CUSTOMER DATA SHEET Referred by Name/Phone * Please PRINT your personal information to assist us in the preparation of your income tax return. Taxpayer: First Name: M.I.: Last Name: Address: Apt: Type a question Single Married Filing Joint Married Filing Separate Head of Household City: Zip: State: Date of Birth: Age: Social Security #: Drivers Lic #: Exp. Date: Issue Date: Cell #: Home #: Email: Occupation: Type a question Can anyone else claim you as a dependent? If Yes, Check Here Spouse: First Name: M l.: Last Name: SS #: Drivers Lic. #: Exp. Date: Issue Date: Cell #: Work #: Date of Birth: Age: Dependents No. 1 Name Date of Birth Age Social Security # Relationship Months Lived with You Custody? Yes or No Dependents No. 2 Name Date of Birth Age Social Security # Relationship Months Lived with You Custody? Yes or No Dependent No. 3 Name Date of Birth Age Social Security # Relationship Months Lived with You Custody? Yes or No Dependent No. 4 Name Date of Birth Age Social Security # Relationship Months Lived with You Custody? Yes or No Dependent No. 5 Name Date of Birth Age Social Security # Relationship Months Lived with You Custody? Yes or No Dependent No. 6 Name Date ofBirth Age Social Security # Relationship Months Livedwith You Custody?Yes or No Check any items that apply to you: ( ) Income Type a question Wage/Salary Statement(W2) How Many? Interest Received(1099 INT) Gambling Winnings/Losses(W2G) Tip Income Type a question Retirement Income (1099R Unemployment Income (1099G) Rental Property Income Dividends, Capital Gains Type a question Self-Employment Income(1099 Misc.) Social Security (SSA-1099) F.I.P Income Alimony received Expenses Type a question Work/Medical Expenses Property Taxes Paid Make IRA Contribution? Type a question Mortgage Interest Paid Buy or Sell Home? Pay Child Support Type a question Education Expenses/Loan Alimony Paid Gifts to Charity Do you have Children in Child Care? Y / N If Yes, answer the following: Type option 1 Type option 2 Provider’ Name Provider’s Address Provider’s EIN or Social Security # Provider’s Telephone # Child’s Name Child’s Name Amount Paid $ Amount Paid $ Renter’s Information (Credit Applicable in certain States) How much Rent did you pay Per Month? $ # of Months’ Rent was Paid Was your Heating included with the Rent? Y / N Type option 1 Type option 2 If NO, How much did you pay for heating (or Kerosene) for the year? $ Landlord’s Name Phone # Landlord’s Address City Zip Did you have Medical insurance through the Marketplace Yes No Number of months you had medical coverage If you DO NOT want IN & OUT Tax Service to prepare your city return, please initial here If you DO NOT want IN & OUT Tax Service to prepare your state return, please initial here DIRECT DEPOSIT PAYMENT OPTION PLEASE COMPLETE BANK INFORMATION BANK NAME ROUTING # ACCOUNT# Type a question Taxpayer’s Signature Clear Date - Month - Day Year Date Spouse’s Signature Clear Date - Month - Day Year Date Letter of Engagement to Prepare Tax Return The undersigned person(s) has authorized IN & OUT Tax Service, or any authorizedrepresentative of IO Tax to prepare their federal and/or state tax return(s). IO Tax claims noresponsibility for the tax return(s) other than preparing the said return(s). The accuracy of thereturn(s) will be directly related to the information that you, the taxpayer(s), provide IO Tax orany authorized representative of IO Tax. The information received by IO Tax will be used incompliance with the rules and regulations of the Internal Revenue Service. Two forms of identification such as a social security card or a form with picture identificationshould be presented to the preparer during service. We will gladly key your check-stubinformation for estimates ONLY. You must provide our office with the appropriate documentssuch as a W-2, 1099, 1098, child-care information, college student, mortgage information, andany related tax filing forms in order for your tax return to be properly e-filed to the IRS. Wewill supply you with a copy of your tax return and advise you to keep it in a safe and secureplace in case needed. We will not be able to provide you with another copy once the office hasclosed for the tax season. You will have to contact the IRS to receive additional copies at thattime. In the event of an electronic filed tax return refund, IO Tax makes no claim or guaranteesregarding the time for expected delivery. All dates and/or responsibility are limited to thepreparation of the return for electronic transmission. After electronic transmission, any delayscaused by the IRS, Bank(s) and/or any other government agency involved are not theresponsibility of IO Tax. By signing this Letter of Engagement, to Prepare Tax Returns, you have agreed to fullycompensate and authorize IO Tax to prepare your tax return(s). If and when payment of servicesis rendered, it is to be electronically deducted from your refund; the taxpayer(s) is/are fullyresponsible for any unpaid balance. Any outstanding balance must be paid in full during thetime of services rendered. The taxpayer(s) will be responsible for any and all fees and expenses,including collection fees, attorney fees, damages, court cost and interest that may incur in IOTax collecting the unpaid debt. IO Tax will have the right to report to any Credit ReportingAgency using any information provided. You agree that you have provided all necessarydocuments to prepare your tax return. You declare that all information you’ve provided duringyour tax interview are true, correct and complete. Signature Clear Date - Month - Day Year Date Signature Clear Date - Month - Day Year Date Social Security Number Social Security Number Preview PDF Submit Social Security # Should be Empty: Now create your own Jotform - It's free! Create your own Jotform
