TEST FORM New Client Intake Step 1 of 2 50% Name First Last Address Street Address Address Line 2 City State / Province / Region 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 PhoneEmail Copy of Return Pick-Up Mailed Direct Deposit? Yes No Bank Routing Number Bank Account Number DID YOU BUY ANY LARGE ITEM IN 2020 (ex: boat, car) Yes No Enter Dollar AmountDID YOU SELL, PURCHASE, OR REFINANCE A HOME IN 2020? Yes No Attach Closing Documents if Available Drop files here or Select files Accepted file types: pdf, Max. file size: 2 MB. DID YOU MAKE ANY ENERGY IMPROVEMENTS TO YOUR MAIN HOME? Yes No Attach Related Documents if Available Drop files here or Select files Accepted file types: pdf, Max. file size: 2 MB. DO YOU PAY FOR ANY LONG TERM CARE INSURANCE? Yes No Enter AmountDID YOU PAY FOR HEALTH INSURANCE (NOT THROUGH AN EMPLOYER)? Yes No Enter AmountDO YOU HAVE ANY FOREIGN BANK ACCOUNTS? Yes No ENTER COUNTRY OF FOREIGN BANK ACCOUNTS DID YOU HAVE ANY CRYPTO CURRENCY TRANSACTIONS? Yes No UPLOAD CRYPTOCURRENCY STATEMENTSMax. file size: 2 MB.DO YOU HAVE RECEIPTS FOR CHARITABLE CONTRIBUTIONS? Yes No HAVE YOU PUT A $$$ VALUE FOR NON-CASH CHARITY ITEMS? Yes No DID YOU MAKE A QUALIFIED CHARITABLE DISTRIBUTION FROM YOUR IRA? (MUST BE 72+ TO USE) Yes No UPLOAD CONTRIBUTION / GIVING STATEMENTMax. file size: 2 MB.DID YOU PAY INTEREST ON A STUDENT LOAN? Yes No UPLOAD 1098-EMax. file size: 2 MB.ARE ANY MEMBERS OF YOUR FAMILY IN COLLEGE? Yes No UPLOAD 1098-TMax. file size: 2 MB.DID YOU CONTRIBUTE TO A 529 SAVINGS PLAN? Yes No ENTER AMOUNTDID YOU RECEIVE A CARES ACT STIMULUS PAYMENT? Yes No ENTER AMOUNTARE YOU SELF-EMPLOYED? Yes No DID YOU MISS WORK DUE TO COVID-19 SYMPTOMS, ILLNESS, OR QUARANTINE?? Yes No NUMBER OF DAYS DID YOU MISS WORK TO CARE FOR A FAMILY MEMBER WITH COVID-19?? Yes No NUMBER OF DAYS DURING 2020, DID YOU WORK WITHIN THE CITY LIMITS OF KANSAS CITY, MISSOURI AND WERE REQUIRED TO BEGIN WORKING FROM HOME IN THE MIDDLE OF THE YEAR? Yes No
