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Client Data Form-Must be filled out on/before appointment.
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Indicates required field
Is this your first time filing with The Wozny Tax Company
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YES
NO
How did you hear about us?
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TAXPAYER: FULL LEGAL NAME
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First
Last
Phone Number
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TAXPAYER OCCUPATION TITLE
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TAXPAYER: DATE OF BIRTH
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TAXPAYER: LAST 4 OF SOCIAL SEC #
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TAXPAYER EMAIL
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SPOUSE: FULL LEGAL NAME
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First
Last
TYPE IN "NA"
Phone Number
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SPOUSE OCCUPATION TITLE
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SPOUSE: DATE OF BIRTH
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SPOUSE: LAST 4 OF SOCIAL SEC #
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SPOUSE: EMAIL
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Drivers License (Take Picture & Upload) Mandatory Law to file in 2017
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Max file size: 20MB
Take a picture of your Drivers License & Upload using the button.
CURRENT ADDRESS
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Line 1
Line 2
City
State
Zip Code
Country
Drivers License (Take Picture & Upload)-Mandatory to file 2017
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Max file size: 20MB
Take picture of drivers license and upload using button provided.
DID YOU LIVE IN MORE THAN 1 STATE IN 2017?
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Yes
No
IF YES, WHICH STATES?
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DID YOU WORK IN MORE THAN ONE STATE IN 2017?
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Yes
No
IF YES, WHICH STATES?
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ON DECEMBER 31ST, 2017 WERE YOU
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SINGLE
MARRIED
MARRIED BUT LIVING APART
DIVORICED
IF MARRIED BUT LIVING APART WHAT DATE DID YOU SEPARATE?
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IF MARRIED BUT LIVING APART, WAS IT COURT ORDERED?
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Yes
No
IF DIVORCED, WHAT YEAR WAS IT OFFICIAL?
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DO YOU HAVE DEPENDENTS YOU ARE CLAIMING?
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Yes
No
DEPENDENTS
Name
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First
Last
RELATIONSHIP TO YOU
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DATE OF BIRTH
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LAST 4 OF SOCIAL
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# OF MONTHS LIVED WITH
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CHILD CARE EXPENSES?
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Yes
No
Name
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First
Last
RELATIONSHIP TO YOU
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DATE OF BIRTH
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LAST 4 OF SOCIAL
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# OF MONTHS LIVED WITH
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CHLID CARE EXPENSES?
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Yes
No
Name
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First
Last
RELATIONSHIP TO YOU
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DATE OF BIRTH
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LAST 4 OF SOCIAL
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# OF MONTHS LIVED WITH
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CHLID CARE EXPENSES?
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Yes
No
Name
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First
Last
RELATIONSHIP TO YOU
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DATE OF BIRTH
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LAST 4 OF SOCIAL
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# OF MONTHS LIVED WITH
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CHLID CARE EXPENSES?
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Yes
No
HEALTH INSURANCE
WAS ENTIRE HOUSEHOLD COVERED ALL 12 MONTHS WITH HEALTH INSURACE?
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Yes
No
**IF NO, LIST THE NAME AND MONTHS OF INDIVIDUALS NOT COVERED ALL 12 MONTHS***
TAXPAYER
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First
Last
SPOUSE
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First
Last
MONTHS NOT COVERED
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January
February
March
April
May
June
July
August
September
October
November
December
MONTHS NOT COVERED
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January
February
March
April
May
June
July
August
September
October
November
December
DEPENDENT 1
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First
Last
[object Object]
MONTHS NOT COVERED
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January
February
March
April
May
June
July
August
September
October
November
December
DEPENDENT 2
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First
Last
[object Object]
MONTHS NOT COVERED
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January
February
March
April
May
June
July
August
September
October
November
December
DEPENDENT 3
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First
Last
[object Object]
MONTHS NOT COVERED
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January
February
March
April
May
June
July
August
September
October
November
December
DEPENDENT 4
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First
Last
[object Object]
MONTHS NOT COVERED
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January
February
March
April
May
June
July
August
September
October
November
December
QUESTIONAIRE
ARE YOU A HOMEOWNER?
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Yes
No
DID YOU PAY REAL ESTATE TAXES IN 2017?
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Yes
No
DID YOU PAY ANY AMOUNTS TO AN EX-SPOUSE IN ALIMONY OR MAINTENANCE? (CHILD SUPPORT DOES NOT COUNT)
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Yes
No
IF YES, HOW MUCH?
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NAME OF EX-SPOUSE PAID TO
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First
Last
DID YOU HAVE CHILD CARE EXPENSES IN 2015?
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Yes
No
ADDITIONAL INFORMATION OR COMMENTS
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IF YES, HOW MUCH WAS PAID?
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NAME OF PERSON OR BUSINESS PROVIDING CARE
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**SOCIAL SECURITY or EIN# MANDATORY**
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ADDRESS OF CARE PROVIDER
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Line 1
Line 2
City
State
Zip Code
Country
DID YOU MAKE ANY ENERGY EFFICIENT IMPROVEMENTS IN 2017?
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Yes
No
(EXAMPLE: BOILER, EXTERIOR DOORS, EXTERIOR WINDOWS, CIRCULATING FANS, INSULATION MATERIAL)
WILL YOU BE CLAIMING ANY EDUCATIONAL EXPENSES?
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Yes
No
IF YES, WHAT DEGREE (MASTERS, TRADES, BACHELORS)
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IF YES, DID YOU RECEIVE A FORM 1098-T
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Yes
No
WILL YOU BE CLAIMING INTEREST PAID ON STUDENT LOANS?
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Yes
No
IF YES, DID YOU RECEIVE A FORM 1098-E
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Yes
No
DID YOU RECEIVE ANY UNEARNED INCOME IN 2017-check all that apply
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INTEREST INCOME (SAVINGS OR BANK ACCOUNTS) 1099-INT
DIVIDENDS- 1099-DIV
SALES FROM STOCKS OR BONDS- 1099-B
DO YOU HAVE SIGNIFICANT MEDICAL EXPENSES?
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Yes
No
**SIGNIFICANT is defined as being greater than 10% of your income in order to qualify**
DID YOU HAVE ANY CASH OR NON-CASH DONATIONS TO A CHARITABLE ORGANIZATION IN 2017?
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Yes
No
CASH/MONETARY DONATION AMOUNT
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NON-CASH ITEMS DONATED AMOUNT
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DID YOU HAVE ANY RETIREMENT DISTRIBUTIONS FROM ANY RETIREMENT FUNDS? (FORM 1099-R)
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Yes
No
DID YOU DO ANY ROLL-OVERS WITHIN BETWEEN RETIREMENT ACCOUNTS IN 2017?
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Yes
No
DO YOU HAVE ANY SELF-EMPLOYMENT INCOME IN 2017?
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Yes
No
IF YES, DO YOU HAVE ALL OF YOUR INCOME AND EXPENSES CATEGORIZED AND ADDED TOGETHER?
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Yes
No
TYPE OF BUSINESS ACTIVITY?
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DID YOU HAVE RENTAL INCOME AND/OR RENTAL PROPERTY IN 2017?
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Yes
No
DID YOU HAVE SOCIAL SECURITY INCOME IN 2017?
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Yes
No
ARE THERE ANY TAX YEARS WHICH YOU HAVE NOT FILED RETURNS IN?
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Yes
No
IF YES, WHICH YEARS?
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DID YOU MAKE FEDERAL or STATE ESTIMATED PAYMENTS IN 2017?
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Yes
No
IF YES, HOW MUCH PAID TO FEDERAL
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IF YES, HOW MUCH PAID TO STATE?
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ANY ADDITIONAL COMMENTS OR CONCERNS?
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Comments
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AFTER
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REQUIRED-PLEASE READ BEFORE SIGNING
All information provided in this
questionnaire
will be used for tax filing purposes only. All socials will be reviewed and verified for accuracy. This form is used to help make sure we have covered any areas of your tax return that might have changed from prior years. We WILL contact you before completing any returns to verify and ask further questions about answers you have provided on this sheet. Thank you for taking the time to fill it out. Our goal is to make sure we never miss something that could benefit you.
The Wozny Tax Company (Accountant) will prepare our personal or corporate income tax returns based on information we will present to the accountant. The Wozny Tax Company will perform due dilligence but will not audit or otherwise verify the data we submit. Although the accountant may ask us for clarification of some of the information or for additional information, It is the accountants responsibility to prepare our tax return correctly according to the law and the information that we have provided. It is our responsibility to provide the accountant with all the information required to prepare complete and accurate returns. Your tax return cannot be filed until all forms are signed and returned to our office
I declare that to the best of my knowledge and belief what is stated above is correct, complete and is truly stated.
NAME
*
First
Last
DATE
*
Phone Number
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Home
Tax Updates
About the Firm
Why Wozny Tax Co
Services
Tax Preparation
Tax Planning
Tax Issues
Small Business Accounting
Quickbooks Services
Payroll
Audits
Bank Financing
Strategic Business Planning
New Business Formation
Non-Profit Organizations
Deductions
Contact
Client Forms
Upload Files
