Client Questionnaire (Page 2 of 4) in pdf

CLIFFORD W. STUMBO, CPA

CLIENT QUESTIONNAIRE

***SEPARATE QUESTIONAIRE FOR AFFORDABLE HEALTHCARE ACT COMPLIANCE***

PART IV. EXPENSES- DID YOU (OR YOUR SPOUSE) PAY:

Yes No Unsure

1. Alimony: If yes, provide the recipient's SSN?

2. Contributions to a retirement account?

IRA

Roth IRA

401K

Other

3. College Expenses (Form 1098-T, Need Payment Transcipt and Textbooks Receipts)

4. Home Mortgage Interest? (Form 1098)

5. Real estate taxes? Personal property taxes for vehicles, boats, etc?

6. Charitable contributions?

7. Medical expenses (including health insurance premiums, long-term care premiums paid out of pocket)?

8. Unreimbursed employee business expenses (such as teacher supplies, uniforms or mileage)?

9. Child/dependent care expenses, such as day-care?

PART V. LIFE EVENTS - DID YOU (OR YOUR SPOUSE):

Yes No Unsure

1. Have a Health Savings Account? (Forms 5498-SA, 1099-A, W-2 Box 12 Code W)

2. Have debt from a mortgage or credit card canceled/forgiven by a commerical lender? (Form 1099-C)

3. Buy, sell or have a foreclosure of your home? (Form 1099-A)

4. Have Earned Income Credit (EIC) disallowed in a prior year? If yes, which tax year?

5. Purchase and install energy efficient home items (such as windows, furnance, insulations, etc.)?

6. Received the First Time Homebuyers Credit in 2008?

7. Pay any student loan interest? (Form 1098-E)

8. Make estimated tax payments or apply last year's refund to your 2012 tax?

stimated tax payments or apply last year ar's refund to this year's tax return?

this year's tax return?

PART VI. BUSINESS INFORMATION - DID YOU (OR YOUR SPOUSE):

Yes No Unsure

1. Did you have a business this tax year? If yes, check which ones:

ones:

Business

Rental

Farm

2. Did you make any payments in 2012 that would require you to file Form(s) 1099?

ayments last year that would require you to file Form(s) 1099? ($600 or more per vendor)

3. If yes to No. 2, did you or will you file all reported Form(s) 1099? (Due date to file is Feb. 28th)

ADDITIONAL DEPENDENTS:

Marital

Full-time

Earned less

Name (first, last)

Relationship to you

No of months

Status as of

student

than $3,950

Do not enter your name or

Date of Birth

(e.g. daughtter, son

lived in your

US Citizen

Dec 31st

spouse's name below

mm/dd/yy

mother, sister, none)

home

Yes or No

S or M

Yes or No

OTHER COMMENTS/QUESTIONS:

***SEE ADDITIONAL PAGE FOR AFFORDABLE HEALTHCARE ACT COMPLIANCE***

Client Questionnaire Page 2

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