Individual Income Tax Questionnaire

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Individual
Income Tax
Questionnaire
11610 Andrew Street
Phone - (218) 829-3501 - Brainerd
Brainerd, MN 56401
(218) 963-3424 - Nisswa
(Business Hwy 371 S)
Credits: see page 4 for required documentation
I (We) assure you that the information provided in this form, along with any other information sheets provided for
preparation of my (our) income tax returns is correct to the best of my (our) knowledge and belief. I (We) understand
that payment for your services is due upon receipt of my (our) tax returns.
______________________________
______________________________
____________
Signature
Signature
Date
Taxpayer(s)
Social Security #
Occupation
Date of Birth
Name(s)
-
-
-
-
Address
Street
City
State
Zip
If you have any refunds and you would like them to be
Home Phone _________________________
directly deposited to your account, please provide :
Work Phone
_________________________
Cell Phone
_________________________
Voided check (for checking account)
Cell Phone
_________________________
Deposit Slip (for savings account)
Fax
_________________________
Same as your 2011 tax return
E-Mail
_________________________
Did you or do you plan to make IRA contributions for this year?
Yes____No____
Contributor
Type of Account
Dates
Amounts
(Traditional, Roth, Educ.)
Did you have an interest in or a signature authority over a financial account in a foreign country?
Yes____No____
If Yes : Name of country___________
Did you pay $1,800 or more to any one household employee this year?
Yes____No____
Do you want to designate $3 to the federal presidential election campaign fund?
Yes____No____
Yes____No____
Do you want to designate $5 to the state elections campaign fund?
Yes____No____
Yes____No____
Your choice(s) of political party?
______________
____________
Did you have a theft or casualty loss over 10% of your gross income after insurance proceeds?
Yes____No____
If yes, please explain : ______________________________________________________________________
Did you make gifts of more than $13,000 to any one individual during the year?
Yes____No____
If yes, please explain : ______________________________________________________________________
Did you receive correspondence from the State or the IRS during the year?
Yes____No____
If yes, please explain : ______________________________________________________________________
If you want to donate to the Minnesota Nongame Wildlife fund, fill in the amount :
$_______
Income Tax Return
$_______
Property Tax Return
Do you foresee any significant changes to your financial situation that will affect your tax liability for 2013? If so, please
explain briefly : _____________________________________________________________________________________
Property Tax Refund: If you want us to prepare your Minnesota renter or homeowner property tax refund return form
M-1PR, you need to provide us with your 2012 Certificate of Rent Paid or your 2013 Statement of Property Taxes Due.
There is an additional fee for this service.
We will notify you by mail when your tax returns are completed. Please let us know if your mailing address is different
from the address above. _____________________________________________________________________________

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