Client Information Sheet Client Information Sheet Filing Status - Please Select One*SingleHead of HouseholdMarried Filing JointMarried Filing SeperateQualifying Widow(er)Taxpayer InformationName* First Middle Last Date of Birth* Date Format: MM slash DD slash YYYY Social Security Number*Daytime Telephone Number*Evening Telephone Number*Email* Spouse InformationName* First Middle Last Date of Birth* Date Format: MM slash DD slash YYYY Social Security Number*Gender*Daytime Telephone Number*Evening Telephone Number*Email* Demographic InformationPhysical Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Dependent InformationName First Last Date of Birth Date Format: MM slash DD slash YYYY Months in HomeSocial Security NumberRelationshipName First Last Date of Birth Date Format: MM slash DD slash YYYY Months in HomeSocial Security NumberRelationshipName First Last Date of Birth Date Format: MM slash DD slash YYYY Months in HomeSocial Security NumberRelationshipName First Last Date of Birth Date Format: MM slash DD slash YYYY Months in HomeSocial Security NumberRelationshipDid you pay childcare expenses during the previous tax year?YesNoIf YES, please provide the tax professional with the receipt issued by the care-provider. The receipt must Include the caregiver’s name, address, EIN or SSN, and the full amount paid. If you had multiple childCare providers, you must provide receipts for all providers with the above-mentioned information.*Receipt Issued by the care-provider.* Drop files here or Accepted file types: pdf. Did you (and if applicable, your entire household) have health insurance coverage for the entire year?*YesNoIf Yes, was the insurnace purchased through the Insurance Marketplace?*YesNoAre you or anyone listed on your tax return being claimed as a dependent on another tax return?*YesNoIf Yes, who?*Have you ever been disallowed from claiming the Earned Income Tax Credit?*YesNoAre you or anyone listed on your tax return, permanently disabled and/or blind?*YesNoIf Yes, who?*Years of disability and/or blindness:*If you are due a refund, how would you prefer to receive your refund?*Paper Check Mailed by the IRS (tax preparation fees paid before filing)Direct Deposit (tax preparation fees paid before filing)Check Printed in our Office (pay nothing upfront)Direct Deposit (pay nothing upfront)Debit Card (pay nothing upfront)If Direct Deposit was selected, please enter the following:Routing Number:*Account Number:*Account Type:*CheckingSavingsDo you or your spouse have any debt that may warrant the Internal Revenue Service or other government agency to take all or a portion of your tax refund?*YesNoIf Yes, please provide further information:*Taxpayer IdentificationID Type*ID Number*ID Issue Date*ID Expiration Date*ID State*Spouse Identification Information(if applicable)ID TypeID NumberID Issue DateID Expiration DateID StateTerms of ServiceI certify that the information listed above was provided accurately and honestly. I understand that I do not hold American Tax Company, LLC. responsible for errors that results from dishonest or missing information. I agree to the Terms of Service
