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Dear Clients:
Please answer this questionnaire and bring it to us with your 2011 Income Tax Information. We are requiring this questionnaire to be completed this year. Please also note questions to discuss with us. We look forward to seeing you soon. Thank you!
Submit details for any question answered “Yes”:
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YES
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NO
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1.
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Did any births, adoptions, marriages, divorces, or deaths occur in your family last year? If yes, provide details.
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2.
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Will the address on your current returns be different from that shown on your prior year returns? If yes, provide the new address and date moved.
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3.
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Were there any changes in dependents from the prior year? If yes, provide details.
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4.
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Are you entitled to a dependency exemption due to a divorce decree?
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5.
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Did any of your dependents have income of $950 or more? ($400 if self-employed)
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6.
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Did any of your children under age 19, age 24 if they are a full time student, have investment income over $1,900?
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If yes, do you want to include your child’s income on your return?
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7.
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Are any dependent children married and filing a joint return with their spouse?
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8.
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Did any dependent child 19-23 years of age attend school less than 5 months during the year?
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9.
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Did you receive income from any legal proceedings, cancellation of student loans or other indebtedness during the year? If yes, provide details.
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10.
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Did you make any gifts during the year directly or in trust exceeding $13,000 per person?
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11.
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Did you have any interest in, or signature, or other authority over a bank, securities, or other financial account in a foreign country?
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12.
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Were you the grantor, transferor or beneficiary of a foreign trust?
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13.
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Were you a resident of, or did you have income in, more than one state during the year?
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14.
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Do you wish to have $3 (or $6 on joint return) of your taxes applied to the Presidential Campaign Fund?
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15.
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Do you wish to contribute $3 to the NC Public Campaign Fund? If yes, indicate which Political Party:
Taxpayer ___________ Spouse ____________
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16.
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Do you want any overpayment of taxes applied to next year’s estimated taxes?
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17.
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Do you want any federal refund deposited directly into your bank account? If yes, enclose a voided check.
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.1) Do you want any balance due directly withdrawn from this same bank account on the due date?
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.2) Do you want next year’s estimated taxes withdrawn from this same bank account on the due dates?
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18.
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Do either you or your spouse have any outstanding child or spousal support payments or federal debt?
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19.
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Did you make any large purchases or home improvements?
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20.
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Do you expect a large fluctuation in your income, deductions or withholding next year? If yes, provide details.
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21.
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Did you receive any distribution from an IRA or other qualified plan that was partially or totally rolled over into another IRA or qualified plan within 60 days of the distribution? (Form 1099R)
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22.
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If you received an IRA distribution, which you did not roll over, provide details. (Form 1099R)
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23.
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Did you “convert” IRA funds into a Roth IRA? If yes, provide details. (Form 1099R)
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24.
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Did you receive any disability payments this year?
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25.
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Did you receive tip income not reported to your employer?
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26.
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Did you sell and/or purchase a principal residence or other real estate? If yes, provide settlement sheet (HUD-1) and Form 1099-S
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27.
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Did you collect on any installment contract during the year? Provide details.
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28.
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Did you receive tax-exempt interest or dividends not reported on Forms 1099-INT or 1099-DIV?
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29.
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During 2011, did you have any securities that became worthless or loans that became uncollectible?
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30.
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Did you receive unemployment compensation? If yes, provide Form 1099-G.
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31.
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Did you have any casualty or theft losses during the year? If yes, provide details.
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32.
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Did you have foreign income, foreign accounts, pay any foreign taxes, or file any foreign information reporting or tax return forms? Provide details.
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33.
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If in a business, did you file all required 1099 forms?
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34.
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Has the IRS, or any state or local taxing agency, notified you of changes to a prior year’s tax return? If yes, provide copies of all notices/correspondence received.
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35.
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Are you aware of any changes to your income, deductions and credits reported on any prior years’ returns?
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36.
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Did you purchase gasoline, oil, or special fuels for non-highway vehicles?
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37.
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Did you purchase an alternative fuel or electric vehicle? If yes, provide purchase invoice.
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38.
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If you, or your spouse, have self-employment income, did you pay any health insurance premiums or long-term care premiums? If yes, provide details.
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39.
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Were either you or your spouse eligible to participate in an employer’s health insurance or long-term care plan?
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40.
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If you, or your spouse, have self-employment income, do you want to make a retirement plan contribution?
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41.
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For business mileage, we need the miles before and miles after June 30, 2011.
January – June miles ___________(51¢/mile)
July – December miles____________(55.5¢/mile)
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42.
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Were you granted or did you exercise any stock options? If yes, provide details.
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43.
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Were you granted any restricted stock? If yes, provide details.
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44.
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Did you pay any household employee over age 18 wages of $1,700 or more?
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If yes, provide copy of Form W-2 issued to each household employee.
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If yes, did you pay total wages of $1,000 or more in any calendar quarter to all household employees?
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45.
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Did you surrender any U.S. savings bonds?
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46.
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Did you use the proceeds from Series EE U.S. savings bonds purchased after 1989 to pay for higher education expenses?
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47.
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Did you realize a gain on property, which was taken from you by destruction, theft, seizure or condemnation?
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48.
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Did you start a business?
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49.
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Did you purchase rental property? Did you start a rental activity?
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50.
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Did you acquire any interests in partnerships, LLCs, S corporations, estates or trusts this year?
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51.
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Do you have records to support travel, entertainment, or gift expenses? The law requires that adequate records be maintained for travel, entertainment, and gift expenses. The documentation should include amount, time and place, date, business purpose, description of gift(s) (if any), and business relationship of recipient(s).
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52.
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Has your will or trust been updated within the last three years?
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53.
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Did you incur expenses as an elementary or secondary educator? If so, how much?
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54.
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Did you make any energy-efficient improvements (remodel or new construction) to your home?
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55.
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Can the Internal Revenue Service discuss questions about this return with the preparer?
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56
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Did you pay real estate taxes on your principal residence? If so, how much?
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