660 Patrick Place
Brownsburg, IN 46112
317.852.7000
1630 West Oak Street
Zionsville, IN 46077
317.733.1000
FAX 317.852.7070
E-MAIL [email protected]
Welcome to Storen Financial!
We are glad you chose us for your tax planning and preparation needs. We strive to provide a welcoming
environment that offers professional tax preparation at a reasonable price. Our educated, personable staff is
ready to help you navigate the process.
We want you to feel at ease. While you are here, please enjoy a hot cup of coffee, our public wifi and our
children’s play area. We know your time is precious, so we encourage you to mail, email, fax or drop off the
following documents in advance of your appointment:
__ Your tax returns from the last 2 years
__ The new client information sheet
__ Your supporting documents for the current return
Having this information in advance will allow us to serve you in the most efficient and effective manner possible.
Our website has a wealth of information and resources for you. Look for sheets on how to value your goodwill
donations, links to help you track your refunds and up-to-date tax information on our blog. We also have a “Client
Portal” accessible from our website that allows you to retrieve your tax returns anytime.
Please contact us with your questions—we are here to serve you!
Sincerely,
The Team at Storen Financial
www.storenfinancial.com
INVEST Financial Corporation, member FINRA/SIPC, and its affiliated insurance agencies offer securities, advisory services and
certain insurance products and are not affiliated with Storen Financial. INVEST does not provide tax and accounting advice.
storenfinancial new client information
filing status – check box that best describes your situation on the last day of the year.
single
can someone else claim you as a dependent?
yes
no
I don’t know
married filing joint
married at year end or lost spouse during year
married filing separate
married at year end and not including spouse’s income on return
head of house
not married/legally separated AND you supported a child, dependent, or relative
supported person’s name _________________________________ ssn _________–_______–_________
qualifying widow(er)
lost spouse within past 2 years and have dependent child(ren)
need help in determining what my best option is. Let’s talk about it.
tax payer
social security #___________ – _________ – ____________
first name & m.i ___________________________________
last name ____________________________________
occupation _______________________________________
date of birth
_____/_____/_______
date of death
_____/_____/_______
preferred phone (______)_________________ ext. ______
alternate phone (______)_________________
name preferred to be addressed by __________________
county of residence 1/1 of tax year _________________
county of employment 1/1 of tax year __________________
school distict ___ _______________________________
___ Cell
___Home
___ Work
___ Cell
___Home
___ Work
spouse
social security #___________ – _________ – ____________
first name & m.i ___________________________________
last name ____________________________________
occupation _______________________________________
date of birth
_____/_____/______
date of death
_____/_____/______
preferred phone (______)_________________ ext. ______
alternate phone (______)_________________
name preferred to be addressed by __________________
county of residence 1/1 of tax year _________________
___ Cell
___Home
___ Work
___ Cell
___Home
___ Work
county of employment 1/1 of tax year __________________
home mailing address
street _____________________________________________________________________________________________
city/state/zip _______________________________________________________________________________________
e-mail address for correspondence _ ____________________________________________________________________
dependent information
first name
last name (if different)
date of birth
direct deposit information
bank name ___________________________
account type:
checking
savings
social security #
relationship
lives with taxpayer (yes/no)
routing # ____________________ acct # _______________________
signature of person completing form ____________________________________________________________________
11.27.2015
660 Patrick Place
Brownsburg, IN 46112
317.852.7000
1630 West Oak Street
Zionsville, IN 46077
317.733.1000
[ZIONSVILLE]
334/116th St.
[CARMEL]
FAX 317.852.7070
E-MAIL [email protected]
86th St.
65
Meridian St.
an R
d.
[BROWNSBURG]
136
ig
Mich
5
I-6
I-74
I-4
56th St.
I-70
[DOWNTOWN]
[AVON]
36/Rockville Rd.
SR 267/Green St.
I-70
N
▲
Airport
I-65
Meridian St.
[PLAINFIELD]
5
I-46
ZIONSVILLE
BROWNSBURG
I-74
WALMART
BILL ESTES
FORD
Northfield Drive
N
▲
Dr.
N
▲
[ZIONSVILLE]
56th St.
[BROWNSBURG]
www.storenfinancial.com
INVEST Financial Corporation, member FINRA/SIPC, and its affiliated insurance agencies offer securities, advisory services and
certain insurance products and are not affiliated with Storen Financial. INVEST does not provide tax and accounting advice.
Zionsville Rd.
[POST OFFICE]
Ford Rd.
Green St./267
Oak Street
POST
OFFICE
STOREN FINANCIAL
660 PATRICK PLACE
[BOONE VILLAGE]
ield
/136
[CVS]
hf
Nort
Main St.
Patrick Plac e
K-MART
STOREN FINANCIAL
1630 WEST OAK STREET
660 Patrick Place
Brownsburg, IN 46112
317.852.7000
1630 West Oak Street
Zionsville, IN 46077
317.733.1000
What should I bring to my tax appointment?
FAX 317.852.7070
E-MAIL [email protected]
___ Tax returns from the past 2 years if this is your first visit
___ W-2s
___ Distributions from IRAs, Annuities, 401ks (1099-R)
___ Interest and dividend income (1099-INT and/or 1099DIV)
___ Stock sales with cost basis (1099-B)
___ Mortgage interest statement (1098)
___ Property taxes paid
___ Contributions to charities
___ Income and expenses for your business
___ Any other income received (ex. Social Security SSA 1099; rent; gambling winnings)
___ Closing papers from home sale/purchase
___ Closing papers from mortgage refinance
___ Auto registration cards for excise tax
___ Student loan interest paid
___ College tuition paid
___ Unreimbursed expense for your job
___ Mileage for work, charity, or medical
___ K-1s from corporations/investments/partnerships
___ Insurance forms (1095)
For information and resources:
www.storenfinancial.com
INVEST Financial Corporation, member FINRA/SIPC, and its affiliated insurance agencies offer securities, advisory services and
certain insurance products and are not affiliated with Storen Financial. INVEST does not provide tax and accounting advice.
AFFORDABLE CARE ACT (Obamacare) Client Questionnaire:
CAUTION: The Affordable Care Act is an important part of your tax return for 2015. This questionnaire must be answered
accurately. If there are any questions on how to complete this questionnaire please address them with your preparer.
Client Name:
1)
Were you (and your family if applicable) covered by health insurance
for any month of 2015?
2)
If you had health insurance, mark the months covered. If you were covered for a full year, please indicate by marking
“Full Year” in the first column below.
Full Jan
Year
Feb
Mar
Apr
May
Jun
Circle one:
Jul
Aug
Yes
Sep
No
Oct
Nov
Taxpayer
Spouse
Dependent 1
Dependent 2
Dependent 3
3)
If you did not have health insurance every month of 2015, did you apply for
or qualify for an exception to the penalty or an exemption from coverage?* Circle one:
Yes
No
N/A
Exception Description (if known) _________________
Exemption Certificate # (ECN) ____________________
*if you’re uncertain or need assistance answering this, please indicate by checking this box: ❒
4) Do you have a dependent for whom someone else is court ordered
to carry health insurance on that dependent?
5)
6)
Circle one:
Yes
No
N/A
Circle one:
Yes
No
N/A
Did you or any family member change health plans during the year?
(changed jobs, canceled existing policy, added to someone else’s plan, etc.) Circle one:
Yes
No
N/A
Did you or any family member purchase insurance from the marketplace?
(healthcare.gov – you should have received Form 1095-A)
Client Initial: ______
Date: ___/___/___
Preparer Initial: _____ Date: ___/___/___
Dec
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name: (please print)
Engagement Letter & Questionnaire
This letter is to confirm and specify the terms of our engagment with you and to clarify the nature and extent of services
we will provide. In order to ensure an understanding of our mutual responsibilities, we ask all clients for whom returns are
prepared to confirm the following arrangements.
We will prepare your 2015 federal and state income tax returns from information which you will furnish to us. We will not
audit or otherwise verify the data you submit, although it may be necessary to ask you for clarification of some of the
information.
It is your responsibility to provide all the information required for the preparation of complete and accurate returns. This
applies also to the following questionnaire in that each question has been answered correctly. You should retain all the
documents, cancelled checks and other data that form the basis of income and deductions. These may be necessary to
prove the accuracy and completeness of the returns to a taxing authority. You have the final responsibility for the income tax
returns and therefore you should review them carefully before you sign them.
The law provides various penalties that may be imposed when taxpayers understate their tax liability. If you would like
information on the amount of the circumstances of these penalties, please contact us.
Your returns may be selected for review by the taxing authorities. Any proposed adjustments by the examining agent are
subject to certain rights of appeal. In the event of such government tax examination, we will be available upon request to
represent you and may render additional invoices for the time and expenses incurred*. Our fee for these services will be
based upon the amount of time required at standard billing rates plus out-of-pocket expenses. All invoices are due and
payable upon presentation. (*Unless you are enrolled in the Storen Plus program. Ask your preparer for information.)
We want to express our appreciation for this opportunity to work with you.
Personal information yes no
Other than a spouse, does another person financially support you?
 
Were there any changes in dependents from the prior year?
 
Did you sell, exchange, purchase or lease any real estate during the year?  
Did you foreclose or abandon a principal residence or real property during the year?  
Did you have any debts canceled or forgiven this year?  
Did you pay any student loan interest this year?  
Did you make any withdrawals from an IRA, Roth, Keogh, SIMPLE, SEP, 401(k),
 
403(b), or other qualified retirement plan? Did you receive any distributions from a Health Savings Account (HSA)?  
Did you receive any unemployment benefits during the year?
 
Did your receive any awards, prizes, hobby income, gambling or lottery winnings?  
Do you have any foreign accounts or assets (real estate, pension, investments)?  
Did you receive an Identity Protection PIN from the Internal Revenue Service
or have you been a victim of identity theft?
 
I (we) agree that the above data is correct for the 2015 tax return, and I (we) acknowledge I (we) have the records to support the
data furnished for the preparation of the tax return. Also, I (we) am (are) citizen(s) of and have lived in the United States for at
least half the tax year.
Taxpayer: Date: Spouse: Date: