Questionnaire Questionnaire for Tax Assessment LEARN ABOUT US 1 2 3 4 5 6 7 8 1. GENERAL INFORMATIONMarital Status*SingleHead of HouseholdMarried Filing SeparatelyMarried Filing JointlyQualifying Widow/Widower with Dependent Child FilingI’m not sureTaxpayerTitle*First Name(s)*Last Name*Email* Mobile Phone*Daytime PhoneCitizenship*Occupation*Date of Birth* Date Format: DD slash MM slash YYYY Did you claim state residency?*YesNoWhich state?*Green Card Status*N/AGreen Card HolderDate Issued Date Format: MM slash DD slash YYYY Date Rescinded Date Format: DD slash MM slash YYYY Current Address*City*State / ProvinceZIP / Post Code*Country*AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican 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 RicoQatarRéunionRomaniaRussiaRwandaSaint 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 IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweSpouseTitleFirst Name(s)Last NameEmail Mobile PhoneDaytime PhoneCitizenshipOccupationDate of Birth Date Format: DD slash MM slash YYYY Did you claim state residency?YesNoWhich state?Green Card StatusN/AGreen Card HolderDate Issued Date Format: MM slash DD slash YYYY Date Rescinded Date Format: DD slash MM slash YYYY Current AddressCityState / ProvinceZIP / Post CodeCountryAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican 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 RicoQatarRéunionRomaniaRussiaRwandaSaint 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 IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe 2. GENERAL QUESTIONSWhat taxation services are you looking for?USNZBothDid any of the details provided on the previous pages change during the tax year?YesNoPlease provide details below*Do you have any dependents?YesNoA dependent is a child in your care, under the age of 19 (or a student under 24), with US citizenship/residency. A dependent may also be a relative in your care, with US citizenship/residency that lives with a disability.Please list your dependents*Do you need to file a US tax return for the current tax year?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 received any correspondence from the IRS that you are yet to respond to?YesNoFor which tax year did you last file a NZ tax return?Can you supply a copy of the last NZ return you filed?YesNoHave you received any correspondence from the IRD that you are yet to respond to?YesNo 3. WORLDWIDE INCOME & GIFTSPlease answer the following questions to determine your tax benefitsDo you receive salary, wages and employment related benefits?YesNoAre you self-employed or do you receive hobby income?YesNoDo you receive any of the following? Please record the country and/or states in the space providedInterest Yes Interest Country / State*Dividends Yes Dividends Country / State*Winnings / Prize Money Yes Winnings / Prize Money Country / State*Beneficiary Income from a trust Yes Beneficiary Income from a trust Country / State*Distributions from Trusts Yes Distributions from Trusts Country / State*Employee Share Options Yes Employee Share Options Country / State*Distributions from a company Yes Distributions from a company Country / State*Estate Income / Inheritance Yes Estate Income / Inheritance Country / State*Capital Gains Yes Capital Gains Country / State*Royalties Yes Royalties Country / State*Rental Income Yes Rental Income Country / State*Income from farming Yes Income from farming Country / State*Distributions from Partnerships Yes Distributions from Partnerships Country / State*Distributions from S-Corporations Yes Distributions from S-Corporations Country / State*Gifts ($15,000 USD) Yes Gifts Country / State*Employment related retirement fund distributions Yes Employment related retirement fund distributions Country / State*Non-employment related retirement fund distributions Yes Non-employment related retirement fund distributions Country / State*KiwisaverNot applicableNZOther Income Yes Other Income Country / State* 4. WORLDWIDE INVESTMENTSHave you deposited cash with financial institutions?YesNoCountry / State for deposited cash*Did you have an aggregate balance of $10,000 USD or more in all financial accounts outside of the US?YesNoHow many accounts did you have? (exclude loan accounts)*Do you have any of the following? Please record the country or states in the space providedPersonal Residence Yes Personal Residence Country / State*Commercial Rental Property Yes Commercial Rental Property Country / State*Personal property (e.g. artwork) Yes Personal property Country / State*Holiday Home Yes Holiday Home Country / State*Residential Rental Property Yes Residential Rental Property Country / State*Other Investments Yes Other Investments Country / State*Did you dispose of any investments during the year?YesNoDid you transfer any property to a trust during the year?YesNoDid you engage in any exchange of property for other property?YesNoDid you form an entity such as a company, trust or other entity during the year?YesNoWere you the recipient or donor of any gifts during the year?YesNoWere you the grantor, transferor or beneficiary of a foreign trust (outside of the United States)?YesNo 5. WORLDWIDE LIABILITIESMortgages Yes Mortgages Country / State*Are mortgages secured over a principal residence? Yes Mortgages secured over a principal residence Country / State*Do you have any loans Yes Do you have any loans Country / State*Did any creditor relieve you of debt(s) during the year? Yes Did any creditor relieve you of debt(s) during the year Country / State*Do you have any other liabilities?YesNoCountry / State of other liabilities*Please provide details below* 6. WORLDWIDE ASSOCIATIONSPlease select the following options that apply to you Trustee of a trust Settlor of a trust Partner in a partnership Beneficiary of a trust Directory of a company Shareholder of a company Please provide entity names, percentages of shareholding/ownership and any changes to shareholding/ownership during the year.Are there any other entities in which you have direct or indirect financial interestYesNoPlease provide details below* 7. LOCATIONDid you move countries during the last 5 years?YesNoPlease complete the following table*FromToPurposeTemporary or PermanentDate of moveImmigration Status 8. MISCELLANEOUSIs there any other information you wish to provide?Any special considerations for preparation?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.SignatureDate Date Format: DD slash MM slash YYYY CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms. Call us to make an appointment today. +64 9 525 5931 CONTACT US
