Wages and Salaries (Attach W-2's) Name of Payer Gross Soc. Name: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Name: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Name: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Name: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec DEPENDENTS: Income Date of Social Security Relationship Months Name (First, Initial, Last) Over Birth Number Lived in $2,000? Home (Y/N) INCOME: 1. Provide all applicable exemption certificate numbers issued for each member of your family.ΔΆ Tax Return Questionnaire 2014 Tax Year - of Complete the information below if you or any individual included in your tax family did NOT have insurance coverage for any month of Please circle any months a member of your tax family was NOT insured. If you were issued a hardship exemption by the Marketplace (Exchange).
If you had compliant health insurance through an employer plan, private policy or with a government plan and provide Form 1095-B, 1095-C or other proof of insurance document. If a dependent filed a return for Provide a copy of the return. If so, you will also need a copy of that taxpayer s 1095-A. If you are claiming someone on your return who was included on another taxpayer s policy with a Marketplace. In some family situations you may have more than one 1095-A. If you had health care coverage with a government Marketplace (Exchange) during Please provide Form 1095-A, issued by the Marketplace. More than one might apply to your tax family. Please read the following statements carefully. Tax Return Questionnaire Tax Year Name and Address: Social Security Occupation Number: Taxpayer: Address: Spouse: Address: Phone Numbers Work: Home: Address: Do you wish $3 to go to the Presidential Election Campaign? (Tax amount not affected) Yes Filing Status: Single Married Head of Household Qualifying Widow Birth Date: Month, Day, Year Yourself: / / Spouse: / / HEALTH INSURANCE COVERAGE: YOU MUST PROVIDE PROOF OF HEALTH INSURANCE COVERAGE BEGINNING ON JANUThe IRS requires that you report certain information related to your health care coverage on your 2014 tax return. This will save you time and money, and help us help you more effectively.
1 Print this form out, take some time to fill it out, and bring it with you when you come to the office.