Fillable SECUs Low-Cost Tax Preparation Program (NC State Employees’ Credit Union)

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SECUs Low-Cost Tax Preparation Program (NC State Employees’ Credit Union)

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ATTENTION MEMBER: PLEASE DETACH AND RETAIN THIS PAGE FOR YOUR RECORDS
SECU’s Low-Cost Tax Preparation Program
Fee Schedule
Thank you for choosing SECU’s Low-Cost Tax Preparation Service. Each return prepared is subject to
a $75 fee which is due at the time of completion. (In most cases, your completed return will be ready
no later than five business days after the day you drop it off.) We will not file your return, nor provide
you a copy of it, until you have reviewed it, signed it, and paid the fee. This fee is non-refundable
once you have been provided with a completed paper copy of your tax return.
If you later discover a change that needs to be made to your filed return, the credit union can help you
prepare an amendment for $25. (The $25 fee will be waived if the amendment is a result of a credit
union error.)
Taxpayers with Dependents (or otherwise claiming certain tax benefits)
Federal law requires paid tax return preparers to verify information used to prepare a return containing
certain tax benefits, many of which are available to taxpayers with dependents. To comply with the law
in these instances, your preparer may ask additional questions or request documentation regarding
residency, support, non-custodial parents, government assistance, etc. These required inquiries may
seem personal or intrusive but are designed to confirm the tax benefits are being claimed as allowed by
the IRS regulations. Because of our duty to comply with IRS regulations, we will be unable to claim
these benefits on your tax return and we may not be able to complete the return at all if you choose not
to provide the information requested.
Please bring the following items in order for SECU to complete your return:
□
Completed Eligibility Checklist and Intake Sheet (contained in this packet)
□
Picture ID for taxpayer and spouse, if applicable
□
Social Security cards for yourself and all individuals on your return (spouse and dependents)
□
Your complete 2018 tax return
□
All income forms including W-2s, 1099s, and other documents
□
Documentation of higher education expenses paid (1098-T forms, receipts for required books and
supplies, statements from school, student loan interest, etc.)
□
Daycare expenses and daycare provider’s name, address, and tax ID number
□
Documentation to support itemized deductions, if applicable (mortgage loan interest paid, charitable
contributions, property taxes paid for home and auto, medical expenses)
□
Financial statements or other documents to support retirement plan rollovers
□
Health Insurance Marketplace Statement, Form 1095-A (if health insurance obtained through
Marketplace)
ATTENTION MEMBER: PLEASE DETACH AND RETAIN THIS PAGE FOR YOUR RECORDS
ATTENTION MEMBER: PLEASE DETACH AND RETAIN THIS PAGE FOR YOUR RECORDS
Terms and Conditions
These terms and conditions (these “Terms”) govern the tax preparation services State Employees’ Credit Union (“us,” “we,”
or “SECU”) provide you under SECU’s Low-Cost Tax Preparation Program (the “Program”).
1. Services
. We will prepare your current
federal and eligible state individual income tax returns, and any
prior year tax return(s) we agree to prepare, using information
you submit to us. Except to the extent expressly required by
applicable tax law, we will not audit or otherwise verify the
information you provide us, nor will we be responsible for
expressing an opinion concerning the accuracy of such
information. After you approve the return, we will
electronically file the return unless (i) you request that the return
be filed by mail, or (ii) we try but are unable to electronically
file the return. If we do not electronically file the return, we
will provide you the completed return to timely mail to the
appropriate taxing authority.
2. Limited Scope. The Program is limited to
preparing individual federal and eligible state income tax
returns for SECU, Local Government Federal Credit Union
(“LGFCU”) or North Carolina Press Association Federal Credit
Union (“NCPAFCU”) members whose tax return items satisfy
our eligibility guidelines. The eligible state returns we prepare
and a limited summary of our eligibility guidelines can be found
at www.ncsecu.org/TaxServices/LowCostTaxProgram.html.
We disclaim any obligation to provide tax advice or advisory
services, though we may, in our discretion, make you aware of
tax information we recognize as relevant to your situation. We
reserve the right to (i) amend our eligibility guidelines at any
time, and (ii) refuse to provide services under the Program if we
determine that the preparation of a return is inconsistent with
the Program or otherwise not in our best interests.
3. Fee. You agree to pay us: (i) a $75.00 fee for
preparing your current federal and eligible state tax returns, (ii)
a $25.00 fee for each amendment we prepare to your federal
and eligible state tax returns that we originally prepared, unless
covered by the accuracy promise described below in Section 4,
and (iii) if we agree to prepare your prior year(s) federal and
eligible state tax returns, a fee of $75.00 for each year for which
we prepare the returns (each, a “Fee”). We must receive
payment in full on the Fee before we electronically file your
return or deliver the return to you to file by mail. We will not
electronically file your return or provide a mailable copy
without full payment of the Fee unless SECU offers and you are
eligible for and elect in writing to participate in the Fee From
Refund Option for the Fee. A summary of the eligibility
requirements and rules of the Fee From Refund Option is
available upon request.
4. Accuracy Promise. If we make an error in
preparing your federal or state return that directly results in the
Internal Revenue Service (“IRS”) or the state taxing authority
assessing a penalty or interest based on your federal or state
return that we prepare, we will reimburse you, up to our
limitation of liability, for any resulting penalty or interest you
pay the IRS or the applicable state taxing authority directly
caused by our error. Under no circumstances will we pay any
additional taxes due, or reimburse you for any additional refund
that may have been due to you, as a result of an error. Any
additional taxes due will be your sole responsibility. We will
pay for penalties and interest as described in this Section only
if (i) the penalty or interest is not attributable to your failure to
abide by these Terms (including, but not limited to, Section 5)
or an improper or unsupportable deduction, credit or other tax
position you take, (ii) you notify us within 60 days after you
receive notice from the applicable taxing authority regarding
any potential interest or penalty (the “Notice”) and you provide
us with the Notice and any information we reasonably request,
(iii) you take any action we reasonably request in order to limit
further penalties and interest from accruing, such as filing an
amended return, and (iv) you were not aware of the error when
you filed your return. If we, in our discretion, prepare any
amended return(s) on your behalf as a result of our error, such
amended returns shall be limited to the three (3) year period
immediately preceding the then-current filing year. THIS
SECTION STATES OUR ENTIRE OBLIGATION AND
LIABILITY, AND YOUR SOLE AND EXCLUSIVE
REMEDY, FOR ANY ERRORS IN YOUR RETURN
CAUSED BY US.
5. Your Responsibilities
. You agree to provide
us complete, accurate and timely information necessary to
prepare your tax return. You promise that all the information
you submit to us to prepare your tax return is true, accurate and
complete and includes all income, deductions and other
information necessary to correctly prepare your tax return. If
you become aware that any information you provided us is
incorrect or incomplete in any respect, you must immediately
notify us in writing. You are ultimately responsible for the
accuracy of your tax return.
6. Records Retention. You are responsible for
maintaining the records necessary to support any claimed
income, deductions, credits and other information relating to
your tax return.
7. LIMITATION OF LIABILITY. WE WILL
NOT BE LIABLE TO YOU FOR ANY CONSEQUENTIAL,
SPECIAL, INDIRECT, INCIDENTAL, OR PUNITIVE
DAMAGES, REGARDLESS OF WHETHER YOU
INFORMED US OF THE POSSIBILITY OF SUCH
DAMAGES. CONSEQUENTIAL DAMAGES INCLUDE,
FOR EXAMPLE, LOST PROFITS, LOST REVENUES, AND
LOST BUSINESS OPPORTUNITIES. IN NO EVENT
SHALL OUR AGGREGATE LIABILITY EXCEED
$10,000.00.
8. Miscellaneous. These Terms, and your and
our rights under these Terms, shall be governed and interpreted
in accordance with North Carolina law. The exclusive venue
for any dispute relating to these Terms shall lie in Wake County,
North Carolina. These Terms constitute our entire agreement
with you regarding our responsibilities under the Program and
supersede any other agreements. Any amendment to these
Terms must be in writing and signed by the party charged. We
may delay or waive the enforcement of any of our rights under
these Terms without losing that right or any other. A
determination that any part of these Terms is invalid or
unenforceable will not affect the remainder of these Terms.
You may not assign these Terms.
Nov. 2019
ATTENTION MEMBER: PLEASE DETACH AND RETAIN THIS PAGE FOR YOUR RECORDS
Tax Preparation Eligibility Questionnaire
Credit union membership is required for participation in our tax preparation service. Are you a
member of SECU, LGFCU, or NCPAFCU?
□ Yes – Please continue to the checklist below.
□ No – If you are eligible to join one of the credit unions listed, speak with an employee to join, and
then complete the checklist below. If you are not eligible to join one of the credit unions
listed, we will not be able to complete your return.
Did you or your spouse (if filing jointly):
Yes
No
1
reside in more than one state during the year?
2
reside in any state other than GA, NC, SC, TN, or VA?
3
have military income (including National Guard and Reserves income) reported on
Form W-2?
4
have a 1099-R with distribution code 5, A, E, or K?
5
have rental income?
6
have foreign income?
7
sell stocks, bonds or mutual funds and need help calculating basis?
8
have tobacco allotments or timber sales?
9
have non-cash charitable contributions over $500?
10
have direct farming income or income from the rental of farm land/property?
11
sell any business or farm related property?
12
have installment payments for property sold?
13
sell any property involving barter agreements?
14
have a self-employment loss (self-employment expenses exceed income)?
15
have household employees that you paid $1,000 or more?
16
have any casualty losses?
17
have self-employment use of your home you wish to deduct?
18
have eligible expenses for (and wish to claim) the adoption credit?
19
have eligible expenses for (and wish to claim) the federal fuel tax credit?
20
have a child who received $1,000 – $10,000 from interest and dividends and you
wish to claim this income on your own return?
21
receive, sell, send, exchange, or otherwise acquire any financial interest in
any virtual currency (Bitcoin, etc.)?
22
sell any investment(s) in a qualified opportunity fund during the year?
Answering “yes” to any of these questions means that your return is outside the scope of our program
and we will not be able to assist in the preparation of your return.
If you feel comfortable preparing your own return online, the IRS has a Free File option available. Go
to www.irs.gov and click the link for “Free File”. If your income is below $66,000, you may qualify for no
cost do-it-yourself software. If your income is above $66,000, you will have access to fillable forms to
file your return.
NOTE: This list of questions is not all-inclusive. An SECU preparer will review your information to
determine if any other items are present that will make this return out of the scope of our tax program.
CONSENT TO DISCLOSE
2019 Tax Return Information
Print member(s) name here: ___________________________________________________
This consent form authorizes State Employees’ Credit Union (“we,” “us,” or “SECU”), as tax preparer, to disclose
your tax return information under the conditions described below.
Federal law requires this consent form be provided to you. Unless authorized by law, we cannot disclose your
tax return information to third parties for purposes other than the preparation and filing of your tax return without
your consent. If you consent to the disclosure of your tax return information, Federal law may not protect your
tax return information from further use or distribution.
You are not required to complete this form to engage our tax return preparation services. If we obtain your
signature on this form by conditioning our tax return preparation services on your consent, your consent will not
be valid. If you agree to the disclosure of your tax return information, your consent is valid for the amount of
time that you specify. If you do not specify the duration of your consent, your consent is valid for one year from
the date of signature.
As a convenience, we can let you know about SECU products we think would be of interest to you based on the
information you provide us to prepare your 2019 tax return. To provide you this information, we may disclose
your tax return information to other SECU employees. Also, to help us better determine your eligibility for certain
SECU lending products and inform you about the SECU products we think will be most relevant for you, we
would disclose some of your tax return information, as indicated below, to one or more credit reporting agencies.
If you would like for SECU to disclose your tax return information for either or both purposes, please check the
applicable box(es) below, sign and date your consent to the disclosure of your tax return information:
I hereby authorize SECU to disclose all my tax return information to SECU employees to inform
me about credit union products that SECU determines may be of interest to me. NOTE: You can
request a more limited disclosure of your tax return information as you may direct.
I hereby authorize SECU to disclose my name, address, phone number, date of birth, social security
number and income to credit reporting agencies to determine my eligibility for certain credit union
products. NOTE: Your credit score will not be impacted by SECU disclosing your information
for this purpose, and SECU will not receive your credit report as a direct result of this disclosure.
We will not disclose your tax return information for any other purpose in connection with this consent, except as
required or permitted by law. By checking the box(es) above and signing below, you authorize us to disclose
your tax return information as described above.
Your signature: ________________________________ Date: ________________
Spouse signature: ________________________________ Date: ________________
(if married and filing jointly)
If you believe your tax return information has been disclosed or used improperly in a manner unauthorized by
law or without your permission, you may contact the Treasury Inspector General for Tax Administration (TIGTA)
by telephone at 1-800-366-4484, or by email at complaints@tigta.treas.gov.
SECU USE ONLY
□ Taxpayer(s) declined to complete form
SECU Emp #: _______________ Initials: _________ Date: ___________________
CONSENT TO USE
2019 Tax Return Information
Print member(s) name here: ___________________________________________________
This consent form authorizes State Employees’ Credit Union (“we,” “us,” or “SECU”), as tax preparer, to use
your tax return information under the conditions described below.
Federal law requires this consent form be provided to you. Unless authorized by law, we cannot use your tax
return information for purposes other than the preparation and filing of your tax return without your consent.
You are not required to complete this form to engage our tax return preparation services. If we obtain your
signature on this form by conditioning our tax return preparation services on your consent, your consent will not
be valid. Your consent is valid for the amount of time that you specify. If you do not specify the duration of your
consent, your consent is valid for one year from the date of signature.
As a convenience, we can let you know about SECU products we think would be of interest to you based on the
information you provide us to prepare your 2019 tax return. To provide you this information, we will need to use
your tax return information.
If you would like for SECU to use your tax return information to let you know about SECU products while we
are preparing your return, please check the box below, sign and date your consent to the disclosure of your tax
return information:
I hereby authorize SECU to use my tax return information to inform me of credit union products
such as real estate, vehicle, credit card, and consumer loan products, and SECU financial advisory
services, which include financial products and services relating to retirement, investment,
insurance, general financial condition, and trust and estate planning, such as individual retirement
accounts, life insurance and mutual funds, that SECU determines may be of interest to me.
We will not use your tax return information for any other purpose in connection with this consent, except as
required or permitted by law. By checking the box above and signing below, you authorize us to use your
tax return information as described above.
Your signature: _______________________________ Date: ________________
Spouse signature: ________________________________ Date: ________________
(if married and filing jointly)
If you believe your tax return information has been disclosed or used improperly in a manner unauthorized by
law or without your permission, you may contact the Treasury Inspector General for Tax Administration (TIGTA)
by telephone at 1-800-366-4484, or by email at complaints@tigta.treas.gov.
SECU USE ONLY
□ Taxpayer(s) declined to complete form
SECU Emp #: _______________ Initials: _________ Date: ___________________
1 SECU Tax Preparation Services Intake Sheet – Tax Year 2019
DEMOGRAPHIC INFORMATION
Information About the Taxpayer Information About the Spouse (if applicable)
SSN
Full Name
(First, Middle Initial, Last)
Date of Birth
Mailing Address
(House # & Street Name or PO
Box, City, State, and Zip Code)
Daytime Phone #
Best Time to Call
□ 8:30 – 11:30 AM □ 11:30 AM – 2 :30 PM
□ 2:30 – 5:30 PM □ Any time
□ 8:30 – 11:30 AM □ 11:30 AM – 2 :30 PM
□ 2:30 – 5:30 PM □ Any time
Job Title
US Citizen?
□ Yes □ No □ Yes □ No
Full Time Student?
□ Yes □ No □ Yes □ No
Totally/permanently
disabled?
□ Yes □ No □ Yes □ No
Legally blind?
□ Yes □ No □ Yes □ No
Do you have any type
of account at a foreign
(non-US) financial
institution?
□ Yes □ No
Answer yes if you have an interest in or have signature
authority (i.e. POA) on someone else’s foreign bank account.
□ Yes □ No
Answer yes if you have an interest in or have signature
authority (i.e. POA) on someone else’s foreign bank account.
If yes, did the total
value of all foreign
accounts exceed
$10,000 at any time
durin
g
the
y
ear?
□ Yes □ No
□ Unsure □ N/A
□ Yes □ No
□ Unsure □ N/A
Are you a dependent
of another taxpayer?
□ Yes □ No □ Unsure □ Yes □ No □ Unsure
Identification
(to be completed by
SECU employee)
Type and #
: ____________________________
Issue Date
: __________ Exp. Date:__________
Type and #
: _____________________________
Issue Date
: __________ Exp. Date:__________
MARITAL STATUS – As of December 31, 2019, were you:
□
Never Married (Including registered domestic partnerships, civil unions, or other formal relationships under state law)
Did you get married in 2019?
□ Yes □ No
Did you live with your spouse any time during calendar year 2019?
□ Yes □ No
□
Married
Did you live with your spouse any time between 7/1/19 and 12/31/19?
□ Yes □ No
If you intend to file a separate return from your spouse, mark the box to the right and enter his/her
name and SSN in the “Information About the Spouse” section above.
□
If you intend to file a separate return from your spouse, did your spouse
itemize deductions on his or her return?
□
Yes □ No
Date of separate maintenance agreement:
□
Legally
Separated
Was agreement signed by a judge in a court of law?
□ Yes □ No
If your agreement was NOT signed by a judge and you intend to file a separate return from your
spouse, mark the box to the right and enter his/her name and SSN in the “Info About the Spouse”
section above.
□
□
Divorced Year of final divorce decree:
□
Widowed Year of spouse’s death:
2 DEPENDENTS
Answer the following for anyone who lived with you at any time during the year, as well as anyone you supported who did not
live with you. If more than 3, complete the Additional Dependents page as necessary. Skip this page if none of these apply.
PERSON 1 PERSON 2 PERSON 3
Name (First and Last)
What is this person’s date of birth?
What is this person’s social security number?
Number of Months this person lived in your home during the year
This person’s relationship to you (son, daughter, grandchild, parent
etc.)
If this person is your adopted or foster child, was he/she placed in
your home by a legal adoption process or placement agency?
□ Not an adopted or
foster child
□ Yes □ No
□ Not an adopted or
foster child
□ Yes □ No
□ Not an adopted or
foster child
□ Yes □ No
Does your address appear on the dependent’s records (school or
medical records, utility bills, driver’s license, etc.) for the tax year?
□ Yes □ No □ Yes □ No □ Yes □ No
Is this person a resident of the United States, Canada, or Mexico?
□ Yes □ No □ Yes □ No □ Yes □ No
Is this person Single or Married?
□ Single □ Married □ Single □ Married □ Single □ Married
Is this person a Full-time student?
□ Yes □ No □ Yes □ No □ Yes □ No
Is this person Totally/Permanently Disabled?
□ Yes □ No □ Yes □ No □ Yes □ No
Did this person have less than $4,200 of income?
□ Yes □ No □ Yes □ No □ Yes □ No
Did this person provide more than half of his/her own support
(living expenses for food, transportation, clothing, shelter, etc.)?
□ Yes □ No □ Yes □ No □ Yes □ No
Is this person required to file a tax return?
If yes, enter their Adjusted Gross Income.
□ Yes □ No
$
□ Yes □ No
$
□ Yes □ No
$
Did you (or your spouse, if filing jointly) provide more
than half of this person’s support (living expenses for food,
transportation, clothing, shelter, etc.)?
□ Yes □ No □ Yes □ No □ Yes □ No
Did you (or your spouse, if filing jointly) pay more than half
the cost of maintaining a home (rent, utilities, food, etc.) for this
person?
□ Yes □ No □ Yes □ No □ Yes □ No
Did you receive benefits from any government or third party assistance program during the tax year? (i.e. SNAP, Welfare,
Section 8 housing vouchers, etc.)
□ Yes □ No If yes, indicate type(s):________________________________________
If any person listed is your child who has a living parent OTHER than you (or your spouse, if married), please continue. If not, skip to the next page.
Was this dependent either of the following:
under the age of 19 at the end of the year
OR a full-time student under the age of 24 at the end of the year
OR totally and permanently disabled
□ Yes – Continue to
next question.
□ No – Skip to next
page.
□ Yes – Continue to
next question.
□ No – Skip to next
page.
□ Yes – Continue to
next question.
□ No – Skip to next
page.
How many days or months during the year did the dependent live
with his/her other parent?
Did you receive child support payments to help support this child?
□ Yes □ No □ Yes □ No □ Yes □ No
If you are the custodial parent (the dependent lived with you for
more than 6 months/183 days),
do you
have an agreement with
the dependent’s other parent allowing them to claim the
dependent this year?
□ Yes □ No
□ Unsure □ N/A
□ Yes □ No
□ Unsure □ N/A
□ Yes □ No
□ Unsure □ N/A
If you are the non-custodial parent (the dependent lived with
you for less than 6 months/183 days), do you have appropriate
documentation (Form 8332, or a divorce decree, separation
agreement or custody arrangement) from the custodial parent
that supports your eligibility to claim this dependent?
□ Yes □ No
□ Unsure □ N/A
□ Yes □ No
□ Unsure □ N/A
□ Yes □ No
□ Unsure □ N/A
3
ADDITIONAL HOUSEHOLD INFORMATION
Did anyone else live with you at any point during the tax year who will not be listed on your tax return?
□ Yes □ No
Did you help support anyone else who may or may not have lived with you? □ Yes □ No
If you answered yes to either of the above questions, please list the person’s name and relationship to you here:
AFFORDABLE CARE ACT
Yes No Unsure
1 Did you have coverage through the Marketplace? (If yes, you must provide Form 1095-A)
1a
If you answered “yes” to question 1, is everyone listed on your Form 1095-A being claimed
on this tax return?
1b If you answered “yes” to question 1, were you covered by an employer or Medicare plan?
INCOME
Type of Income Yes No Unsure
If Yes,
# of Forms
1 Wages or Salary (Form W-2)
2 Tip Income
3 Scholarships
4
Interest/Dividends from checking/savings accounts, bonds, CDs, brokerage (Forms
1099-INT, 1099-DIV
)
5 Itemized last year and received a state or local tax refund
6
Alimony income or separate maintenance payments. Amount: $____________
Date divorce decree/separate maintenance finalized or last modified:______________
7 Self-employment Income
7a Expenses related to self-employment income or any other income you received
7b Payments for self-employed health insurance
8 Cash/check payments for any work performed not reported on Forms W-2
9 Income (or loss) from the sale of stocks, bonds, or real estate (Forms 1099-S, 1099-B)
10
Filed a federal return last year containing a "capital loss carryover" on Form 1040
Sch D
11
Disability income - such as payments from insurance or worker's comp (Forms 1099-R,
W-2
)
12 Payments from Pensions, Annuities, and/or IRAs (Form 1099-R)
12a
If you answered yes to question 12, does a former spouse receive a portion of your
retirement benefits?
(
This mi
g
ht be required under the terms of a QDRO.
)
13 Unemployment Compensation (1099-G)
14 Social Security or Railroad Retirement Benefits (Forms SSA-1099, RRB-1099)
15
Other Income (gambling, lottery, prizes, awards, jury duty, Sch K-1 from estate or
partnership, royalties, foreign income, etc.) - Specify: _________________
16
Debt from a mortgage or credit card cancelled/forgiven by a commercial lender
(Forms 1099-C, 1099-A)
4
ADJUSTMENTS
Last year, did you (or your spouse) have any of the following: Yes No Unsure
1
Alimony or separate maintenance payments made by you or your spouse
Date divorce decree/separate maintenance finalized or last modified: __________________
If BEFORE 01/01/2019 provide:
Recipient’s SSN: _______________________ Amount paid: $_______________
2
Contributions to a retirement account:
□ Traditional IRA – Indicate amount(s): Taxpayer-$___________ Spouse-$___________
□ Roth IRA – Indicate amount(s): Taxpayer-$___________ Spouse-$___________
□ 401K/403B/457
□ Voluntary Pension Plan Contributions (beyond any amount required by your employer)
□ Other (SEP IRA, SIMPLE IRA, etc.) – Indicate type (if known): ____________________
3
Classroom supplies or development courses applicable to the curriculum of an educator (teacher,
teacher’s aide, counselor, etc.): Taxpayer-$__________ Spouse-$___________
4 Student Loan Interest payments
5 A Health Savings Account? (Forms 5498-SA, 1099-SA, W-2 with code W box 12)
5a
If you answered yes to question 5 and you took distributions during the year from your HSA, were all
of the funds used for qualified medical expenses?
If no, indicate the amount NOT used for qualified expenses - $___________________
5b
If you answered yes to question 5, which type of high deductible health plan coverage do you have?
□ Sin
g
le □ Famil
y (
covers more than 1 person
)
DEDUCTIONS
For this section, you are not required to provide us with a copy of your receipts or other documentation
unless we need it to calculate the deductible amount. However, you MUST have documentation to
provide to the IRS if asked. If you had one of the items listed below but would not be able to provide
proof to the IRS if requested, you should mark “no.”
Last year, did you (or your spouse) pay any of the following:
Yes No
If “Yes”, enter
amount below
or provide
documentation.
1 Medical expenses (including after-tax health insurance premiums)
2
Home mortgage interest (Form 1098) paid on a (mark all that apply):
□ Primary Residence □ Second/Vacation Home □ Home Equity Loan
3 Real estate taxes for your home (Form 1098 or county records)
4 Personal property taxes for your vehicle
5 Charitable contributions – Cash
6 Charitable contributions – Non-cash ($500 limit to be within the scope of our program)
CREDITS
Did
y
ou or
y
our spouse have… Yes No Unsure
1 Child or dependent care expenses (such as daycare)
2
College/post-secondary education expenses for you, your spouse, or dependents (Form
1098-T
)
3 A Mortgage Credit Certificate from the purchase of your home?
4 Any of the following credits disallowed in a prior tax year?
If yes, mark the boxes for disallowed credits:
□ Earned Income Credit □ Child Tax Credit/Additional Child Tax Credit □ American Opportunity Credit
OTHER TAX ITEMS
Did
y
ou
(
or
y
our spouse
)
… Yes No Unsure
1 Sell your home or have a foreclosure? (Form 1099-A for foreclosures)
2 Live in an area that was affected by a natural disaster last year?
3
Make estimated tax payments or apply last year’s refund to this year’s tax?
If yes, list dates and amounts: ________________________________________________
4 Receive the First Time Homebuyer’s Credit in 2008?
___________________________________________________ ___________________________________________________
5
STATE SPECIFIC TAX ITEMS
1
Did you or your spouse purchase products from outside your state of residence where no sales tax was paid?
□ Yes □ No □ Unsure
2
In which county (or counties) did you reside during 2019? _________________________________________________
3
Would you like to contribute a portion of your state refund to a state sponsored charitable fund? Any amount contributed
WILL CHANGE your state refund. This election CANNOT be revoked once your return is s ubmitted.
□ Yes □ No If yes, your preparer will provide you with a list of eligible charities. Amount of contribution $____________
4
Provide the following only if you reside or earn income in Virginia, are married, AND wish to file separately from your
spouse: Spouse’s 2019 Federal AGI ______________ Spouse’s 2019 VA AGI ________________
5
Provide the following only if you reside in South Carolina AND receive Military Retirement Income:
Total # of months of: Active duty service ______ Inactive reserve service ______ Inactive National Guard service ______
MISCELLANEOUS DEMOGRAPHIC QUESTIONS Taxpayer Spouse
Has the IRS issued you an IP PIN as a result of Identity Theft? (If yes, provide letter.)
□
Yes
□
No
□
Yes
□
No
Do you want $3 of your tax to go to the Presidential Election Campaign Fund?
(Your tax or refund will NOT change based on your answer.)
□ Yes □ No □ Yes □ No
Do you expect the income on your tax return to continue at the level reported?
□
Yes
□
No
□
Yes
□
No
Have we completed your return in the past?
□ Yes □ No □ Yes □ No
Veteran of the US Armed Forces? (If you prefer not to answer, leave blank.)
□
Yes
□
No
□
Yes
□
No
REFUND
If you are due a refund on your return, would you like:
Direct Deposit? □ Yes □ No
If yes, provide your account info to the right.
Direct Deposit Account Information
Routing #: _____________________ Account #: _____________________
Type of Account:
□ Checking □ Share/Savings □ Money Market
To split your refund between different
accounts? □ Yes □ No
If yes, complete the secondary account number
info to the right.
Secondary Direct Deposit Account Info (for split refunds only)
Routing #: _____________________ Account #: _____________________
Type of Account:
□ Checking □ Share/Savings □ Money Market
To purchase US Savings Bonds? □ Yes □ No
BALANCE DUE
If you have a balance due, would you like to make a payment directly from your bank account?
□
Yes
□
No
If yes, enter debit account info and draft date: Routing #: _____________ Account #: _______________ Draft Date: __________
Account Type:
□ Checking □ Savings (non-credit union accounts only*) □ Money Market (non-credit union accounts only*)
*Do NOT choose Savings or Money Market if paying from a credit union account. Funds can NOT be directly debited from these.
TAXPAYER SIGNATURES
By signing and dating below, I certify that I personally completed this form and/or I have reviewed entries I did not personally
make. To the best of my knowledge, all entries on this form are true, correct, and complete. I have received, reviewed and agree
to the SECU Low-Cost Tax Preparation Program Terms and Conditions.
Taxpayer Date Spouse Date
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ADDITIONAL INFORMATION AND NOTES
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SECUs Low-Cost Tax Preparation Program (NC State Employees Credit Union)

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Completed 30 July 2020

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