Can anyone else claim you as a dependent? If Yes, Check Here
Dependents:
1 of 3Check any items that apply to you:<\center>
Income
Expenses
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.
REFERRED BY NAME/Phone