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  • CONNEXTIONIST CORPORATION

    TAX RETURN QUESTIONNAIRE - 2021-2022
  • SOCIAL SECURITY CARD
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    Pick a Date
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  • SPOUSE SOCIAL SECURITY CARD
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    Pick a Date
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  • UNEMPLOYMENT
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    1. Number of qualifying Individuals (under 19 years of age or 24 if a full time student) .
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  • DEPENDANT(S) SOCIAL SECURITY
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  • HEALTH INSURANCE COVERAGE:

    YOU MUST PROVIDE PROOF OF HEALTH INSURANCE COVERAGE
    BEGINNING ON JANUARY 1

    The IRS requires that you report certain information related to your health care coverage on your 2021-22tax return. Please read the following statements carefully. More than one might apply to your “tax family”.


    1.  If you had health care coverage with a government Marketplace (Exchange) during 2020.  Please provide Form 1095-A, issued by the Marketplace. In some family situations you may have more than one 1095-A.

    2.  If you are claiming someone on your return who was included on another taxpayer’s policy with a Marketplace. If so, you will also need a copy of that taxpayer’s 1095-A.

    3.  If a dependent filed a return for a previous tax return. Provide a copy of the return.

    4.  If you had compliant health insurance through an employer plan, private policy or with a government plan and provide Form 1095-B, 1095-C or other proof of insurance document.

    5.  If you were issued a hardship exemption by the Marketplace (Exchange). Provide all applicable exemption certificate numbers issued for each member of your family.

    6.  Complete the information below if you or any individual included in your “tax family” DID NOT have insurance coverage for any month of 2021-22.

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  • INSURANCE DOC(S)
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  • WAGE/SALARY DOCS
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  • OTHER INTEREST, CAPITAL GAINS & LOSS
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  • OTHER INCOME
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  • TUITION & FEES, FOREIGN TAX, ADV CHILD CREDIT PAYMENT DOCS
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  • If the vehicle is being used by the owner, please provide the following information. Commuting mileage must not be added to business mileage.

  • PAYMENTS, DEDUCTIONS, INTEREST DOC
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  • BUSINESS, EDUCATION DETAILS
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  • HEALTH INSURANCE COVERAGE:

    YOU MUST PROVIDE PROOF OF HEALTH INSURANCE COVERAGE
    BEGINNING ON JANUARY 1

    The IRS requires that you report certain information related to your health care coverage on your 2021-22 tax return. Please read the following statements carefully. More than one might apply to your “tax family”.


    1.  If you had health care coverage with a government Marketplace (Exchange) during 2020.  Please provide Form 1095-A, issued by the Marketplace. In some family situations you may have more than one 1095-A.

    2.  If you are claiming someone on your return who was included on another taxpayer’s policy with a Marketplace. If so, you will also need a copy of that taxpayer’s 1095-A.

    3.  If a dependent filed a return for a previous tax return. Provide a copy of the return.

    4.  If you had compliant health insurance through an employer plan, private policy or with a government plan and provide Form 1095-B, 1095-C or other proof of insurance document.

    5.  If you were issued a hardship exemption by the Marketplace (Exchange). Provide all applicable exemption certificate numbers issued for each member of your family.

    6.  Complete the information below if you or any individual included in your “tax family” DID NOT have insurance coverage for any month of 2021-22.

  • If you are self employed and you previously prepared your return - please provide a copy of your tax return.

  • IRA, SCHOLARSHIP, ADDITIONS, DISPOSITIONS, PREVIOUS YR TAX RETURN
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  • If "Yes", provide a copy of the closing statements of the sale and a copy of the
    closing statement at the time of your purchase, details of any capital improvements you
    made during the time you owned the property, and any expenses of sale
    incurred by you. If you have purchased a replacement property indicate cost and date
    acquired. If you have previously sold a residence, provide a copy of form 2119 from your
    tax return for the year of sale.

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  • PENSION PAYMENTS, CLOSING STATEMENTS
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  • Percentage ownership of not 100% ____________ %
    (Please indicate if income and expenses below are listed at 100% or your percentage.)

  • If yes, what percentage did you occupy as a tenant? __________%

  • SUPPORTING DOCUMENTS "YES' RESPONSES
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  • SUPPORTING DOCS
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  • SUPPORTING DOCS
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