2014 Tax Questionnaire - Taxvision
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25755 North Point PKWY, Ste 66, Alpharetta, GA 30022
380 Lexington Ave, Suite 1700, New York, NY 10168
Tel: (770) 455-6566 Fax: (770) 396-9459
Tel: (212) 444-8087 Fax: (770) 396-9459
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Please complete the information below, review each question, check yes/no and provide
additional information as necessary
PERSONAL INFORMATION
Taxpayer:
SS#:
Email:
Phone#:
U.S. Status:
Citizen
Green Card
Visa (Type)
Other
Spouse:
SS#:
Email:
Phone#:
U.S. Status:
Citizen
Green Card
Visa (Type)
Other
YES NO
Did your marital status change during the year? If yes, please provide us with the date it changed:
Did your address change during the year? If yes, please provide us with the date you moved:
and your new address:
Could you be claimed as a dependent on another person's tax return for 2014?
DEPENDENTS
Were there any changes in dependents? If ‘Yes’, please provide the following:
Name(s) - As it appears on their Social Security Card(s) ______________________________________________________
Date of Birth _______________________________
Social Security Number(s) ______________________________________________________
Relationship (i.e. Son, Daughter, Mother, Father) ___________________________________
Were any of your unmarried children who might be claimed as dependents 19 years of age or older at the end of 2014?
Did you have any children under age 19 or full-time students under age 24 at the end of 2014, with interest and dividend income in excess of
$1,000, or total investment income in excess of $2,000?
HEALTH CARE COVERAGE
Did you and your dependents have health care coverage for the full year?
Did you receive any of the following IRS documents? Forms 1095-A (Health Insurance Marketplace Statement), 1095-B (Health Coverage) or
Form 1095-C (Employer Provided Health Insurance Offer and Coverage)
If so, please
attach.
If you or your dependents did not have health care coverage during the year, do you fall into one of the following exemptions categories: Indian
tribe membership, health sharing ministry membership, religious sect membership, incarceration, exemption non-citizen or economic
hardship?
If you received an exemption certificate, please
attach.
INCOME
(Possible forms to attach: W-2, 1099-INT, 1099-DIV, 1042, SSA-1099, 1099-MISC)
Did you have any foreign income or pay any foreign taxes?
Did you cash any Series EE U.S. savings bonds issued after 1989 and pay qualified higher education expenses for yourself, your spouse, or
your dependents?
Did you receive any rental income?
If yes, please complete rental income/expense spreadsheet
Did any of your accounts earn interest or dividend income?
Did you receive any disability income?
Did you receive unreported tip income of $20 or more in any month?
FOREIGN FINANCIAL ASSETS
(If yes, please complete Foreign Financial Asset
Spreadsheet)
Did you have a foreign financial asset?
Did you have an interest in or signature or other authority over a financial account in a foreign country, such as a bank account, securities
account, or other financial account?
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