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2016 Individual Tax Questionnaire

Contact Information

Your Name:
Home phone:
Cell phone:
Work phone:

Personal Information

Did your marital status change during 2016?
Are you legally married?
If Yes, do you and your spouse want to file separate returns?
If Yes, will you file a joint federal return and be required to file single state returns?
If No, are you in a domestic partnership, civil union, or other state-defined relationship?
Did your address or other contact information change during 2016?
Can you or your spouse be claimed as a dependent by another taxpayer?
Did you and your spouse have health care coverage in 2016?
If so please select provider:

Other provider:
Did you move to another state in 2016?
If yes, please provide an explanation below:


Were there any changes in dependents from the prior year?
Note: Include non-child dependents for whom you provided more than half the support?
Did you pay for child care while you worked or looked for work?
Do you have any children under age 18 with unearned income more than $2100?
Do you have any children age 18 or student children, aged 19 to 23, who did not provide more than half of their cost of support with earned income and that have unearned income of more than $2100?
Did you adopt a child or begin adoption proceedings during 2016?

Identity Theft

Did you or your spouse experience identity theft in 2016 or prior years?
If so, did you receive a federally issued PIN for your 2016 return? Please provide below:

Purchases, Sales and Debt

Did you have any debts canceled, forgiven, or refinanced during 2016?
Did you start a new business, purchase a new rental property, farm or acquire any new interest in any partnership or S corporation during 2016?
Did you sell an existing business, rental property, farm, or any existing interest in a partnership or S Corporation during 2016?
Did you sell, exchange, or purchase any real estate in 2016?
Did you withdraw any amounts from your Individual Retirement Account (IRA) or Roth IRA to acquire a principal residence?
Did you receive grants of stock options from your employer, exercise any stock options granted to you or dispose of any stock acquired under a qualified employee stock purchase plan?
If you have options from this year or prior years please provide a vesting schedule from your employer.
Did you pay any student loan interest in 2016?
Are your total mortgages on your first and/or second residence greater than $1,000,000?
If so, please provide the principal balance and interest rate at the beginning and end of the year.
Did you have an outstanding home equity loan at the end of 2016 greater than $100,000?
If so, please provide the principal balance and interest rate at the beginning and end of the year.
Did you re-finance during the year?
Are you claiming a deduction for mortgage interest paid to a financial institution and someone else received the Form 1098?
Are you claiming mortgage interest paid to someone other than a bank or financial institution?
If so, did you receive a Form 1098?
Did you pay any mortgage insurance premiums this year?
Did you sell any securities not reported on your Form 1099-B? (i.e. puts and calls)

Itemized Deductions

Business Auto Expenses: Do you have un-reimbursed business automobile expenses?
If yes, automobile expenses need to be substantiated with mileage logs and trip sheets for each trip. Commuting miles between your home and a fixed work location are not considered deductible. Can you substantiate your automobile expenses with the required supporting documentation?
If yes, please provide the following information:
Auto Make, Model, and Year:
Date Placed in Service:
Mileage From January 1, 2016 to December 31, 2016:
Total Miles Driven:
Total Business Miles Driven:
Did you incur any casualty or theft losses during the year?
Did you make any large purchases, such as motor vehicles and boats?
Did you incur any casualty or loss attributable to a federally declared disaster?
For contributions made with cash to a charitable organization, do you have receipts substantiating the amount given? Receipts are required regardless of the dollar amount, even for as little as a $1 contribution.
For each contribution in the amount of $250 or more and made with checks or credit cards to a charitable organization, do you have written acknowledgement from the charity substantiating the amount given? Written acknowledgements are required. Cancelled checks are insufficient.
Did you contribute property (other than cash) with a fair market value of more than $5,000 to a charitable organization?

Foreign Reporting

Were you or your spouse a grantor or transferor for a foreign trust, have an interest in or a signature or other authority over a bank account, securities account or other financial account in a foreign country?
Did you or your spouse own any foreign financial assets?
Did you create or transfer money or property to a foreign trust?
Did you have any foreign income or pay any foreign taxes during 2016?
During 2016, did you receive a gift or inheritance from a foreign person?

Savings Plans

Did you or your spouse have any transactions pertaining to a medical savings account (MSA) during 2016? If you received a distribution from an MSA, please include Form 1099-SA.
Did you or your spouse have any transactions pertaining to a health savings account (HSA) during 2016? If you received a distribution from an HSA, please include Form 1099-SA.
Did you or your spouse contribute to a Roth IRA or convert an existing IRA into a Roth IRA?
Did you or spouse roll into a Roth IRA any distributions from a retirement plan, an annuity plan, tax shelter annuity, or deferred compensation plan?


Did you withdraw any amounts from your IRA to pay for higher education expenses incurred by you, your spouse, your children or grandchildren?
Did you or your dependents incur any post-secondary education expenses, such as tuition?


Did you move to a different home because of a change in the location of your job?
Did you pay in excess of $1,000 in any quarter, or $2,000 during the year, for domestic services performed in or around your home to individuals who could be considered household employees?
If yes, has a Form W-2 or Form 1099-MISC been issued to the respective individual(s)?
Did you or your spouse receive distributions from long-term care insurance contracts? If Yes, please include Form 1099-LTC.
Did you use gasoline or special fuels for business or farm purposes (other than for a highway vehicle) during the year?
If Yes, please provide the gallons of gasoline or special fuels used for off-highway business purposes:
Have you received a punitive damage award or an award for damages other than for physical injuries or illness?
Were you notified by the IRS or other taxing authority of any changes in prior year returns?
Did you install any alternative energy equipment in your residence such as solar water heaters, solar electricity equipment (photovoltaic), or fuel cells?
Did you install any energy efficiency improvements or energy property in your residence such as exterior doors or windows, insulation, heat pumps, furnaces, central air conditioners, or water heaters?
Did you engage in any bartering transactions?
Did you or your spouse serve in the military or were you or your spouse on active duty?


If you are a resident of Massachusetts, did you make any purchases out of state for which you owe use taxes?


Did you retire or change jobs in 2016?
Did you receive deferred, retirement or severance compensation?
If Yes, enter the date received (Mo/Da/Yr):
Did you or your spouse turn age 70 1/2 during the year and have money in an IRA or other retirement account while not taking a distribution?
Did you rollover any retirement funds?
Do you hold retirement accounts outside of your company/job?
Type (IRA/Rollover IRA/ROTH/ROTH Rollover, etc.):

Sale of Your Home

Did you sell your home in 2016?
If Yes, did you receive Form 1099?
If Yes, did you own and occupy the home as your principal residence for at least two years of the five-year period prior to the sale?
Did you ever rent out this property?
Did you ever use any portion of the home for business purposes?
Have you or your spouse sold a principal residence within the last two years?
At the time of the sale, was the residence owned by the:

Real Estate Professional

Did you perform real estate activities such as rental, development, brokerage, acquisition or management that exceeded 750 hours in all such activities?
Can you substantiate such hours claimed?

S Corporation and Partnership/LLC

Did you receive (or will you be receiving) any K-1s during 2016?
If yes, please refer to page 11 in your Tax Organizer.
List below those K-1's that you materially participated in (500 hours or more).
Can you substantiate such hours claimed?


Did you make gifts of more than $14,000 to any individual or if married, did you and/or your spouse make combined gifts of over $28,000 to any individual?
If yes, please provide additional information below:
Gift amount: $
Property type:

Trust and 529 Plans

For any trust you created or that you are the trustee, have any beneficiaries died during 2016?
Did you withdraw amounts from a Coverdell Education Savings Account or Qualified Education Program (Section 529 plan)? If Yes, include Form 1099-Q.
Did you or your spouse make any contributions to Qualified State Tuition Plans (Section 529 plans) during 2016:
TS Name of
Designated Beneficiary
State Sponsoring
Account Number 2016 Amount Contributed

Other Items for Planning

Do you have a will?
Date of Will/Last Updated?
Does your spouse have a will?
Date of Will/Last Updated?
Have you created a living trust?
Do you have a Health Care Proxy for members of your household over the age of 18?
Do you have a Will with guardians set up for your children?
If your net worth is over $1 million (MA exemption), have you discussed an estate plan with an attorney or Newburg & Company?
Do you have disability/life insurance outside of what your employer provides?
Coverage details:
Have you created an irrevocable life insurance trust?
Do you have long-term care insurance?
Coverage details:


List brokerage houses where investments are held:
How many times a year on average do you meet or speak with your investment advisor?
Does your financial advisor maintain an up to date financial plan for you?

2017 Tax Planning

Do you expect any of the following to occur in 2017?:
A change in your marital status or the number of dependents
A substantial change in your income or withholdings
A substantial change in your deductions
If yes to any of the above, please provide explanations below:


Have you uploaded or sent in all your information for tax preparation?
If not, when is the expected date that all your data will be sent/uploaded?
Will you be receiving any requisite tax information (e.g. K1 forms, etc.) late or after the April 15, 2017 deadline that may warrant filing an extension?
Will estimates be provided?
Please provide details below:

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