REFERRED BY NAME/Phone - Valerie's Tax Service

CUSTOMER DATA SHEET

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

Single Head of Household Married Filing Joint Married Filing Separate

City:

Zip:

State:

Date of Birth:

Age::

Social Security #:

Drivers Lic #:

Exp. Date: Issue Date:

Cell #:

Home #:

Email:

Occupation:

Message

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:

Occupation:

Dependents:

Name

Date of Birth

Age

Social Security #

Relationship

Months Lived with You

Custody? Yes or No

1 of 3

Check any items that apply to you:<\center>

Income

Wage/Salary Statement (W2) How Many?

Retirement Income (1099R)

Self-Employment Income (1099 Misc.)

Unemployment Income (1099G)

Social Security (SSA-1099

Gambling Winnings/Losses (W2G)

Rental Property Income

F.I.P Income

Tip Income

Dividends, Capital Gains

Alimony received

Expenses

Work/Medical Expenses

Mortgage Interest Paid

Education Expenses/Loan

Property Taxes Paid

Buy or Sell Home?

Alimony Paid

Do you have Children in Child Care? Y / N If Yes, answer the following: Provider’ Name __________________________________________________________ Provider’s Address _______________________________________________________ Provider’s EIN or Social Security # ____________________________________________ Provider’s Telephone # _____________________________________________________ Child’s Name________________________________________ Amount Paid $________ Child’s Name________________________________________ 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 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#_______________________________________

Taxpayer’s Signature __________________________________ Date ______________ Spouse’s Signature __________________________________ Date ______________

Letter of Engagement to Prepare Tax Return The undersigned person(s) has authorized IN & OUT Tax Service, or any authorized representative of IO Tax to prepare their federal and/or state tax return(s). IO Tax claims no responsibility for the tax return(s) other than preparing the said return(s). The accuracy of the return(s) will be directly related to the information that you, the taxpayer(s), provide IO Tax or any authorized representative of IO Tax. The information received by IO Tax will be used in compliance 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 identification should be presented to the preparer during service. We will gladly key your check-stub information for estimates ONLY. You must provide our office with the appropriate documents such as a W-2, 1099, 1098, child-care information, college student, mortgage information, and any related tax filing forms in order for your tax return to be properly e-filed to the IRS. We will supply you with a copy of your tax return and advise you to keep it in a safe and secure place in case needed. We will not be able to provide you with another copy once the office has closed for the tax season. You will have to contact the IRS to receive additional copies at that time. In the event of an electronic filed tax return refund, IO Tax makes no claim or guarantees regarding the time for expected delivery. All dates and/or responsibility are limited to the preparation of the return for electronic transmission. After electronic transmission, any delays caused by the IRS, Bank(s) and/or any other government agency involved are not the responsibility of IO Tax. By signing this Letter of Engagement, to Prepare Tax Returns, you have agreed to fully compensate and authorize IO Tax to prepare your tax return(s). If and when payment of services is rendered, it is to be electronically deducted from your refund; the taxpayer(s) is/are fully responsible for any unpaid balance. Any outstanding balance must be paid in full during the time 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 IO Tax collecting the unpaid debt. IO Tax will have the right to report to any Credit Reporting Agency using any information provided. You agree that you have provided all necessary documents to prepare your tax return. You declare that all information you’ve provided during your tax interview are true, correct and complete.

Signature of Primary Taxpayer Date

Social Security Number

Signature of Spouse (If applicable) Date

Social Security Number

REFERRED BY NAME/Phone