This tax questionnaire will assist us in understanding changes that may impact your 2021 tax returns. Please answer the various questions below. Certain “yes” answers may flag our staff to make additional inquires. Your tax documents can be provided to us separately by uploading to your online vault.

Name of person completing this form. Note only one person needs to complete this form (if married filing joint) *

First Name Last Name

Spouse/Partner Name, if applicable

First Name Last Name

Did your address change during the year? *

Yes No

New Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Did your telephone number change during the year? *

Yes No

Home Phone Number

Area Code Phone Number

Cell Phone Number

Area Code Phone Number

Work Phone Number

Area Code Phone Number

Did your marital status change in 2021? *

Yes No

If so, please describe the change. *

I got married I got divorced My spouse passed away

Could you be claimed as a dependent on another person's tax return for 2021? *

Yes No Unsure

Were there any changes in your dependents? *

Yes No

If yes, please provide us additional details. *

Were any of your unmarried children who might be claimed as dependents 19 years of age or older (or 24 years or older if student) at the end of 2021? *

Yes No

Did you have any children under age 19 (or full-time students under age 24) at the end of 2021, with interest and dividend income in excess of $1,100, or total investment income in excess of $2,200? *

Yes No

Did you receive an Advanced Child Tax Credit (check or direct deposit) in 2021? *

Yes No

Upload IRS Letter 6419 to SmartVault and confirm the total amount of Advanced Child Tax Credit received in 2021: *

(IRS Letters were mailed out by the IRS in January 2022)

Did you receive an Economic Impact Payment (check or direct deposit) in 2021? *

Yes No

Complete the following table for all Economic Impact Payments received. If you received EIP via direct deposit, check your bank for deposits from "IRS TREAS". Additionally, if you have received an IRS Letter 6475, please upload a copy to SmartVault. *

Did you receive any pandemic unemployment benefits in 2021? *

Yes No

Please upload the following to SmartVault: *

Did you take a COVID related retirement distribution? *

Yes No

Please upload the following to SmartVault: *

Do you have a Sole Proprietorship or Single Member LLC business? *

Yes No

Did you take a Paycheck Protection Program (PPP) Loan for your Sole Proprietorship or Single Member LLC business? *

Yes No

Please fill in the table regarding PPP Loans for your Sole Prop or SMLLC business. *

	When did you obtain the loan?	Amount of Loan	Date Forgiven (if forgiven)
PPP 1
PPP 2

Provide any additional information related to COVID stimulus received in 2021:

Did you and your dependents have health insurance coverage for the full year or partial year? *

Full year Partial year No coverage

How did you obtain health insurance? *

Employer sponsored plan Covered CA or through my State's plan Individual plan Other

Did you receive any of the following IRS documents? Form 1095-A (Health Insurance Marketplace Statement), 1095-B (Health Coverage) or Form 1095-C (Employer Provided Health Insurance Offer and Coverage). *

Yes No

Do you fall into one of the following exemptions categories: Indian tribe membership, health care sharing ministry membership, religious sect membership, incarceration, general hardship or unable to renew existing coverage? If you received an exemption certificate, please send it to us. *

Yes No N/A

Is your health coverage under a High Deductible Health Plan (HDHP) with an option for a Health Savings Account (HSA)? *

Yes No N/A I don't know

Did you make an HSA distribution? *

Yes No

Please provide the following:

Was the entire amount used for medical expenses? *

Yes No

Provide more detail on the HSA distribution: *

Did you make a contribution to your HSA? *

Yes No

How much have you contributed to your HSA account (outside of employer contributions) to date? *

2021 HSA Contribution to date

Would you like to make additional HSA contributions to max out your account by 4/15/2022? *

Yes No N/A Unsure

Did you or your spouse/partner change employers during the year? *

Yes No

If yes, please describe the change. *

Did you receive unreported tip income of $20 or more in any month? *

Yes No

Did you receive any disability income? *

Yes No

If yes, please describe the type of disability income you received. *

Did you have any foreign income or pay any foreign taxes that is not recorded in a Form 1099? *

Yes No

Describe the foreign income you earned or the foreign taxes you paid. *

Regarding virtual currency, did you do any of the following (check all that apply): *

Received Virtual Currency Sold Virtual Currency Exchanged Virtual Currency N/A; no financial interest in virtual currency

For any virtual currency that was sold in 2021, provide the following: *

Provide any additional information about your virtual currency that may be relevant for tax preparation:

Did you start a business or farm, purchase rental or royalty property, or acquire an interest in a partnership, S corporation, trust, or REMIC? *

Yes No

Provide a brief description: *

Did you buy or sell any stocks, bonds or other investment property in 2021? *

Yes No

Provide a brief description: *

Did you buy or sell real estate (principal residence, second home or investment property)? *

Yes No

Provide a brief description of the real estate sold or bought: *

Provide the following document(s): *

Did you install solar panels on your home? *

Yes No

Provide the following: *

Did you buy an electric vehicle? *

Yes No

Provide the following: *

Did you install an electric vehicle charger for your home? *

Yes No

Provide the following: *

Did you have any debts cancelled or forgiven? *

Yes No

Provide a brief description: *

Did you receive a distribution from a retirement plan (401(k), IRA, SEP, SIMPLE, Qualified Plan, etc.)? *

Yes No

Provide the following: *

Did you make a contribution to a retirement plan (401(k), IRA, SEP, SIMPLE, Qualified Plan, etc.)? *

Yes No

If so, which type of plan? *

My company's 401(k), 403(b) or 457 plan An Individual Retirement Plan (IRA) A SEP A SIMPLE Qualified Plan I'm not certain which type of plan it is

Did you transfer or rollover any amount from one retirement plan to another retirement plan? *

Yes No

Provide a brief description: *

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

Yes No

Did you, your spouse, or a dependent incur any tuition expenses that are required to attend a college, university, or vocational school? *

Yes No

Did you, your spouse/partner, or a dependent incur significant medical expenses in 2021 (expenses totaling over 7.5% of your adjusted gross income)? *

Yes No

If you have a mortgage, is your mortgage balance over $1 million? *

Yes No N/A

What is the principal balance of the mortgage as of December 31st? *

Did you take out a Home Equity Line of Credit (HELOC), Home Equity Loan, or Cash Out Refinance? *

Yes No Unsure

Provide the following:

If you have an overpayment of 2021 taxes, which refund method do you prefer? *

Apply the refund(s) to my 2022 estimated tax Direct deposit into my checking or savings account Paper check

Has your bank account on file for direct deposit changed? *

Yes No

Provide the following: *

If you have a balance due, which method of payment do you prefer? *

Send a check(s) Direct debit from my checking or savings account Online payment through the IRS or State Franchise Tax Board websites

Has your bank account on file for direct debit changed? *

Yes No

Provide the following: *

Do you expect your 2022 taxable income and withholdings to be different from 2021? *

Yes No

Provide a brief description: *

Do you want to allocate $3 to the Presidential Election Campaign Fund? *

Yes No

Does your spouse want to allocate $3 to the Presidential Election Campaign Fund? *

Yes No N/A

May the IRS discuss your tax return with your preparer? *

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 that had a balance of over $10,000 at any time during 2021? *

Yes No

Upload to SmartVault a document that contains the following information regarding your financial account: *

Are you a partner or shareholder in an S-Corp and/or LLC? *

Yes No

Did your S-Corp and/or LLC make a Pass-through Entity (PTE) Elective Tax? *

Yes No Unsure

Provide the amount of Pass-through Entity (PTE) Elective Tax? *

Are you a shareholder in a foreign corporation or a partner in a foreign partnership? *

Yes No

Provide a brief description: *

Did you receive a distribution from, or were you the grantor of, or transferor to, a foreign trust? *

Yes No

Did you engage the services of any household employees? *

Yes No

Provide a brief description regarding services of household employees: *

Were you notified or audited by either the Internal Revenue Service or the State taxing agency? *

Yes No

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

Upload to SmartVault a document that contains the following information regarding the gift: *

Did you make any out of state purchases of tangible personal property in which you did NOT pay sales tax and may owe use tax? *

Yes No

If so, please provide us with the total amount of purchases made. *

Please feel free to provide us any additional information you feel would be helpful in understanding your 2021 tax situation.

2021 Tax Questionnaire

PERSONAL INFORMATION

DEPENDENTS

COVID Stimulus

HEALTH CARE COVERAGE

INCOME

PURCHASES, SALES AND DEBT

RETIREMENT PLANS

EDUCATION

ITEMIZED DEDUCTIONS

ESTIMATED TAXES

MISCELLANEOUS