Form 11652
Questionnaire and Supporting Documentation
Form 1040 Schedule C (Profit or Loss from Business)
(Rev. May 2005)
Catalog Number 25988D
Department of the Treasury — Internal Revenue Service
www.irs.gov
Name
Social security number
Business Address
Telephone Numbers
(Home) (Business)
Business Website (if available)
1.
Please provide a description of your business. (Type of work, product sold, service provided, hours of operation, where business is
conducted)
2.
Did you receive Form(s) 1099 MISC for the income reported?
No Yes (Please send a copy of the Form(s) 1099)
3.
If you did not receive Form(s) 1099 MISC for the income reported, provide a copy of the record of income showing the
customer name. Also, include the social security number or employer identification number, if available.
4.
Is a license a requirement of your occupation? No Yes
Do you have a business license? No Yes (Please provide a copy of your license.)
5.
How do you advertise for business? (Please submit copies of your advertisement and paid receipts)
Newspaper
Personal Computer
Flyers
Other (Please explain.)
6.
By law, you are required to keep adequate records. What type of records do you maintain to verify business income
and expenses? (Check all boxes that apply.) (Please submit copies of records.)
Accounting Records
Computer Records
Business Bank Accounts
Paid Invoices/Receipts
Business Stationery
Insurance
Advertising
Car/Truck Expense
Rental Expense
Log Books
Ledgers
Suppliers (name & address)
Other (Please specify.)
This is not an all inclusive listing. If you have other forms of documentation to support your business, please explain and
submit copies of the documents.
7.
Did you file state and/or local sales tax returns for the tax year?
No Yes
(Please send copies.)
Note: If you claimed a refund on your return and have not received it, we will not consider your claim until we review your
documentation and make a final determination regarding your tax liability. Failure to complete all parts of this
questionnaire and submit documentation to verify income and expense may delay our review of your claim for refund.
Form 11652 (Rev. 5-2005)
