Taxpayer Questionnaire Form

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Taxpayer Questionnaire
(PLEASE ANSWER ALL QUESTIONS)
Tax Year
___________________
EIC CLIENTS ATTACH TO FORM 8867 FOR DUE DILIGENCE
TAXPAYER : First Name
SPOUSE: First Name
Last Name:
Last Name:
SSN:
D.O.B.
SSN:
D.O.B.
Your Occupation:
Spouse Occupation:
CONTACT INFORMATION
Home Address_______________________________________ City_________________ State _____________ Zip______________
Best Phone Number (
) ______________ Alternate Number (
) ______________ E-mail ________________________________
FILING STATUS
___Married
___Separate
___Head Of Household
___Single
___Qualifying Widow
The IRS defines any dependent as a qualifying child or a qualifying relative one that you Partially or Fully support
economically. If any child you are claiming as a dependent is NOT your son or daughter be prepared to provide a written
statement why the parent is not claiming the child.
EIC: The child and/or qualifying person must live with you for more than 6 months with proof of residency for each child claimed.
Did your dependents live with you for more than 6 month __Yes __No Can anyone else claim your dependents __Yes __No
DEPENDENTS
First Name
Last Name
Proof of SSN
Relationship
DOB
Do all members of your household have medical insurance _____Yes _____No (Attach Proof)
Did you receive form 1095-A (Marketplace) 1095-B (Non Marketplace) 1095-C (Employer) _____Yes ____No
EIC: Do you have dependents age 18 or older in school/college ____Yes ____ No (Attach Form 1098-T)
EIC: Do you have dependents age 18 or older with a disability ____ Yes ____ No Were they employed _____Yes _____No
EIC: Dependents with disability need: ___Doctor’s or Health Care Statement or ___Social Service Disability Statement
PROOF OF INCOME (check all that apply)
W-2 Forms/Last Check
Self-Employment
Rental Income
Miscellaneous
Stub w/Form 4852
(Attach Income/Expense Summary)
(Attach Property Worksheet)
Income/Form 1099
Unemployment
Retirement and/or Social
Interest and/or
Sales of Stock
Security Income
Dividend Income
Form 1099-B
Sale of Real Estate
Winning Income 1099-G
Alimony Paid/Rec.
State Tax 1099-G
I am fully aware that the information from my questionnaire and attached forms will be used to figure my income, credits and
deductions, which will be used to arrive at my tax refund and/or liability. I have reviewed my tax return with ARKED Enterprises. By
signing below under penalties or perjury, the information provided to ARKED Enterprises is true, complete and correct.
X
Signature Required________________________________________________
Date_____________________

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