Tax Questionnaire

Previous Address # 01

Previous Address (Street, City, State, ZIP) *

Lived From Date*

Lived Until Date*

I am Resident Alien. I am Nonresident Alien.

Enter the Identity Protection PIN (IP PIN) you received.

Your IP PIN*

Spouse's IP PIN*

Dependents

Dependent # 01

First Name*

Last Name*

Social Security Number

Date of Birth*

Relationship

Months Lived with You*

I provided more than half the support. I paid for higher education (tuition, fees). I paid for childcare or daycare expenses. Had health insurance all year. Is disabled. Is Full-time Student. Had income of their own.

Details of income the dependent received.

Income Amount ($)*

Income Description*

Spouse basic information.

Spouse First Name*

Spouse Middle Name / Initial

Spouse Last Name*

Spouse Social Security Number

Spouse Date of Birth*

Spouse Occupation / Job Title

Spouse is not a U.S. Citizen.

Spouse is Resident Alien. Spouse is Nonresident Alien.

Spouse can be claimed as a dependent on someone else's return. Spouse is legally blind. Spouse wants $3 to go to Presidential Election Campaign Fund.

W-2 Income

Number of W-2 forms to attach*

Number of states on all W-2 Forms (Line 15)*

Received tips not reported on W-2. Received wages as a household employee. I am a member of the U.S. Armed Forces. Spouse is a member of the U.S. Armed Forces. Received wages from a foreign employer.

Details of total Tips received not reported on W-2.

Amount of Tips not reported on W-2 ($)*

Interest Income

Number of 1099-INT forms to attach*

Amount of Interest not reported on Forms ($)*

I / spouse received tax-exempt interest. I / Spouse cashed in U.S. Savings Bonds. I / Spouse incurred interest on savings bond used for education.

Details of total Tax-exempt Interest received.

Tax-exempt Interest Amount ($)*

Details of total U.S. Savings Bonds cashed in.

Bonds Purchase Date*

Bonds Amount ($)*

Dividends Income

Number of 1099-DIV forms to attach*

Social Security Benefits

Number of SSA-1099 forms to attach*

I / spouse repaid Social Security benefits.

Details of total Social Security amount repaid.

Social Security Amount Repaid ($)*

Retirement Distributions

Number of 1099-R forms to attach*

I / spouse rolled over retirement distributions. I / spouse converted a traditional IRA to a Roth IRA.

Details of retirement distributions rollover.

Roll Over Amount ($)*

It was Traditional IRA to Traditional IRA. It was Roth to Roth. It was 401(k) to IRA. It was Other Type of Roll Over.

Details of other rollover type.

Describe other rollover type*

Details of traditional IRA to a Roth IRA conversion.

Converted Amount ($)*

Royalties Income

Amount of Royalties Received*

Received for Oil & Gas. Received for Copyrights. Received for Patents. Received for Other Type of Royalties.

Details of other Royalties type.

Describe Other Royalties type*

Details of business Income (No Forms).

Gross Sales ($)*

Returns and Allowances ($)*

Details of business expenses.

Advertising ($)*

Commissions and Fees ($)*

Contract Labor ($)*

Insurance (other than health) ($)*

Interest ($)*

Mortgage (paid to banks, etc.) ($)*

Mortgage (other) ($)*

Legal and Professional Services ($)*

Office expense ($)*

Pension and profit-sharing plans ($)*

Vehicles, machinery, and equipment rent ($)*

Other business property rent ($)*

Repairs and maintenance ($)*

Supplies ($)*

Taxes and licenses ($)*

Travel ($)*

Utilities ($)*

Wages ($)*

List with amount of other expenses ($)*

Details of business use of Home.

Home Office Description*

Date began use for Business*

Sqft used for Business*

Total Sqft of Home::*

I / Spouse own our home. Part of this home was used as a daycare facility. It is my principal place of business. I have detailed records of home expenses.

Details of Home Expenses.

Home Office Description*

Date began use for Business*

Details of business equipment purchased.

List of equipment description and cost ($)*

Partnerships, S-Corp Income

Capital Gain Income

I have capital loss carryover from previous years.

Details of capital loss carryover.

Amount of Carryover ($)*

Partnerships, S-Corp Income