Client Intake - My Bookkeeping Guy

2019 Client Intake Form (#2)

Complete only applicable fields. Please skip sections if we already have your info from prior tax filings.

*** New Clients—Please provide us a copy of your prior year tax returns and depreciation schedules. ***

FILING STATUS

Single

Married Filing Joint

Married Filing Single

Head of Household

Qualifying Widower

ADDRESS

Address Line 1

Address Line 2

City

State

Zip Code

TAXPAYER

First Name

Middle Name

Last Name

Social Security Number

Occupation

Mark if Legally Blind

Mark if Dependent of Another

Date of Birth

Date of Death

Work/Daytime Phone

Home/Evening Phone

SPOUSE

First Name

Middle Name

Last Name

Social Security Number

Occupation

Mark if Legally Blind

Mark if Dependent of Another

Date of Birth

Date of Death

Work/Daytime Phone

Home/Evening Phone

DEPENDENTS

First, Middle, Last Name

Date of Birth

Social Security Number

Relationship

EMPLOYMENT & RETIREMENT INFORMATION

A.) Are You Employed?

Yes

B.) Are You Unemployed?

Yes

C.) Are you contributing to a 401k, 403b or other pre-tax account?

Yes

D.) Have you ever opened any form of pretax account in the past?

Yes

E.) Have you considered a ROTH conversion of pretax accounts?

Yes

F.) Would you like a ROTH conversion tax "WHAT IF" prepared with your return?

Yes

STATE & OTHER

A.) Are you requesting state return(s)?

Yes

If yes, what State(s)?

B.) Are you requesting local, school, RITA or county return(s)?

Yes

Please specify

Tax Client Income and Expense Questions

Please Provide Us Your Form 1095(s) In Order to Complete The Health Insurance Mandate Tax Forms.
Please Let Us Know if You:

Had More Than $10,000 in a Foreign Bank Account at Any Point During 2018
Had Non-Cash Foreign Assets Exceeding $50,000 in Value at Any Point During 2018
Invested in Bitcoin or any other Cryptocurrencies in 2018 or prior years

The below checklist provides basic information. There very well could be more information needed to be supplied. For situations that are beyond the information provided below, please make sure detailed notes are provided to assist the preparer in determining the proper way to account for the situation. Missing information will delay the processing of the return.

BASIC QUESTIONS

Please check the box to the left for any of the following that apply. If not leave blank. If checked, please provide a brief explanation below if the information will assist the preparer in any way. (Note: Please check for you AND your spouse)

1. Did your marital status change from the prior year?

2. Did you change your address from last year?

3. Any change in your dependents from last year?

4. Did you have children under 19 (or 24 if a full time student) who had more than $2,100 in unearned income?

5. Are all your dependents either US Residents or Citizens?

6. Did you pay any adoption expenses?

7. Did you provide over half the support for someone you aren't claiming as a dependent?

8. Are you being claimed or eligible to be claimed as a dependent of someone else's return?

9. Were either you or your spouse in the military or National Guard?

10. Did you purchase or sell your primary residence? Or did you refinance your primary residence?

11. Have you been notified by the IRS of changes to a previously submitted tax return? Or have you received any other IRS or State Notices?

12. Did you make any gifts over $15,000 to any individuals?

Comments/Description:

INCOME

Please check any of the following that you and/or your spouse received.

1. W-2 Income

2. Interest and/or Dividends

3. Tax Exempt Interest and/or Dividends

4. Taxable refunds, credits or offsets? (including prior year State refunds)

5. Alimony

6. Business income (Self Employment Income). If "yes" please fill a Schedule C Worksheet and provide financials.

7. Stock Sales (Capital Gains)- (MAKE SURE ALL BASIS INFO IS PROVIDED).

8. Capital Loss Carryforward from prior year

Amount of Capital Loss Carryforward from prior year:

9. Any other Assets Sold or any other Gains or Losses

10. Rental Real Estate Income (If "yes" please fill out a Schedule E Worksheet)

11. Passive Activity Loss Carryforward from prior year

Amount of Passive Activity Loss Carryforward from prior year:

12. K-1's (1120S, 1065, 1041)

13. Unemployment

14. Social Security Income

15. Other Income

Please list Other Income:

16. Foreign Income

17. IRA or Pension Distributions

A.) Are any of these Rollovers? (Should not be taxed)

B.) Are any of these ROTH conversions? (taxable)

More info about these distributions:

ADJUSTMENTS TO INCOME

Please check any of the following that apply to you and/or your spouse:

1. Educator Expenses (Teaching Expenses)

2. Health Savings Account Deductions

3. Moving Expenses

4. Contributions to SEP, SIMPLE and other Qualified Plans

5. Self Employed Health Insurance

6. Alimony

7. IRA Contributions

8. Student Loan Information

9. Tuition and Fees Deduction (you or your dependents)

TAX AND CREDITS

For the following, please check any of the following that apply:

1. Itemized Deductions (* If "yes" please fill out Schedule A Worksheet)

2. Child and Dependent Care Expenses

3. First Time/Long Time Homebuyer

4. Energy Efficiency Related Upgrades/Repairs

5. Oil & Gas Investment credits

6. Other tax shelters or credits

ESTIMATED PAYMENTS (Please fill in if Estimates were made or refunds from a prior year were applied.)

$ Federal

Date

Quarter

E-FILE / FILING INFO - REFUND / PMT INFO

1. How do you want any refund sent to you? (Must choose one.)

Direct Deposit (takes a few days)

Applied to Next Year's Return

Paper Check in the Mail (could take several weeks)

2. Any taxes due will be paid by check along with Voucher provided by tax preparer. It is the taxpayer's responsibility to mail payments before tax due dates.

Special Information for the Tax Preparer

Is there something "unique" that the preparer should pay special attention to or know? If yes, please explain.

Tax Client Home Office Deduction Info

Fill out completely or mark "N/A". Do not leave blank.

Date home was first used for Business:

Square Footage of Area Used for Home Business

Total Square Footage of the Home

Deduction Expenses (Current Year)

Casualty Losses

Deductible Mortgage Interest

Real Estate Taxes

Insurance

Rent

Repairs and Maintenance

Utilities

Other (please specify type and amount):

Other #1: Type

Other #1: Amount

Other #2: Type

Other #2: Amount

Other #3: Type

Other #3: Amount

Other #4: Type

Other #4: Amount

Depreciation

Do you have depreciable assets?

Yes

If yes, please provide a detailed depreciation schedule below.

Asset #1 Date Aquired

Asset #1 Description of Item/Property

Asset #1 Cost Basis or Purchase Price

Asset #2 Date Aquired

Asset #2 Description of Item/Property

Asset #2 Cost Basis or Purchase Price

Asset #3 Date Aquired

Asset #3 Description of Item/Property

Asset #3 Cost Basis or Purchase Price

Asset #4 Date Aquired

Asset #4 Description of Item/Property

Asset #4 Cost Basis or Purchase Price

Additional Forms

If you are not required to submit a Schedule A, Schedule C, or Schedule E, you may skip this section and proceed to the Next.

Check here if you need to fill out a Schedule A

Schedule A

Fill out COMPLETELY or mark "N/A". DO NOT leave blank. Include any back-up documents.

Medical Expenses (Current Year)

Medical & Dental Expenses

Medical Insurance Premiums Paid (other than Social Security Medicare payments)

Long Term Care Premiums

Prescription Drugs and Medications

Medical Miles Driven

Tax Expenses - LIMITED TO $10,000 (Current Year)

State and Local Income Taxes Paid (other than those on W-2s, 1099s, etc.)

Last year Income Taxes Paid

Real Estate Taxes

Personal Property Taxes

Other Taxes (please specify)

Qualified New Vehicle Taxes

Additional State or Local/Taxes

Interest Expense (Current Year)

Home Mortgage Interest reported on Form 109

Home Mortgage Interest paid to others

Refinancing Points Paid in 2018

Investment Interest (other than K-1)

Contributions (Current Year)

Cash Contributions (note: Please provide a detailed list for donations over $500)

Non Cash Contributions (note: Please provide a detailed list for donations over $500)

Volunteer Mileage Driven

Casualty & Theft Losses

If you had any casualty or theft losses during the year, please provide detail below, including date, description, amount of casualty or loss, any insurance reimbursement & basis in the property.

Check here if you need to fill out a Schedule C

Schedule C

Fill out COMPLETELY or mark "N/A". DO NOT leave blank. Use a separate Worksheet for EACH Schedule C.
** Please Note: If possible, it is preferred a Trial Balance, P&L and Balance Sheet be provided by the client. They may be uploaded in the Client Portal.

Business Info (Required for all)

Business Owner

Taxpayer

Spouse

Address of Business

Address Line 1

Address Line 2

City

State

Zip Code

Country

Name of Business

EIN Number (if any)

For the Business Code box below, click here for a reference of available codes accepted by the IRS. Use the code that best describes your business.

Business Code

Accounting Method

Cash

Accrual

Other

(Please specify Other accounting method)

Date Business Started

Did you materially participate in the business?

Yes

General Questions (Required for all)

Are you claiming use of a home office? (If yes, please upload a Home Office Deduction Worksheet)

Yes

Do you have depreciable assets? (If yes, please upload a detailed depreciation schedule)

Yes

Vehicle Information

Year/Make/Model:

Date Placed in Service:

Total Miles Driven:

Business Miles:

Commuting Miles:

Self Insured Health Insurance Deduction?

Yes

If yes, how much did you pay?

Income Questions

Will you upload, or have you uploaded, your P&L or Income Statement in the Client Portal?

Yes

Total Sales

Other Income

Cost of Goods Sold (Required if no P&L or Trial Balance Available)

Beginning Inventory

Purchases

Cost of Labor

Materials and Supplies

Ending Inventory

General Expenses (Required if no P&L or Trial Balance Available)

Advertising

Auto Expenses (other than mileage)

Commissions

Contract Labor

Depletion

Depreciation (Need Sched)

Employee Benefit Programs

Insurance (Other than Health)

Interest

a.) Mortgage Interest

a.) Other Interest

Legal & Professional

Office Expense

Pension & Profit Sharing Plans

Rent or Lease

a.) Vehicles, Machinery

b.) Other

Repairs & Maintenance

Supplies

Taxes & Licenses

Travel

Meals (Total)

Utilities

Wages

Other (please specify)

Check here if you need to fill out a Schedule E

Schedule E

Fill out COMPLETELY or mark "N/A". DO NOT leave blank. If you have multiple properties, you will need to upload separate worksheets for EACH property in the Client Portal.

Property Owner

Taxpayer

Joint

Property Description

Address

Address Line 1

Address Line 2

City

State

Zip Code

General Questions:

Active Participant

Property was used for personal use by you or your family for more than 14 days (or 10% of the total rented days).

Enter the number of days for personal use:

Enter the number of days rented:

Do you have depreciable assets?

Yes

Income (current year):

Rents Received:

Royalties:

Property Expenses (current year):

Advertising

Cleaning/Maintenance

Commissions

Insurance

Legal and Other Professional

Management Fees

Qualified Mortgage Interest

Other Interest

Repairs

Supplies

Real Estate Taxes

Other Taxes

Utilities

Other (please specify)

Assets

Depreciation (please provide detailed schedule). New assets placed in service this year:

1. Description

1. Date Placed in Service

1. Purchase Amount

2. Description

2. Date Placed in Service

2. Purchase Amount

3. Description

3. Date Placed in Service

3. Purchase Amount

4. Description

4. Date Placed in Service

4. Purchase Amount

5. Description

5. Date Placed in Service

5. Purchase Amount

Two Forms of ID Required For ALL Returns

Taxpayer First Name

Last Name

Taxpayer Social Security Number

Photo ID #1 — Required

Choose File

One Other Form of ID — Required

Choose File

Spouse First Name

Last Name

Spouse Social Security Number

Photo ID #1 — Required

Choose File

One Other Form of ID — Required

Choose File

Upload image of voided check here if Direct Deposit wanted

Choose File

By my signature below, I hereby authorize the use of this identification above to electronically file my federal tax return according to IRS Publication 1345.

Taxpayer Signature

Sign Here

Date

Spouse Signature

Sign Here