2019 Client Questionnaire : Michael P. Rudy CPA & Associates

Full Name

Date Of Birth

Email Address

Phone

Township

School District

2019 Tax Return Questionnaire

Please answer each question below. If your answer requires supporting documents, please bring all applicable documentation/tax forms to your tax appointment. You may also choose to scan and submit supporting documents electronically using our Client Document Submission tool (see link on home page).

Select Recipient*

Select an account representative to receive your documents. If you are unsure who to send your documents to, select General.

PERSONAL INFORMATION

Did your address change during the year?

YES
NO

Date Moved

Please enter the date you moved.

New Township

New Address

Street Address Address Line 2 City State ZIP Code

Did you get married, legally separated or divorced during the year?*

YES
NO

Marital Status Change*

Got Married
Got Legally Separated
Got Divorced

Did you pay or receive alimony in 2019?*

YES
NO

Date of Divorce Separation Agreement*

If you paid or received alimony, what was the Date of the Divorce Separation agreement?

Does your spouse (if married) have separate debt, liabilities or taxes owed that you would prefer to file separately?

YES
NO

Could you be claimed as a dependent on another person's tax return for 2019?

YES
NO

Were there any changes in dependents?

YES
NO

Did you have any children under age 19 or full-time students under age 24 at the end of 2019, with unearned income in excess of $2200?

Unearned income is any income other than from wages or self-employment income.

YES
NO

INCOME

At anytime during 2019 did you receive, sell, send, exchange or have a financial investment in any virtual currency (bitcom or other)?

YES
NO

Did you start a business, farm, purchase a rental property, or acquire an interest in a business?

If so, please bring all documents applicable to the formation of this business (IRS EIN, PA formation approval letters, etc.)

YES
NO

Did you sell any stocks, bonds, business assets, or investment property during the year? Bring your annual brokerage statement and annual 1099-B.

Check that basis was provided for all security sales (call your broker for any missing info). If you have a brokerage account, please contact your advisor and ask if a corrected statement is forth coming. This would avoid having to file an amended return where additional tax preparation fees would be incurred.

YES
NO

Did you receive distributions from any retirement type plan? Any retirement rollovers or Roth conversions during 2019?

YES
NO

Did you receive any prizes, awards, jury duty, lottery/gambling winnings, unemployment, disability, gifts, or any miscellaneous income? Please notate all that apply

Did you have any foreign income or pay any foreign taxes?

Note: After 1/1/15, PA no longer allows a foreign tax credit.

YES
NO

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?

YES
NO

Did you have any debts cancelled, debts forgiven, have any property foreclosed, seized or taken over during 2019?

YES
NO

Did you have a dedicated home office?

If so, we need the total house square footage, the office square footage, and a 2019 utility summary

YES
NO

Did you purchase or sell your principal residence in 2019? If yes, bring in the "HUD-1" settlement sheet(s). If a 1st time homeowner, did you pull IRA money to buy house? (Note: 401k money does not qualify)

YES
NO

Are you are over age 59 ½ and receiving distributions from your IRA accounts? (If so please complete the following)

YES
NO

What was the combined total dollar value of all traditional IRA accounts for you on December 31, 2019?

What was the combined total dollar value of all traditional IRA accounts for your spouse on December 31, 2019?

Did your children receive any savings bonds in 2019?

YES
NO

If yes, what interest was accrued/earned in 2019?

ADJUSTMENTS TO INCOME

Teachers Only (K-12, non-athletic) Did you have any out of pocket expenses for teaching supplies, books, etc?

YES
NO

Did you make a contribution or take a distribution from an HSA or MSA account during 2019?

YES
NO

If you took a distribution, were all the funds used for qualified medical expenses

YES
NO

Did you pay any alimony?

If so, we need the amount paid, complete name and SSN of the recipient.

YES
NO

Amount Paid*

If you paid alimony, enter that amount here.

Name of Recipient*

If you paid alimony, enter the full name of the recipient here.

SSN of Recipient

If you paid alimony, enter the Social Security Number of the recipient here.

Have you already or do you plan to make a contribution to your IRA, SEP or SIMPLE plan?

YES
NO

ITEMIZED DEDUCTIONS

(Note: Investment advisor fees are no longer deductible)

Did you refinance any mortgage or loan in 2019?

If so, bring in all refinance settlement sheet(s). New primary residence loans are limited to $750,000 (pre-existing loans are grand-fathered to $1,000,000).

YES
NO

Do you have a home equity loan or line of credit?

YES
NO

Were the loan proceeds used 100% to buy, maintain or improve your primary residence?

YES
NO

Did you donate any non-cash items (clothing, furniture, household goods)?

YES
NO

If so, please provide receipts and enter a summary of value here:

Did you have any casualties (fire, flood, theft, damage, etc) during the year or anything in a Federally declared disaster area?

YES
NO

If so, please note the amount of insurance reimbursement & your costs not covered by insurance for discussion with us.

Small Businesses and Employees, for State and Local Tax Purposes

Did you use your car on the job (not commuting to/from work)?. IRS and PA requires a log (existing or you need to create one).

YES
NO

Did you get any reimbursements?

YES
NO

Was that reimbursement included in your W-2?

YES
NO

Did you pay for any job related expenses, including those to work out of town for part of the yr? (temporary job site).

YES
NO

Did you get any other reimbursements?

YES
NO

Was that reimbursement included in your W-2?

YES
NO

Credits

Did you make any energy efficient improvements to your primary residence or purchase solar, wind, geothermal or fuel cell energy source?

(NOT windows, siding, normal HVAC systems or insulation.)

YES
NO

Summarize ALL costs paid for energy efficient improvements to your primary residence in the current year.

(NOT windows, siding, normal HVAC systems or insulation.)

Did you, your spouse or dependent have tuition expenses in 2019 (even if the classes were not attended until Jan-March 2020)?

If yes, a copy of the 1098-T is required. You may scan and submit electronically using our Client Document Submission tool (see link on home page).

YES
NO

Did you receive a distribution from an Educational Savings Account or Qualified Tuition Program?

YES
NO

If you fully closed out a QTP, did you incur a loss (distributions were less than contributions)?

YES
NO

Did you pay child/dependent expenses so you/your spouse could work/look for work during 2019?

YES
NO

If so, did you take part in the Section 125 pre-tax dependent care benefit program (W-2 box 10)?

YES
NO

Did you pay any adoption expenses in 2019?

YES
NO

HEALTHCARE

Did you or your spouse and all dependents have health insurance through the marketplace?

If purchased through the marketplace, bring form 1095-A for each health insurance plan (should be maximum of 2 if you & your spouse were covered under separate healthcare.gov plans). If you did not receive one or both 1095-A Forms, call your health insurance provider for them to send you a copy. We cannot prepare your return without this form if you received your health insurance through the marketplace.

YES
NO

Did you pay for your own health insurance or long-term care insurance for 2019?

YES
NO

If so, please provide the amount for each (insurance only, not co-pays or deductibles and do not include insurance taken out of your pay “before tax”).

Did you have total out of pocket medical expenses (including your after-tax insurance payments) that exceeded 7.5% of your income?

YES
NO

General

Did you make a contribution to anyone’s State 529 plan during 2019? (Deductible for PA purposes)

If so, please bring their social security number and amount contributed to each 529 plan for the year.

YES
NO

If so, we need their social security number and amount contributed to each 529 plan for the year.

(Indicate each person and amount on a separate line)

Did you or your spouse make any gifts to an individual that total more than $15,000, or any gifts to a trust?

YES
NO

Did you engage the services of any household employees?

YES
NO

Did you have an interest in or signature authority over a financial account in a foreign country, such as a bank account, securities account, or other financial account?

YES
NO

What was the aggregate value?

Did you receive any notice (from IRS, State or Local) regarding a prior year tax return? If yes, please bring in the notice(s).

You may scan and submit electronically using our Client Document Submission tool (see link on home page).

YES
NO

May the IRS discuss your tax return with your preparer?

YES
NO

Did you make any IRS, State or Local estimated tax payments (not taxes withheld)?

YES
NO

If yes, please bring in the date & amount of each payment to all authorities.

Do you want your refund, if applicable, to be refunded or applied to next year?

Refunded
Applied to next year.

If refunded, do you want to directly deposit the funds into your checking or savings account?

YES
NO

If payment owed, do you want to pay electronically from checking or savings?

YES
NO

Account Type

Checking
Savings

Bank Name

Routing Number

Account Number

Do you expect your 2020 taxable income and withholdings to be different from 2019?

I expect higher
I expect lower
I expect about the same

2019 Client Questionnaire