2022 Tax Questionnaire If you are human, leave this field blank.Thank you for answering the questions below. Your answers assist us by ensuring significant tax issues are not overlooked. Once submitted a copy of this survey will be sent directly to your email or you may print a copy for your records. If you encounter any difficulties, do not hesitate to contact our Tax Administrator, Amy vonSchondorf ([email protected], 585-491-9801)Name *Email *Who is your Tax Professional? *Not sureCaralyn WhiteDan NitschkeDennis SteinHannah MendicinoJenna DeverellKevin WoodworthMatt LesnickMike CookeMike YanusPam DuffySam TorchiaPersonal Information:Did your marital status change?YesNoAre you married?YesNoIf Yes, do you and your spouse want to file separate returns?YesNoIf No, are you in a domestic partnership, civil union, or other state-defined relationship?YesNoCan you or your spouse be claimed as a dependent by another taxpayer?YesNoDid you or your spouse serve in the military or were you or your spouse on active duty?YesNoDependents:Were there any changes in dependents from the prior year?Note: Include non-child dependents for whom you provided more than half the supportYesNoDid you or your spouse pay for child care while you or your spouse worked or looked for work?YesNoDo you have any children under age 18 with unearned income more than $1,150?YesNoDo 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 $1,150?YesNoDid you adopt a child or begin adoption proceedings?YesNoAre any of your dependents non-U.S. citizens or non-U.S. residents?YesNoHealthcare:Did you obtain healthcare coverage through the Marketplace?If Yes, include all Forms 1095-A.YesNoIf you received advance premium tax credit, are married, and are filing separately from your spouse, are you a victim of domestic abuse or spousal abandonment?YesNoDid you, your spouse, or a dependent have healthcare purchased through the Marketplace and for whom you did not receive Form 1095-A? YesNoDid you receive Form 1095-A for someone claimed as a dependent on another taxpayer's return or who is filing their own return and is not claimed as a dependent on another taxpayer's return?YesNoAre any of your dependents required to file a tax return?YesNoWas anyone covered on your health insurance policy also covered on another health insurance policy for any part of the year?YesNoWere you eligible for employer-sponsored healthcare coverage?YesNoDid you or your spouse have any transactions pertaining to a health savings account (HSA)?If you received a distribution from an HSA, include all Forms 1099-SAYesNoDid you or your spouse have any transactions pertaining to a medical savings account (MSA)?If you received a distribution from an MSA, include all Forms 1099-SAYesNoDid you or your spouse receive any distributions from long-term care insurance contracts?If Yes, include all Forms 1099-LTCYesNoIf you or your spouse are self-employed, are you or your spouse eligible to be covered under an employer's health plan at another job?YesNoIf Yes, how many months were you covered?If you or your spouse are self-employed, are you or your spouse eligible to be covered under an employer's long-term care plan at another job?YesNoIf Yes, how many months were you covered?Education:Did you, your spouse, or your dependents incur any post-secondary education expenses, such as tuition?YesNoDid you or your spouse pay any student loan interest?YesNoDid you or your spouse withdraw any amounts from your IRA to pay for higher education expenses incurred by you, your spouse, your children or grandchildren?YesNoDid you or your spouse withdraw any amounts from a Coverdell Education Savings Account or Qualified Education Program (Section 529 plan)?If Yes, include all Forms 1099-Q.YesNoIf Yes, were the amounts withdrawn used for qualified tuition expenses?YesNoDeductions and CreditsDid you or your spouse contribute property (other than cash) with a fair market value of more than $5,000 to a charitable organization?If Yes, provide the appraisal of property contributed. An appraisal is not required for contributions of publicly traded securities or contributions of non-publicly traded stock of $10,000 or less.YesNoDid you or your spouse incur any casualty or theft losses?YesNoDid you or your spouse make any large purchases, such as motor vehicles and boats?YesNoDid you or your spouse incur any casualty or loss attributable to a federally declared disaster?YesNoDid you or your spouse purchase a new alternative technology vehicle, including a qualified plug-in electric drive motor vehicle?YesNoDid you or your spouse use gasoline or special fuels for business or farm purposes (other than for a highway vehicle)?YesNoIf Yes, provide the number of gallons of gasoline or special fuels used for off-highway business purposes.Did you or your spouse install any alternative energy equipment in your residence such as solar water heaters, solar electricity equipment (photovoltaic) or fuel cells?YesNoDid you or your spouse 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?YesNoInvestments Did you or your spouse have any debts canceled, forgiven or refinanced?YesNoDid you or your spouse start or purchase a business, rental property, or farm, or acquire any new interest in any partnership or S corporation?YesNoDid you or your spouse sell an existing business, rental property, farm, or any existing interest in a partnership or S corporation?YesNoDid you or your spouse sell, exchange, or purchase any real estate?If Yes, include closing statements.YesNoDid you or your spouse receive grants of stock options from your employer, exercise any stock options granted to you or your spouse or dispose of any stock acquired under a qualified employee stock purchase plan?YesNoDid you or your spouse engage in any put or call transactions?If Yes, provide the transaction details.YesNoDid you or your spouse close any open short sales?YesNoDid you or your spouse sell any securities not reported on Form 1099-B?YesNoRetirement or Severance:Did you or your spouse contribute to a Roth IRA or convert an existing IRA into a Roth IRA?YesNoDid you or your spouse roll into a Roth IRA any distributions from a retirement plan, an annuity plan, tax shelter annuity or deferred compensation plan?YesNoDid you or your spouse turn age 72 and have money in an IRA or other retirement account without taking any distribution?YesNoDid you or your spouse make a qualified charitable distribution directly from an IRA?YesNoDid you or your spouse retire or change jobs?YesNoDid you or your spouse receive deferred, retirement or severance compensation?YesNoIf Yes, enter the date receivedPersonal Residence Did your address change?YesNoIf Yes, provide the new addressIf Yes, did you move to a different home because of a change in the location of your job?YesNoDid you or your spouse claim a homebuyer credit for a home purchased in 2008?YesNoDid you or your spouse withdraw any amounts from your Individual Retirement Account (IRA) or Roth IRA to acquire a principal residence?YesNoAre your total mortgages on your first and/or second residence greater than $750,000?YesNoDid you or your spouse take out a home equity loan?YesNoDid you or your spouse have an outstanding home equity loan at the end of the year?YesNoAre you claiming a deduction for mortgage interest paid to a financial institution and someone else received the Form 1098?YesNoDid you or your mortgagee receive mortgage assistance payments?If Yes, include all Forms 1098-MAYesNoSale of Your HomeDid you sell your home?YesNoDid you receive Form 1099-S?If Yes, include Form 1099-SYesNoDid you or your spouse own and occupy the home as your principal residence for at least two years of the five-year period prior to the sale?YesNoDid you or your spouse ever rent out the property?YesNoDid you or your spouse ever use any portion of the home for business purposes?YesNoHave you or your spouse sold a principal residence within the last two years?YesNoAt the time of the sale, the residence was owned by the...TaxpayerSpouseBothGifts Did you or your spouse make any gifts, including birthday, holiday, anniversary, graduation, education savings, etc., with a total (aggregate) value in excess of $16,000 to any individual?YesNoDid you or your spouse make any gifts of difficult-to-value assets (such as non-publicly traded stock) to any person regardless of value?YesNoDid you or your spouse make any gifts to a trust for any amount?YesNoDo you or your spouse have a life insurance trust?YesNoDid you or your spouse assist with the purchase of any asset (auto, home) for any individual?YesNoDid you or your spouse forgive any indebtedness to any individual, trust or entity?YesNoForeign Matters:Did you or your spouse perform any work outside of the U.S. or pay any foreign taxes?YesNoWere you or your spouse a grantor or transferor for a foreign trust, have any interest in or a signature authority over a bank account, securities account or other financial account in a foreign country?YesNoDid you or your spouse create or transfer money or property to a foreign trust?YesNoDid you or your spouse own any foreign financial assets?YesNoWere you or your spouse subject to the transition tax on undistributed foreign income and elect to pay the tax in installments?YesNoDid you or your spouse have an interest in an S corporation that had undistributed foreign income subject to the transition tax?YesNoIf Yes, did the corporation cease to be an S corporation?YesNoIf Yes, was there a sale or liquidation of substantially all of the corporation's assets or did the corporation cease business?YesNoIf Yes, did you or your spouse transfer any share of stock in the corporation?YesNoMiscellaneous:Did you or your spouse pay in excess of $1,000 in any quarter, or $2,400 during the year for domestic services performed in or around your home to individuals who could be considered household employees?YesNoDid you or your spouse receive unreported tip income of $20 or more in any month?YesNoHave you or your spouse received a punitive damage award or an award for damages other than for physical injuries or illness? YesNoDid you or your spouse engage in any bartering transactions?YesNoWere you or your spouse notified by the IRS or other taxing authority of any changes in prior year returns?YesNoFor any trust that you or your spouse created or are trustee, did any beneficiaries, grantors, or trustees die or move?YesNoIn 2022, did you or your spouse: (a) receive (as a reward, award, or compensation); (b) sell, exchange, gift or otherwise dispose of a digital asset (or a financial interest in a digital asset)YesNoIn 2022, did you or your spouse receive Payroll Protection Program loan forgiveness or are you or your spouse seeking forgiveness?YesNoIf No, enter the date loan forgiveness was denied or that you or your spouse decided not to seek forgivenessIn 2022, did you or your spouse have any student loan(s) discharged under the Biden-Harris Administration's student loan debt relief plan?YesNoCaptcha *reCAPTCHA is required.Submit
