Drop-Off Information Sheet (Page 2 of 2) in pdf

Planning with Purpose

2017 Tax Season

Affordable Care Act requires proof of health insurance for each individual claimed on return

Check if you have included: _______1095A (comes from Marketplace)

_______1095B (comes from insurance company)

_______1095C (comes from employer)

If none of forms above are provided, check proof being provided below:

_______Statement of coverage from Insurance Company showing who was covered and dates

_______Social Security Statement showing Medicare premiums

_______Insurance bills for each month showing premiums paid if shows who had coverage

_______ Other documentation showing dates of coverage and who was covered

Do you have any bank accounts located in any country other than the US?

___yes

___ no

Do you own real estate in any country other than the US?

___yes

___ no

Do you have any investments located in any country other than the US?

___yes

___ no

If yes, there may be additional filing requirements. We will call you if you answered yes to any of the above.

Address if you have moved since last year’s tax return was filed:

______________________________________________________________________________

Preferences for your copy of the tax return: _____paper copy

______e-mailed to you

_____both ($3.00 charge for both)

___ Balance due – check to be mailed

___ Refunds to be mailed

___ Direct deposit any refunds

___ Withdraw any balance due on April 15

To verify we have the right bank info, provide the last 4 digits of the account number: ________

___check here if information will be provided when e-filing forms are signed

Prefer to be contacted by ____ phone

___ email ___no preference

Telephone #: ___________________

email address: _________________________________

Latest time at night that we can call: ___ 8pm ___9pm ___10pm ___11pm

other limits: __________________________________________

Copy of state ID or driver’s license provided:

_____Taxpayer

_____Spouse (write N/A if not applicable)

This is a new requirement to e-file a NYS tax return this year.

If no ID provided, the NYS tax return must be mailed and cannot be e-filed

Signature of Taxpayer

Date

Only one signature is required for a joint tax return

Drop-Off Information Sheet Page 2

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