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Questionnaire!

2022 Personal Income Tax Questionnaire

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Please Upload the following items to your portal 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 10, 2023.

W - 2 (Wage and Tax Statements)
W- 2G (Gambling Winnings/Loss Detail - breakdown by Taxpayer and Spouse)
1099 - B (Brokerage Statements)
1099 - INT (Interest Statements)
1099 - DIV (Dividend Statements)
1099 - K (Payment Card and Third Party 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 or Rental Income)
1099 - NEC (Non-Employee Compensation)
1099/5498 - SA (HSA or MSA Distributions/Contributions)
1099 - LTC (Long-Term Care and Accelerated Death Benefits)
1099 - Q (Educational Program Payments)
1099/5498 - QA (Distributions from/Contributions to ABLE accounts)
5498 - (IRA Contributions)
1098 - (Mortgage Interest)
1098 - T (Tuition Statement) Accountant must have form on hand to claim credit.
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 Information

Taxpayer Name

First Last

Taxpayer Last 4 digits of SSN*

Taxpayer Date of Birth*

Taxpayer Occupation

Taxpayer Status

Check all that apply

Legally Blind

Campaign Fund

Spouse Name

First Last

Spouse Last 4 digits of SSN

Spouse Date of Birth

Spouse Occupation

Spouse Cell Phone

Spouse Email

Spouse Status

Check all that apply

Legally Blind

Campaign Fund

Marital Status as of end of the year

Single

Married

Married, but I want to file separately

Mailing Address

Street Address Address Line 2 City State ZIP Code

Township

School District

Cell Phone

Daytime Phone

Home Phone

Email

Dependents

Please list if there are any changes from last year's return.

First Name	Last Name	Date of Birth	Last 4 Digits of SSN	Relationship	Months Lived with You	Months of Full Time Student	% Supported By You	% Supported By Others	Actions

There are no Dependents.

ITEMIZED DEDUCTIONS

Used only if higher than standard deduction.

MEDICAL EXPENSES YOU PAID

Deductible 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?

Yes

No

Are you / spouse eligible for an employer health plan?

Yes

No

How many months were you covered on an employer health plan?

Long-Term Care Insurance Premiums: Taxpayer

Long-Term Care Insurance Premiums: Spouse

Medical 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 You

Miles Driven for Medical Care

TAXES YOU PAID

Real 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 PAID

Do 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 Institutions

Mortgage Insurance Premiums

Interest Paid to an Individual

Interest Paid - Individual SSN

Only include last four digits

Interest Paid - Individual Name

First Last

Interest Paid - Individual Address

Were all mortgage, refinance, and loan proceeds used to buy, build, or improve your main home and one other?

Yes

No

Amount Used for Other Purposes

What other purposes?

Closing Points on New Home Purchase or Current Year Refinance

(Please upload a copy of settlement papers on your portal.)

Investment Interest

Type of Investment

GIFTS TO CHARITY

If 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, Check, or Credit Card 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 PAID

Unreimbursed Employee Expenses

(tools, uniforms, protective clothing, union/professional dues, travel, publications)

Job-Related Educational Expenses

(books, tuition)

Miles Driven Directly between Work and School

Gambling Losses

(up to winnings only)

CREDITS

CHILD AND DEPENDENT CARE EXPENSES YOU PAID

Did you pay for child care so that you and your spouse could work or go to school?

If yes, please give details below.

Yes

No

Details

Child Name

Relationship to Taxpayer

Amount paid to Care Provider ($)

Care Provider Name

Last 4 digits of EINs/SSN

Address

Did your employer pay for childcare?

Yes

No

Amount paid by employer

ESTIMATED TAX PAYMENTS YOU MADE

Quarter 1, April 15

Federal

Date

Amount ($)

State

Date

Amount ($)

2nd State

Date

Amount ($)

Local

Date

Amount ($)

Quarter 2, June 15

Federal

Date

Amount ($)

State

Date

Amount ($)

2nd State

Date

Amount ($)

Local

Date

Amount ($)

Quarter 3, Sept 15

Federal

Date

Amount ($)

State

Date

Amount ($)

2nd State

Date

Amount ($)

Local

Date

Amount ($)

Quarter 4, Dec/Jan 15

Federal

Date

Amount ($)

State

Date

Amount ($)

2nd State

Date

Amount ($)

Local

Date

Amount ($)

COMMENTS OR QUESTIONS:

If you have a tax refund, would you like it directly deposited into your bank account?

Yes

No

If Yes:

Use the same account as last year

Please 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 25 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.

Date

CAPTCHA

Send my form to…*

If you do not have an assigned CPA, or do not know, select "Other".

Thank you

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. Sincerely, Gift CPAs

Best Wishes for a successful year in 2023.

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Property Description & Address	Rents/Royalty	Expenses Paid	Advertising	Auto/Travel Expense	Number of Miles	Cleaning and Maintenance	Commissions	Insurance	Legal and Professional	Management Fees	Mortgage Interest	Other Interest	Repairs	Improvements (list)	Supplies	Taxes	Utilities	Other (describe below)	What percent of the property did you occupy during the year?	Days rented at fair value during the year?	Days used by you or relatives during the year?	Were you active in managing the rental property during the year?	Actions

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Client Login

Personal

Questionnaire!

2022 Personal Income Tax Questionnaire

General Information

Questions - General Information

Purchases, Sales, and Debts

Sale of your home

Severance & Retirement

Retirement Accounts

Casualty and Theft Losses

Energy Saving Home Improvements

Adoption Expenses You Paid

Miscellaneous

Health Insurance

Income

RENT AND ROYALTY INCOME

OTHER INCOME

Adjustments to Income

EDUCATION ADJUSTMENTS / CREDITS

OTHER ADJUSTMENTS

BUSINESS USE OF PERSONAL VEHICLE

ITEMIZED DEDUCTIONS

MEDICAL EXPENSES YOU PAID

TAXES YOU PAID

INTEREST YOU PAID

GIFTS TO CHARITY

OTHER ITEMIZED DEDUCTIONS YOU PAID

CREDITS

CHILD AND DEPENDENT CARE EXPENSES YOU PAID

ESTIMATED TAX PAYMENTS YOU MADE

Quarter 1, April 15

Quarter 2, June 15

Quarter 3, Sept 15

Quarter 4, Dec/Jan 15

Thank you

Best Wishes for a successful year in 2023.

Don't hesitate to contact us any time.

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