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CLIENT FORMS
TAXPAYER INFORMATION
First Name
*
Last Name
*
Your SSN:
*
Birthdate
*
Occupation
*
Email Address
Marital Status as of 12/31/2012
*
Single (never married)
Single (spouse decreased)
Married
Married (but separated from spouse)
Married (but lived apart last 6 months of year)
Divorced (with divorce decree)
If married, are you filing taxes with your spouse?
Yes
No
I don't know
Are you a dependent of another?
*
Yes
No
Spouse Name
Last Name
Spouse SSN:
Birthdate
Spouse Occupation
Email Address
Street Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Home Phone
*
Cell #1
*
Active Duty Military
Yes
No
Combat Zone:
DEPENDENT #1
First Name
Last Name
SSN
Birthdate
Age
Relationship
Son
Daughter
Fosterchild
Grandchild
Step-xxx
Niece
Nephew
Aunt
Uncle
Parent
None
Months in home
12 mo.
less than 12 mo.
never
Student
Yes
No
Disabled
Yes
No
If Disabled, Type of disability
DEPENDENT #2
First Name
Last Name
SSN No.
Birthdate
Age
Relationship
Son
Daughter
Fosterchild
Grandchild
Step-xxx
Niece
Nephew
Aunt
Uncle
Parent
None
Months in home
12 mo.
less than 12 mo.
never
Student
Yes
No
Disabled
Yes
No
If Disabled, Type of disability
DEPENDENT #3
First Name
Last Name
SSN No.
Birthdate
Age
Relationship
Son
Daughter
Parent
Grandchild
Cousin
Step-xxx
Aunt
Uncle
Grandparent
Months in home
12 mo.
less than 12 mo.
never
Student
Yes
No
Disabled
Yes
No
If Disabled, Type of disability
DEPENDENT #4
First Name
Last Name
SSN No.
Birthdate
Age
Relationship
Son
Daughter
Parent
Grandchild
Cousin
Step-xxx
Aunt
Uncle
Grandparent
Months in home
12 mo.
less than 12 mo.
never
Student
Yes
No
Disabled
Yes
No
If Disabled, Type of disability
DEPENDENT #5
First Name
Last Name
SSN No.
Birthdate
Age
Relationship
Son
Daughter
Parent
Grandchild
Cousin
Step-xxx
Aunt
Uncle
Grandparent
Months in home
12 mo.
less than 12 mo.
never
Student
Yes
No
Disabled
Yes
No
If Disabled, Type of disability
Please answer the following question to the best of your knowledge?
Did you receive Social Security or Retirement Income?
*
Yes
No
Did pay College Tuition or Student Loans?
*
🛈
Yes
No
Did you have income other than your W-2 (s)?
*
Yes
No
Did you pay someone to watch your child?
*
Yes
No
Did you receive Unemployment Compensation?
*
Yes
No
Do you owe any delinquent:
*
🛈
Child Support
Alimony?
Student Loans
Back Taxes
None
Other
Other
How Many People Live in Your Household
How many people lives with you:
Adults?
How many people lives with you:
Children?
How many people lives with you:
How many work?
How many people lives with you:
Does any person provide additional income to support your living expenses
*
Yes
No
If so, How much? If no money is received enter 0
*
What type of public assistance to do you receive?
*
🛈
Food Stamps
Welfare
Child care assistance
Housing assistance
Red Cross
None
Other
Other
Does the other parent help support the child?
Yes
No
Single, Divorced, or Separated Parents
What documents do you have to show that you live separate from your spouse?
*
🛈
Rental agreements
Utility bills
Bank accounts
Telephone bills
Restaining order
Other
Other
What documents do you have to show that you paid over half household expense?
*
🛈
Property Taxes
Mortgage Interest
Rents paid
Utility bills
Groceries Receipts
Property Insurance
Repair receipts
Other:
Other:
How often does the child stay with the other parent?
Where is the child's other parent located?
What school does the child attend?
Who watches the child while you are at work?
Is the caregiver being claimed as a dependent?
If a family member cares for the child, do they live with you?
*
Yes
No
Do they file a tax return?
Yes
No
🛈
Myself
Other Parent
Other
Carries health insurance?
Myself
Other Parent
Other
Pays other medical expense?:
Myself
Other Parent
Other
Pays for activities & essentials?
Myself
Other Parent
Other
Pays for the day care?
Myself
Other Parent
Other
College Expenses
What school(s) were attended
🛈
Me
Parents
Other
Room & Board:
Me
Parents
Other
Tuition:
Me
Parents
Other
Books:
Me
Parents
Other
W H O P A Y S
:
Do you want Direct Deposit?
*
Yes
No
Routing Number
+
-
Account Number
+
-
PLEASE ENTER YOUR FULL NAME IN THE BELOW BOX
*
Date Signed
*
By checking this box will act as my signature and certify this information is true and accurate.
*
Signed