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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin 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 at any point held a US Green Card*YesNoDate Issued Date Format: MM slash DD slash YYYY Date Rescinded Date Format: 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?YesNoDate Issued Date Format: MM slash DD slash YYYY Date Rescinded Date Format: DD slash MM slash YYYY 2. TAX SERVICESDo you need to file a US tax return for the last tax year (2019)?*YesNoFor which tax year did you last file a US tax return?*Can you supply a copy of the last US return you filed?*YesNoHave you used the Streamlined Filing Amnesty Program before?*YesNo 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, WYYes - All OthersNoDid you receive salary, wages and employment related benefits?*Yes - from the USYes - from NZYes - from another countryNoUS State Where Earned*AK, FL, NV, NH, SD, TN, TX, WA, WYAll OthersWere you self-employed or did you receive hobby income?*Yes - from the USYes - from NZYes - from another countryNoUS State Where Earned*AK, FL, NV, NH, SD, TN, TX, WA, WYAll OthersDid you dispose of any investments?*YesNoDid you have an investment portfolio in NZ or any other country, other than the US?*NZOtherNonePlease answer the following questions for all income, not just US based income.Distributions From a Company*YesNoneEmployee Share Options*YesNoneEstate Income / Inheritance*YesNoneCapital Gains*YesNoneDistributions from Partnerships*YesNoneDistributions from S-Corporations*YesNoneGifts ($15,000 USD)*YesNoneRoyalties*Yes - USYes - Other CountryNoneUS State Where Earned*AK, FL, NV, NH, SD, TN, TX, WA, WYAll OthersRental Income*Yes - USYes - Other CountryNoneUS State Where Earned*AK, FL, NV, NH, SD, TN, TX, WA, WYAll OthersIncome from Farming*Yes - USYes - Other CountryNoneUS State Where Earned*AK, FL, NV, NH, SD, TN, TX, WA, WYAll Others 4. FBARDo you prepare your own FBARs? (FinCEN 114)*YesNoHave 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?YesNoHow many accounts did you have? (exclude loan accounts)*Less than 10More than 10More than 20Did you deposit more than $10,000 USD cash with financial institutions outside of the US?*YesNo 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%NoPlease 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?*YesNoWere you a Trustee, Settlor or Beneficiary of a Trust?*Yes - US BasedYes - Outside USNoPlease list the names of the trusts below.*KiwiSaverDo you have a KiwiSaver or similar account for yourself, partner or any dependents?*YesNoDo you make voluntary/additional contributions (outside of your employment contributions) to KiwiSaver accounts for you, your partner or dependents?*YesNoIf 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.SignatureCAPTCHA 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?CommentsThis field is for validation purposes and should be left unchanged.