Client Information

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First Name

Last Name

SS#/ITIN#:

Date of Birth

Profession

Cell#

Spouse’s First Name:

Last Name

SS#/ITIN#:

Date of Birth

Profession

Cell#

Home Address

City

State

Zip

Filling Status: (check one ✓)

Single Married Filling Jointly Married Filling Saparately Head of household

Can you or spouse be claimed as a dependent on anyone else tax return

Yes No

Name of Dependent/Child #1

Date of Birth of Dependent

Social Security #/ ITIN

Relationship

Name of Dependent/Child #2

Date of Birth of Dependent

Social Security #/ ITIN

Relationship

Name of Dependent/Child #3

Date of Birth of Dependent

Social Security #/ ITIN

Relationship

Name of Dependent/Child #4

Date of Birth of Dependent

Social Security #/ ITIN

Relationship

Do you owe taxes from previous years or have deliquent Child Support or Alimony?

Yes No

Did you have Obama Care Health (ACA)Insurance Last year?

Yes (Provide 1095-A Form) No Not at all

Advance Child Tax Credit Payment in 2021:

How Much Stimulus Payment did you receive in 2021:

Did you Buy or Sell Crypto Currency in 2021:

Yes No

How would you like your Refund

Direct Deposit Cheque

Direct Deposit:

Bank Name

Routing

Account#

Tax Payer DL # / ID

Issue Date

Expire Date

Spouse DL # / ID

Spouse DL Issue Date

Spouse DL Expire Date

Taxpayer DL/ID card Scan copy upload (Max 1 file - front only)

Spouse DL/ID card Scan copy upload (Max 1 file - front only)

Tax Payer Status:

US Citizen Other

(If other, please enter Country Name)

Spouse:

US Citizen Other

(If other, please enter Country Name)

Disclaimer

Disclaimer: This is to certify that all the information above is correct according to my best knowledge and the prepare will not be held responsible for any rejections/audits or refunds on my Tax Return.

Our tax services include tax preparations for:

Income Tax

Individuals and Families

Small Businesses

Audits

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