Thompson Flaherty

Thompson Flaherty




The purpose for this questionnaire is to gather information needed in preparing an accurate income tax return, which may avoid lost deductions, IRS audits, interest, and penalties. We are updating our database. Please provide us with contact information.

Please provide the following items:

Copies of all W-2’s, 1098, 1099, 1095-A, 1095-B or 1095-C Copy of prior year’s tax returns (2012,2013,2014)

Forms and the amount of other income received by you and your spouse. (New clients only).

Copies of all K-1 Forms received by you or your spouse Email address:______

from any Partnerships, S-Corporations, Trusts or Estates I would like to receive the Thompson Flaherty monthly newsletter

Please complete all Blocked information due to IRS Revenue Procedure Changes

First Name: / M.I. / Last Name: / SS#
Spouse’s First Name: / M.I. / Last Name (if different) / SS#
Address: / City: / State: / Zip:
Telephone No. Daytime: / Evening: / Cell:
Your Date of Birth: (mm/dd/yy) / Spouse’s Date of Birth: (mm/dd/yy)
Check if legally blind: Taxpayer
Spouse / Check if Permanently Disabled Taxpayer
As of December 31st were you: Single Legally married Separated Divorced Same sex Civil Union
Qualifying Widow(er) Head of Household
Can your parents or someone else claim you or your spouse as a dependent on their tax return? Yes No
Your Occupation: / Spouse’s Occupation:

Family and Dependent Information

List dependents who lived in your home and anyone living outside your home that you or your spouse supported during the tax year. For example: son, daughter, step child, foster child, adopted child, brother, sister, stepbrother, stepsister, or a descendant of any of them, also mother or father.

First Name Last Name SS# / Date
mm/dd/yy / Relationship
to you / Lived with you more than 6 months? / Did dependent file a joint tax return? / Is child
a full time
student or
and totally
disabled? / Did you provide more than
50% of their support? / Did the person have gross income over $4000?

Special Rules for parents who are divorced or legally separated or lived apart at all times during the last 6 months of the year. If the child lived in your home for less than half of the calendar year:

  • Did one or both parents provide over half of the child’s total support? Yes No
  • Is the child in custody of one or both parents for more than half the year? Yes No
  • Did the custodial parent sign Form 8332 or similar statement releasing the exemption? Yes No

If yes, please provide Form 8332 – or copy of divorce decree for non-custodial parent claiming child.

During the tax year did you, your spouse, or anyone in your household:

Receive any investment income? Yes No Were you a resident of, or did you earn income in Yes No

(For example: interest or dividends?) more than one state in 2015?

Receive a distribution from an IRA or Yes No Receive any gambling winnings? If yes, please Yes No

retirement plan? Separate your gambling winnings and losses by

each day of gambling activity.

Receive Social Security or Yes No Purchase/sell your principal home or second Yes No

Disability Income or Benefits? Home in 2015?

If yes, provide a copy of closing statements.

Receive unemployment compensation? Yes No

Did you claim the First-Time Homebuyer Credit Yes No

Receive any income which is exempt from Yes No on a prior year tax return? federal taxes? (ie., municipal bond interest)

Did you pay any interest on the purchase of a boat Yes No

Did you have any debts cancelled or RV/Camper that has living quarters?

Or forgiven?Yes No

Did you pay mortgage insurance premiums in Yes No Do you or your spouse wish to have $3.00 Yes No 2015 on a home purchased after 12/31/06?

of your taxes applied to the Presidential

Campaign Fund and/or contribute to any Refinance your principal and/or second home Yes No

Illinois Nonprofit organization? or take a home equity loan in 2015?

Were all home equity proceeds used for Yes No

refinancing or improving that property?

Pay over $250 in private education Yes No

expenses at an Illinois (K-12) or homeActively participate in the operations of any Yes No

school program?partnerships or S corporations for which you are

reporting an income or loss on your 2015 tax return?

Are you an elementary or high school Yes No S-Corporation Shareholders; provide copy of

teacher, aide, principal, or counselor? last paycheck stub for 2015.

If yes, please indicate the amount of

unreimbursed classroom expenses

you paid in 2015. $______Actively participate in the operations of any rental Yes No

activity for which you are reporting an income or

loss on your 2015 return?

Receive or pay alimony this year? Yes No

Have any foreign income, foreign financial assets, Yes No

Receive a refund from a state tax return Yes Nointerest in foreign companies or held foreign bank

filed last year?accounts individually or jointly during 2015?

Did you purchase or dispose of any business Yes No

Sell any stocks, bonds, or real estate Yes No assets (furniture, equipment, vehicles, real estate,

held for investment purposes? etc.), or convert any personal assets to business use?

Have any worthless stock or any loans Yes No Did you pay for any business expenses that your Yes No

that became uncollectible in 2015? employer did not reimburse you for (mileage,

supplies, dues etc.)

Pay student loan interest? Yes No Receive any prizes, awards, court awards, Yes No

Scholarships or bartered any good during the year?

Attend, or pay tuition for college or Yes No

Vocational School?

Pay for child/dependent care (including a Yes No Make gifts during 2015 directly or in a trust Yes No

nanny) that allowed you to work?totaling over $14,000 per person?

If yes, please list the provider’s name,

address, and Tax ID number.

Pay any of your medical or long-term healthcare Yes No

Did you have any children under age 19 insurance premiums, deductibles, co-pays or any

or full-time students under age 24 at the other out-of-pocket medical expenses for you or

end of 2015 with interest,dividend and Yes No your dependents in 2015 in excess of 7.5% of

capital gain income in excess of $1050? your income (10% of income if under age 65)?

Receive a distribution from or make a Yes No Purchase any motor vehicles, boats, or home Yes No

contribution to an educational savings building materials in 2015?

account or qualified tuition program? If yes, please provide documentation

containing the sales tax paid.

Were you or your spouse an active Yes No Do you want any overpayment of 2015 taxes Yes No

participant in an employer or self-employed applied to your 2016 taxes?

pension, profit sharing, or tax-sheltered

annuity at any time during 2015?

Do you expect a large fluctuation in your income Yes No

Contributions to/or Distributions from Yes No or withholding in 2016?

a Health Savings Account or

Flexible Savings Account in 2015?

If so, were all distributions used for Yes No Do you expect to receive a lump sum distribution Yes No

Qualified Medical Expenses? from a pension or profit sharing plan in 2016?

Incur moving expenses in 2015 as a Yes No Did you incur a loss because of damaged or stolen Yes No

result of starting a new job? property?

Did you add any energy efficient property Yes No Do you anticipate having significant Investment Yes No

to your home in 2015? Some examples Income in 2016?

include, but are not limited to, windows, doors,

furnaces, air conditioner, water heaters, Do you anticipate having wages or self-employment Yes No

insulation and geothermal heat pumps. income in excess of $125,000 in 2016?

Did you purchase a plug-in Electric Drive Yes No Did you and your dependents have Health Insurance Yes No

Motor Vehicle or qualified fuel cell vehicle? Coverage which meets the Affordable Care Act

“ObamaCare” Standards for the entire year

Did you receive any notices from the IRS or of 2015?

a state taxing authority? Yes No

Did you obtain health insurance through the government

sponsored exchange “The Marketplace” in 2015? Yes No

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). If so, please attach.

ROTH IRA REGULAR IRA HSA Taxpayer Spouse Taxpayer Spouse Taxpayer Spouse

Contributions paid

for 2015 prior to 12/31/15______

Contributions to be

paid on or before 4/15/16______

Did you convert a Traditional IRA to a Roth IRA in 2015? Yes No

Did you transfer or rollover any amounts from one retirement plan to another retirement plan? Yes No

Did you pay any federal and state estimated taxes for 2015? Yes No

If yes, please list:

Federal State

DueDate paidAmount Date paidAmount





Do you want to electronically file your tax return? Yes No

Do you want your income tax refund directly deposited to your bank account? Yes No

If yes, please provide:

Bank Name:______Checking Savings

Bank Routing No.:______

Bank Account No.:______

May the IRS discuss this return with the preparer? Yes No

Would you like a copy of your tax return emailed to you as a PDF file instead of receiving a paper copy? Yes No

Amount of purchases in 2015 for which Sales Tax has not been paid, (i.e. internet purchases) please provide the dollar

amount of those purchases. $______This tax can be paid for on the Illinois income tax return.

Note: The IRS may require documentation for any listed data. By completing this questionnaire, you

Acknowledge that the information is factual and that you will furnish substantiation if requested.


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