Client Questionnaire (Page 3 of 4) in pdf

Client Questionnaire Page 3

HEALTH CARE COVERAGE QUESTIONAIRE – 2014

Taxpayer Name: _____________________________________________________________________

Taxpayer Signature: _______________________________________________________ Date: _____________

I agree, the information (below) is true and accurate:

YES or NO

I had qualifying health care coverage every month of 2014? _____

If YES, provide copy of insurance card _____

If NO, Was coverage provided through the Marketplace/ Exchange? ______

-If YES, provide copy of Form 1095A ____

My Spouse had qualifying health care coverage every month of 2014? _____

If YES, provide copy of insurance card ______

If NO, Was coverage through the Marketplace/ Exchange? ______

-If YES, provide copy of Form 1095A _____

My “tax dependents” had qualifying health care coverage every month of 2014? ____

If YES, provide copy of insurance card(s) _____

If NO, Was coverage through the Marketplace/ Exchange? ______

-If YES, provide copy of Form 1095A _____

THE TAX FILER AND/OR TAX DEPENDANT(S) DID NOT HAVE HEALTHCARE COVERAGE FOR THE FULL YEAR:

I acknowledge there will be a “Shared Responsibility Payment” included on my tax return filing. ______

Are your “tax dependents” required to file a tax return? _____

If YES, we require a copy of the tax return if Clifford W. Stumbo, CPA is not the tax preparer.

***List of Exemptions from “Shared Responsibility Payment” on Page 2***

Client Questionnaire Page 3