QCAP Tax Screening Form
Unfortunately, all of our appointments are booked. If you wish to be on a waiting list, please complete this form and click "Submit". Upon receipt of your form, we will contact you if an appointment becomes available.
* Required
Your name:
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Please enter your name.
Year of birth:
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Please enter the year you were born.
Spouse’s name (if filing jointly):
Spouse's Year of birth:
Full Address (include apt #, city, zip code):
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Phone #:
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Email address:
1. Did you live in Massachusetts during ALL of 2009?
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Yes
No
2. Do you (and your spouse) have a Social Security number or ITIN?
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Yes
No
3. Did you (or your spouse) own a business in 2009?
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Yes
No
4. Did you (or your spouse) receive any of the following in 2009?
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rental income, railroad retirement, active military income, K-1 income, royalties
Yes
No
5. Did you own a home in 2009?
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Yes
No
If YES, do you still own the home?
Yes
No
6. Did you pay rent in 2009?
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Yes
No
If YES, was part of your rent subsidized?
Yes
No
7. Did you, your spouse, or your dependent attend college in 2009?
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Yes
No
If YES, was the person a foreign/international student?
Yes
No
8. Did you (or your spouse) retiree from a U.S., state, or local government job?
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Yes
No
9. Did you have health insurance in 2009?
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Yes
No
Did your spouse (if filing jointly) have health insurance in 2009?
Yes
No
10. Check all sources of income (for you and your spouse) for 2009.
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Employee Wages (W-2)
Non-Employee Income (1099-MISC)
Bank Interest (1099-INT)
Sale of Stocks or Bonds (1099-B)
Dividends (1099-DIV)
Social Security/SSDI (1099-SSA)
Unemployment (1099-G)
Retirement Distributions (1099-R)
Debt Cancellation (1099-C)
Alimony
Gambling Winnings (W-2G)
Awards and Prizes
11. What was the total dollar amount from all sources of income in Item 10 above?
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12. How many people will be on the tax return (including you, spouse, and dependents)?
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