Covid 19 Questionairre for 2022

Client(s) Name
SSN
Tax Professional
1. Did you receive Stimulus Payments:
EIP 1?
If so, how much did you receive?
EIP 2?
If so, how much did you receive?
EIP 3?
If so, how much did you receive?
2. Did your receive Unemployment Compensation?
a. If so, do you have form 1099 G?
3. Are you self employed?
a. Were you self employed in 2019?
b. Were you self employed in 2020?
c. Were you self employed in 2021?
4. If so, did you receive an EIDL or the Targeted EIDL from the SBA?
a. If so, when did you receive the EIDL?

MonthDayYear
Date
b. If so, when did you receive the Targeted EIDL?

MonthDayYear
Date
c. If you received the EIDL, how much did you receive?
d. If you received the Targeted EIDL, how much did you receive?
5. Did you receive a PPP Loan?
a. PPP Loan 1st Draw?
If so, when?

MonthDayYear
Date
How much did you receive?
b. PPP Loan 2nd Draw?
If so, when?

MonthDayYear
Date
If so, how much did you receive?
c. Have 1st Draw PPP Loan been forgiven?
d. Have 2nd Draw PPP Loan been forgiven?
6. If you answered yes to question 3 (a, b and/or c) did you have to miss work due to a COVID related illness you or someone you were caring for and/or COVID exposure and was told to self quarantine by a medical
a. If so, how many people did you care for?
b. What was their relationship to you?
1.
2.
3.
c. If so, how many days did you miss from January 1, 2021 to March 31, 2021?
1. What was the date range for the days you missed in between January 1, 2021 to March 31, 2021?
Starting Date

MonthDayYear
Date
Ending Date

MonthDayYear
Date
d. How many days did you miss from April 1, 2021 to September 30, 2021?
1. What was the date range for the days you missed in between April 1, 2021 to September 30, 2021?
Starting Date

MonthDayYear
Date
Ending Date

MonthDayYear
Date
e. Did you take the sick leave credit in 2021 for tax year 2020?
1. If so, how many days did you miss/take on last year's tax return?
2. What was your net Self employment income for TY 2019, if any?
3. What was your net Self employment income for 2020, if any?
f. If you answered "NO" to 4 (e) above and "YES" to 3 (a, b, and/or c) above, why didn't you take the Sick Leave credit on your last year tax return?
f. Explanation Continued
g. Did you also work a job as an employee during the following years?
1. Tax Year 2019
2. Tax Year 2020
3. Tax Year 2021
h. If so, did you receive Sick Leave Pay from your employer?
1. If so, how much were you compensated for such?
i. If so, did you receive Family Leave Pay from your employer?
1. If so, how much were you compensated for such?
7. If you answered yes to question 3 (a, b and/or c) above, did you miss work to care for your dependents due to a state mandate for school/daycare/adult-care center closure?
a. If so, how many people did you care for?
b. What was their relationship to you?
1.
2.
3.
c. If so, how many days did you miss from January 1, 2021 to March 31, 2021?
1. What was the date range for the days you missed in between January 1, 2021 to April 30, 2021?
Starting Date

MonthDayYear
Date
Ending Date

MonthDayYear
Date
d. If so, how many days did you miss from April 1, 2021 to September 30, 2021?
1. What was the date range for the days you missed in between April 1, 2021 to September 30, 2021?
Starting Date

MonthDayYear
Date
Ending Date

MonthDayYear
Date
(please do not include any voluntary days that you didn't allow your dependent(s) to attend said facility)
e. Did you take the sick leave credit in 2021 for tax year 2020?
4. If so, how many days did you miss/take on last year's tax return?
5. What was your net Self employment income for TY 2019, if any?
6. What was your net Self employment income for 2020, if any?
f. If you answered "NO" to 4 (e) above and "YES" to 3 (a, b, and/or c) above, why didn't you take the Family Leave Credit on your last year tax return?
f. Explanation Continued...
g. Did you also work a job as an employee during the following years:
1. Tax Year 2019
2. Tax Year 2020
3. Tax Year 2021
h. If so, did you receive Family Leave Pay from your employer?
1. If so, how much were you compensated for such?
8. Did you receive Advance Child Tax Credit Payments in 2021?
a. If so, how much did you receive in all (TOTAL)?
Signature

Clear
Date

MonthDayYear
Date
Covid - 19 Due Diligence Questions 3 | 3

Jordan & Associates, LLC C 2022
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