New Client Information Sheet
ADVERTISEMENT
1Client Information Sheet
TAXPAYER INFO
Filing Status: ___Married
___Head of Household
___Widowed
(date of death ________)
___Single
___Married Filing Separate
*not eligible for EIC (date separated ______)
Primary Taxpayer’s Name ____________________________________________
___ Blind ___Student
Date of Birth __________________ Social Security # ____-____-______
___ Deceased
Did the taxpayer have health insurance in 2014? YES_____ NO_____
(*must provide copy of 1095 B, C or proof of insurance*)
If so, was it through the market place? YES_____ NO_____ (*form 1095A is required to file*)
Spouse’s Name ______________________________________________________
___ Blind ___Student
Date of Birth __________________ Social Security # ____-____-______
___ Deceased
Did the spouse have health insurance in 2014? YES_____ NO_____
(*must provide copy of 1095 B, C or proof of insurance*)
If so, was it through the market place? YES_____ NO_____ (*form 1095A is required to file*)
Address ___________________________________________________
City, State, ZIP _____________________________________________
Phone # (
we must have a valid phone # where you can be reached in order to complete your taxes)
Home: _____________ Cell: ______________ Other: _____________________
*Please provide an email address for your tax return to be emailed to you.
Email: ____________________________________________________________
____ I would like to receive a copy of my Income Tax Return via Email
Dependents Claimed on Income Tax Return
(List additional dependents on back of form.)
1. Full Name __________________________________
Son
Daughter
Parent Other __________
Date of Birth _____________Age ________Social Security # _____-_____-_____Months Person Lived w/ You Last Year ______
Did the dependent have health insurance in 2014? YES____ NO_____
(*must provide copy of 1095 B, C or proof of insurance*)
If so, was it through the market place? YES_____ NO_____ (*form 1095A is required to file*)
2. Full Name __________________________________
Son
Daughter
Parent
Other __________
Date of Birth _____________Age ________Social Security # _____-_____-_____Months Person Lived w/ You Last Year ______
Did the dependent have health insurance in 2014? YES____ NO_____
(*must provide copy of 1095 B, C or proof of insurance*)
If so, was it through the market place? YES_____ NO_____ (*form 1095A is required to file*)
3. Full Name __________________________________
Son
Daughter
Parent
Other __________
Date of Birth _____________Age ________Social Security # _____-_____-_____Months Person Lived w/ You Last Year ______
Did the dependent have health insurance in 2014? YES____ NO_____
(*must provide copy of 1095 B, C or proof of insurance*)
If so, was it through the market place? YES_____ NO_____ (*form 1095A is required to file*)
If eligible for a refund how would you like to receive it? Check One:
___Refund Check mailed to your home
___Direct Deposit
(fill out bank information below)
Bank Name: ____________________________ Routing Number: ______________________
___checking account ___saving account (account number: ______________________________)
___No-Money-Paid-Up-Front
(tax preparation fee will be deducted from refund-additional fees apply)
(Enter Bank info above) (**2 phone #’s are required to qualify)
____Check
____Direct Deposit
(pick up at PPS office)
___I would like to receive a text message when my refund is ready to be picked up.
(provide cell phone # above)
***Remember to include***
___copy of driver’s license and SS card
___copy of Social Security card for all dependents
___all tax documents (W-2’s, etc.)
___tax preparation discount coupon
___copy of voided check (for direct deposit customers) ___proof of insurance for taxpayer & dependents
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business