Fringe Benefits Questionnaire


       

  

FRINGE BENEFITS QUESTIONNAIRE

Due Date: Monday, November 28, 2011


icon Fringe_Benefits_Questionnaire_Excel_2011.xls (31 KB)  
icon Fringe_Benefits_Questionnaire_Adobe_2011.pdf (48 KB)

Attention all business owners..... In order for us to follow Internal Revenue Service regulation and continue to keep you in compliance, we must have the following information regarding your auto, health insurance and/or long-term care insurance. 

The following information is needed to process your 2011 W-2 whether Rozovics & Wojcicki, P.C. prepares your payroll or you use a payroll service.  Please follow all pertinent instructions and return the information to us by November 28, 2011.   If you would like a copy of your 2010 questionnaire, we would be happy to provide that to you.  Please email your request to jodi@rozwoj.com.  Keep in mind, if you have multiple companies, we require "separate" forms for each.

FRINGE BENEFITS QUESTIONNAIRE (form above)

If applicable, please complete the fringe benefits questionnaire for each owned/leased auto used in your business (please provide one form per vehicle).  An Adobe (.pdf) and a Microsoft Excel (.xls) version of the questionnaire is available for download above.  If you have Excel, you can fill out the form, save and email to jodi@rozwoj.com.  If you have Adobe, you can print and fax it back to our office. Our fax number is 847-299-7526.

Please don't delay in supplying us with this important year-end information.  If we do not receive the completed questionnaire(s) by November 28, 2011, we will assume that the value of your personal use is $5,000.00, and increase your W-2 by that amount.

HEALTH INSURANCE/LONG-TERM CARE INSURANCE (Sub-Chapter S Corporations only)

Please list the amount of group insurance premiums paid for each shareholder (including family members) on line 14 .  Also, if any shareholder has paid long-term care premiums, please include that dollar amount on the questionnaire under line item 15.