Yes
No
Personal Information
Did your marital status change during the year?
If yes, explain: Did your address change from last year?
Can you be claimed as a dependent by another taxpayer?
Did you change any bank accounts, or did routing transit numbers (RTN) and/or bank
account number change for existing bank accounts that have been used to direct deposit
(or direct debit) funds from (or to) the IRS or other taxing author during the tax year?
Did you receive an Identity Protection PIN (IP PIN) from
the IRS or have you been
a victim of identity theft? If yes, attach the IRS letter.
Dependent Information
Were there any changes in dependents from the prior year?
If yes, explain:
Do you have any children under age 19 or a full-time
Do you have dependents who must file a tax return?
Did you provide over half the support for any other person(s) other than your
dependent children during the year?
Did you pay for child care while you worked, looked for work, or while a
full-time student?
Did you pay any expenses related to the adoption of a child during the year?
If you are divorced or separated with child(ren), do you have a divorce decree
or other form of separation agreement which establishes custodial responsibilities?
Did any dependents receive an Identity Protection PIN (IP PIN) from the IRS or
have they been a victim of identity theft? If yes, attach the IRS letter.
Purchases, Sales and Debt Information
Did you start a new business or purchase rental property during the year?
Did you sell, exchange, or purchase any assets used in your trade or business?
Did you acquire a new or additional interest in a partnership or S corporation?
Did you sell, exchange, or purchase any real estate during the year?
Did you purchase or sell a principal residence during the year?
Did you foreclose or abandon a principal residence or real property during the year?
Did you acquire or dispose of any stock during the year?
Did you take out a home equity loan this year?
Did you refinance a principal residence or second home this year?
Did you sell an existing business, rental, or other property this year?
Did you lend money with the understanding of repayment and this year it
became totally uncollectable?
Did you have any debts canceled or forgiven this year, such as a home mortgage or
student loan(s)?
Did you purchase a qualified plug-in electric drive vehicle or qualified fuel cellī
vehicle this year?
Income Information
Did you have any foreign income or pay any foreign taxes during the year, directly
or indirectly, such as from investment accounts, partnerships or a foreign employer?
Did you receive any income from property sold prior to this year?
Did you receive any unemployment benefits during the year?
Did you receive any disability income during the year?
Did you receive tip income not reported to your employer this year?
Did any of your life insurance policies mature, or did you surrender any policies?
Did you receive any awards, prizes, hobby income, gambling or lottery winnings?
Do you expect a large fluctuation in income, deductions, or withholding next year?
Did you have any sales or other exchanges of virtual currencies, or used virtual currencies to pay for goods or services, or you are holding virtual currencies as an investment
Retirement Information
Are you an active participant in a pension or retirement plan?
Did you receive any Social Security benefits during the year?
Did you make any withdrawals from an IRA, Roth, myRA,
Keogh, SIMPLE, SEP,401(k), or other qualified retirement plan?
Did you receive any lump-sum payments from a pension, profit sharing or
401(k) plan?
Did you make any contributions to an IRA, Roth, myRA, Keogh, SIMPLE, SEP,
401(k), or other qualified retirement plan?
Education Information
Did you, your spouse, or your dependents attend a post-secondary school
during the year, or plan to attend one in the coming year?
Did you have any educational expenses during the year on behalf of yourself,
your spouse, or a dependent? If yes, attach any Form(s) 1098-T and receipts for
qualified tuition and related expenses
Did anyone in your family receive a scholarship of any kind during the year?
If yes, were any of the scholarship funds used for expenses other than tuition,
such as room and board?
Did you make any withdrawals from an education savings or 529 Plan account?
Did you make any contributions to an education savings or 529 Plan account?
Did you pay any student loan interest this year?
Did you cash any Series EE or I U.S. Savings bonds issued after 1989?
Would you like a worksheet to aid in the completion of a Free Application for
Federal Student Aid (FAFSA) with the U.S. Department of Education?
If yes, for what school year?
Health Care Information
Did you have qualifying health care coverage, such as employer-sponsored coverage
or government-sponsored coverage (i.e. Medicare/Medicaid) for your family?
"Your family" for health care coverage refers to you, your spouse if filing jointly, and
anyone you can claim as a dependent. If yes, attach any Form(s) 1095-B and/or 1095-C
you received.
Did anyone in your family qualify for an exemption from the health care coverage
mandate? Examples of exemptions include (but are not limited to) certain non-citizens
members of a health care sharing ministry, members of Federally-recognized Indian
tribes, and exemptions requested from the Marketplace. If yes, attach the Exemption
Certificate Number (ECN) or type of exemption.
Did you enroll for lower cost Marketplace Coverage
through healthcare.gov under
the Affordable Care Act?
If yes, attach any Form(s) 1095-A you received.
Did you enroll for lower cost Marketplace Coverage through
healthcare.gov under
the Affordable Care Act and share a policy with
anyone who is not included in
your family?
Did you make any contributions to a Health savings account (HSA) or Archer MSA?
Did you receive any distributions from a Health savings account (HSA), Archer
MSA, or Medicare Advantage MSA this year?
Did you pay long-term care premiums for yourself or your family?
Did you make any contributions to an ABLE (Achieving a Better Life Experience)
account? If yes, attach any Form(s) 5498-QA you received.
Did you receive any withdrawals from an ABLE (Achieving a Better Life Experience)
account? If yes, attach any Form(s) 1099-QA you received.
If you are a business owner, did you pay health insurance premiums for your
employees this year?
Itemized Deduction Information
Did you incur a casualty or theft loss or any
condemnation awards during the year?
Did you pay out-of-pocket medical expenses (Co-pays, prescription drugs, etc.)?
Did you make any cash or noncash charitable contributions (clothes, furniture, etc.)?
If yes, please provide evidence such as a receipt from the donee organization, a
canceled check, or record of payment, to substantiate all contributions made.
Did you donate a vehicle or boat during the year? If yes, attach Form 1098-C
or other written acknowledgement from the donee organization.
Did you pay real estate taxes for your primary home and/or second home?
Did you pay any mortgage interest on an existing
home loan? If yes, attach any
Form(s) 1098 you received.
Did you incur interest expenses associated with
any investment accounts you held?
Did you have any expenses related to seeking a new job during the year?
Did you make any major purchases during the year (cars, boats, etc.)?
Did you make any out-of-state purchases (by telephone,
internet, mail, or in person)
for which the seller did not collect state sales or use tax?
Miscellaneous Information
Did you make gifts of more than $15,000 to any individual?
Did you utilize an area of your home for business purposes?
Did you engage in any bartering transactions?
Did you retire or change jobs this year?
Did you incur moving costs because of a permanent change of station as a member of the Armed Forces on active duty?
Did you pay any individual as a household employee during the year?
Did you make energy efficient improvements to your main home this year?
Did you receive a distribution from, or were you a grantor
or transferor for a foreign
trust?
Did you have a financial interest in or signature authority over a financial account
such as a bank account, securities account, or brokerage account, located in a
foreign country?
Do you have any foreign financial accounts, foreign financial assets, or hold
interest in a foreign entity?
Did you receive correspondence from the State or the IRS?
If yes, explain:
Do you have previous years of tax returns that are either unfiled or filed with
unpaid balances due?
Do you want to designate $3 to the Presidential Election Campaign Fund? If you
check yes, it will not change your tax or reduce your refund.
Any other comments for tax return:
