The CCUSA Tax Service
Tax Questionnaire
W2 Status
W4 Certificate

Tax Questionnaire

To begin the process of getting your tax return, please complete the following questionnaire. This will get your account setup and the tax return process started. We will contact you if we require additional information.

CCUSA ID

Year:
CCUSA or WEUSA ID:

Employers

1. We need to verify that we have received all your W-2 forms. As pertains to your 2009 employer(s), please complete the information below for each employer you had in 2009 and from whom you received a paycheck in 2009.


Company Name#1:
State:
Occupation:

Company Name#2:
State:
Occupation:

Company Name#3:
State:
Occupation:

Company Name#4:
State:
Occupation:

Company Name#5:
State:
Occupation:

Social Security Number

2. Please provide your name and your US Social Security number EXACTLY as it appears on your Social Security card.

Name:
Social Security Number:

Passport

3. What country issued the passport that you used to enter the U.S.?

Country:

Marital Status

4. What is your marital status?

Status:

Address

5. Where should we send your tax statement and any tax refund?
(Remember, it takes several months for us to receive your refund from the government. It's best to give us the address of your permanent residence.)

Home Address:

Number & Street:

City:

State:

Country:

Postal Code: (optional)

Other Address:

Number & Street:

City:

State:

Country:

Postal Code: (optional)

Refund

6. If you are owed a refund, how would you like us to send it to you?

US Check*

Western Union
(We can not send Western Union to Brazil and South Africa. Please choose other option. We will charge you a $25 fee for this service. Please indicate below the EXACT name you wish us to use when transferring funds to you. Western Union will not release money to you unless you use the exact name for pick up that we have used when transferring the funds.

Enter Desired Name:

Enter Destination Country:

Wire Transfer to your bank
(We will charge you a $25 fee for this service. Your own bank may also charge you a fee for this service. We cannot send wire transfers to Brazil.)

Complete bank name:

Complete bank address: Number & Street:

City:

State:

Country:

In whose name is the account - yours, relative's, etc? Please give the name EXACTLY as it appears on the bank account:

Bank account number:

IBAN number:
EU countries now require a complete IBAN (Int'l Bank Account Number) instead of your bank account number alone.

**SWIFT code:
(if the bank is located in your country)

**ABA routing number:
(if the bank is located in the U.S.)

*We will not take responsibility for stolen checks that are fraudulently cashed.

**You must contact your bank and ask for these numbers. The SWIFT code is usually comprised of a series of letters. The ABA routing number is a series of nine numbers.

Please note that in cases where the tax refund is small, we reserve the right to send you a U.S. check which is the most economical option for you. Further, if you provide incorrect information regarding your name, your address or bank information and it necessitates our having to send funds to you a second time, we will charge you an additional $25 fee!

Referral

7. Were you referred to CCUSA Tax? If so, please enter that person's full name.

Referred by:
Please enter the FULL NAME of the person that referred you. If you were not referred, please enter "No One"