Client Information Sheet

Filing Status - Please Select One*

Taxpayer Information

Name*

First Middle Last

Date of Birth*

Social Security Number*

Daytime Telephone Number*

Evening Telephone Number*

Email*

Spouse Information

Name*

First Middle Last

Date of Birth*

Social Security Number*

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

Months in Home

Social Security Number

Relationship

Name

First Last

Date of Birth

Months in Home

Social Security Number

Relationship

Name

First Last

Date of Birth

Months in Home

Social Security Number

Relationship

Name

First Last

Date of Birth

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

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?*

If Direct Deposit was selected, please enter the following:

Routing Number:*

Account Number:*

Account Type:*

Checking
Savings

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

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

Client Information Sheet