Questionnaire for US Tax Preparation Step 1 of 8 - Contact Information 12% 1. CONTACT INFORMATIONMarital Status*SingleMarried - Spouse IS NOT a US citizen, resident or green card holderMarried - Spouse IS a US citizen, resident or green card holderHead of HouseholdQualifying Widow/Widower with Dependent Child FilingI’m not sureTaxpayerName* Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Last Phone*Email* Address* Street Address Address Line 2 City ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country What Citizenship and Residency do you hold?* US Citizen / Resident NZ Citizen / Resident Other Citizen / Resident Do you or have you ever held a U.S. Green Card?* Yes No Date Issued MM slash DD slash YYYY Date Rescinded DD slash MM slash YYYY SpouseSpouse Name Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Last What Citizenship and Residency do you hold? US Citizen / Resident NZ Citizen / Resident Other Citizen / Resident Do you or have you ever held a US Green Card? Yes No Date Issued MM slash DD slash YYYY Date Rescinded DD slash MM slash YYYY 2. TAX SERVICESDo you need to file a US tax return for the last tax year (2022)?* Yes No For which tax year did you last file a US tax return?* Can you supply a copy of the last US return you filed?* Yes No Have you used the Streamlined Filing Amnesty Program before?* Yes No If you answered yes to the above question, which years did the Streamlined years cover?* 2010-2020 No 3. GENERAL QUESTIONSPlease answer the following questions for the period 1 Jan - 31 Dec of the last tax year in which you did not file.Did you or your spouse live in the USA?* Yes - AK, FL, NV, NH, SD, TN, TX, WA, WY Yes - All Others No Did you receive salary, wages and employment related benefits?* Yes - from the US Yes - from NZ Yes - from another country No US State Where Earned* AK, FL, NV, NH, SD, TN, TX, WA, WY All Others Were you self-employed or did you receive hobby income?* Yes - from the US Yes - from NZ Yes - from another country No US State Where Earned* AK, FL, NV, NH, SD, TN, TX, WA, WY All Others Did you dispose of any investments?* Yes No Did you have an investment portfolio in NZ or any other country, other than the US?* NZ Other None Please answer the following questions for all income, not just US based income.Distributions From a Company* Yes None Employee Share Options* Yes None Estate Income / Inheritance* Yes None Capital Gains* Yes None Distributions from Partnerships* Yes None Distributions from S-Corporations* Yes None Gifts ($15,000 USD)* Yes None Royalties* Yes - US Yes - Other Country None US State Where Earned* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucy Louisana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada Rental Income* Yes - US Yes - Other Country None US State Where Earned* CA All Others Income from Farming* Yes - US Yes - Other Country None US State Where Earned* AK, FL, NV, NH, SD, TN, TX, WA, WY All Others 4. FBARDo you prepare your own FBARs? (FinCEN 114)* Yes No Have you, at any point in the calendar year, had a total balance (from all non-US accounts) that is greater than or equal to $10,000 USD? Yes No How many accounts did you have? (exclude loan accounts)* Less than 10 More than 10 More than 20 Did you deposit more than $10,000 USD cash with financial institutions outside of the US?* Yes No 5. Companies and TrustsDid you or your spouse hold ownership in a non-US corporation?* Yes - Less than 10% Yes - 10% - 50% Yes - 51% - 100% No Please combine the ownership percentage for both you and your spouse, even if your spouse is not a US person.Please list the names of the companies below.*Did you own at least 10% in a non-US partnership?* Yes No Were you a Trustee, Settlor or Beneficiary of a Trust?* Yes - US Based Yes - Outside US No Please list the names of the trusts below.*KiwiSaverDo you have a KiwiSaver or similar account for yourself, partner or any dependents?* Yes No Do you make voluntary/additional contributions (outside of your employment contributions) to KiwiSaver accounts for you, your partner or dependents?* Yes No If you have made voluntary contributions to your KiwiSaver, you may have to report your KiwiSaver as a Trust to the IRS. If you are not sure what voluntary contributions are, please give us a call on +649 525 5931. Declaration:I hereby declare that the details provided above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein, immediately.SignatureHiddenDate DD slash MM slash YYYY CAPTCHA 6. Cost for ServiceBelow is the total estimated cost for service. This fee is only an estimate and may change if this questionnaire is submitted to NZ US Tax Specialists. This fee is for 1 year of tax filing. If you require more than one year of filing, this fee will increase. Fee Exclusive of GST. Fees are subject to GST (if any)Total $0.00 If the above fee is agreeable, please continue and submit this questionnaire. NZ US Tax Specialists does not offer discounts. Is there any other information you wish to provide?Any special considerations for preparation?NameThis field is for validation purposes and should be left unchanged.