2018 Personal Questionnaire 2018 Personal Questionnarie Step 1 of 7 14% Please select the name of the CPA who is managing your account.If you do not have an assigned CPA, or do not know, select "Other".OtherSteve GiftJim BruzgaJesse LambertJason VathisChuck HenryShawn BrubakerAndrew SartalisChristine SobolewskiRick GrovesRandy YohTess PuglioTammie WisniewskiJamie BeaneBarb LeeseMary FlynnPatricia BowersJeff HalliganValerie HeilEric KetnerPlease Upload the following items to your portal The information requested on this form is for the preparation of your personal income tax return and relates to you and your family personally, not to your business operations. Please complete this form no later than March 15, 2019. W - 2s (Wage and Tax Statements) W- 2G (Gambling Winnings/Loss Detail) 1099 - B (Brokerage Statements) 1099 - INT (Interest Statements) 1099 - DIV (Dividend Statements) 1099 - K (Payment Card and Third Part Network Transactions) 1099 - R (Distributions from Pensions, Annuities, Retirement) SSA - 1099 (Social Security) 1099 - G (Unemployment Compensation, State or Local Income Tax Refunds, etc.) 1099 - MISC (Miscellaneous Income) 1099 - SA (HSA or MSA Distributions) 5498 (IRA Contributions) 5498 - SA (HSA or MSA Contributions) 1098 (Mortgage Interest) 1099 - LTC (Long-Term Care and Accelerated Death Benefits) 5498 (IRA Contributions) 1098 - T (Tuition Statement) Accountant must have form on hand to claim deduction. 1098 - E (Student Loan Interest) 1095 - A (Insurance Purchased Through Exchange) 1095 - B (Insurance Purchased Through Other Insurers) 1095 - C (Insurance Provided Through Employer) Schedule K - 1 (Partner’s, Shareholder’s, or Beneficiary’s Share of Income) Voided Check General InformationTaxpayer Name First Last Taxpayer Last 4 digits of SSN*Tax Payer Date of Birth* Tax Payer OccupationTax Payer StatusCheck all that apply Legally Blind Campaign Fund Spouse Name First Last Spouse Last 4 digits of SSNSpouse Date of Birth Spouse OccupationSpouse - OtherCheck all that apply Legally Blind Campaign Fund Marital Status as of end of the yearSingleMarriedMarried, but I want to file separatelyMailing Address Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code TownshipSchool DistrictCell PhoneDaytime PhoneHome PhoneEmail DependentsPlease list if there are any changes from last year's return. Name Date of Birth Social Security Number Relationship Months Lived with You Months as Full-Time Student Percentage Supported by You Percentage Supported by Others   Edit Delete There are no Dependents. Add Dependent Questions - General InformationDid your marital status change during the year?YesNoDid your address change during the year?If yes, please provide dates of moves belowYesNoAddress DatesWere there any changes in dependents from the prior year?YesNoDo you have any children under 19 or full-time students ages 19-24 with income?YesNo5. Did you and/or your spouse receive an Electronic Filing PIN from the IRS?YesNoIf yes, please provide PIN(s)Taxpayer's PINSpouse's PINPurchases, Sales, and DebtsDid you start a new business, purchase a new rental property or farm, or acquire any new interest in any partnership or S Corporations during the year?YesNoDid you sell an existing business, rental property, farm, or any existing interest in a partnership or S Corporation during the year?YesNoDid you receive any income from any property or business sold in a prior year?YesNoDid you receive grants of stock options from your employer, exercise any stock options granted to you, or dispose of any stock acquired under a stock option or qualified employee stock purchase plan?If yes, please upload closing statements through your portal.YesNoDid you purchase, sell, refinance, or exchange your home or any real estate during the year?If yes, please provide closing statement(s)YesNoDid you take out a home equity loan during the year?If yes, please provide closing statement, and specify what the funds were used for.YesNoWhat were the funds used for?Did you have any debts, canceled, forgiven, or refinanced during the year?YesNoAre there any interest-free loans of $10,000 or more to you or from you? If yes, please provide details.YesNoLoan detailsDid you participate in an installment sale this year?(Please provide a copy of Form 6252 through your portal for the year of sale if we did not prepare your return that year.)YesNoSale of your homeDid you sell your home during the year?If yes, please answer the questions below.YesNoDid you, or your spouse if filing jointly, own the home as your principal residence for at least two years of the five-year period prior to the sale?YesNoDid you, and your spouse if filing jointly, occupy the home as your principal residence for at least two years of the five-year period prior to the sale?YesNoHave you or your spouse sold any other principal residence within the last two years?YesNoWas the home acquired through a tax-free (1031) exchange?YesNoDid you ever use any portion of the home for business purposes?YesNoDid this home qualify for one of the Home Buyer credits?YesNoSeverance & RetirementDid you or your spouse change jobs or retire during the year?YesNoDid you or your spouse receive retirement/severance compensation?YesNoAmount ReceivedDate Received Retirement AccountsDid you or your spouse turn age 70 ½ during the year and have money in an IRA or other retirement account without taking any distributions?YesNoWhy?Did you withdraw any amounts from any IRA to acquire a principal residence?YesNoDid you withdraw any amounts from any IRA to pay for higher education expenses incurred by you, your spouse, your children, or your grandchildren?YesNoDid you or your spouse establish or contribute to any IRA?YesNoDid you convert any Traditional IRAs into Roth IRAs?YesNoIf yes, amount for TaxpayerAmount for SpouseDid you or your spouse ever make any nondeductible IRA contributions?If yes, please also provide a copy of your most recent Form 8606 for you and your spouse through your portal if we did not prepare it.YesNoIf yes, please provide the end-of-year value of all traditional IRAs for Taxpayer If yes, please also provide a copy of your most recent Form 8606 for you and your spouse if we did not prepare it.Are you or your spouse covered by an employer retirement plan?If yes, please fill in amounts below.YesNoRetirement Plan(s)Plan Type$ Contributions for Taxpayer$ Contributions for Spouse Casualty and Theft LossesDid any sudden and unexpected event cause loss or damage to any of your property this year?YesNoIf yes, did you have insurance?YesNoDid you file a claim with your insurance company?YesNoIf yes, please provide details about each event and each item lost or damaged (description, cost, and value before and after damage). If no claim was filed with your insurance company, no deduction can be taken.Energy Saving Home ImprovementsDid you make any improvements to your home that are considered energy saving?If so, please provide detail and a copy of previously filed Forms 5695 through your portal if we did not prepare.YesNoAdoption Expenses You PaidDid you adopt a child or begin adoption proceedings during the year?YesNoAdoption Expenses MiscellaneousWere you notified by the IRS or other taxing authority of any changes in prior year returns?YesNoDid you have an interest in or signature authority over any financial account in a foreign country?YesNoDid you create or transfer money or property to a foreign trust?YesNoDid you have any foreign income or pay any foreign taxes during the year?YesNoDid you or your spouse establish or contribute to a Health Savings Account (HSA)?YesNoDid you or your spouse receive distributions from long-term care insurance contracts?If yes, please upload Forms 1099-LTC to the portal.YesNoDid you move to a different home because of a change in the location of your job?YesNoDid you engage in any bartering transactions?YesNoIf yes, please provide details.Do you owe your state any Use Tax for out-of-state purchases?YesNoIf yes, please provide details.Use Tax detailsTransaction details.Did you make gifts of more than $15,000 to any individual?YesNoHave you or your spouse ever filed a Gift Tax return?If yes, please provide a copy of the return through your portal.YesNoDid you pay someone $2,100 or more to work in your home during the year?If yes, please provide details and a copy of any W-2s you issued through your portal.YesNoDid you mine any digital currency?YesNoDid you use gasoline or special fuels for farm or off-road business purposes during the year?YesNoDid you receive an award for punitive damages or for damages other than physical injuries or illness?YesNoAre you a voluntary EMT or Firefighter?YesNoHealth InsuranceDid you receive Form 1095-A? If yes, skip the next question.YesNoIf not, did you maintain health insurance at any point in the year?YesNoAre you entitled to claim dependents? If no, skip the next questionYesNoIf yes, were the dependents covered by health insurance at any point in the year?YesNoDid you or any of your dependents, if applicable, have any gaps or lack of coverage during the year?YesNoIf yes, please list time periods when you did not have coverage Was any gap 3 months or less?YesNoIf you had gaps that lasted greater than 3 months, did any of the following exceptions apply?Check all that apply Part of a recognized religious sect Incarcerated Member of an Indian Tribe Part of a health care sharing ministry Illegal alien Could not afford coverage Do you qualify for a hardship exemption?YesNoIf so, provide the exemption certificate number (ECN):Are you eligible for any state or local health benefit program, such as Medicare or Medicaid?YesNoDid you purchase health insurance on the exchange?YesNoWere you eligible for health care coverage through your employer or your spouse’s employer?YesNoIf yes, did you enroll?YesNoDid you receive an advanced PTC (Premium Tax Credit)?YesNoIf yes, is there more than one tax family sharing the credit?YesNoAre you covered under a policy from the exchange in which someone else holds the policy?YesNoif yes, do you claim yourself?YesNo IncomeTips Not Included on W-2Business Income(please attach detail through your portal)Farm Income(please attach detail through your portal)RENT AND ROYALTY INCOMERent and Royalty Income Property Description & Address Rents/Royalty Expenses Paid Advertising Auto/Travel Expense Number of Miles Cleaning and Maintenance Commissions Insurance Legal and Professional   Edit Delete There are no Addresses. Add Address SCHEDULE OF IMPROVEMENTS TO RENTALPlease list improvements and furnishings purchased during the year.DateDescription of Asset PurchasedCost OTHER INCOMEAlimony IncomeOther IncomePlease ExplainAdjustments to IncomeEDUCATION ADJUSTMENTS / CREDITSEducator Expenses Paid(unreimbursed classroom materials expense by K-12 teacher/counselor/principal/aide)529 Plan Contributions(provide forms through your portal)Qualified Education Expenses(computer, books, software, etc.)OTHER ADJUSTMENTSPenalty for Early Withdrawal of SavingsAlimony PaidName of Alimony RecipientAlimony Recipient - Last 4 of SSNMoving Expenses(Please upload list through portal. Expenses deductible only if moving to a different home due to a change in job location.)Health/Medical Savings Account ContributionsPlease upload Forms 5498-SA through your portal.Health/Medical Savings Account Contribution Type HSA MSA Individual Family Were all distributions used for eligible medical expenses?YesNoMedical Insurance Premiums paid by self-employed taxpayers can be deducted as an adjustment. (Please provide details.)BUSINESS USE OF PERSONAL VEHICLEDo not include expenses of business-owned vehicles here. Report those expenses with business income and expenses. Do not complete this section if your expenses were reimbursed by your employer and the reimbursement is not reported in your wages. Please make sure you have detailed records to support these expenses.Did you use your car for business other than for commuting?YesNoAre you an Employee or Proprietor/Partner?EmployeeProprietor/PartnerVehicle DetailMakeModelYear Date First Used for Business Lower of Cost or Value on that DateOdometer at Start of Last YearOdometer at End of Last YearMilesBusiness +Commuting +Personal= Total Miles Do you have evidence to support the business miles claimed?YesNoIs the evidence in writing?YesNoActual Personal and Business Expenses (gas, repair, lease, insurance)Business Parking and TollsInterest on Vehicle Loan (if self-employed)Personal Property Tax (vehicle registration)Expenses Reimbursed by EmployerDo you have another vehicle available for personal use?YesNo ITEMIZED DEDUCTIONSUsed only if higher than standard deduction.MEDICAL EXPENSES YOU PAIDDeductible only if itemizing and above 7.5% of adjusted gross income. Medical Insurance Premiums You Paid(Do not include pretax employee payments.)Are you / spouse self-employed?YesNoAre you / spouse eligible for an employer health plan?YesNoHow many months were you covered on an employer health plan?Long-Term Care Insurance Premiums: TaxpayerLong-Term Care Insurance Premiums: SpouseMedical Expenses You Paid(Do not include expenses paid by insurance/HSA/MSA. Include doctors, dentists, nurses, prescription medicine, lab fees, hearing aids, eyeglasses, contact lenses, hospitals, medical transportation, and lodging.)Insurance Reimbursements and Health/Medical Savings Account Reimbursements Paid to YouMiles Driven for Medical CareTAXES YOU PAIDReal Estate Taxes on Personal Residences and Investment Property(Do not include business/rental property taxes here.) Personal Property Tax on Personal Vehicles (Auto Registration)(Does not apply to PA residents.)Special Item Sales Tax (i.e., Sales Tax on Car or Boat Purchase)Balance Paid with Prior Year State and Local Income Tax Returns(Include tax only, not any interest or penalties.)INTEREST YOU PAIDDo not include rental property interest or student loan interest here.Home Mortgage Loans and Home Equity Loans. Number Attached: Please provide Forms 1098 through your portal.Interest Paid to Financial InstitutionsMortgage Insurance PremiumsInterest Paid to an IndividualInterest Paid - Individuals SSNOnly include last four digitsInterest Paid - Individual Name First Last Interest Paid - Individual AddressWere all mortgage, refinance, and loan proceeds used to buy, build, or improve your main home and one other?YesNoAmount Used for Other PurposesWhat other purposes?Closing Points on New Home Purchase or Current Year Refinance(Please upload a copy of settlement papers on your portal.)Investment InterestType of InvestmentGIFTS TO CHARITYIf your non-monetary contributions total over $500, please describe the contributed items. Indicate the date, charity name, and address of the contributions; the date and cost of the original purchases; the value of contributions; and how you determined those values. For all contributions, you must keep canceled checks or written receipts. For all contributions over $250 you must keep written acknowledgement from the charity and have in possession before filing. For non-monetary contributions over $5,000, you must keep a written appraisal.Cash or Check Contributions to Charity(monetary gifts to church and other qualified charities)Non-Monetary Contributions to Charity(items given to Goodwill, Salvation Army, and other qualified charities)Miles Driven for Qualified Charity:OTHER ITEMIZED DEDUCTIONS YOU PAIDUnreimbursed Employee Expenses(tools, uniforms, protective clothing, union/professional dues, travel, publications)Job-Related Educational Expenses(books, tuition) Miles Driven Directly between Work and SchoolJob-Related Legal FeesGambling Losses(up to winnings only) CREDITSCHILD AND DEPENDENT CARE EXPENSES YOU PAIDDid you pay for child care so that you and your spouse could work or go to school?If yes, please give details below.YesNoDetailsChild NameRelationship to TaxpayerAmount paid to Care Provider ($) Care Provider DetailNameLast 4 digits of EINs/SSNAddressDid your employer pay for childcare?YesNoAmount paid by employerESTIMATED TAX PAYMENTS YOU MADEQuarter 1, April 15FederalDateAmount ($) StateDateAmount ($) LocalDateAmount ($) Quarter 2, June 15FederalDateAmount ($) StateDateAmount LocalDateAmount ($) Quarter 3, Sept 15FederalDateAmount ($) StateDateAmount ($) LocalDateAmount ($) Quarter 4, Dec/Jan 15FederalDateAmount ($) StateDateAmount ($) LocalDateAmount ($) COMMENTS OR QUESTIONS:If you have a tax refund, would you like it directly deposited into your bank accountIf yes:Use the same account as last yearPlease use different account (Please upload voided check to your portal)Thank you for allowing us to handle your tax needs. Clients like you are the reason Gift CPAs has been able to serve our community for more than 30 years. With that in mind, we wanted to remind you that we have a referral incentive program geared toward our valued tax clients. If you refer anyone to us and we subsequently prepare their personal tax return, we will give you the choice of a $25 gift certificate to a local restaurant or we will make a $25 donation on your behalf to the charity of your choice. We look forward to working with you this coming tax season. As always, let us know if you have any questions or concerns.Declaration* I have reviewed the information given to you on this form and to the best of my knowledge it is true, correct, and complete. I have maintained the underlying records required by law to support this information. I authorize Gift CPAs to prepare my personal income tax return based on this information and to retain copies of appropriate documents This iframe contains the logic required to handle Ajax powered Gravity Forms.