Part I – Marital Status and Household Information

Name

First NameLast Name
Part I – Marital Status and Household Information
1. Do you or any member of your household have a disability?

YesNo
2. Are you or your spouse a Veteran from the U.S. Armed Forces?

YesNo
3. Have you, your spouse, or dependents been a victim of tax related identity theft or been issued an Identity Protection PIN?

YesNo
5. Did you live in an area that was declared a Federal disaster area?

YESNO
6. Did you, or your spouse if filing jointly, receive a letter from the IRS?

YesNo
As of December 31, 2023, under state law was your marital status? (This includes registered domestic partnerships, civil unions, or other formal relationships)

MarriedDivorcedLegally SeparatedWidowed
If so, did you get married in 2023?

YesNo
Type Did you live with your spouse at any time during the last six months of 2023?

YesNo
Date of separation agreement:
Date of Spouses Death
Part III – Income – Last Year, Did You (or Your Spouse) Receive
Did you have wages or salary?

YesNo
Tip Income?

YesNo
Scholarship

Yesno
Interest

YesNo
Refund of State/City

YesNo
Alimony income?

YesNo
Self-Employment income

YesNo
Did you sell or buy Stocks/bonds or dividends.

YesNo
Did you have disability income?

YesNo
Did you have retirement income

YesNo
Rental Property

YesNo
Gambling, lottery, prizes etc?

YesNo
Unemployment income?

YesNo
Part IV – Expenses – Last Year, Did You (or Your Spouse) Pay
1. (B) Alimony or separate maintenance payments? If yes, do you have the recipient’s SSN? Yes No 2. Contributions or repayments to a retirement account? IRA (A) Roth IRA (B) 401K (B) Other 3. (B) College or post-secondary educational expenses for yourself, spouse or dependents? (Form 1098-T) 4. Any of the following? (A) Medical & Dental (including insurance premiums) (A) Mortgage Interest (Form 1098) (A) Taxes (State, Real Estate, Personal Property, Sales) (B) Charitable Contributions

5. (B) Child or dependent care expenses such as daycare? 6. (B) For supplies used as an eligible educator such as a teacher, teacher’s aide, counselor, etc.? 7. (A) Expenses related to self-employment income or any other income you received? 6. (B) For supplies used as an eligible educator such as a teacher, teacher’s aide, counselor, etc.? 8. (B) Student loan interest? (Form 1098-E)

7. (A) Expenses related to self-employment income or any other income you received?

8. (B) Student loan interest? (Form 1098-E)
Part V – Life Events – Last Year, Did You (or Your Spouse)
Due Diligence Questionnaire
First
Last
IRS regulations require paid tax preparers to perform a series of due diligence requirements for the Earned Income Credit, Child Tax Credit, American Opportunity Tax Credit, and Head of Household Filing Status. We believe you are/may be eligible for one or more of the credits or the filing status. As part of our engagement with you and to comply with these requirements, we ask all clients for whom returns are prepared to answer the following due diligence questions.
Were you taxpayers a US citizen or resident alien for all of 2023?

YesNo
Are dependent(s) claimed on your tax return your: son, daughter, stepchild, foster child, or a descendant of any of them (for example, your grandchild), or brother, sister, half-brother, half-sister, stepbrother, stepsister, or a descendant of any of them (for example, your niece or nephew)?

YesNo
Did any dependents(s) file a joint return with another person for 2023?

YesNo
Did dependent(s) live with you in the United States for more than half of 2023?*
You can't claim the EIC for a child who didn't live with you for more than half of the year, even if you paid most of the child's living expenses.

YesNo
Do you believe dependent(s) could also meet the qualifications to be a qualifying child of another tax filer?*
Sometimes a child meets the tests to be a qualifying child of more than one person. However, only one of these persons can actually treat the child as a qualifying child. Only that person can use the child as a qualifying child.

YesNo
Are dependent(s) claimed on your tax retum your: son, daughter, stepchild, foster child, brother, sister, stepbrother, stepsister, half-brother, half-sister, or a descendant of any of them (for example, your grandchild, niece, or nephew)?

YesNo
Did dependent(s) provide over half of his or her own support for 2023?

YesNo
Did dependent(s) live with you for more than half of 2023?

YesNo
Did dependent(s) file a joint return with another person for 2023?

YesNo
Are dependent(s) a U.S. citizen, a U.S. national, or a U.S. resident alien?*

We are required to obtain from the taxpayer a document proving the existence of the child such as one of the following (that would have the child's name on it):

Health care provider statement
Place of worship statement

YesNo
American Opportunity Tax Credit
As of the beginning of 2023, has the student completed the first 4 years of postsecondary education (generally, the freshman through senior years of college), as determined by the eligible educational institution?

YesNo
Head of HousehoId Filing Status
Are you, the taxpayer, unmarried on 12/31/23 and do you provide more than half of the cost of keeping up a home for the year for a qualifying person?

YesNo
Yes

Can you provide documentation to substantiate the above answers?No
Yes

Have you ever had any of these credits disallowed or reduced in the past?No
First
Last
SSN
Date

MonthDayYear
Date
Signature
EITC Question
1. Does the child's other parent(s) live with you?

YesNo
2. If not, where does the parent(s) live? (city and state)
3. Is there court papers on file for custody/visitation?

YesNo
4. If so what State and County?
5. When was the last time the child(ren) seen the other biological parent(s)
6. How often does the child(ren) see the other biological parent(s)?
7. Is there a visitation order for the other biological parent(s)? YES NO

YesNo
Childcare Expense
1. Do you pay someone for childcare?

YesNo
2. If so who? (name and address)
3. How much do you pay them? (full amount or co-pay amount)
4. Do you receive help from the county to pay for childcare expense?

YesNo
5. Can you provide receipts for proof of payment?

YesNo
Should be Empty:

Part I – Marital Status and Household Information

Part III – Income – Last Year, Did You (or Your Spouse) Receive

Part IV – Expenses – Last Year, Did You (or Your Spouse) Pay

Part V – Life Events – Last Year, Did You (or Your Spouse)

Due Diligence Questionnaire

EITC Question

Childcare Expense