Pater Van Den Elsenstraat 6

Client Questionnaire

(please answer all questions)

Pater van den Elsenstraat 6

5056 ES Berkel-Enschot

Tel. 013-5400255 or 06-45746705

Fax. 013-5400256

Email:

Websites:

1. Personal details

Your information

Name…………………………………………………..

Address …………………………………………………..

Postal code + City …………………………………………………..

Country…………………………………………………..

Telephone private …………………………………………………..

Telephone work…………………………………………………..

Telephone mobile…………………………………………………..

Email address(es)…………………………………………………..

Sofinumber …………………………………………………..

Date of birth………………………………………….... M / F

Your nationality…………………………………………………..

Bank account (for tax refund)…………………………………………………..

Addresses of residence in 2001From …. - …. 2001 until …. - …. 2001

…………………………………………………..

From …. - …. 2001 until …. - …. 2001

…………………………………………………..

Do you have the 30% ruling?Yes / No

What was your marital status in 2001?Married / living together / divorced

Did your marital status change in 2001?Yes / No ……………………………………

Information from your spouse/partner

Name …………………………………………………..

Sofinumber …………………………………………………..

Date of birth………………………………………….... M / F

Bank account for tax refund…………………………………………………..

Did your spouse/partner live in NL in 2001?Yes / No ……………………………………

Did he/she receive any income in 2001?Yes / No

Children

Do you have children living at home? Yes / No

Their initials and their date of birth…………………………………………………..

…………………………………………………..

2. Tax return

Did you receive a tax form?Yes / No

If yes, what is the deadline?…………………………………………………..

Did you file a tax form for 2000?Yes / No

If so, please send us a copy of it.

Salary and other income

Did you or your partner receive a salary ?Yes / No

If so, please send us the year statement(s) from the salary

Did you or your partner receive a social

security payment from the government?Yes / No

If so, please send us the year statement(s) from the social security payments from the government like GAK, GUO, Sociale Verzekeringsbank etc. The child allowance is tax free.

Do you have a company car? Yes / No

If so, please state:

- name, type and year;…………………………………………………..

- the list-price of the car when new;…………………………………………………..

- the period you had the car(s);From …. - …. 2001 until …. - …. 2001

…………………………………………………..

From …. - …. 2001 until …. - …. 2001

…………………………………………………..

From …. - …. 2001 until …. - …. 2001

…………………………………………………..

- the total amount of private kilometres …………………………………………………..

you drove if it’s less than 7.000 (only if

you made a registration);

- did you pay your employer for private Yes / No ……………………………………

use of the car and how much?

Did you regular travel by public transport Yes / No

to your work?

If yes, please state: …………………………………………………..

- the distance declared on the public …………………………………………………..

transport statement or the travel statement

from your employer

- how many days per week you travelled …………………………………………………..

with public transport to your work.

- the travel allowance/reimbursement you …………………………………………………..

received from your employer (most times if

you receive an allowance you can’t deduct

any costs).

Did you regularly travel by bike to your Yes / No

work over a distance of at least 10 km?

If so, do you have a so called Yes / No

‘fietsverklaring’ (bike statement)?

Do you receive other non-job related Yes / No

income next to your regular job?

If so, a summary of:

the income;
the costs.

Did you receive interest from your bank Yes / No ……………………………………

regarding the year 2000? (only if you

don’t have the 30% ruling)

Did you receive regular payments from Yes / No

your ex-husband or –wife?

If so, how much and from who?…………………………………………………..

Property

Do you own a house?Yes / No

If so,

- the WOZ statement you received from …………………………………………………..

the local government with the value of the

house (for 2001 – 2004)

- the interest you paid on the mortgage …………………………………………………..

(not the redemptions);

- the amount of the mortgage debt on …………………………………………………..

31th December 2001

If you bought/sold a house in 2001:

- the statement of account from the notary;

- the valuer’s fee for getting the mortgage;

- a copy of the policy of the mortgage.

When did you move to your new house? …………………………………………………..

Do you rent property to other people? Yes / No

(only if you don’t have the 30% ruling)

If yes,

- what’s the value of the property?…………………………………………………..

- did you make any debts for the property?…………………………………………………..

Other possessions and debts (only if you don’t have the 30% ruling)

The value of your bank savings …………………………………………………..

(on 1 January and 31 December) …………………………………………………..

…………………………………………………..

A summary of your share holdings etc. ………………………………………………….

(on 1 January and 31 December)…………………………………………………..

…………………………………………………..

A summary of other debts …………………………………………………..

(on 1 January and 31 December) …………………………………………………..

…………………………………………………..

Tax deductions

Did you have costs for study for yourself Yes / No

or your partner? …………………………………………………..

Have you made payments to an Yes / No

ex-husband or wife? …………………………………………………..

Have you made payments for your pension Yes / No

(‘lijfrente’) which are not already mentioned …………………………………………………..

on your salary slip (premiums you pay …………………………………………………..

yourself to an insurance company)? …………………………………………………..

Have you made gifts/donations? Yes / No ……………………………………

Did you have costs for professional Yes / No

childcare? …………………………………………………..

Do you have any questions?…………………………………………………..

…………………………………………………..

3. Insurance, mortgage and investments

As an insurance broker we also offer all kind of insurances and mortgages. We would like to give you quotations and advice on your insurances. If you agree with that please read the questions below. We will contact you about it.

By the way: we offer free tax advice when we can help you with your insurances, mortgage or investments. For the conditions see our website.