Tax Disclosure Questionnaire

Tax Disclosure Questionnaire

This Tax Disclosure Questionnaire collects information necessary to evaluate tax filing obligations, reporting exposure, and potential disclosures required for preparation of federal and state tax returns. Complete all applicable items; provide explanations where requested.

Taxpayer Information

Period Ending:

Entity Type

Please check any applicable entity classification. If more than one applies, provide details in the explanation fields.

Individual / Sole Proprietor
C Corporation
S Corporation
Partnership
Trust / Estate
LLC
Other (describe below)

Taxpayer Identification Number (TIN)

Provide either Social Security Number (for individuals) or Employer Identification Number (for entities). Enter only the number you intend to report on the tax return.

Disclosure Questions

For each item, check the box if the answer is YES. If you check YES, provide a factual explanation in the corresponding explanation field. Failure to disclose material facts may result in penalties.

1. During the tax period, were any previously filed returns amended or expected to be amended? Check if yes

2. Is the taxpayer currently under audit, examination, or subject to an outstanding tax assessment or proposed adjustment? Check if yes

3. During the tax period, were there any notices of federal, state, or local tax liens, levies, or collections? Check if yes

4. Did the taxpayer have any foreign financial accounts, foreign trusts, or reportable foreign assets during the period? Check if yes

5. Were there any related-party transactions, non-arm's-length transfers, or allocations that could affect taxable income or basis? Check if yes

6. Was there any change in ownership, control, or capital structure of any entity that could change filing obligations or tax attributes? Check if yes

7. During the period, did the taxpayer receive any income that was not reported on Forms W-2 or 1099 (including cash payments, barter income, or digital asset receipts)? Check if yes

8. Are there any contingent liabilities, ongoing disputes, or lawsuits with potential tax consequences? Check if yes

9. Has the taxpayer claimed any tax credits, deductions, or elections that are unusual or aggressive relative to industry practice? Check if yes

10. Are there any other facts, transactions, or events not addressed above that may materially affect tax liability or reporting? Check if yes

Preparer / Representative

Certification

By signing below, the signer certifies, under penalties of perjury, the following statements are true, correct, and complete to the best of the signer's knowledge and belief:

1. The taxpayer identification number provided above is correct and will be provided on the tax return to which this Questionnaire relates, or the taxpayer is awaiting issuance of a number and will supply it promptly upon receipt.

2. The taxpayer is not currently subject to backup withholding due to failure to report interest or dividends, unless previously disclosed in this Questionnaire.

3. All material facts, transactions, and events that could reasonably be expected to affect tax reporting or liabilities for the period have been disclosed herein. The taxpayer will promptly supplement this disclosure if material additional facts become known prior to filing.

4. The taxpayer understands that intentional false statements or omissions may subject the taxpayer to civil and criminal penalties under applicable tax law.

I affirm the foregoing statements under penalties of perjury.

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