Client Questionnaire
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4CLIFFORD W. STUMBO, CPA
CLIENT QUESTIONNAIRE
TODAY'S DATE
NEW CLIENT?
Yes
No
PART I. YOUR PERSONAL INFORMATION
First Name
M.I.
Last Name
Are you a US Citizen?
Yes
No
Spouse's First Name
M.I.
Last Name
Is Spouse a US Citizen?
Yes
No
Mailing Address
Apt #
City
State
Zip Code
Contact Information
Cell:
Email:
Phone:
Spouse Cell:
Spouse Email:
Date of Birth
Job Title
Are you:
Legally Blind
Yes
No
Totally/Permanently Disabled
Yes
No
Spouse's Date of Birth
Spouse's Job Title
Is Spouse:
Legally Blind
Yes
No
Totally/Permanently Disabled
Yes
No
Can anyone claim you or your spouse on their tax return?
Yes
No
Unsure
Did you make internet purchases where NO SALES TAX was paid? ie. Amazon
Yes
No If yes, Amount?
For direct deposit purposes, is the Bank and Account # same as last year?
Yes
No If no, provide voided check.
PART II. MARITAL STATUS AND HOUSEHOLD INFORMATION
As of December 31, were you?
Single
Married: Did you live with your spouse during any part of the last six months of 2012?
of tax year?
Yes
Yes
No
No
Divorce or Legally Separated: Date of final decree or separate maintenance agreement:
Widowed: Year of spouse's death:
List names below of everyone who lived in your home (other than you or spouse). Also, list anyone who lived outside
of your home that you supported. If additional space is needed, please check here
and list on bottom of next page.
Marital
Name (first, last)
Relationship to you
No of months
Status as of
Full-time
Earned less
Do not enter your name or
Date of Birth
(e.g. daughtter, son
lived in your
US Citizen
Dec. 31st
Student
than $3,950?
spouse's name below
mm/dd/yy
mother, sister, none)
home
Yes or No
S or M
Yes or No
Yes or No
PART III. INCOME - DID YOU (OR YOUR SPOUSE) RECEIVE:
Yes No Unsure
1. Wages or Salary? (Forms W-2's) Tip Income?
2. Interest/Dividends from: checking/savings accounts, bonds, CDs, brokerage? (Forms 1099-INT, 1099-DIV)
3. Have any interest or authority over a financial account in a foreign country?
4. Self Employment payments (such as cash received for services, small businesses)? (Form 1099-MISC)
5. Refund of state income taxes? (Form 1099-G)
6. Alimony Income?
7. Income (or loss) from the sale of Stocks, Bonds or Real Estate? (Forms 1099-B, 1099-S)
8. Social Security or Railroad Retirement Benefits? (Forms SSA-1099, RRB-1099)
9. Distributions from Pensions, Annuities, and/or IRA? Disability Income? (Forms 1099-R)
10. Unemployment Compensation? (Form 1099-G)
11. Income from S-Corporations or Partnerships? (Forms K-1)
12. Other Income (Gambling, Lottery, Prizes, Awards, Jury Duty, etc.)
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Parent category: Life