TAXPAYER INFORMATION FORM

Did you file your taxes with us last year?

Yes

No

General Questions

Name

DOB

Driver License

Issue Date

Expire Date

Do you have a spouse?

Yes

No

Spouse Name

DOB

Driver License

Issue Date

Expire Date

Current Address

City

State

Zip

Contact Phone

EMAIL Address

What “City” if any, should we file for your local tax return.

Dependents

Do you have Dependents?

Yes

No

ALL CLIENTS

FIRST NAME	LAST NAME	Birth Date	Age On 12/31 last yr	Mths in home	SS##

Tax Form Questions

Did you receive a 1095 A form for your Affordable Care Act insurance?

Yes

No

Please Include Form if you received it

Did you receive any Advanced Health Care payments from the government?

Yes

No

Please Include Form if you received it

Were you notified by the IRS that you are required to complete a “Certification” for the Earned Income Credit? (EIC)

Yes

No

Please Include Form if you received it

Could any other person claim your children this tax year?

Yes

No

Please Include Form if you received it

Day Care? Form Enclosed? Whom to? Address? SS#? Amount

Yes

No

Please Include Form if you received it

Education Credit/Tuition Form Enclosed?

Yes

No

What year of school?

Please Include Form if you received it

Do you have a long form?

Yes

No

Other Notes

6,364

Personal Security Code

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