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Beckley: 304.255.0204 | Princeton: 304.425.8291
info@AmericanTaxCo.com
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Client Information Sheet
Filing Status - Please Select One
*
Single
Head of Household
Married Filing Joint
Married Filing Seperate
Qualifying Widow(er)
Taxpayer Information
Name
*
First
Middle
Last
Date of Birth
*
MM slash DD slash YYYY
Social Security Number
*
Daytime Telephone Number
*
Evening Telephone Number
*
Email
*
Spouse Information
Name
*
First
Middle
Last
Date of Birth
*
MM slash DD slash YYYY
Social Security Number
*
Gender
*
Daytime Telephone Number
*
Evening Telephone Number
*
Email
*
Demographic Information
Physical Address
*
Street Address
Address Line 2
City
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Ohio
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Pennsylvania
Rhode Island
South Carolina
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Tennessee
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Armed Forces Americas
Armed Forces Europe
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State
ZIP Code
Mailing Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Dependent Information
Name
First
Last
Date of Birth
MM slash DD slash YYYY
Months in Home
Social Security Number
Relationship
Name
First
Last
Date of Birth
MM slash DD slash YYYY
Months in Home
Social Security Number
Relationship
Name
First
Last
Date of Birth
MM slash DD slash YYYY
Months in Home
Social Security Number
Relationship
Name
First
Last
Date of Birth
MM slash DD slash YYYY
Months in Home
Social Security Number
Relationship
Did you pay childcare expenses during the previous tax year?
Yes
No
If 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
Select files
Accepted file types: pdf, Max. file size: 256 MB.
Did you (and if applicable, your entire household) have health insurance coverage for the entire year?
*
Yes
No
If Yes, was the insurnace purchased through the Insurance Marketplace?
*
Yes
No
Are you or anyone listed on your tax return being claimed as a dependent on another tax return?
*
Yes
No
If Yes, who?
*
Have you ever been disallowed from claiming the Earned Income Tax Credit?
*
Yes
No
Are you or anyone listed on your tax return, permanently disabled and/or blind?
*
Yes
No
If 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:
*
Checking
Savings
Hidden
Do 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?
*
Yes
No
If Yes, please provide further information:
*
Taxpayer Identification
ID Type
*
ID Number
*
ID Issue Date
*
ID Expiration Date
*
ID State
*
Spouse Identification Information
(if applicable)
ID Type
ID Number
ID Issue Date
ID Expiration Date
ID State
Hidden
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