FRIENDLY TAX SERVICE

2016 TAX RETURN PREPARATION QUESTIONNAIRE

PERSONAL INFORMATION
Primary Applicant: (IN CAPITAL LETTERS)
FirstName
LastName:
Middle/Initial Name:
Date of Birth: (MM/DD/YYYY) SSN #:
Current Address:
Phone Mobile:
Occupation:
Visa Status as of Dec, 31st (US Citizen, Green Card, EAD, H1,
F1, J1, L1):
Spouse (Secondary Applicant): (IN CAPITAL LETTERS)
FirstName:
LastName:
Middle/Initial Name:

If ITIN is required, please put the comment as 'APPLY IT

Spouse DOB (MM/DD/YYYY) SSN#/ITIN #: NUMBER'
Visa Status as of Dec, 31st (US Citizen, Green Card, EAD, H1,
F1, J1, L1):
If spouse is working, please put the occupation:
Have you changed your name since your last return? (circle)
(Yes/No):
If yes, what was your previous Surname?
Home Email Address Work Email Address

DEPENDANT CHILDREN/Parents Information (Note: Parents in this context are referred as parents of Primary or Secondary Applicants)
Visa Status as of Dec,
SSN/ITIN (If ITIN is required, 31st (US Citizen,
please put the comment as Green Card, EAD, H1,
Child's/Parent Name (IN CAPITAL LETTERS) 'APPLY ITIN NUMBER' Date of Birth (MM/DD/YYYY) Relationship F1, J1, L1):

EMPLOYMENT INFORMATION: (Please send copies of W2/1099)

Company Name Title From To W2/1099

INTEREST INCOME: (Please send copies of Bank interest document 1099-INT)

Financial Institution (Police Credit Union, Bank etc) Amount

DIVIDEND INCOME (If unsure, enclose Statement from Company)

Name of Public Company Unfranked Amount Franked Amount Imputation Credit

STOCK GAIN/LOSS (If unsure, enclose Statement from Company)

Name of stock Purchase Date Purchase Value Number of Stocks Sale Date

CHILD CARE EXPENSES: (Please send copies if received from care provider)
EIN or SSN or ITIN of the
Care Provider Name Address provider From To

DEPENDENT CARE EXPENSES

Expense Type Name From To Amount
SELF EDUCATION EXPENSES. ( Course taken at educational institution and connected to your current job)
Course Name Amount

Student Union Fees

Course Fees ( Not HECS Contributions)
Travel (use of private vehicle, taxi, public transport )
Reference Books/Stationery
Equipment

Commuting Expenses:

Commuting Type By Car/Train/Air

Mileage: <<Put # of miles per year>>
Distance from working place and home <<please provide this mileage>>
If by Train, please provide per day travel expenses
If by Air, please provide details on air, rental car expenses.

OTHER WORK RELATED DEDUCTIONS:

Amount Amount
Any major work related expenses:

Apartment Rent in US:

Rental Office Address in US: Ownership % Rental Amount per month ($) State Name From (MM/DD/YYYY)

Moving Expenses:
Loging/Hotel
From State To State Travel Expenses Movers Exp Expenses

PROPERTY In US/India:

Property name on: Last Name: First Name :

Property Address:
Date of Purchase (MM/DD/YYYY)
Interest paid from 1st Jan - 31st Dec, 2016 (In $$)
Bank Name
Bank Address:
Bank Phone Number:
Loan Number:

Rental Property in US/India:

Rental Property Address: Ownership % Rental Income ($) From To

Note. If you have an annual financial report from your real estate, please enclose.

PRIVATE HEALTH INSURANCE.

if NO, add the insurance
Do you have health insurance coverage from your employer? Yes/NO payments under the medical
expenses.

HEATH INSURANCE COVERAGE INFORMATION

if NO, list the months for which

Do you have health insurance for all 12 months of 2016? YES/NO you don't have health insurance.

if NO, list the months for which

Does you spouse and kids have health insurance for all 12 you spouse/kids don't have
months of 2016?? YES/NO health insurance.

MEDICAL EXPENSES. AMOUNT ($)

Hospital Charges
Doctor Co-pays
Prescription Drug Copays
Any other medical expenses not covered by Insurance

Charitable/DONATIONS AMOUNT ($)

EDUCATION OFFSET EXPENSES (Primary School Max $375, High School Max $750 per child)
School Stationery and textbooks etc Amount
Computer
ComputerRelated
Equipment
Home Internet
School Stationery and textbooks etc
Tools of Trade

For DIRECT DEBIT/CREIDT: If you would like your tax refund direct credited to your nominated account please provide the following ( same account can be used for tax due
payment also):
a. Account Name
Please refer to your
checkbook, it should be
b. Routing Number (ABA number/paper or electronic number) first number with 9digits.
c. Account Number
d. Type of Account:
e. Bank Name

For Driver License Info: : This additional information would help to combat stolen-identify tax fraud to protect you and your tax refund. If you have a driver's license or state issues identification card, please
provide the requested information from it.
The return will NOT be rejected if you do not provide this information, however providing the information may help process the return more quickly.
If filling single, provide Driving license ID#, Location of Issuance, Issue date and expiration date.
If filling joint, provide your spouse Driving license ID#, Location of Issuance, Issue date and expiration date.
If your spouse doesn't have driving licence, provide a state ID, Location of Issuance, Issue date and expiration date.
Primary applicant Driver/State ID: Spouse applicant Driver/State ID:
Primary applicant Driver/State ID Location of Issuance Spouse applicant Driver/State ID Location of Issuance
Primary applicant Driver/State ID Issue date: Spouse applicant Driver/State ID Issue date:
Primary applicant Driver/State ID expiration date: Spouse applicant Driver/State ID expiration date:
RE

ITIN is required, please put the comment as 'APPLY ITIN

NUMBER'

plicants)

Date when Did child/parent

landed in US came to US during
during 2016: 2016/2015/2014??

Please send W2/1099

copies

Please send copies of

bank interest copies.

Please send copies of

DIV statements.

Please send copies of

Sale Value broker statements.

Amount
Please send copies of
provider tax
statements.

Please send copies of

provider tax
statements.
 Please send copies of
tuition or collage
statements.

Add multiple rows if

lived in multiple state
and apartments in a
To (MM/DD/YYYY) given year.

Moving Data

Add multiple rows for

multiple rental
properties..
wing ( same account can be used for tax due

r's license or state issues identification card, please