Self-Employed Tax Credit Intake Form SELF-EMPLOYMENT QUALIFIED SICK AND FAMILY LEAVE CREDIT INTAKE FORM Fields marked with an * are required Section 1 Label SECTION 1: CLIENT INFORMATION FULL LEGAL NAME * STREET ADDRESS ON PERSONAL TAX RETURNS * CITY * STATE * - Select State - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington DC ARMED FORCES AFRICA \ CANADA \ EUROPE \ MIDDLE EAST ARMED FORCES AMERICA (EXCEPT CANADA) ARMED FORCES PACIFIC ZIP CODE * PHONE NUMBER * 12 of 12 Character(s) left EMAIL ADDRESS * HAVE YOU MOVED IN THE LAST 3 YEARS * SELECT YES OR NO YES NO CONSULTANT NAME * Section 2 Label SECTION 2: CREDIT FOR SICK & FAMILY LEAVE Which Days Unable to Work 1A Label 1a.) WHICH DAYS WERE YOU UNABLE TO WORK IN 2020/2021 BECAUSE YOU: Which Days Unable to Work 1A Descriptions Label 1. Were subject to a Federal, State, or local quarantine or isolation order related to COVID-19; 2. Were advised by a health care provider to self-quarantine due to concerns related to COVID-19; or 3. Were experiencing symptoms of COVID-19 and were seeking a medical diagnosis. Maximum Days Description Label *Up to a maximum of 10 days between 4/1/2020 - 3/31/2021, and 10 days between 4/1/2021 - 9/30/2021 # OF DAYS BETWEEN 4/1/2020 - 3/31/2021 * (PLEASE LIST ALL DATES INDIVIDUALLY IN MONTH-TO-DATE FORMAT AS SHOWN ABOVE) # OF DAYS BETWEEN 4/1/2021 - 9/30/2021 * (PLEASE LIST ALL DATES INDIVIDUALLY IN MONTH-TO-DATE FORMAT AS SHOWN ABOVE) Days Unable to Work 2A Label 2a.) NOT INCLUDING ANY DAYS FROM QUESTION 1a.) WHICH DAYS WERE YOU UNABLE TO WORK IN 2020/2021 BECAUSE YOU: Days Unable to Work 2A Descriptions Label 1. Were caring for an individual who was subject to Fed/State/Local quarantine or isolation orders related to COVID-19, or who was advised by a healthcare provider to self-quarantine due to concerns related to COVID-19; 2. Were caring for a child if the child’s school or place of care was closed, or if the child care provider was unavailable due to COVID-19 precautions; or 3. Were experiencing any other substantially similar conditions specified by the Secretary of Health and Human Services in consultation with the Secretary of the Treasury and the Secretary of Labor Maximum Days 2A (1) Description Label *Up to a maximum of 50 days between 4/1/2020 - 3/31/2021 and 60 days between 4/1/2021 - 9/30/2021 # OF DAYS BETWEEN 4/1/2020 - 3/31/2021 CARING FOR YOUR CHILD * (PLEASE LIST ALL DATES INDIVIDUALLY IN MONTH-TO-DATE FORMAT AS SHOWN ABOVE) # OF DAYS BETWEEN 4/1/2021 - 9/30/2021 CARING FOR YOUR CHILD * (PLEASE LIST ALL DATES INDIVIDUALLY IN MONTH-TO-DATE FORMAT AS SHOWN ABOVE) Maximum Days 2A (2) Description Label *Up to a maximum of 10 days between 4/1/2020- 3/31/2021 and 10 days between 4/1/2021 - 9/30/2021 # OF DAYS BETWEEN 4/1/2020 - 3/31/2021 CARING FOR ANY OTHER INDIVIDUAL * (PLEASE LIST ALL DATES INDIVIDUALLY IN MONTH-TO-DATE FORMAT AS SHOWN ABOVE) # OF DAYS BETWEEN 4/1/2021 - 9/30/2021 CARING FOR ANY OTHER INDIVIDUAL * (PLEASE LIST ALL DATES INDIVIDUALLY IN MONTH-TO-DATE FORMAT AS SHOWN ABOVE) Section 3 Label SECTION 3: QUALIFIED LEAVE PAY EQUIVALENTS 3a.) DID YOU RECEIVE THE EQUIVALENT OF QUALIFIED SICK LEAVE PAY FROM AN EMPLOYER FOR ANY OF THE DAYS SPECIFIED IN QUESTION 1a*? * SELECT YES OR NO YES NO HOW MANY DAYS? * AMOUNT PER DAY * 3b.) DID YOU RECEIVE THE EQUIVALENT OF QUALIFIED SICK OR FAMILY LEAVE PAY FROM AN EMPLOYER FOR ANY OF THE DAYS SPECIFIED IN QUESTION 2a*? * SELECT YES OR NO YES NO HOW MANY DAYS? * AMOUNT PER DAY * Section 3 Descriptions Label * You would have been eligible, had you been an employee of an employer (other than yourself), to receive qualified sick leave wages under the Emergency Paid Sick Leave Act or qualified family leave wages under the Emergency Family and Medical Leave Expansion Act. 3c.) PLEASE LIST THE ORIGINAL FILING DATE OF YOUR 2020 FORM 1040 * Certifications Section Label CERTIFICATIONS The Applicant must certify to all the below by initialing next to each item: As the Applicant, I certify that I have the required authority to sign and submit this questionnaire. * I certify the information provided in this questionnaire and in all supporting documentation is true and correct in all material respects. I make this certification after reasonable inquiry, people, systems, and other information available to the Applicant. * As the Applicant, I recognize and agree to hold harmless American Incentive Advisors, its employees, and officers, from any damages, monetary or otherwise, that may arise as a result of incorrect information supplied by the Applicant in relation to the activity of obtaining Self Employment qualified sick and family leave credits. * Electronic Signature of the Applicant * Title of the Applicant * I Acknowledge that the checked box on the left serves as my notice that my manually typed electronic signature above is legally binding the same as my legally written signed signature * TODAY'S DATE * Submit Tax Documents Label SUBMIT 1040 TAX & SUPPLEMENTAL DOCUMENTS The Required files are the 1040 Tax Documents for 2019, 2020 & 2021 tax years. If no documents were filed for one of these tax years, please upload a document attesting that no documents were filed for that particular year. The Maximum File Size is 15 MB For All Files Combined. Please Do Not Use Scanned Documents, The File Size Limit Will Be Exceeded And Your Upload Will Fail. SUBMIT 1040 TAX DOCUMENTS FOR 2019 * CLICK HERE TO SELECT FILES Cancel Select the 1040 Tax Documents for 2019 to submit for review. Allowed File Types: PDF, DOC, DOCX SUBMIT 1040 TAX DOCUMENTS FOR 2020 * CLICK HERE TO SELECT FILES Cancel Select the 1040 Tax Documents for 2020 to submit for review. Allowed File Types: PDF, DOC, DOCX SUBMIT 1040 TAX DOCUMENTS FOR 2021 * CLICK HERE TO SELECT FILES Cancel Select the 1040 Tax Documents for 2021 to submit for review. Allowed File Types: PDF, DOC, DOCX SUBMIT SUPPLEMENTAL DOCUMENTS CLICK HERE TO SELECT FILES Cancel Select Supplemental Documents for review. If applicable: Copies of K-1's, W2's or 1099's for 2021 for e-filing Allowed File Types: PDF, DOC, DOCX Confidentiality Info Label Confidentiality Information: For American Incentive Advisors, LLC and its subcontractors to conduct their review and determination of qualification for various State and Federal tax credits, certain CLIENT information will be made available to AIA, its field consultants, and subcontractors, which may include State and Federal Income Tax Returns and other supplementary information. Whereas, the CLIENT has agreed to furnish these confidential records, AIA and its agents, agree to hold confidential or proprietary information in trust and confidence and agrees that it shall be used only for the contemplated purposes necessary. Should a Consulting Agreement be signed by the two parties, AIA will make third party disclosures to the State Taxing Authority and/ or Internal Revenue Service for the purpose of securing tax credits and/or refunds for the CLIENT. This confidential information will not be shared or disclosed to any other third party except the employees/associates of who have a need to know. This policy will also govern all communications between the parties, including fax and e-mail. CLIENT gives referring field consultant permission, as a conduit to AIA and subcontractors of AIA, to receive and deliver the completed documents. If you are a human seeing this field, please leave it empty.
