Kimber Accounting - DROP OFF QUESTIONNAIRE

DROP OFF QUESTIONNAIRE

SECTION 1 — FILING STATUS*

Single

Married Filing Joint

Married Filing Separate

Head of Household

SECTION 2 — TAXPAYER INFORMATION

Last Name*

First Name*

Middle Initial

Suffix

Social Security Number*

Date of Birth*

Occupation*

Work Phone*

Extension

Cell Phone*

Email Address*

Address*

Apt #

City, State, Zip Code*

Home Phone

SECTION 3 — SPOUSE INFORMATION

Last Name*

First Name*

Middle Initial

Suffix

Social Security Number*

Date of Birth*

Occupation*

Work Phone and Ext

Cell Phone*

Email Address*

SECTION 4 — DEPENDENT INFORMATION

First Name, Middle Initial, Last Name

Social Security Number

Relationship

Date of Birth

Months Lived with Taxpayer

Child Care Expense

First Name, Middle Initial, Last Name

Social Security Number

Relationship

Date of Birth

Months Lived with Taxpayer

Child Care Expense

First Name, Middle Initial, Last Name

Social Security Number

Relationship

Date of Birth

Months Lived with Taxpayer

Child Care Expense

SECTION 5 — ADDITIONAL QUESTIONS

Can you be claimed as a dependent on someone else’s tax return?*

Yes

Did you receive any Unemployment Benefits?*

Yes

Do you have any taxable bank interest or dividends?*

Yes

Do you have any retirement income or Social Security benefits?*

Yes

Do you have any work expenses that you are not reimbursed for?*

Yes

If yes, how much? (i.e. boots, uniforms, union dues)*

If you are receiving a REFUND would you like it directly deposited?

CHECKING

SAVINGS

N/A

Routing Number

Account Number

HEALTH INSURANCE

Did you have Health Insurance through the Marketplace at any point this year?

If you had Marketplace health insurance, we will need your Form 1095-A to complete your return.

Yes

Did you earn overtime pay at any point this year?*

If you earned overtime, we need documentation showing your total overtime for the year.

Yes