2021-22 TAX QUESTIONAIRE

CONNEXTIONIST CORPORATION

CONNEXTIONIST CORPORATION

TAX RETURN QUESTIONNAIRE - 2021-2022
Name*

First NameMiddle NameLast NameSuffix
Social Security Number*
(###-##-####)
ATTACH SUPPORTING DOCUMENT(S)*

SOCIAL SECURITY CARD
FRONT & BACK Cancelof
DATE OF BIRTH*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Occupation*
Primary Phone Number*

Area CodePhone Number
Email*
example@example.com
Spouse

First NameMiddle NameLast NameSuffix
Social Security Number
(###-##-####)
ATTACH SUPPORTING DOCUMENT(S)

SPOUSE SOCIAL SECURITY CARD
FRONT & BACK Cancelof
DATE OF BIRTH

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
Occupation
Primary Phone Number

Area CodePhone Number
Spouse Email
example@example.com
FILING STATUS:*

SINGLEMARRIEDMARRIED FILING SEPARATELYHEAD OF HOUSEHOLDQUALIFYING WIDOW
Did you receive unemployment insurance?*

YESNO
UNEMPLOYMENT COMPENSATION RECEIVED
ENTER $ AMOUNT (0.00)
ATTACH SUPPORTING DOCUMENT(S)

UNEMPLOYMENT

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	N/A	Amount
Casualty & Theft Losses

	AMOUNT
1. Tax Preparation
2. Union Dues
3. Business Publications
4. Professional Dues/Fees
5. Safety Deposit Box Rental
6. Small Tools used in your trade or business
7. Business telephone
8. Uniforms & Cleaning
9. IRA Custodial fees
10. Investment Expenses
11. Education Expenses (attach details)
12. Business Entertainment
13. Other Miscellaneous deductions

ADJUSTMENTS TO INCOME:

	N/A	Maximize	Amount
1. Your IRA deduction
2. Spouse's IRA deduction
3. Keogh SEP deduction
4. Penalty for early withdrawal of savings.
5. Alimony paid - List name and Social Security Number
6. Self-employed health insurance premiums

Did anyone in your family receive a scholarship of any kind during 2021-22? If yes, please supply details. (This includes athletic scholarships)

YESNO
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.
ATTACH SUPPORTING DOCUMENT(S)

IRA, SCHOLARSHIP, ADDITIONS, DISPOSITIONS, PREVIOUS YR TAX RETURN

Cancelof

Did you receive any payments from a pension or profit sharing plan? (If yes, provide pertinent information or statements from the plan.)

YESNO
Did you sell your primary residence during 2021 or 2022?

YESNO20212022
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.
Did you change your state residency during 2020? If "Yes", please provide the following:

YESNO

If yes,

	Information
Previous address:
Date of move:
Distance: (Miles)
Cost of move:
Describe

ATTACH SUPPORTING DOCUMENT(S)

PENSION PAYMENTS, CLOSING STATEMENTS

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BUSINESS INCOME & EXPENSES (SOLE PROPRIETORSHIP)*

	N/A	Q. 1 ONLY	Q.2 ONLY	EIN	BUSINESS ADDRESS
1. PRINCIPLE
2. BUSINESS NAME
EMPLOYER ID NUMBER
BUSINESS ADDRESS

Type a question

ELECTRONIC SUBMISSION*

	Q.1 CHECKING OR SAVINGS	Q. 2 ACCOUNT NUMBER	Q.3 BANK ROUTING NUMBER	Q.4 EMAIL
1. ACCOUNT TYPE
2. YOUR ACCOUNT NUMBER
3. BANK ROUTING NUMBER
4. EMAIL ADDRESS

Please sign and submit*

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	N/A	FIRST MIDDLE LAST	RELATIONSHIP	MONTHS LIVED IN HOME	SOCIAL SECURITY NUMBER	DATE OF BIRTH	INCOME OVER $2,100? (Y OR N)
1
2
3
4
5

	N/A	NAME	JAN	FEB	MAR	APR	MAY	JUN	JUL	AUG	SEP	OCT	NOV	DEC
1
2
3
4
5

	NNAME OF PAYER	GROSS WAGE (WITHHELD)	SOC. SEC. (WITHHELD)	MEDICARE (WITHHELD)	FED INC. TAX (WITHHELD)	ST INC.TAX (WITHHELD)	N/A
1
2
3
4
5

	N/A	INVESTMENT	DATE ACQUIRED	COST OR OTHER BASIS	DATE SOLD	NET SALE PROCEEDS
1
2
3
4
5

	N/A	INVESTMENT	DATE ACQUIRED	COST OR OTHER BASIS	DATE SOLD	SALE PROCEEDS
1
2
3
4
5

	N/A	TOTAL AMOUNT RECIEVED	TAXABLE AMOUNT
PENSIONS
IRA DISTRIBUTIONS
ANNUITIES
ROLLOVERS
RENTS/ROYALTIES
PARTNERSHIPS
S CORPORATIONS
ESTATES
TRUSTS
SOCIAL SECURITY BENEFITS
STATE/LOCAL TAX REFUNDS

	N/A	Number
DEPENDANTS
Qualifying Individuals (under 19 years of age or 24 if a full time student)

	N/A	NAME	ADDRESS	AMOUNT PAID
CARE PROVIDER 1
CARE PROVIDER 2
CARE PROVIDER 3
CARE PROVIDER 4

	SELECT ANSWER	AMOUNT PAID
If payments were made to an individual, were services performed in your home?
If "YES", have payroll reports been filed?
Expenses incurred in connection with adoption? "SPECIAL NEEDS" CHILD
Tuition & Fees paid for higher education (Hope & Lifetime Learning Credits)
Foreign Tax Credits

	N/A	FEDERAL/STATE	AMOUNT
PAYMENT TYPE 1
PAYMENT TYPE 2
PAYMENT TYPE 3
PAYMENT TYPE 4
PAYMENT TYPE 5
PAYMENT TYPE 6

	N/A	DENTAL/MEDICAL/OTHER	AMOUNT
1. Out of pocket costs for prescription medicines, drugs, insulin, doctors, dentists, nurses, and medical and dental insurance premiums (including Medicare B) paid in 2021-22 (reduce any insurance reimbursements)
2. Transportation and lodging incurred to obtain medical care
3. Other - hearing aids, eyeglasses, medical devices, etc.
4.
5.

	N/A	AMOUNT
1. State and local income taxes not listed elsewhere
2. Real estate taxes not listed elsewhere
3. Personal property taxes (includes owners tax on auto registration)

	N/A	TYPE	AMOUNT	NAME	ADDRESS
1. Home mortgage interest paid to financial institutions
2. Home mortgage interest paid to individuals NAME & ADDRESS
3. 3. Points paid on [ ] purchase [ ] refinance (include details)
4. Investment Interest
5. Student Loan Interest

	N/A	AMOUNT
1. Employee business expenses - attach details
2. Reimbursed
3. Not Reimbursed
4. Job hunting expenses (list)

	N/A	YES	NO
Did your principle residence ( and second residence, if any loan(s) exceed the fair market value of the residence?
Do you have a balance borrowed against a home (equity line of credit) in excess of $100,000, or total mortgage indebtedness in excess of $1,000,000?
Did you exercise any stock options?
Did you purchase, sell, or own any bonds you paid more or less than the face amount?
Did you sustain any non-business bad debts?
Did you or your spouse make any gifts in excess of $14,000 to any one doner?
Were you the recipient of, or did you make a "below-market" or "interest-free" loan?
Do you have a child under the age of 18 as of December 31, 2021 or 2022 who has earned an income (interest, dividends, etc.) of more than $1,050?
Did you lease a car which you used for business purposes?
If "Yes", provide (1) fair market value or capitalized cost of the car on the 1st day of the lease or rental agreement, (2) tern of the lease, (3) number of payments made, (4) number of days the car was leased in 2016, (5) percentage of business use, (6) business or work the car was used in, (7) amount of expenses reported by you to your employer on Form W2.

	N/A	MAKE	MODEL	DATE OF PURCHASE	PURCHASE PRICE	MILEAGE TYPE	AMOUNT
CAR 1
CAR 2
CAR 3
CAR 4

	ADDRESS	NUMBER OF DAYS RENTED	NUMBER OF DAYS USED PERSONALLY
LOCATION
If Vacation Home:

	N/A	AMOUNT
COVID STIMULUS 1
COVID STIMULUS 2
3. RENTAL INCOME
4. ROYALTIES RECEIVED
1. ADVERTISING
2. ASSOCIATION DUES
3. AUTO MILES DRIVEN
4. TRAVEL
5. CLEANING & MAINTENANCE
6. COMMISSIONS
7. INSURANCE
8. LEGAL & PROFESSIONAL FEES
9. ALLOCATED TAX PREPARATION FEES
10. LICENSES AND PERMITS
11. MANAGEMENT FEES
12. MORTGAGE INTEREST -- (FORM 1098)
13. OTHER INTEREST
14. REPAIRS
15. SUPPLIES
16. PROPERTY TAXES
17 . UTILITIES
18. OTHER

	N/A	DIRECT COSTS (benefit only business portion of home)	INDIRECT COSTS (other)
HOME INSURANCE
REPAIRS & MAINTENANCE
UTILITIES
RENT
OTHER

	N/A	QUESTION 1 ONLY	QUESTION 2 ONLY %	BRIEF DESCRIPTION	QUESTION 5 & 6
1. Do you use any part of your home regularly and exclusively for business?
2. Estimated percentage of time spent in home office compared to total time spent in this business activity. (e.g., 10%, 20%)
3. Description of work done in home office
4.Description of work done outside of work office
5.Total area of home
6.Total area of home used regularly for business.

	N/A	AMOUNT
Days used as a daycare facility.
Prior year carryover of unallowed losses
Cost of home and improvements and prior depreciation.
Depreciation of home, improvements, furniture, and equipment.

	N/A	AMOUNT
1. GROSS RECEIPTS OR SALES
2. RETURNS AND ALLOWANCES
3. OTHER INCOME
1. ADVERTISING
2. BAD DEBTS (N/A CASH BENEFITS)
3. COMMISSIONS & FEES
5. HEALTH INSURANCE
6. OTHER INSURANCE
7. MORTGAGE INTEREST
8. OTHER INTEREST
9. LEGAL & ACCOUNTING FEES
10.ALLOCATION OF TAX PREP FEES
11. OFFICE EXPENSE
12. PENSION & PROFIT SHARING PLANS
13. RENT, VEHICLES
14. RENT, EQUIPMENT
15. RENT, BUILDING
16. REPAIRS & MAINTENANCE, BUILDING
17 . REPAIRS & MAINTENANCE, EQUIPMENT
18. REPAIRS & MAINTENANCE, VEHICLES
19. SUPPLIES
20. PAYROLL TAXES
21. OTHER TAXES
22. LICENSES
23.TRAVEL
24. MEALS AND ENTERTAINMENT (IN FULL)
25. UTILITIES
26. WAGES
27. MANAGEMENT FEES
28. CONSULTING EXPENSES
29. PAYROLL SERVICE
30. EMPLOYEE VEHICLE EXPENSE
31. EMPLOYEE MILEAGE REIMBURSEMENT
32. CLIENT GIFTS (LIMITED TO $25 EACH)
33. EDUCATION & SEMINARS
34. OTHER

	N/A	AMOUNT
1. BEGINNING OF YR INVENTORY
2. PURCHASES
3. COST OF ITEMS USED PERSONALLY
4. COST OF LABOR
5. MATERIALS & SUPPLIES
6. OTHER COSTS
7. END OF YEAR INVENTORY

1. Business is owned by:

2. Accounting Method:

3. Inventory method:

4. Did you materially participate in the business?

5. Is this the first year of the business.