Name
*
First Name
Last Name
Spouse's name
First Name
Last Name
Occupation
Email address
*
Spouse's email address
Phone
(###)
###
####
Current address
Have you lived at the same address all year?
Date moved
* only needed if moved during the tax year
MM
DD
YYYY
Previous address
* only needed if moved during the tax year
Filing status
Dependents
* Existing clients - fill in name(s)
* New clients - fill in all info
Did you purchase health insurance from a government marketplace?
1095-A (Marketplace health insurance)
0
1
2
Would you like direct deposit of refund (recommended if applicable)
*
Would you like direct debit of tax amount due (recommended if applicable)
*
Can chose withdrawal date on or before April 15th
Name of Bank
Type of bank account
At any time during 2023, did you: (a) receive (as a reward, award, or payment for property or services); or (b) sell, exchange, gift, or otherwise dispose of a digital asset (or a financial interest in a digital asset)?
*
If yes, send us a .csv file of 2023 transactions detailing dates acquired and sold, descriptions, proceeds, and cost.
W-2
0
1
2
3
4
5
6
7
8
9
10+
1099-INT (bank/investment interest)
0
1
2
3
4
5
6
7
8
9
10+
Foreign account: At any time during 2023, did you have a financial interest in or signature authority over a financial account (such as a bank account, securities account, or brokerage account) located in a foreign country?
If "Yes," are you required to file FinCEN Form 114, Report of Foreign Bank and Financial Accounts (FBAR), to report that financial interest or signature authority?
1099-DIV (dividends, capital gains)
0
1
2
3
4
5
6
7
8
9
10+
1099-NEC/MISC
0
1
2
3
4
5
6
7
8
9
10+
1099-B (stock sales)
0
1
2
3
4
5
6
7
8
9
10+
1099-G (refund of prior year state or local taxes)
0
1
2
3
4
5
6
7
8
9
10
UC-1099-G (unemployment compensation)
0
1
2
3
4
5
6
7
8
9
10+
1099-R (retirement, IRA’s, pensions, annuities, ins. contracts)
0
1
2
3
4
5
6
7
8
9
10+
SSA-1099 (social security)
0
1
2
W-2G (gambling winnings)
0
1
2
3
4
5
6
7
8
9
10
1098 (mortgage interest)
0
1
2
3
4
5
6
7
8
9
10+
Real estate taxes
1098-E (student loan interest paid)
0
1
2
3
4
5
6
7
8
9
10+
1098-T (tuition & fees paid)
0
1
2
3
4
5
6
7
8
9
10+
Cost of college books / course materials
Charitable contributions (cash and check)
Charitable contributions (goods)
Submit additional info if over $500: name and address of organization, description, condition, date of contribution, date acquired, how acquired, donor’s cost basis, fair market value, method used to determine fair market value
Child / dependent care expenses
1099-SA (Health Savings Account)
0
1
2
3+
Were all distributions listed on 1099-SA used to pay for qualified medical expenses?
Un-reimbursed educator expenses ($300 max)
Un-reimbursed employee expenses (for PA and local taxes)
2023 Estimated tax payments
IRS, State, Local
Notes and questions to accountant
CONSENT TO USE OF TAX RETURN INFORMATION Federal law requires this consent form be provided to you. Unless authorized by law, we cannot use your tax return information for purposes other than the preparation and filing of your tax return without your consent. You are not required to sign this section to engage our tax return preparation services. If we obtain your signature on this form by conditioning our tax return preparation services on your consent, your consent will not be valid. Your consent is valid for the amount of time that you specify. If you do not specify the duration of your consent, your consent is valid for one year from the date of signature. I, undersigned, permit Schaeffer Financial & Tax, LLC and it’s representative to use the information I provide during the preparation of my 2023 tax return to determine whether to offer me the firm’s additional financial advisory services that may or may not affect the above stated tax year, if applicable. If you believe your tax return information has been disclosed or used improperly in a manner unauthorized by law or without your permission, you may contact the Treasury Inspector General for Tax Administration (TIGTA) by telephone at 1-800-366-4484, or by email at complaints@tigta.treas.gov
*
