11. Management Fees

12. Mortgage interest (form 1098)

13. Other interest

14. Repairs

15. Supplies

16. Property Taxes

17. Utilities

Other (description)

18a

18b.

18c.

18d.

18e.

18f.

18g.

18h.

18i.

18j.

18k.

18l.

Depreciation:

Property

Date Acquired

Cost or Other Basis

Depreciation Method

Prior Depreciation

Business Income and Expenses (Sole Proprietorship)

Principle business or professional:

Business name:

Employer ID Number

Business Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Business Ownership:

Taxpayer

Spouse

Accounting Method:

Cash

Accural

Inventory Method:

Cost

Lower cost or market

Other

N/A

Did you materially participate in the business?

Yes

Check if this is the first year of the business

Fill out only if you don't have a Profit & Loss Statement: Income - Amount

1. Gross receipts or sales amount

2. Returns and allowances

3. Other Income

Cost of Goods Sold - Amount

1. Beginning of year inventory

2. Purchases

3. Cost of items used personally

4. Cost of labor

5. Materials and supplies

6. Other costs

7. End of year inventory

Expenses - Amount

1. Advertising

2. Bad debt (N/A cash benefits)

3. Commissions and fees

4. Employee benefits

Health Insurance

6. Other Insurnace

7. Mortgage interest

8. Other Interest

9. Legal and accounting fees

10. Allocation of tax preparation fees

11. Office expense

12. Pension and profit-sharing plans

13. Rent, vehicles

14. Rent, equipment

15. Rent, building

16. Repairs and maintenance, building

17. Repairs and maintenance, equipment

18. Repairs and maintenance, vehicles

19. Supplies

20. Payroll taxes

21. Other taxes

22. Licenses

23. Travel

24. Meals & entertainment

25. Utilites

26. Wages

27. Mangement fees

28.Consulting expenses

29. Payroll service

30. Employee vehicle expense

31. Employee mileage reimbursement

32. Client gifts (limited to $25 each)

33. Education and seminars

34. Other (Description)

35.

36.

37.

38.

39.

40.

Depreciation (Sole proprietorship)

Property

Date Acquired

Cost or Other Basis

Depreciation Method

Prior Depreciation

Farm Income and Expense

Primary Product

Employer ID Number

Accounting Method

Cash

Accrual

check if you are materially participated in farm operations:

Taxpayer

Spouse

Fill out only if you don't have a Profit & Loss Statement: Farm Income - Amount

1. Sales of livestock and other resale items

2. Cost of above

3. Sales of livestock, produce, etc. you raised

4. Cooperative distributions(1099-PATR)

5. Cooperative distributions, taxable portion

6. Agricultural program payments

7. Agricultural program, taxable portion

8. Commodity Credit Corporation Loans

9. Crop insurance loans

10. Custom hire

11. Other:

Expenses - Amount

1. Car and truck expenses

2. Chemicals

3. Conservation expense

4. Custom hire (machine work)

5. Employee benefit programs

6. Employee health insurance

7. Feed purchased

8. Fertilizers and lime

9. Freight and trucking

10. Gasoline, fuel, oil

11. Other insurance

12. Mortgage interest

13. Other interest

14. Labor hired

15. Legal & Professional fees

17. Pension and profit share plans

16. Allocated tax preparation fees

18. Vehicle Rental

19. Machinery & Equipment rental

20. Land Rental

21. Repairs and maintenance

22. Seeds & plants purchased

23. Storage & warehousing

24. Supplies purchased

25. Payroll Taxes

26. Other Taxes

27. Utilites

28. Vet, breeding & Medicine

29. Other

30. Other

31. Other

32. Other

Depreciation (Farm)

Property

Date Acquired

Cost or Other Basis

Depreciation Method

Prior Depreciation

Business Use of Home

Do you use any part of your home regularly and exclusively for business?

Yes

Estimated percentage of time spent in home office?

Description of work done in home office.

Description of work done outside of home office.

Total area of home?

Total area of home used regularly for business?

Home Insurnace

Direct Costs (benefit only business portion of home)

Indirect costs (Other)

Repairs and maintenance

Direct Costs (benefit only business portion of home)

Indirect costs (Other)

Utilities

Direct Costs (benefit only business portion of home)

Indirect costs (Other)

Rent

Direct Costs (benefit only business portion of home)

Indirect costs (Other)

Other

Direct Costs (benefit only business portion of home)

Indirect costs (Other)

Daycare Facility

Days used as a daycare facility

Prior year carry over of unallowed losses

Cost of home improvement and prior depreciation

Depreciation of home, improvement, furniture, and equipment

Daycare Facility

Property

Date Acquired

Cost or Other Basis

Depreciation Method

Prior Depreciation

Household Employees (Nanny Tax)

Employee Identification Number:

Did you pay a household employee at least $2300 this year?

Yes

If yes, please provide the following:

Name

First Last

Wages paid

Federal Income tax withheld

Social Security tax withheld

Medicare tax withheld

State income tax withheld

Has a W-2 been filed?

Yes

If not, do you want us to prepare one for you?

Yes

Have the necessary state employment returns been filed?

Yes

If not, do you want us to prepare them for you?

Yes

Was the household employee under 18 years of age and a student?

Yes

Additional Tax Information or Questions:

67064

New Tax Client Form

Dependents:

Income:

Tax Return Questionnaire

If you would like your tax refund (if any) deposited directly into your bank:

If we have not previously prepared your return, please provide a copy of your previous tax return and driver's license.

Dependents

Income

1. Wages & Salaries - Include W-2's

2. Interest / Dividend Income - Include 1099's

3. Capital Gain & Losses

4. Other Gains & Losses

5. Pensions, IRA Distributions, Annuitites, and Rollovers - Include 1099 K

6. Rents/ Royalties, Partnerships, S Corporations, Estates, Trusts

7. Unemployment Compensation Received - Include 1099 G

8. Social Security Benefits Received

9. Other Income

Credits

Child & Dependent Care

Adoption Expenses

Itemized Deductions:

Medical & Dental - Amount

Adjustments to Income

For the Year: (provide details for any "yes" responses)

Rental and Royalty Income and Expense

Fill out only if you don't have a Profit & Loss Statement:

Expenses and Amount

Business Income and Expenses (Sole Proprietorship)

Fill out only if you don't have a Profit & Loss Statement: Income - Amount

Cost of Goods Sold - Amount

Expenses - Amount

Farm Income and Expense

Fill out only if you don't have a Profit & Loss Statement: Farm Income - Amount

Expenses - Amount

Business Use of Home

Daycare Facility

Household Employees (Nanny Tax)

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