Exhibit 203e — USA v. Alexandra Acosta (Dkt. 81.18)

Record facts

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Case 0:23-cr-60170-RNS   Document 81-18   Entered on FLSD Docket 06/14/2024   Page 1 of 7
Dec 29 20, 10:42 Victory Tax Inc 754-200-4139 p.4

2D)6

Taxpayer Questionnaire

PERSONAL INFORMATION
Primary Taxpayer
Last Name: MLL:
COSTG
Bi Taxpaye.’s PIN:
Worl : Celt Phone:
Bos 444 -FO FS
pation: . Dependent on Lagally Bind? Disabled?
Seo Ly $ Vet E e another reti.m? Yes No
jEmail Address: Text Message: No = |Cell Phone Canier
Preferred Contact: Preferred Language: : For 1040 NR: .| Taxpayer:
Yes No Male Female

Filing $ ‘Circle which Status number applies)

If. You were NOT married on or before December 31, 2018
Your dependents lived with you less than 6 mantis during the year.

2 = Married Filing Joint If You were martied as of December 31, 2018 or your spouse died during 2018.
3 = Married Filing Separate I¢ You were married on ar before Dacember 3%, 2018 and your spouse is
filing a tax return using this filing status.
“1 MEFS, did you live together at ANY ¢ me during the tax year? Yas No
If yes, did you {ive together during the final § months? Yes No
“If MS, did your so0use itemize his/her deductions? Yes No

NOTE: If spotse itemized deductions, taxpayer must also ltemize deductions.

4 = Head of Household If You were NOT married as of December 31, 2018
Your child, foster child, or grandchild lived wth your more than § months.

5 = Qualified Widew(er) If: Your spouse died during elther 2016 cr 2017 and
Your child, stepchild or foster, child ved with you far 12 rrontiss in 2018.
Spouse

First Name: Last Namie: ML:

S.8.N.: Birthdate: Spouse's PIN:
(*"° Phone: Work Phone: Cell Phone:

coupavan: Dependent on Legaily Blind? Disablec?
another return? Yee No

jemel Address: Text Message: Yes No [Cell Phone Caner

Preferred Contact Spouse: Male Female ,

RECEIVED BY IRS-EEFAX 12/29/2020 9:54AM (GMT-06: 00)

Acosta GX 203e [0001]
Case 0:23-cr-60170-RNS   Document 81-18   Entered on FLSD Docket 06/14/2024   Page 2 of 7
Dec 29 20, 10:42 Victory Tax |nc 754-200-4139 pd
Address
Gare-of (or additional} Address Information
Street Address: Apt. #:
Coley: State: Zip Code:
fae Address Info:(4 =AP OPO, 2=Sialesico, 3-Foreign or Blank} Combat Zone:
Bank Information
; (far Direct Deposit IntoTaxpayers Personal Acct)
iaore Name:
Account Type: Savings Checking
qRouting Numoen Account Number:
Will this refund go to an account outside of ihe US? Yes No
Client Referral
Referral Type: Deseristion:

Health Insurance
(Affordable Care Act}

in order to comply with the Affordable Care Ac
coverage.

[Recelvad health care coverage through employer for entire year (including COBRA Coverage)?

Receivad health care coverage from ite government such as Medicaid, Medicare or Veterans Benefits?
Purchased private health insurance (NOT through the Marketplace”) for the entire year?

Purchased health inguranee through the “Marketplace” (Form 1095-A)?

At leasi one family nember (including taxpayer) did not have health care coverage at anytime auting the year?

t, answer the folowing questions regarding healthcare insurance

Yes No
Yes No
Yes No
Yes No
Yes No

RECEIVED BY IRS-EEFAX

12/29/2020 9:

Acosta GX 203e [0002]

SHAM (GMT-06:00)_
Case 0:23-cr-60170-RNS   Document 81-18   Entered on FLSD Docket 06/14/2024   Page 3 of 7
Dec 29 20, 10:42 Victory Tax Inc 154-200-4139 p.6
DEPENDENTS
Fs; Name Last Name Birthdate SSN Relationship | 20 | OPP | etc

Children who lived with you and are being clarmed on another return

Non Dependents claimed for EIC and Disabled person's dependent rare expenses

[Erier the depandents name, blindats, SEN, Relalonship, number of monihis Wed Wilh he Taxpayer, staring wih tie youngall casenaent Rate: to ihe Imermation below lor

Dep. and EFC codes,

Dependent Codes ' ElC Cades
1 =Lived with Taxpayer E = Eligibie as of December 31, 2018, under the age of 19
2 = Lived Elsewhere 5 = Student as of December 31, 2018, under the age of 24 and full-time student
3 = Taxpayer's parent D = Disabled as cf December 31, 2018, Permanently & fotally disabled, at any age
4 = Other Degendent K = Qualifying Child was Kidnapped

N= Not aligible
CHILD TAX AND EARNED INCOME CREDIT

Number of Children under age 17 {CTC}
TThig taformation ie dinth Number of Children under age 49 (EIC)
enendar's Table stove” Number of Chitdren between age 47 & 24, full time student (EIC)
Number of Childran Totally Disabled (EIC)
Include Form 8862 - Information to Claim ElC After Disallowance? Yas No
Frotal amount Paid: CHILD C ARE CREDIT Humber Cared for:
A. if married. d'd both, Taxpayer and Spouse work during the time of dependent care? Yes No
F r - —— Ne
B. IfnotoA was Taxpayer or Spouse disahled o° 2 full-t'me student for mare than S months? — ¥es, Disabled
ii ne to A and B. this return is not eligible for dependant care credit —— Vos, Student
Gare Provider #1 Information
Yame SSN or
_FIN
Address . Amount Paid
; Care Provider #2 Information
{Name SSN oor
__EIN
Address Amount Paid
DEPENDENT CARE EXPENSES .
List dependants cared fer
First Name Last Name SSN Expenses

RECEIVED BY IRS-EEFAX = 12/29/2020 9:54AM (GMT-06:00)
Acosta GX 203e [0003]
Case 0:23-cr-60170-RNS   Document 81-18   Entered on FLSD Docket 06/14/2024   Page 4 of 7
Dec 29 20, 10:42 Victory Tax Ine 754-200-4138 p.7

“WAGES AND SALARIES
(Use Actual Form W-2 for Data Entry)

Taxpayer Employer's Name Wages Federal Withholding St Withholding

Spouse

Emptoyer’s Name Wages Federal Withholding 8: Withholding

INTEREST AND DIVIDEND INCOME
(Use Actual Forms 1098, 10998, 1099-INT, 1009-DIV for Data Entry}

Sched.

Paye.'s Name interest Dividends Withholding
ADDITIONAL INCOME
Unemoloyment Income
Sociat Security, from Form SSA1099
Other Income: di ZL; Y eae op
GEE CAA LEZY
Scholarship income not inéluded onFom W-2 A Ver § EG .

LEP Maral nate
Sygahe 2 wg.
rave! Eb 35;

Other Income Subject to Self-employment Tax BY eas Oo, % 99

le C - Business Income{Loss) , eed 2, TSF

Prior Year's Stale and Losal Income Tax Refund

Alimony Receivec

Gambiing Income

IRA OR Pension Distribution from 1093R

Railroad Ret remani trom Fann RRB1099

ADJUSTMENTS

Student Laan interest Deduction

IRA Contributions (Limit of $5,800 per taxpayer, if over 50 lim't is $6,500)

uition aad Fees Deduction
Alimony Pal
Recipient's SSN Reciplent’s Name
CREDITS
Education Credits

American Opportunity Creclt

Lite

Titna Leaming qualified exsenses

Other Federal Tax Paymerts

RECEIVED BY IRS-EEFAX 12/29/2020 9:54AM (GMT-06:00)

Acosta GX 203e [0004]
Case 0:23-cr-60170-RNS   Document 81-18   Entered on FLSD Docket 06/14/2024   Page 5 of 7
Dec 29 20, 10:43 Victory Tax Inc 754-200-4139 p.6
ITEMIZED EXPENSES Sch-A

Medical and Dental Expenses . ites

Number of Miles driven to Doctor / Dental Visits during the year (ine 1) /, y 4 &y
Medical / Dental Expense Description Amaunt
Medical / Denial Expense Description Amount

Taxes Pald _ Amount

State Taxes Paid on last year's state return (line 5, vast] ¢ CH

Real Estate Property Taxes Paid {Ene 8b}

Personal Property Taxes Paid (ic. vehicle registration} . (line Se) s 7 VO

Other Taxes Paid ¢.e. Non-resident Stale Taxes Pald) ‘ (ine 6}

Interest Paid Amount
Home Morigage Interest, fram Ferm 1098 (ing 8) Zz +} aS f
Points Paid (Principle Purchase of Residence OR Qualified Refinance) (See Fons Instructions}

Gifts to Charity Miles
Number of Miles driven for Volunteer Work with Charitable Organization (line 41)

Charitable Cash or Check Contributions Annount

Dassrption (line 14)
Description
6754 Fax
Description
Chbry 54
Descfiation i . 5 ny oO ?
One Swoeiice GL/ LEO
Non-Cash Chafitable Contributions (i mare than.$500 must atlach Form 8283} Amount
Datcription {line 12)
Descript'o
Baseripte

Other Miscellaneous Deductions . Amount
Other Miscellaneous Expenses {l.e. gambling losses-no more than reported winnings) —_ Ene 16)

Other Expenses Aout
Desor ation tine 16)

Daser ation

Deser ation

RECEIVED BY IRS-EEFAX 12/29/2020 9:54AM (GMT-06:00)

Acosta GX 203e [0005]
Case 0:23-cr-60170-RNS   Document 81-18   Entered on FLSD Docket 06/14/2024   Page 6 of 7
Dec 29 20, 10:43 Victory Tax Inc 754-200-4139 po

EARNED INCOME CREDIT
A ifigatio
Could you, or your spouse if fling jointly, be considered a “Qualifying Child" on another persons tax

return during tax year 2018?
NOTE: Ifyou answered “Yea”, you are nofable ta quality for the earned Income credit (skip Part Wand

Yes No

Part lf}.
Fart li: Qualifying dren Child 7 Child 2
ts the Child: (line 9) xams Mame
The Taxpayers Son, Daughter, or adopted chiid OR
A child of the Taxpayer's son, daughter or adopted child Of
. Yes No Yes No
The Taxpayer's stepchiki OR
The Taxpayer's eligible faster child?
the child is manied, are you cla'ming this child as a dependent?
wae . mn Yes No Yes No
(IF child és not married, then simply mark yes) dine 0)
Did the child liva with in the United Statos “or over half of t, OR
wi you in wn al os over half of the yes. Yes No Yos No
The full year if the child 's an eligible foster child? (line 11)
Was the child, at the end of the year: (line 12)
Underage 19 OR : ,
Under age 24 and a full-time student OR Yes No Yes Ne
Any age and permanently and totally disabled?
Could any olner person check "Wes" on lines 9 through 12 for the child? Yea No Yes No
Prep Notes It yas, quastios on line 13b and {3c must iso be answored.(fing 134)

® Ifyou checked "No" on any of the first four questions above, then:
Te child is not the taxpayer's qualifying ch.ld. If the taxpayer does not have a qualifying child, go to
"Part lll" to see if the taxpayer can claim the EIC for people who do not have qualifying children _
Part lil: Earned Income Credit for Taxpayers without a Qualifying Child
Was your main home, and your spouse if filing jointly. in the United States for more than half tha year? Yes No
(Military personnet on extended activa dyty outside she U.S. are considered te ba living in the U.S. during inal period.)
NOTE; if you answerad "No", you are not able te qualify far the eamed income credit (skip Part ti and Part til}.

Part IV- Due Biligence Requirements

To comply with the EIC kn owledge requirement, you must not know or have. reason te know that any information used 10 determine the
lsxpayer's &.ig-bility for, and the amount of, the EIC is incorrect. You may not ignore the implications of information furn’shed 4o or known by
you, and you must rake reasonable inquires if the information furnished appears to be incorrect, Inconsistent, cr incomplete. At the tine
you make lhese inquitles, you must document in your files tha inquiries made and the taxpayer's rassonses,

. Form 8879 Information

( 1) = Gheck mailed “ron IRS (4 } = Balareo Due Tax Payer's PIN Spouse's PIN
( 2} = Direct Denasitio TP's Acct, (4) = RACIRT

Was the return preparad by ihe Taxpayer (self-prepared)? C] Yes C] No

Was the raturn prepared by 4 Paid-Preparar? J Yes (] No

TAXPAYER QUESTIONNAIRE REVIEW

The above information is true anc ca-reel, and tf we understand that the Information given on th’s questionnalre wili be used to complete my
/ our 2018 tax return(s}. 17 We agree to hold this company harmlass for any er-ors that trey may make on my / our tax return. 1/ We also
understand hat error on my / our retum will cause 4 delay in the provessing of the return and the receipt of the refund, if any.

Taxpayer Signature: Date:

Spouse Signature: Date:

RECEIVED BY IRS-EEFAX 12/29/2020 9:54AM (GMT-06:00)
Acosta GX 203e [0006]
Case 0:23-cr-60170-RNS   Document 81-18   Entered on FLSD Docket 06/14/2024   Page 7 of 7
Deo 29 20, 10:43 Victory Tax inc 754-200-4139 p.10

FINANCIAL PRODUCTS

Complete the followirg if refund type ig a RAC/RT
Identification Information: Bank Products require at least 7 of the following forms of ID

() Drivers License C) DMVW/BMV State [D © military 1D ©) US Passport/Resident Alien ID
© Matricular Consular © Foreign assport

Taxpayer iD NUMBER STATE EXP, DATE

Spouse ID NUMBER STATE. “_, EXP. DATE

Applicatios Informatian:

If fing 2 joint retum, who is borrower? T= Taxpayer Only; S = Spouse Only; B = Bath Taxpayer & Spouse
With the IRS removing the Debit indicator {Dl}, there is a chance that a RAC/RT will rot be refunded in full.
Same reasons for not getting a complete RT refund:

1. IRS says you owe back taxes

2. IRS says you have 4 current garmishment

3. (RS is auciting your Earred Income Credit

4. Earned Income Tax Credit (EITC) is daimed and an EITC qualifying child is a foster child
5. You have an outstanding debt with any bank that provides RAC/RT

PLEASE NOTE - WE DO NOT HAVE ANY CONTROL OVER THE ABOVE REASONS!
Taxpayer |nitiai Spouse Initial
T unterstano that all information 1 hava provided on this form fs true, any of this information is incorrect, | uncerstand that a

formal letter will be sent if the cefund is not paid in full.
In sdditon, | understand thal my refund may be provided to ne in more than 1 chack,

Taxpayer Signature: Date:

Spouse Signature: Date:

. FOR OFFICE USE ONLY
Process Checklist (to be included in customer file)

[] Make copies of form of ID and Social Security cards
CL! Interview sheet filled out

Ci One copy of téx return, W-2s and/or 1099 (Taxpayer & Spouse, if applicable)
(7) Signature on 8879/Pin # and Bank application

RECEIVED BY IRS-EEFAX, 12/29/2020 9:54AM (GMT-06:00)
Acosta GX 203e [0007]


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