Annual Individual Information Form (TY2021)

Please send all your tax information and documents to your Onvio portal. Let us know if you needed assistance

accessing the portal. If you need extra space, please use notes section. Thank you

Part I. Your Personal Information

1. Your First Name

M. I.

Last Name

Date of Birth

Are you a U.S. Citizen?

2. Your Spouse’s First Name

M. I.

Last Name

Spouse’s Date of Birth

Is your spouse a U.S. Citizen?

3. Mailing Address

Apt#

City

State

Zip Code

4. Home Phone

Cell Phone

Spouse’s Email

5. Your Job Title

6. Are you: Legally Blind?

7. Are you: Totally and Permanently Disabled?

8. Your Spouse’s Job Title

9. Is your spouse: Legally Blind?

10. Is your spouse totally and Permanently Disabled?

Please complete questionnaire below by checking “Yes”, “No” or “Unsure” to all questions. If you mark yes to any questions, please upload supporting documents. If assistance is needed, please call, or email the office.

Part II. Marital Status and Household Information

1. As of December 31, 2021, were you:

Single

Head of Household

Married: Did you live with your spouse during any part of the last six months of 2021?

Divorced or Legally Separated

Widowed

If married, did you live with your spouse during any part of the last six months of 2021?

If divorced or legally separated, indicate date of final decree or separate maintenance agreement

If widowed, indicate year of spouse’s death

2. List names below of everyone who lived in your home in 2021 (other than you or spouse). Also, list anyone who lived outside of your home that you supported during 2021. Use notes section if additional space is needed.

1. Name (first, last)

Date of Birth

Relationship to you (e.g. daughter, son, mother, sister, none)

Number of months lived in your home in 2021

US Citizen or resident of US, Canada or Mexico in 2021?

Marital Status as of 12/31/21

Full-time Student in 2021?

Received less than $3800 income in 2021?

With physical or mental disability?

2. Name (first, last)

Date of Birth

Relationship to you (e.g. daughter, son, mother, sister, none)

Number of months lived in your home in 2021

US Citizen or resident of US, Canada or Mexico in 2021?

Marital Status as of 12/31/21

Full-time Student in 2021?

Received less than $3800 income in 2021 ?

With physical or mental disability?

3. Name (first, last)

Date of Birth

Relationship to you (e.g. daughter, son, mother, sister, none)

Number of months lived in your home in 2021

US Citizen or resident of US, Canada or Mexico in 2021?

Marital Status as of 12/31/21

Full-time Student in 2021?

Received less than $3800 income in 2021?

With physical or mental disability?

4. Name (first, last)

Date of Birth_5

Relationship to you (e.g. daughter, son, mother, sister, none)

Number of months lived in your home in 2021

US Citizen or resident of US, Canada or Mexico in 2021?

Marital Status as of 12/31/21

Full-time Student in 2021?

Received less than $3800 income in 2021?

With physical or mental disability?

5. Name (first, last)

Date of Birth

Relationship to you (e.g. daughter, son, mother, sister, none)

Number of months lived in your home in 2021

US Citizen or resident of US, Canada or Mexico in 2021?

Marital Status as of 12/31/21

Full-time Student in 2021?

Received less than $3800 income in 2021?

With physical or mental disability?

Can anyone claim you or your spouse on their tax return?

Did any of your dependents have any income in 2020?

Part III. Banking Information – In 2021, did you (or your spouse):

1. Have any foreign income or pay any foreign taxes?

2. Have any financial interest, or signature authority over a foreign account?

3. Have any transactions involving virtual Cryptocurrency?

4. Make any purchases online or in another state without paying sales tax?

Part IV. Income – In 2021, did you (or your spouse) receive:

1. Wages or Salary? (Form W-2)

If yes, how many jobs did you have in 2021?

2. Scholarships? (Forms W-2, 1098-T)

3. Interest/Dividends from: checking/savings accounts, bonds, CDs, brokerage or private loan? (Forms 1099-INT, 1099-DIV)

4. Refund of state/local income taxes? (Form 1099-G)

5. Alimony Income?

Year the Alimony Agreement created?

Self-Employment (Form 1099-MISC or 1099-NEC) or Business Income (Please give details of business/EIN/% of ownership in an attached form), K-1s, 1099-Ks?

Cash/check payments for any work performed not reported on Forms W-2 or 1099?

Income (or loss) from the sale of Stocks, Bonds or Real Estate (including your home)? (Forms 1099-S, 1099-B)

Disability Income (such as payments from insurance, or worker’s compensation)? (Forms 1099-R, W-2)

Distributions from Pensions, Annuities, and/or IRA? (Form 1099-R)

11. Unemployment Compensation? (Form 1099-G)

Do you need instructions on how to obtain the form?

12. Social Security or Railroad Retirement Benefits? (Forms SSA-1099, RRB-1099)

13. Income (or loss) from Rental Property?

14. Forgiven Debt (Form 1099-C)?

15. Other Income: (gambling, lottery, prizes, awards, jury duty, etc.)? (Forms W-2 G, 1099-MISC)

Specify:

16. Did you receive an Economic Impact Payment (Stimulus Check)?

Part V. Deductions – In 2021 Did you (or your spouse) pay:

1. Alimony?

2. Contributions to any of these accounts?

Choose which one is applicable:

IRA

Roth IRA

401K

SEP IRA

3. Educational expenses for yourself, spouse, or dependents, such as tuition, books, fees, etc.? (Form 1098-T)

4. Business related expenses (such as uniforms or mileage) or supplies as a teacher?

5. Medical expenses (including health insurance premiums)?

6. Home mortgage interest? (Form 1098)

7. Real estate taxes for your home or personal property taxes for your vehicle?

8. Cash or non-cash charitable contributions

(Please include any receipts, if applicable

9. Child or dependent care expenses such as day-care?

Please provide invoice copy.

10. Participate in a Land Conservation project or partnership (commonly referred as Conservation Easement or Fee Simple)?

Part VI. Life Events – In 2021 Did you (or your spouse):

1. Have a Health Savings Account? (Forms 5498-SA, 1099-SA, W-2 with code W in Box 12)

2. Have debt from a mortgage or credit card canceled/forgiven by a commercial lender? (Forms 1099-C, 1099A)

3. Buy, sell, or have a foreclosure of your home? (Form 1099-S)

4. Have Earned Income Credit (EIC) disallowed in a prior year? I

If yes, for which tax year?

5. Receive the EIP (Stimulus Check) sent in or around March of 2021?

? If yes, how much did you receive?

6. Did you receive the Advance Child Tax Credit Payments (Plus-Up Payments)?

7. Purchase and install energy-producing items? (solar panels, electronic vehicle charger, or other alternative energy sources)

8. Pay any student loan interest? (Form 1098-E)

9. Make any Federal/State estimated tax payments or apply last year’s refund to your 2021 tax?

Provide copies.

10. Adopt a child or have a new dependent?

Have you received their SSN?

11. File a 2020 federal tax return containing a “capital loss carryover” & or NOL on Form 1040 Schedule D?

12. Become a victim of identity theft or receive an IRS Identity Protection PIN?

13. Make contributions to a College Savings plan? (529)

14. Make any state specific contributions? (FTC, GA GOAL, GA Heart)

) If yes, how much for each

Please provide approval letter.

15. Have health insurance coverage for all of 2021?

16. Receive 1095-A Health Insurance Marketplace Statement?

17. Make gifts to individuals greater than $15,000 in 2021?

18. Receive any IRS or State Government notices which remain unaddressed?

Notes: