Loss of Income Dates Confirmation SS - Direct Funder

Fact Finding Questionnaire

Loss of Income Dates Confirmation

Please take the time to fill out this form with precision and completeness. Specifically, note the importance of providing specific dates where requested as this information will be used for various tax forms that we need to file on your behalf. Careful attention to detail will enhance the strength of your claim.

Click below to view sample tax form showing where these dates may be needed:

Form 7202-2021

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Should you encounter any questions or uncertainties while completing the form, our dedicated support team is just a click away. Visit the “Help and Support” section in your client portal, or call us at (480) 790-9186 and we’ll promptly assist you. Your peace of mind is our top priority.

Loss of Income Dates Confirmation

Step 1 of 9

1. Your Contact Information

Name

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Cell Phone

2. Date(s) Verification

Before we begin, let's be sure we aren't claiming any double benefits that the IRS does not allow:

Did you receive any Unemployment Compensation Income between January 1, 2021 and September 30, 2021?*

Yes

Please note: The dates you received Unemployment Income cannot overlap with the dates you enter below that you are claiming for the Sick Family Leave Tax Credit. Double benefits are not allowed. The IRS will check to verify.

Please upload your 2021 bank statements or any supporting documents below showing any Unemployment Compensation payments to confirm the dates they were received.

Max. file size: 100 MB.

Now, let's talk about "caring for yourself" and how Covid-19 affected your ability to perform your business related services:

Between the dates of 01/01/2021 to 3/31/2021 please tell us how many days you were unable to perform services as a self-employed individual. NOTE: You can claim up to 10 days during this period. Important: Be sure to only claim the days that you were actually off from work and remember to keep records of those dates in case the IRS requests additional information. Hover help icon for example:*

Did you miss work due to:
Quarantine
- Federal, state, or local lockdown orders related to COVID-19
- Quarantining or isolation order related to COVID-19
Illness
- Symptoms of COVID-19 or seeking a medical diagnosis
- Sickness due to vaccination side effects
- Caring for someone with COVID symptoms
Vaccination
- A COVID-19 vaccination appointment
- Side effects due to vaccination

Please enter a number from 0 to 10.

IMPORTANT NOTE: You have selected a number that is less than 10 days for the time period of January 1, 2021 through March 31, 2021 that you were unable to work in this section. As a reminder, the FFCRA allows up to 10 total days in this date range that you can claim because you were unable to work due to:

Quarantine
Illness
Vaccination

Please enter the dates below that you were unable to work during this time period:

Day 1: (01/01/2021 to 03/31/2021)*

Day 2: (01/01/2021 to 03/31/2021)*

Day 3: (01/01/2021 to 03/31/2021)*

Day 4: (01/01/2021 to 03/31/2021)*

Day 5: (01/01/2021 to 03/31/2021)*

Day 6: (01/01/2021 to 03/31/2021)*

Day 7: (01/01/2021 to 03/31/2021)*

Day 8: (01/01/2021 to 03/31/2021)*

Day 9: (01/01/2021 to 03/31/2021)*

Day 10: (01/01/2021 to 03/31/2021)*

3. Date(s) Verification (Part 2)

Between the dates of 04/01/2021 to 9/30/2021 please tell us how many days you were unable to perform services as a self-employed individual. NOTE: You can claim up to 10 days during this period. Important: Be sure to only claim the days that you were actually off from work and remember to keep records of those dates in case the IRS requests additional information. Hover help icon for example:*

Did you miss work due to:
Quarantine
- Federal, state, or local lockdown orders related to COVID-19
- Quarantining or isolation order related to COVID-19
Illness
- Symptoms of COVID-19 or seeking a medical diagnosis
- Sickness due to vaccination side effects
- Caring for someone with COVID symptoms
Vaccination
- A COVID-19 vaccination appointment
- Side effects due to vaccination

Please enter a number from 0 to 10.

IMPORTANT NOTE: You have selected a number that is less than 10 days for the time period of April 1, 2021 through September 30, 2021 that you were unable to work in this section. As a reminder, the FFCRA allows up to 10 total days in this date range that you can claim because you were unable to work due to:

Quarantine
Illness
Vaccination

Please enter the dates you were unable to work during this time period below:

Day 1: (04/01/2021 to 09/30/2021)*

Day 2: (04/01/2021 to 09/30/2021)*

Day 3: (04/01/2021 to 09/30/2021)*

Day 4: (04/01/2021 to 09/30/2021)*

Day 5: (04/01/2021 to 09/30/2021)*

Day 6: (04/01/2021 to 09/30/2021)*

Day 7: (04/01/2021 to 09/30/2021)*

Day 8: (04/01/2021 to 09/30/2021)*

Day 9: (04/01/2021 to 09/30/2021)*

Day 10: (04/01/2021 to 09/30/2021)*

4. Caring for Your Dependents

Let's talk about "caring for your dependents" and how Covid-19 affected your ability to perform your business related services:

Between the dates of 01/01/2021 to 03/31/2021 Were you unable to work because you were taking care of your child whose school or childcare provider was closed or switched to virtual/remote learning due to COVID-19, your child (or dependent) had COVID-19, or other COVID-related issues for a combined total of 50 days or more? Important: Be sure to only claim the days that you were actually off from work and remember to keep records of those dates in case the IRS requests additional information. Hover help icon for examples of qualifying dependents.*

IMPORTANT NOTE: You have selected "no" indicating that you were NOT unable to work more than 50 days for the time period of January 1, 2021 through March 31, 2021. As a reminder, the FFCRA allows up to 50 total days in this date range that you can claim because you were unable to work due to:

Taking care of a child who’s school or childcare provider was closed or switched to virtual/remote learning
Taking care of your child who had COVID-19 or COVID-like symptoms, etc.

Between the dates of 04/01/2021 to 09/30/2021 Were you unable to work because you were taking care of your child whose school or childcare provider was closed or switched to virtual/remote learning due to COVID-19, your child (or dependent) had COVID-19, or other COVID-related issues for a combined total of 60 days or more? Important: Be sure to only claim the days that you were actually off from work and remember to keep records of those dates in case the IRS requests additional information. Hover help icon for examples of qualifying dependents.*

IMPORTANT NOTE: You have selected "no" indicating that you were NOT unable to work more than 60 days for the time period of April 1, 2021 through September 30, 2021. As a reminder, the FFCRA allows up to 60 total days in this date range that you can claim because you were unable to work due to:

Taking care of a child who’s school or childcare provider was closed or switched to virtual/remote learning
Taking care of your child who had COVID-19 or COVID-like symptoms, etc.

ALSO NOTE: The IRS does not require you to have PROOF that you cared for a minor child under the age of 18 (or dependent). You simply need to affirm with the IRS that you did in fact lose time from work or business because you cared for the dependent (in good faith).

Have you or your CPA ever submitted a tax amendment for 2020 or 2021? If so, please provide us with the full package of 1040-X (Tax amendment) for further review.*

2020/2021 Tax Amendment (1040-X)

Please upload a copy of your 1040X tax amendment package for the year 2020 or 2021 that you stated was filed by you or your CPA.

Drop files here or

Max. file size: 100 MB.

Would you like to add your spouse to this application?*

yes

Your Spouse's Contact Information

Spouse's Name

First Last

Spouse's Address

Street Address City State / Province / Region ZIP / Postal Code Country

Spouse's Email

Spouse's Cell Phone

2. Date(s) Verification (Spouse)

Did your spouse receive any Unemployment Compensation Income between January 1, 2021 and September 30, 2021?*

Yes

Please note: The dates your spouse received Unemployment Income cannot overlap with the dates you enter below that you are claiming for the Sick Family Leave Tax Credit. Double benefits are not allowed. The IRS will check to verify.

Please upload your 2021 bank statements or any supporting documents below showing any Unemployment Compensation payments to confirm the dates they were received.

Max. file size: 100 MB.

Now, let's talk about "caring for yourself" and how Covid-19 affected your spouse's ability to perform their business related services:

Between the dates of 01/01/2021 to 3/31/2021 please tell us how many days your spouse was unable to perform services as a self-employed individual. NOTE: You can claim up to 10 days during this period. Important: Be sure to only claim the days that your spouse was actually off from work and remember to keep records of those dates in case the IRS requests additional information. Hover help icon for example:*

Did your spouse miss work due to:
Quarantine
- Federal, state, or local lockdown orders related to COVID-19
- Quarantining or isolation order related to COVID-19
Illness
- Symptoms of COVID-19 or seeking a medical diagnosis
- Sickness due to vaccination side effects
- Caring for someone with COVID symptoms
Vaccination
- A COVID-19 vaccination appointment
- Side effects due to vaccination

Please enter a number from 0 to 10.

IMPORTANT NOTE: You have selected a number that is less than 10 days for the time period of January 1, 2021 through March 31, 2021 that you r spouse was unable to work in this section. As a reminder, the FFCRA allows up to 10 total days in this date range that you can claim because your spouse was unable to work due to:

Quarantine
Illness
Vaccination

Please enter the dates below that your spouse was unable to work during this time period:

Day 1: (01/01/2021 to 03/31/2021)*

Day 2: (01/01/2021 to 03/31/2021)*

Day 3: (01/01/2021 to 03/31/2021)*

Day 4: (01/01/2021 to 03/31/2021)*

Day 5: (01/01/2021 to 03/31/2021)*

Day 6: (01/01/2021 to 03/31/2021)*

Day 7: (01/01/2021 to 03/31/2021)*

Day 8: (01/01/2021 to 03/31/2021)*

Day 9: (01/01/2021 to 03/31/2021)*

Day 10: (01/01/2021 to 03/31/2021)*

3. Date(s) Verification (Part 2)

Between the dates of 04/01/2021 to 9/30/2021 please tell us how many days your spouse was unable to perform services as a self-employed individual. NOTE: You can claim up to 10 days during this period. Important: Be sure to only claim the days that your spouse was actually off from work and remember to keep records of those dates in case the IRS requests additional information. Hover help icon for example:*

Did your spouse miss work due to:
Quarantine
- Federal, state, or local lockdown orders related to COVID-19
- Quarantining or isolation order related to COVID-19
Illness
- Symptoms of COVID-19 or seeking a medical diagnosis
- Sickness due to vaccination side effects
- Caring for someone with COVID symptoms
Vaccination
- A COVID-19 vaccination appointment
- Side effects due to vaccination

Please enter a number from 0 to 10.

IMPORTANT NOTE: You have selected a number that is less than 10 days for the time period of April 1, 2021 through September 30, 2021 that your spouse was unable to work in this section. As a reminder, the FFCRA allows up to 10 total days in this date range that you can claim because your spouse was unable to work due to:

Quarantine
Illness
Vaccination

Please enter the dates your spouse was unable to work during this time period below:

Day 1: (04/01/2021 to 09/30/2021)*

Day 2: (04/01/2021 to 09/30/2021)*

Day 3: (04/01/2021 to 09/30/2021)*

Day 4: (04/01/2021 to 09/30/2021)*

Day 5: (04/01/2021 to 09/30/2021)*

Day 6: (04/01/2021 to 09/30/2021)*

Day 7: (04/01/2021 to 09/30/2021)*

Day 8: (04/01/2021 to 09/30/2021)*

Day 9: (04/01/2021 to 09/30/2021)*

Day 10: (04/01/2021 to 09/30/2021)*

4. Caring for Dependents (spouse)

Let's talk about "caring for their dependents" and how Covid-19 affected your spouse's ability to perform their business related services:

Between the dates of 01/01/2021 to 03/31/2021 was your spouse unable to work because they were taking care of a child whose school or childcare provider was closed or switched to virtual/remote learning due to COVID-19, a child (or dependent) had COVID-19, or other COVID-related issues for a combined total of 50 days or more? Important: Be sure to only claim the days that your spouse was actually off from work and remember to keep records of those dates in case the IRS requests additional information. Hover help icon for examples of qualifying dependents.*

IMPORTANT NOTE: You have selected "no" indicating that your spouse was NOT unable to work more than 50 days for the time period of January 1, 2021 through March 31, 2021. As a reminder, the FFCRA allows up to 50 total days in this date range that you can claim because you were unable to work due to:

Taking care of a child who’s school or childcare provider was closed or switched to virtual/remote learning
Taking care of your child who had COVID-19 or COVID-like symptoms, etc.

Between the dates of 04/01/2021 to 09/30/2021 was your spouse unable to work because they were taking care of a child whose school or childcare provider was closed or switched to virtual/remote learning due to COVID-19, their child (or dependent) had COVID-19, or other COVID-related issues for a combined total of 60 days or more? Important: Be sure to only claim the days that your spouse was actually off from work and remember to keep records of those dates in case the IRS requests additional information. Hover help icon for examples of qualifying dependents.*

IMPORTANT NOTE: You have selected "no" indicating that your spouse was NOT unable to work more than 60 days for the time period of April 1, 2021 through September 30, 2021. As a reminder, the FFCRA allows up to 60 total days in this date range that your spouse can claim because they were unable to work due to:

Taking care of a child who’s school or childcare provider was closed or switched to virtual/remote learning
Taking care of your child who had COVID-19 or COVID-like symptoms, etc.

Has your spouse or their CPA ever submitted a tax amendment for 2020 or 2021? If so, please provide us with the full package of 1040-X (Tax amendment) for further review.*

2020/2021 Tax Amendment (1040-X)

Please upload a copy of your 1040X tax amendment package for the year 2020 or 2021 that you stated was filed by you or your CPA.

Drop files here or

Max. file size: 100 MB.

5. Acceptance of Terms

Your Signature*

Today's Date*

Your Spouse's Signature*

Today's Date (Spouse)*

Name

This field is for validation purposes and should be left unchanged.

Fact Finding Questionnaire

Loss of Income Dates Confirmation

Loss of Income Dates Confirmation

1. Your Contact Information

2. Date(s) Verification

Before we begin, let's be sure we aren't claiming any double benefits that the IRS does not allow:

Now, let's talk about "caring for yourself" and how Covid-19 affected your ability to perform your business related services:

3. Date(s) Verification (Part 2)

4. Caring for Your Dependents

Your Spouse's Contact Information

2. Date(s) Verification (Spouse)

Now, let's talk about "caring for yourself" and how Covid-19 affected your spouse's ability to perform their business related services:

3. Date(s) Verification (Part 2)

4. Caring for Dependents (spouse)

5. Acceptance of Terms

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