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

Ever Evolving Enterprises

2016 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 of the following outside of the United States?

Real estate in another country?

yes_____

no_____

Checking or savings account(s)?

yes_____

no_____

Investment accounts?

yes_____

no_____

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

Address if changed from last year:

______________________________________________________________________________

Would you like a paper copy___ of your return or a CD ___ or both____ ($3.00 charge for both)

If you will receive a refund would you prefer:

____to have a check mailed

____direct deposit

If balance due would you prefer:

____to mail in a check OR

____ACH withdrawal from bank account

Note: the ACH is done on April 15

regardless of when tax return is filed unless another date is specified.

If doing direct deposit or ACH and want to use the same account as last year, provide the last four digits of the

account number for verification ________last four digits

If we have questions regarding your return before completion, would you prefer to be contacted by:

_____ Email

Email address: _________________________________

_____ Phone

telephone #:

_________________________________

What is the latest time at night that we can call?

____9pm ____10pm ____11pm

Date

Signature of Taxpayer

Drop-Off Information Sheet Page 2

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