Client Information Sheet

Filing Status - Please Select One*
Taxpayer Information
Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Daytime Telephone Number*
Evening Telephone Number*
Email*
Spouse Information
Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Gender*
Daytime Telephone Number*
Evening Telephone Number*
Email*
Demographic Information
Physical Address*
Street Address Address Line 2 City State ZIP Code
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Dependent Information
Name
First Last
Date of Birth
MM slash DD slash YYYY
Months in Home
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
Relationship
Name
First Last
Date of Birth
MM slash DD slash YYYY
Months in Home
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

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?*
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*
Please upload a copy of your ID*
Max. file size: 1 MB.
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
Terms of Service
I 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
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Client Information Sheet

Taxpayer Information

Spouse Information

Demographic Information

Dependent Information

Taxpayer Identification

Spouse Identification Information

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