Personal Information Did your marital status change during the year? Yes No Did your address change during the year? Yes No Could you be claimed as a dependent on another person's tax return for 2022? Yes No Dependents Were there any changes in dependents? Yes No 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 2022? Yes No Did you have any children under age 19 or full-time students under age 24 at the end of 2022, with interest and dividend income in excess of $1,150, or total investment income in excess of $2,300? Yes No Health Care Coverage Did you receive IRS document Form 1095-A (Health Insurance Marketplace Statement), If so, we'll ask for a copy from you. Yes No Did you, spouse and dependents have qualifying health coverage for every month in 2022? Yes No Income Did you receive unreported tip income of $20 or more in any month? Yes No Did you cash any Series EE US savings bonds issued after 1989 and pay qualified higher education expenses for yourself, your spouse, or your dependents? Yes No Did you receive any disability income? Yes No Did you have any foreign income or pay any foreign taxes? Yes No Purchases, sales, and debt 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 Did you purchase or dispose of any business assets (furniture, equipment, vehicles, real estate, etc.), or convert any personal assets to business use? Yes No Did you buy or sell any stocks, bonds or other investment property in 2022? Yes No Did you sell or do you plan to sell any dividend generating stocks or mutual funds during the first 60 days of 2023? Yes No Did you purchase, sell, or refinance your principal home or second home, or did you take a home equity loan? Yes No Did you purchase a home in 2022 and you were overseas on official extended duty? Yes No Did you make any residential energy-efficient improvements or purchases involving solar, wind, geothermal or fuel cell energy sources? Yes No Did you have any debts canceled or forgiven? Yes No Does anyone owe you money which has become uncollectible? Yes No Retirement Plans Did you receive a distribution from a retirement plan (401(k), IRA, SEP, SIMPLE, Qualified Plan, etc)? Yes No Did you make a contribution to a retirement plan (401(k), IRA, SEP, SIMPLE, Qualified Plan, etc)? Yes No Did you transfer or rollover any amount from one retirement plan to another retirement plan? Yes No Did you convert part or all of your traditional, SEP, or SIMPLE IRA to a Roth IRA in 2022? Yes No Education 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 Itemized Deductions Did you incur a loss because of damaged or stolen property? Yes No Did you work out of town for part of the year? Yes No Did you use your car on the job (other than to and from work)? Yes No Estimated Taxes Did you apply an overpayment of 2021 taxes to your 2022 estimated tax (instead of being refunded)? Yes No If you have an overpayment of 2022 taxes, do you want the excess applied to your 2023 estimated tax (instead of being refunded)? Yes No Do you expect your 2023 taxable income and withholdings to be different from 2022? Yes No Did you make any estimated tax payments for the 2022 tax year? Yes No Miscellaneous Do you want to electronically file your tax return? Yes No 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 May the IRS discuss your tax return with your preparer? Yes No 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? Yes No Did you receive a distribution from, or were you the grantor of, or transferor to, a foreign trust or did you have an interest in any foreign assets or accounts? Yes No Was your home rented out or used for business? Yes No Did you have a medical savings account (MSA), a Medicare + Choice MSA, or acquire an interest in an MSA or a Medicare + Choice MSA because of the death of the account holder? Or, were you a policyholder who received payments under a long-term care (LTC) insurance contract or received any accelerated death benefits from a life insurance policy? Yes No Are you a member of the Armed Forces of the United States on active duty who moved pursuant to a military order related to a permanent change of station? Yes No Did you engage the services of any household employees? Yes No Did you or your spouse make any contribution to a 529 Plan in 2022? Yes No 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 $16,000, or any gifts to a trust? Yes No Did your bank account information change within the last twelve months? Yes No At any time during the tax year, did you: receive or sell, exchange, gift, or otherwise dispose of a digital asset (or a financial interest in a digital asset)? Yes No Name First Name Last Name Email Address Address 1 Address 2 City State/Province Zip/Postal Code Country Thank you!
