Name(s):

This Form Completed and Returned

All APPLICABLE Documents and Information as Indicated on the Enclosed 2017 Tax Documentation Checklist

AFFORDABLE CARE ACT Questionnaire (see reverse side)

The Enclosed Engagement Letter Signed and Dated

If You Are a NEW Client Please Provide Copies of Your 2016 Federal and State Income Returns

Preferred E-Mail: Preferred Phone:

Bank Name: Your Account Number:

Bank Routing Number: Account Type: ___ Checking ___ Savings

Yes No : Do you want refunds, if any, applied to your 2018 estimated tax liability?

Yes No : May the IRS or a state tax agency discuss this return with us?

Yes No : If you paid rent during the year: Amount: $ ___________________ Was heat included in rent? Yes No

Yes No : At anytime during the year did you have a financial interest or signature authority over a

foreign financial account located in a foreign country?

Yes No : Did you make gifts totaling more than $14,000 to any individual during the year?

Yes No : Did you, if applicable, take the Required Minimum Distribution(s) (> age 70 1/2) from retirement accounts?

Yes No : Were you issued an Identity Protection PIN by the IRS? If so, please provide IRS letter.

Yes No : Did you make any taxable purchases from out-of-state sellers in 2017 on which sales tax should be paid

but was not charged? If yes, amount of purchases: $

Taxpayer: Spouse:

SSN: SSN:

Occupation: Occupation:

Date of Birth: Date of Birth:

Preferred Tel: Preferred Tel:

Preferred Email: Preferred Email:

Address:___ City ___ Village ___ Town

City: County:

State - Zip: WI School District:

First & Last Name - SSN - Relationship - DOB - College Student? (Yes-No) - Gross Income Less Than $4,050? (Yes-No) - Support You Provided (%)

1)

2)

3)

(Use Reverse Side If Additional Dependents)

*** REQUIRED 2017 INFORMATION ***

BANK INFORMATION IF YOU WOULD LIKE DIRECT DEPOSIT OF ANY TAX REFUNDS

USE REVERSE SIDE TO COMPLETE THE AFFORDABLE CARE ACT QUESTIONNAIRE

AND FOR ANY COMMENTS AND QUESTIONS

PLEASE COMPLETE ONLY IF WE HAVE NOT PREVIOUSLY PREPARED YOUR TAX RETURNOR IF THERE WERE ANY CHANGES

Dependent Children & Others Dependents

PRIMARY CONTACT INFORMATION

(PLEASE ALSO PROVIDE A VOIDED CHECK)

Name(s):

INDIVIDUAL SHARED RESPONSIBILITY PAYMENT

Did you have qualifying health care coverage, also know as minimal essential coverage, for EACH memberof your entire tax household for EACH month of 2017? Your tax household includes you, your spouse (iffiling a joint return), and any individual you can claim as a dependent on your tax return. It also generallyincludes each individual you can, but do not, claim as a dependent on your return if the dependentis properly claimed on another taxpayer's return. An individual is considered to have Minimum Essential Coverage for a month if covered for at least 1 day during that month. Medicare qualifies for Minimum Essential Coverage.

YES NO

If NO, check the months EACH individual of your tax household DID HAVE Minimal Essential Coverage.

Self __JA __FB __MR __AP __MY __JN __JL __AG __SP __OC __NV __DC

Spouse __JA __FB __MR __AP __MY __JN __JL __AG __SP __OC __NV __DC

__JA __FB __MR __AP __MY __JN __JL __AG __SP __OC __NV __DC

__JA __FB __MR __AP __MY __JN __JL __AG __SP __OC __NV __DC

__JA __FB __MR __AP __MY __JN __JL __AG __SP __OC __NV __DC

__JA __FB __MR __AP __MY __JN __JL __AG __SP __OC __NV __DC

__JA __FB __MR __AP __MY __JN __JL __AG __SP __OC __NV __DC

If you were granted an exemption by the Marketplace, please provide the notice with your Exemption

Certificate Number (ECN). We will contact you if you are possibly eligible for other exemptions.

PREMIUM TAX CREDIT (If Applicable)

If you enrolled for lower cost MarketPlace Coverage through healthcare.gov please provide all IRS Forms

1095 received by any individual of your tax household.

If any dependents being claimed on your tax return were required to file a tax return please provide a copy.

Are you covered under a health insurance policy of an individual that will not claim you as a dependent?

YES NO

Is anyone covered under your health insurance that will not be claimed as a dependent on your return?

If YES, please provide SSN, insurance policy number, and date(s) of coverage for dependents not claiming.

YES NO

YOUR COMMENTS AND QUESTIONS

AFFORDABLE CARE ACT *** THIS INFORMATION MUST BE PROVIDED IN ORDER TO PREPARE YOUR TAX RETURN ***

PLEASE PROVIDE

INCOMEWages W-2 forms

Interest & Dividend Income 1099-INT, 1099-OID & 1099-DIV forms, year-end annual summary brokerage statements

State Tax Refund 1099-G forms (WI will not be mailing this form if you e-filed last year or owed taxes)

Alimony Received Amount received in 2017

Sole Proprietor Income Income, expenses, year-end inventory, vehicle expenses & mileage information, etc.

Capital Gains & Losses (1) 1099-B forms, year end annual summary brokerage statements, closing statements, cost basis

IRA Distributions (2) 1099-R forms, information for amounts that were rolled over, cost basis if any

Pensions & Annuities 1099-R forms, information for any amounts that were rolled over

Rental Properties (3) Rental income and expenses. Please provide the # of days rented at fair rental value.

Please also provide the # of days of personal use, if any (cottage, vacation home, etc.)

Pass Through Entities Partnership, S-Corporation, Estate and Trust Schedule K-1 forms

Unemployment Compensation 1099-G forms

Social Security Benefits SSA-1099 forms

Railroad Retirement Benefits RRB-1099 forms

Gambling Winnings W-2G forms, records of winnings & losses. Did losses exceed winnings? __Yes __No

HSA Distributions 1099-SA forms, annual account summary statement. Were all amounts from the HSA

used to pay for qualified medical & dental expenses? __Yes __No

529 Education Account Withdrawals 1099-Q forms, amounts paid for tuition, fees, books, supplies, room and board,

Other Income Jury duty, tip income not reported to employers, hobby income, prizes, and awards,

Form 1099-C (cancelled debt) , Form 1099-MISC (miscellaneous income), other income

ADJUSTMENTS

Educator Expenses Out-of-pocket K-12 classroom costs, up to $250

HSA Contributions (4) Amount of your after-tax contributions, do not include amounts paid by your employer

or with pre-tax dollars through an employer plan

Moving Expenses If move was job related and new workplace is at least 50 miles further from old home

Self Employed Retirement Plan Amount contributed or to be contributed by due date of tax return, including extensions

Alimony Paid Amount paid in 2017, recipients name and SSN

IRA Contributions Traditional or Roth IRA amounts contributed or to be contributed by April 17th, 2018

Student Loan Interest (5) 1098-E forms. Please provided who is primarily liable for the loan

Tuition & Fees Paid 1098-T forms, amount of qualified tuition and fees paid during 2017

Edvest Contributions-WI 529 Plans Amounts contributed during 2017 for each account beneficiary. Name and address of

account owner(s). Name of account beneficiary(s).

Private School Tuition Student name(s), grade(s) & tuition paid. Name, address & FEIN (ID #) of school(s).

ITEMIZED DEDUCTIONSHealth Insurance Premiums paid, do not include amounts paid by employer or with pre-tax dollars

Dental Insurance Premiums paid, do not include amounts paid by employer or with pre-tax dollars

Long-Term Care Insurance - Self Premiums paid, do not include amounts paid by employer or with pre-tax dollars

Long-Term Care Insurance - Spouse Premiums paid, do not include amounts paid by employer or with pre-tax dollars

Mileage Miles driven for medical and dental care

Other Medical & Dental Expenses Out of pocket expenses, including deductibles and co-pays, not covered by insurance

or paid with FSA (Employer Pre-Tax Plans) or HSA funds

Sales Taxes (6) Only if electing not to deduct state income taxes

Real Estate Taxes Real Estate Tax Bill(s) for taxes paid to a municipality in 2017

Home Mortgage Interest (7) Form(s) 1098 for interest, points and/or mortgage insurance premiums paid

Investment Interest Expense Amounts paid, year end summary brokerage statements

Gifts To Charities - Cash or Check (8) Donated amounts, documentation suggested for charities receiving > $250

Gifts To Charities - Used Items (9) Fair market value amounts of items that are in good used or better condition only

Volunteer Expenses and Mileage Out of pocket expenses and/or mileage for volunteering for a charity

IF YOU HAVE

2017 TAX DOCUMENTATION CHECKLIST

PLEASE PROVIDEIF YOU HAVE

2017 TAX DOCUMENTATION CHECKLIST

Casualty and Theft Losses Provide details

Employee Business Expenses Description and amount of unreimbursed expenses, union dues, protective wear, items

and supplies needed for job, travel & lodging, meals and entertainment, etc. For auto

expenses please provide total mileage, commuting mileage and business mileage for

each vehicle you are claiming a deduction. If claiming actual expenses, rather than the

the standard mileage rate, also provide interest paid on auto loan (or payments if

leased), and actual costs such as fuel, maintenance, insurance, etc .

Miscellaneous Deductions Tax preparation fees, job hunting costs, gambling losses, investment fees, etc.

TAX CREDITS

Child and Dependent Care Amount of child care paid for each dependent child under age 13. Name, address,

SSN/EIN and amount paid to each child care provider.

Education Credits 1098-T forms, amounts paid in 2017 for tuition & fees and books & supplies

Energy Credits Qualified energy efficiency improvements to your main home. Amounts paid (except

labor costs) for certain insulation material, exterior windows, exterior doors, and

roofing materials. Amounts paid (including labor costs) for certain water heaters,

central air conditioners, furnaces, and boilers.

WI Homestead Credit 2017 Real Estate Tax Bill or Rent Certificate; amount of child support income, if any

ESTIMATED TAXES

Federal estimated tax payments Amount applied from last year's refund, dates and amounts for estimated payments

State estimated tax payments Amount applied from last year's refund, dates and amounts for estimated payments

YOUR COMMENTS

NOTES

1 When a security is sold, you should receive Form 1099-B reporting the proceeds from the sale. However, your statement will not always provide

the cost/basis information necessary to compute gain or loss. If the statement does not contain cost/basis information you must provide it.

Cost basis can typically be: a) cost of investment plus reinvested dividends and capital gains, if any, b) purchase price of property plus

improvements less depreciation for tax purposes, c) date of death value if inherited, d) donor's basis if received as a gift.

2 Cost basis is the amount of non-deductible IRA contributions less the cost basis amount previously recovered on prior distributions.

3 If you reside in one of the units of the rental property (duplex , 4-family, etc) please indicate if expenses apply only to the rental units or to all

the units including your residence. Do not include expenses only applicable to your residence.

4 You must be covered under a high deductible health plan (HDHP). Please let us know if coverage is self-only or family.

5 You must have primary obligation to repay the loan. You also can not be claimed as a dependent on another taxpayer's return.

6 The amount of sales tax to deduct is provided per an IRS table. Additionally you can deduct sales tax for the purchase or lease of a vehicle or boat.

7 Must be interest paid on acquisition indebtedness or home equity indebtedness secured by your main or second home. Acquisition

indebtedness is debt up to $1,000,000 incurred to acquire, construct or substantially improve your main or second home. Refinancing

acquisition indebtedness is considered acquisition indebtedness to the extent it does not exceed the principal outstanding on the loan

immediately before the refinancing. Home equity indebtedness is debt up to $100,000 no matter how the proceeds are used.

8 Donations by cash or check are only allowed if you either have a bank record (cancelled check or bank statement) or written acknowledgement

from the charity documenting the amount and date. As such, cash donations are not deductible without a written acknowledgement from the

charity. Donations of $250 or more in any one day to any one organization must have written acknowledgement from the charity. A cancelled

check is not sufficient.

9 Donated items must be in good used condition or better. Deduction amount is equal to the fair market value (rummage sale, thrift shop, etc.)

at the time donated. Additional information is needed if the deduction for donated items is more than $500.

(PLEASE CALL IF YOU HAVE ANY QUESTIONS IN REGARDS TO GATHERING YOUR INFORMATION)

This letter confirms the terms of engagement with you and outlines the nature and extent of the services we will provide. 

 We will prepare your 2017 federal and state income tax returns. We will depend on you to provide the information we need to prepare complete and accurate returns. We may ask you to clarify some items but will not audit or otherwise verify the data you submit. A Tax Organizer can be found on our website, www.btacpa.us, to help you collect the data required for your return and to help you avoid overlooking important information. By using it, you will contribute to the efficient preparation of your returns and help minimize the cost of our services. 

 

We will perform accounting services only as needed to prepare your tax returns.  Our engagement should not be relied upon to disclose errors, fraud, or other illegal acts, though it may be necessary for you to clarify some of the information you submit. We will, of course, inform you of any material errors, fraud, or other illegal acts we discover. 

 The law imposes penalties when taxpayers understate and/or are not timely with their tax liability. Please call us if you have concerns about such penalties. 

 Should we encounter instances of unclear tax law, or of potential conflicts in the interpretation of the law, we will outline the reasonable courses of action and the risks and consequences of each. We will ultimately adopt, on your behalf, the alternative you select. 

 We will return your original records to you at the end of this engagement. You should securely store these records, along with all supporting documents, cancelled checks, etc. as these items may later be needed to prove accuracy and completeness of a return. 

 Our engagement to prepare your 2017 tax returns will conclude when you have received the completed returns. Our charge will be based upon our fee schedule for preparing individual income tax returns and time expended, if applicable. Invoices are due and payable upon receipt of your completed tax return. Tax returns will not be e‐filed until paid for in full. Review all tax return documents carefully before signing them. 

 To affirm that this letter correctly summarizes your understanding of the arrangements for this work, please sign this letter in the space indicated and return it to us with your tax documents. 

  

 

Client Signature Date Spouse Signature (if MFJ status) Date

Print Name Print Name

 

Business Name________________________________________________________

FEIN Number________________________

Entity Type:        Sole Proprietorship        Single Member LLC

Description of Business Activity___________________________________________

Business Belongs to:   Taxpayer              Spouse 

Did you make any payments in 2017 that would require you to file Form(s) 1099?           Yes         No

If Yes, did you or will you file all required Forms 1099?           Yes         No

Number of 1099's enclosed _______________Amount

INCOME

   Gross Receipts or Sales $

   Less:

             Returns & Allowances

             Cost of Goods Sold

EXPENSES

Advertising

Vehicle Expense ‐ See Next Page

Commissions & Fees

Contract Labor

Employee Benefits

Insurance (other than health)

Mortgage Interest (paid to banks)

Health Insurance

Other Interest

Legal & Professional Services

Office Expense

Pension & Profit Sharing Plans

Equipment Lease

Rent

Repairs & Maintenance

Supplies

Taxes & Licenses

Travel

Meals & Entertainment

Utilities

Wages

Telephone

Dues & Subscriptions

Bank Service Charges

Other Expenses:  Please list

Equipment Purchases:  Please list

Business Income and Expenses Worksheet (Complete if NOT already prepared by BTA) 

Continued on Next Page

Business Income and Expenses Worksheet Continued

Yes No

Did you have a home office?

If yes, total square footage of home ______________    total square footage of office space ______________

Did you have a personal vehicle used for business?

Description of Vehicle

Date Purchased

Cost or other basis. If leased, enter yearly lease payments

Actual Vehicle Costs in 2017

Total Miles Driven in 2017

   Total Business Miles

   Total Commuting Miles

Was the Vehicle used for Personal Use?

Do you have evidence to support the Business Miles?

   Is evidence in writing?

  Yes         No  Yes         No

  Yes         No  Yes         No

  Yes         No  Yes         No

VEHICLE 1 VEHICLE 2

Did you make any payments in 2017 that would require you to file Form(s) 1099?           Yes         No

If Yes, did you or will you file all required Forms 1099?           Yes         No

Property #1 Property #2 Property #3 Property #4

Description of Property

Gross Rents & Royalties

Expenses:

    Advertising

    Auto & Travel

    Cleaning & Maintenance

    Commissions

    Legal & Other Professional  Fees

    Insurance

    Management Fees

    Mortgage Interest (Form 1098)

    Other Mortgage Interest

    Other Interest

    Repairs

    Supplies

    Taxes

    Utilities

    Wages & Salaries

    Other:

__________% __________% __________% __________%

If property was a vacation home, how 

many days was it occupied by you?_______ days _______ days _______ days _______ days

How many days rented? _______ days _______ days  _______ days _______ days

      Yes       No

Rent and Royalty Income Worksheet

Please fill fortype of property:

What % of the property did you 

occupy during the year?

Were you active in the management of 

the rental property?      Yes       No       Yes       No       Yes       No

Single Family

Multi‐familyVacationLand

Self‐rental

RoyalitiesOther

Commercial

Single FamilyMulti‐familyVacationLandSelf‐rental

Royalities

Other ____________

Commercial

Single FamilyMulti‐familyVacationLand

Self‐rental

RoyalitiesOther

Commercial

Single Family

Multi‐familyVacationLand

Self‐rental

RoyalitiesOther

Commercial