COVID 19 Data Sheet

Name

First Name Last Name

SSN:

1. Did you receive the first Stimulus Payment (EIP 1)?

If so, how much did you receive?

2. Did you receive the second Stimulus Payment (EIP 2)?

If so, how much did you receive?

3. Did your receive Unemployment Compensation?

If so, do you have form 1099 G?

4. Are you self employed?

a. Were you self employed in 2019?

b. Were you self employed in 2020?

c. If so, did you receive an EIDL from the SBA?

If so, how much did you receive?

d. Did you receive a PPP Loan?

If so, how much did you receive?

5. If you answered yes to question 4 (b) did you have to miss work due to a COVID related illness for you or someone you were caring for and/or COVID exposure and was told to self quarantine by a medical physician, etc ?

a. If so, who was the patient and what is their relationship to you?

If other, please notate their relationship to you here:

b. What is the date range for the days you missed?

Beginning Date

Enter the ending date here:

Ending Date

c. Did you also work a job as an employee?

d. If so, did you receive Sick &/or Family Leave Pay from your employer?

e. If so, how much were you compensated for such?

and how often were you compensated for such?

6. If you answered yes to question 4 (b) 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, what is the date range for the days your dependent(s) were out due to such?

Beginning Date

Enter the ending date here: (this will be the date the state lifted said mandate)

Ending Date

(please do not include any VOLUNTARY days that you didn't allow your dependent(s) to attend said facility)

b. If you were also an employee for a company/business, did you receive Family Leave Pay for said situation?

c. If so, how much were you compensated for such?

and how often were you compensated for such?

You certify that all answers on this form is true and accurate and you understand that providing false and/or incorrect information can severely delay your refund and/or cause your refund to not be issued by the IRS and/or the State Taxing Authority.

Client Signauture

Date