Customer Upload Document

PERSONAL FINANCIAL QUESTIONNAIRE PACKET

In order to achieve the best possible resolution with the IRS and or State Department of Revenue, please complete the following questionnaire as thorough as possible. Please list additional information on a separate sheet if necessary.

PERSONAL INFORMATION

Marital Status

Single Married

If married, do you file jointly?

Full Name of Taxpayer (first/last)

Full Name of Spouse (first/last)

Physical Address

City, State, Zip Code

Country

Do you

Own your home Rent Other (specify e.g. share rent, live with relative, etc.)

If other:

Home Phone

Cell Phone

Other Contact Person (Attorney or CPA you want us to talk to)

Taxpayer

_SSN#

_{Date of Birth}

_{Driver’s License #}

Spouse

_SSN#

_{Date of Birth}

_{Driver’s License #}

Please provide the following information for all dependents; EXCLUDING yourself and your spouse:

#	Name	Date of Birth	SSN	Relationship
1
2
3

PERSONAL ASSET INFORMATION

Cash: $

Personal Bank Account(s): Please list additional information on separate sheet if necessary.

#	Bank Name	Address	Checking/Savings	Account #	Balance
1
2
3

Investments: (include stocks, bonds, mutual funds, IRA, 401 and all other investments/retirement accounts) Please list additional information on a separate sheet if necessary.

#	Type of Investment	Company name	Current Value	Balance	Payment
1
2

Credit Card Account(s): Please list additional information on separate sheet if necessary

#	Bank Name	Bank Address	Account #	Credit Limit	Amount Owed
1
2

Life Insurance: (list any life insurance policy with cash value – NOT TERM LIFE)

Policy Number

Owner of Policy

Current Cash Value: $

Outstanding Loan Balance: $

Any Real Estate/Primary Residence/Rental Properties/ Lands Owned: (If more than 1 property, please list additional owned properties on a separate sheet if necessary)

Property Address

Suite/Apt #

City, State, Zip Code

Country

Mortgage Lender

Purchase Date

Fair Market Value: $

Loan Balance: $

Monthly Payment: $

Date of Final Payment

Monthly Property Tax: $

How is Title held (Joint, Tenancy, etc.)

Motor Vehicles Owned: (If more than 2 vehicles, please list additional vehicles on a separate sheet)

1 Vehicle:

Year

Make & Model

Mileage

Lease or Loan

Lease Loan

Date of Purchase/Lease

Date of Final Payment

Current Value: $

Current Loan Value: $

Monthly Payment: $

Name of Lender/Lessor

2 Vehicle:

Year

Make & Model

Mileage

Lease or Loan

Lease Loan

Date of Purchase/Lease

Date of Final Payment

Current Value: $

Current Loan Value: $

Monthly Payment: $

Name of Lender/Lessor

Personal Assets: (recreational vehicles, boats, RV’s, artwork, jewelry, collections, etc….) NOTE: Do not include clothing, furniture and other personal effects. Please list additional information on a separate sheet if necessary.

Description of Asset, Date of Purchase, Current Value, Loan Balance, Name of Lender/Lessor, Date of Final Payment

PERSONAL MONTHLY INCOME & EXPENSE

Income & Expense for Month of: $

INCOME EXPENSES

Source Gross

Monthly

Wages – Taxpayer $

Wages – Spouse $

Interest/Dividends $

Net Self-Employed/Business Income $

Net Rental Income $

Distribution $

Social Security Income – Taxpayer $

Social Security Income – Spouse $

Child Support Income $

Alimony Income $

Other Income $

Other Income $_

TOTAL HOUSEHOLD INCOME $

Item Actual/Monthly

Food, Clothing & Misc. $

Rent/Mortgage $

Utilities $

Vehicles Ownership Costs $

Vehicles Operating Costs $

Public Transportation $

Health Insurance $

Out of Pocket Health Costs $

Court Ordered Payments $

Child Care $

Life Insurance $

Taxes (Income & FICA) $

*Other Secure Debts $

TOTAL HOUSEHOLD EXPENSES $

If You Or Your Spouse Generate Income as A Sole Proprietor Or Independent Contractor Please Provide The Following Information:

Business Name

Employee ID # (If any)

# of Employees (if any)

Average Monthly Payroll: $

Type of Business

Partnership LLC Corporation Other

If Other:

Frequency of Tax Deposits

Business Website (if any)

BUSINESS ASSET INFORMATION: (for Self-Employed)

Business Cash on hand $

Business Bank Account(s) : (Please attach 3 months of business bank statements)

Notes Receivable

Do you have notes receivable?

Yes No

If yes, attach current listing that includes name(s) and amount of note(s) receivable.

Accounts Receivable

Do you have any accounts receivable?

Yes No

If yes, attach current account(s)receivable list.

BUSINESS INCOME AND EXPENSE INFORMATION: (for Self-Employed)

SOLE PROPRIETORSHIP BUSINESS INFORMATION ONLY

Accounting Method Used

Cash Accrual

Please provide current year-to-date Profit & Loss statement or complete the following section:

Income & Expense for Month of

INCOME EXPENSES

Source Gross Monthly

Item Actual Monthly Gross Receipts $

Materials Purchased $

Gross Rental Income $

Inventory Purchased $

Interest $

Gross Wages & Salaries $

Dividends $

Rent $

Cash $

Supplies $

Other Income $

Utilities/Telephone $

Vehicle/Gas/Oil $

Repairs/Maintenance $

Insurance $

Current Taxes $

Other Installment Payments $

TOTAL HOUSEHOLD INCOME $

TOTAL HOUSEHOLD EXPENSES $

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PERSONAL FINANCIAL QUESTIONNAIRE PACKET

PERSONAL INFORMATION

EMPLOYMENT INFORMATION

TAXPAYER

spouse

PERSONAL ASSET INFORMATION

Life Insurance: (list any life insurance policy with cash value – NOT TERM LIFE)

Any Real Estate/Primary Residence/Rental Properties/ Lands Owned: (If more than 1 property, please list additional owned properties on a separate sheet if necessary)

Motor Vehicles Owned: (If more than 2 vehicles, please list additional vehicles on a separate sheet)

1 Vehicle:

2 Vehicle:

PERSONAL MONTHLY INCOME & EXPENSE

INCOME EXPENSES

Monthly

Item Actual/Monthly

If You Or Your Spouse Generate Income as A Sole Proprietor Or Independent Contractor Please Provide The Following Information:

BUSINESS ASSET INFORMATION: (for Self-Employed)

Notes Receivable

Accounts Receivable

BUSINESS INCOME AND EXPENSE INFORMATION: (for Self-Employed)

**SOLE PROPRIETORSHIP BUSINESS INFORMATION ONLY**

INCOME EXPENSES

OTHER FINANCIAL INFORMATION:

TAXES OWED

SOLE PROPRIETORSHIP BUSINESS INFORMATION ONLY