Please Contact This Office at If You Have Any Questions. Additional Forms and References

Please contact this office at if you have any questions. Additional forms and references can be found on

Your Name SSN DOB

Spouse's Name SSN DOB

Dependent NameSSN DOB

Dependent Name SSN DOB

Please note: If there is a possibility that someone else may claim the same dependent that you are claiming above, please check to ensure you are able to declare this dependent on your tax return for this tax period.

Current Mailing Address:

(Street)

(City) (State)(ZIP)
Which County or City?

YES NO

Did your mailing address change from last year’s tax return? If so, please complete the following:

Prior Mailing Address:

(Street)

(City) (State)(ZIP)
Which County or City?

What specific date did the address change/did you move?

Contact Information:

Home Number: ()

Work Number: ()

Alternate Number: ()

E-Mail:

Your Occupation

Spouse's Occupation

Your proposed filing status this year

Is your proposed filing status different from last year?

Did you file your 2013 federal AND state income tax returns? If you answered “NO”, let this office know immediately to bring your account up to date before filing your 2014 tax returns (new clients only).

If any of the taxpayer(s) or dependent(s) on this form died in 2014, please enter the date of death:

Tax Payer/Dependent Name DOD

PLEASE CHECK "YES" OR "NO" FOR EACH QUESTION.

WHERE NECESSARY, ATTACH THE SUPPORTING INFORMATION IN AN ORGANIZED AND READABLE MANNER.

A1. Did you pay any estimated taxes in 2014 or 2015, for tax year 2014? If so, send any supporting documentation, and complete the information below.

ESTIMATED TAX PAYMENTS:

Please provide the following information for making estimated taxes:

Mailed Date Amount to IRSAmount to State

______First Quarter $______$______

______Second Quarter $______$______

______Third Quarter $______$______

______Fourth Quarter $______$______

______Additional $______$______

A2. Were you a full-year State resident in 2014? If not, please be prepared to review residency information from other states and your move date(s). If "NO", what other state(s) were you a resident in, and when did you move (date) ?

A3. Do you have any W2 information from employers? Please include all W-2s.

A4. Do you have any 1099 forms from other income sources? Please include all 1099s.

A5. Do you have any 1098 forms from all sources? Please include all 1098s.

A6. Do you have any tuition information, including interest on student loans? Please include all information.

A7. Do you have any bank & broker statements (interest, mortgages, dividends, gains/losses)? Please include all information.

A8. Do you have any home closing documents (if you recently bought a home)? Please include all information.

A9 Do you have any statements from a business you own, such as K-1 statements from a Partnership? Please include all information.

A10. Do you have any rental income information from property you rent out, and related info? Please include all information.

A11. Do you have any health insurance premiums paid last year (for you, your spouse, your dependents)? Please include all information.

A12. Do you have any medical expenses paid out last year (for you, your spouse, your dependents)? Please include all information.

A13. Do you have any information on any property or investments sold last year? Please include all information.

A14. Do you have any information on any investments sold last year? Please include all information.

A15. Do you have any information on contributions to retirement plans, such as 401K, IRAs, SEPs? Please include all information. Please indicate which type of plan(s) and dollar amounts you contributed to each retirement plan.

For you______(name):



For your spouse______(name):



A16. Do you have any long term care information on spouse and dependents? Please include all information.

A17. Do you have any miles driven for medical related items? Please identify total miles: miles.

A18. Do you have any Charitable contributions (cash and property)? Please include all information. PLEASE NOTE THAT ANY CASH CONTRIBUTIONS TO A QUALIFYING CHARITY SHOULD BE EVIDENCED BY A FORMAL RECEIPT FROM THAT ORGANIZATION. THIS IS A NEW TAX LAW.

A19. Do you have any miles driven for charity? Please identify total miles:

miles.

A20. Did you receive a state tax refund from any State last year? Please include the 1099-G form or provide information on this refunded tax amount.

A21. Do you have any personal property taxes paid on vehicles and other property? Please include all information.

A22. Do you have any disability taxes paid? Please include all information.

A23. Do you have any other state/local taxes paid? Please include all information.

A24. Do you have any Un-reimbursed expenses from employer? (i.e. mileage, safety equipment). Please include all information.

A25. Do you have any job search expenses? Please include all information.

A26. Do you have any uniforms/work related expenses? Please include all information.

A27. Do you have any professional/union dues and subscriptions? Please include all information.

A28. Do you have any educational expenses (Tuition, Books, Interest Paid, etc.)? Please include all information.

A29. Do you have any accounting/legal fees? Please include all information.

A30. Do you have any tax preparation charges? Please include all information.

A31. Do you have any safe deposit box fees? Please include all information.

A32. Do you have any investment expenses? Please include all information.

A33. Do you have any gambling losses? Please include all information.

A34. Do you have any IRA contribution amounts? Please include all information.

A35. Do you have any moving expenses? Please include all information. Also, please identify from where you moved from and when:

A36. Do you have any alimony paid or received? Please include all information.

A37. Do you have any child care expenses (Be sure to bring Daycare FEIN number)? Please include all information.

A38. Do you have any "Casualty Theft" or "Losses"? Please include all information.

A39. Do you have any income from a retirement plan? Please include all information.

A40. Do you have any income from unemployment services? Please include all information. Attach Form 1099-G.

A41. Do you have any royalty income? Please include all information.

A42. Do you have any other income, (gambling, lottery,prizes, jury duty, etc.? Please include all information.

A43. Do you have any income from property sold? Please include all information.

A44. Did your marital status change last year? Please include all information.

A45. Did the number of dependents change last year? Please include all information.

A46. Did you invest in any tax-exempt securities last year? Please include all information.

A47. Did you begin a new employment last year? Please include all information.

A48. Did you begin a new business last year? Please include all information.

A49. Did you close or sell a business last year? Please include all information.

A50. Did you or a dependent reach age 65 last year? Please include all information.

A51. Did you or a dependent reach age 59 1/2 last year? Please include all information.

A52. Did you sell your primary residence last year? Please include all information.

A53. Did you prematurely withdraw funds from a retirement plan? Please include all information.

A54. Did you adopt a child last year? Please include all information.

A55. Did you, your spouse, or a dependent become disabled last year? Please include all information.

A56. Did you refinance any mortgages last year? Please include all information.

A57. Can you be claimed as a dependent on someone else's return for2014? Please include all information.

A58. Were any of your dependents full time college student(s) in 2014? Please include all information.

A59. Have you contributed to a Virginia 529 Education plan? Please include all information.

A60. Have you received any basic military pay? Please include all information.

A61. Have you replaced any windows/doors in your home in2014? Please include all information.

A62. Have you replaced or installed any skylights in your home? Please include all information.

A63. Have you replaced your furnace, central air unit, or water heater in 2014? Please include all information.



A64. Have you purchased a hybrid or "lean-burning" fuel car in 2014? Please include all information.

A65. Have you participated in any “Like-Kind” Section 1031 Exchanges? Please include all information.

A66. Have you participated in a Health Savings Account (HAS) in 2014?

A67. If you answered “YES” to the above question, is your HSA plan an individual plan or a family plan?

A68. (BLANK)

A69. Did you make qualifying energy-efficient improvements to your primary home? If yes, please attach supporting documentation reflecting amounts paid and services/items paid.

A70. If you end up receiving a state or federal refund, would you like the refund directly deposited to your checking or savings account? If so, please provide your bank account number and bank routing number, and select your account type (checking or savings).

Bank Account Number Bank Routing Number

(9 digits)

The Internal Revenue Code and regulations impose preparation and disclosure standards with non-compliance penalties on both the preparer of a tax return and on the taxpayer. These standards differ. Unless The Firm has a reasonable belief that any tax position in The Client’s return will more-likely-than-not be sustained on its merits, a preparer penalty will be imposed on The Firm unless that position has a reasonable basis and is adequately disclosed in the return. And, while This Firm might be able to avoid a preparer penalty by adequately disclosing the return position, The Client might not have to disclose the position in order to avoid applicable taxpayer penalties. If The Firm determines that The Firm would be subject to a preparer penalty by delivering your return to you, you agree to either adequately disclose that position on your return or change the position to one that would not subject this Firm to penalty. If you do not choose to change your position or adequately disclose that position, The Firm, in its sole discretion and at any time, may withdraw from the engagement without completing or delivering tax returns to you. To the best of my knowledge, all information contained within this document is true, correct and complete.

Conflict of Interest and Waiver of Confidentiality: In preparing a tax return for a business entity with more than one owner, or an individual return for a married couple, it must be recognized that the interests of each party may be in conflict. For instance, each party may become separated or divorced, ora business partnership may terminate during or after the period of this engagement. In order for The Firm to proceed with this engagement, this Firm must have the written consent and acknowledgement of each party. This consent is important because this Firm intends to approach this engagement in an objective way without intending to favor any one party. This Firm cannot and will not receive any confidential information from either party; that is, any information received into this office will be made known to each party. By each signature on this engagement letter, each party consents to this waiver of confidentiality between each party.

Taxpayer’s Signature:Date

Spouse’s SignatureDate

Client Last Name______SSN______EIN#______

For clients only. Please do not duplicate.