PLEASE RETURN THIS COMPLETED QUESTIONNAIRE TO US WITH YOUR TAX DOCUMENTS 
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Your name: ______________________________________ Date of birth: _____________Current Occupation:________________________
 
 PH#________________________ Email:______________________

Spouse name: ______________________________________ Date of birth: _____________Current Occupation:______________________
 
 PH#________________________ Email:______________________
 
  • Did you receive any income not included on a W-2, 1099, and/or K-1?                                                                                                          YES   /  NO    
  • Did you purchase items on the internet or from out of state and not pay any sales tax?                                                                           YES   /  NO  
  • Did you and your dependents reside in the US for all of 2018?                                                                                                                        YES   /  NO  
  • Any sort of foreign accounts or trusts, or other offshore activities?                                                                                                                  YES   /  NO  
  • Did you have health care coverage for all of 2018 for you and your dependents? (provide 1095-B)                                                      YES   /  NO  
  • Did you have insurance through Covered CA, or other Obamacare? (provide Form 1095-A and dependents income)                     YES   /  NO       
  • Did you make any gifts of over $15,000 during the year?                                                                                                                                  YES   /  NO  
  • Did you pay over $2,100 during the year to a household employee? (nanny, housecleaner, gardener, etc)                                          YES   /  NO            
  • Did you have any debt cancelled or modified during the year? (provide 1099-A/C)                                                                                              YES   /  NO                                               
  • Was any part of your home mortgage paid by someone else?                                                                                                                          YES   /  NO                                             
  • Did you or other family members take any college or other post-high school classes? (provide 1098-T)                                              YES   /  NO                                
  • Did you pay for child care while you worked?          YES / NO / NA                   Was any part paid through employer plan?                  YES   /  NO  /  NA                                                                                                                            
  • Did you or any of your dependents receive any grants or scholarships?                                                                                                         YES   /  NO  /  NA
  • Is there an active form 8332 "Release/Revocation of Claim to Exemption for Child" (or similar statement) in place?                        YES   /  NO  
  • Have you (or will you before 4/15/2019) contributed to an IRA outside your employer?                                                                             YES   /  NO  
  • Have you contributed or withdrawn from an HSA (health savings account)?                                                                                                YES   /  NO  
  • Were you notified by any taxing authority of changes or audits to a prior years return?                                                                             YES   /  NO  
  • Any dependents move in or out or other dependent changes (including a child reaching age 19)?                                                         YES   /  NO  
  • Can you provide documentation for all deductions, dependents, and marital status if requested by the taxing authorities?           YES   /  NO  
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Spouse Signature ______________________________Date__________


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