1 Did you receive any salary income from the United States during the year? Yes No If yes, please attach a statement describing the payor, amount earned, related expenses, nature of
employment. Please provide a Form W-2.
2 Did you receive any business income from the United States during the year? Yes No If yes, please attach a statement describing the nature of the business, the income and expenses for the
year, assets purchased and information about U.S. office premises and U.S. agents.
3 Did you receive any rental income from U.S. real estate? Yes No If yes, please provide details in Section 6.
4 Did you sell any U.S. real estate during the year? Yes No If yes, please provide full details of acquisition and sale.
5 Did you receive any income from US Partnerships, Estates & Trusts or S-Corporations? Yes No Please provide copies of forms K-1 for each partnership.
6 Did you realise any capital gains or losses from disposal of any assets during the tax year? Yes No This includes shares and securities, traded options and also currency transactions including offshore
currency loans. If yes, please provide the cost of the initial purchase, the date of purchase, sale
proceeds, and date of sale.
7 Did you receive any other income from U.S. sources? Yes No
If yes, please provide details, including payor and amount:
8 Did your spouse (if applicable) receive any U.S. income? Yes No
9 Will your spouse (if applicable) be filing a U.S. income tax return? Yes No Other: Please attach a list of your non-U.S. income for the year. You should note that if your worldwide income
for the year exceeded US $100,000, it is necessary to provide very specific details of your income.
10 Did your income exceed US $100,000? Yes No Provide details and amounts of any taxes withheld or paid in the U.S. during the year. Also provide details
of charitable contributions, casualty or theft losses in the U.S. and any business expenses. By providing your email address below, a copy of your submission will be sent you. We cannot proceed with the preparation of your tax return until we receive a signed copy of this questionnaire. By clicking “I Agree” below, you confirm that your electronic signature should be acknowledged as the legal equivalent of your manual signature and having read our terms and conditions, you consent to be bound by these. You are also agreeing that the information provided in the questionnaire is complete and correct to the best of your knowledge.
Printed name: Email: Date: Please select the team containing your usual PJD Tax Representative. The teams are listed below.
Select your team (required): please see teams listed below -- select an option -- Team Leader: Andrew Jones Team Leader: Michèle Pizzey Team Leader: Paul Devonshire Team Leader: Warwick Wilson
I agree to the terms and conditions and above statement Team Leader: Andrew Jones Andrew Jones – 0203 8612 943 firstname.lastname@example.org Thomas Cheung – 0203 8612 956 email@example.com Aleene Boyadjian – 0203 8612 964 firstname.lastname@example.org John McLaughlin – 0203 8612 951 email@example.com Brian Fernandes – 0203 8612 954 firstname.lastname@example.org Daniela Diemuodeke – 0203 8612 954 Daniela@pjdtax.co.uk Team Leader: Michèle Pizzey Michèle Pizzey – 0203 8612 942 email@example.com Amy Kasemsuk – 0203 8612 952 firstname.lastname@example.org Rebecca Cumberbatch – 0203 8612 963 email@example.com Chanosan Sivaloganathan – 0203 8612 958 Chanosan@pjdtax.co.uk Team Leader: Paul Devonshire Paul Devonshire – 0203 8612 941 firstname.lastname@example.org Daniel Blythe – 0203 8612 957 Danblythe@pjdtax.co.uk Bonnetta Brady – 0203 8612 945 email@example.com Anusa Sivayoganathan – 0203 8612 961 firstname.lastname@example.org Emily Golmohamad – 0203 8612 961 email@example.com Team Leader: Warwick Wilson Warwick Wilson – 0203 8612 944 firstname.lastname@example.org Omar Hussain – 0203 8612 948 email@example.com Geneva Gomes – 0203 8612 965 firstname.lastname@example.org Anam Akhter – 0203 8612 962 email@example.com