Please be advised that you are entering your information on a SECURE WEBSITE. None of the information you are entering is maintained on this website. Upon clicking the SUBMISSION button located at the end of this form, your information is immediately forwarded to our office.
* Denotes Mandatory Entries that are Required
Your Name: *
Your Date of Birth: MM/DD/YYYY *
Spouses Name: (if on tax return)
Spouses Date of Birth: MM/DD/YYYY
Address: *
Unit #:
City: *
Your State: *
Zip Code: *
Do You Own a Business Yes No *
Legal Business Name *
Is This Business a DBA? Yes No *
Tax ID Number or Social Security Number: *
Business Address: *
Suite or Building #:
State: *
Did You Pay Any Child Care Related Expenses In 2011? Yes No *
Your Child's Name: *
Name of Child Care Provider:
Business Address:
City:
State
Zip Code:
Child Care Provider Federal ID#
Amount Paid to Child Care Provider:
Did you get married in 2011? Yes No *
Did you finalize a divorce in 2011? Yes No *
Are you claiming the same dependents as your 2010 tax return? Yes No *
Did you or your spouse give birth to any children or adopt and children in 2011? Yes No *
1st Dependent Name as it appears on Social Security Card:
Date of Birth: mm/dd/yyyy
Social Security Number:
2nd Dependent Name as it appears on Social Security Card:
3rd. Dependent Name as it appears on Social Security Card:
Did you make any Estimated Tax Payments in 2011? Yes No *
Enter the Amount paid: *
Did you do a Roth Conversion in 2011? Yes No *
Did you purchase or re-finance a primary home in 2011? Yes No *
Were you an active member in the military at this time? Yes No *
Did you receive a Homebuyer's Credit for your Primary Home Purchased between 4/8/2008 and 12/31/2008? Yes No *
Please enter the amount of the credit you received *
Did you Sell any Real Estate in 2011? Yes No *
Did you Abandon any Real Estate Property in 2011? Yes No *
Did you have a Foreclosure on any Real Estate in 2011? Yes No *
Did you have any Cancellation of any Debt in 2011? Yes No *
Did you Purchase an Auto, Truck, Motorcycle or Motor Home in 2011? Yes No *
Did you Purchase a Plug in Electric Vehicle in 2011? Yes No *
Did you have any Home Energy Repairs in 2011? Yes No *
Did you receive any home energy credits between 2006 - 2010? Yes No *
Please Enter the Amount: *
Did you have anyone in College in 2011? Yes No *
Name of 1st Child in College? *
Years of College Completed? *
Would you like to add another Child in College? Yes No *
Name of 2nd Child in College *
Do you have any questions for us? Yes No *
Please write your questions below (300 chars left) *
You may now click on the the submit button and your data will be transfered securly to our office.
You can select "File" then "Print" to print this form:
Thank you for taking the time to submit this form.
Should you have any questions or require additional information please contact us at (239) 591-4747 or email us at info@naples-cpa.com.
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