Please complete the following form and upload previous tax returns, your income, and expenses by clicking here now. Name * First Name Last Name Email * Cell Phone (###) ### #### Date of Birth MM DD YYYY SSN Occupation Work Phone (###) ### #### Please check all that apply Disabled Blind Over 65 None of the above Spouse Name First Name Last Name Email Cell Phone (###) ### #### Date of Birth MM DD YYYY SSN Occupation Work Phone (###) ### #### Please check all that apply Disabled Blind Over 65 None of the above Home Address Address 1 Address 2 City State/Province Zip/Postal Code Country DEPENDENTS Dependent 1 First Name Last Name Relationship SSN # months in the home Dependent 2 First Name Last Name Relationship SSN # months in the home Dependent 3 First Name Last Name Relationship SSN # months in the home Dependent 4 First Name Last Name Relationship SSN # months in the home If dependent is other than your child or if child living with you age 18 and older NOT going to school, please list income. A dependent is your child living with you 18 or younger (age 19-23 if attending school full time for at least 5 months during the year) who did not provide more than 1/2 of their own support or a permanently and totally disabled child. Non-custodial parent claiming exemption for child(ren). Custodial parent has released the exemption. Signed Form 8332 attached Dependent child(ren) have unearned income over $1,100.00. Unearned income consists of interest, dividends, capital gains, etc. If you were unmarried (or considered unmarried) at the end of the tax year, and you maintained a home that for more than 1/2 the tax year was the principal place of residence for your qualifying child, you may be eligible for Head of Household filing status. If you are married, you may be considered unmarried for this purpose if your spouse did NOT live in your home during the last 6 months of the tax year. If you are maintaing the household of a parent, the parent does not need to live with you to qualify. The following items may affect your tax return. Please read carefully and indicate those applicable. Received and or paid alimony? DO NOT include child support. If divorce or separation agreement is after Dec 31, 2018 DO NOT COMPLETE National Guard member or Armed Forces Reservist and travel more than 100 miles and stay overnight to fulfill duty Active Military Adoption Expenses/Foster Child Expenses - please provide $ amount and paperwork Debt forgiveness on principal residence or rental property? Foreclosure on principal residence or rental property? Teacher - out-of-pocket expenses incurred for classroom costs. Household services - paid $2,100.00 or more for household services such as babysitting, cleaning, cooking or gardening services (over 18) Gifts totaling more than $15,000 to one individual during the year? If so, please provide gift, recipient's name, address and relationship to you Contribution to an IRA or Roth IRA. (Contributions can be made up to April 15, 2022. ) Age 72 or older. Required Minimum Distribution (RMD) taken. Refinance home/rental property. Please bring closing statement. Cancellation of Debt (other than primary home) Please bring Form 1099-C Stock sale - please provide year end Form 1099. Also please provide basis of the stock if not shown on year end statement. Stimulus Payments Received. Include date received in 2021 only INCOME Wages - Please provide all W-2 forms received by your employer. If you have not received your W-2's by 2/15/22, please contact your employer. DIVIDEND AND INTEREST INCOME Please provide all Forms 1099 that include interest and /or dividend income. You may provide a listing of your interest and dividends on a separate sheet but make sure to everything matches what is reported on the actual Forms 1099-INT and 1099-DIV. If the reports include sale of stock information you need to provide a copy of the entire report. Also if there is any tax-exempt interest the complete form must be provided. INSTALLMENT SALE PAYMENTS RECEIVED Interest Portion $ Principal Portion $ Payer is relative or related party Yes No If payer uses property as principal residence, please provide: Name, SSN, Address Retirement Plan Distributions - Pensions, Annuities, Rollovers, IRA, SEP, Keoghs, Lump-Sum Distributions or Other Retirement Plan Withdrawals Provide all copies of Form 1099-R received for retirement plans distributions PARTNERSHIPS, ESTATES, TRUSTS, AND S CORPS Provide all Schedules K-1 received for tax year. SOCIAL SECURITY OR RAILROAD RETIREMENT BENEFITS Provide Forms SSA-1099 or RRB-1099 OTHER INCOME Unemployment Income Form 1099-G Cancellation of Debt Gambling/Lottery Winnings Health or Medical Savings Form 1099SA State Income Tax Refund Tips & Gratuities not reported on W-2 Other Other Thank you! Self-employment Income - see worksheet for Schedule C Rental Activity Income and Expenses - see worksheet for Rental Properties
