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ACCOUNTANT, TAX & REALTOR SOURCE INC.

Subtitle

NEW CLIENT Information Form

Please complete so that we have your most current information on file



First Name / Last Name _______________________________________________________________


SS# / Date of Birth______________________________________________(DOD)_________________


Spouse First Name / Last Name ________________________________________________________


SS# / Date of Birth______________________________________________(DOD)_________________


Current mailing address:_______________________________________________________________

Apt #_________

City / State / Zip Code ____________________________________________________________


Cell Phone# for calls/texts:_________________________________________________________


Email address:_______________________________________________________________________


Did you receive letter from IRS regarding Advance Child Tax Payment and/or Recovery Rebate? Y_____ N_____


Did you pay for health insurance? Yes_____ (1095A) No____

_

Internet Virtual Currency (bitcoin) during tax year? Y____ N____


Did you donate money to charity this year? Yes ____ N ____(If so, how much) $___________


Students! Scholarship amount was used for fees, books or supplies $___________________

Scholarship amount included in your W2 income $__________________


How did you hear about us? _______________________________________________________


Dependents - EXACT spelling names, SS#, and Date of birth that is on file with SS Admin (803-772-1213)

Child Care Providers- 2441 Yes____ No____ (if yes, complete information below or provide completed document from provider)


Provider name______________________________________________________________

Provider address____________________________________________________________

Tax ID # or SS# ____________________________________Amount Paid ______________


Indicate by ‘X’ if any of the following apply:

*Withdrawal from pension ____(1099-R) *Health insurance thru Marketplace_____(1095-A)


*HSA____(1099-SA) *Interest/Dividends_____    * Unemployment____(1099-G)


*Social Security benefits_____ *Retirement Contribution____ *Adoption____


*Energy Savings Purchases____ *Gambling winnings____(W2-G) *Virtual Currency_____


*Repayment of Homebuyer Credit____  *Student Loan Interest_____ *Alimony Paid or Received ____


*Student Education expenses_____(1098T) *Self-employed____(1099-NEC/Misc) *Business Owner____ 

*Rental property_____   Transportation Owner Operator _____ *Stock Trades____


Do you own a home? Yes ____ No____

Did you purchase or refinance a home during tax year (CD)? (Sch A) Yes ____ No ____

(If no, skip to question #1 below) (If yes, X or write in amount for all that apply)


*Last Year State Refund Received $______       *Medical, dental, optometry ______

*Property taxes paid_____ *Vehicle Taxes_____ *Land or other property taxes paid_____

*Mortgage Interest *Charitable (monetary_______; non-monetary_______)  Refinance of New Home Purchase___

*Energy Savings Purchase______ *Repay $500 homebuyer credit______


Circle Yes or No:

1. Do you have all of that tax documents that were mailed to you? Yes___ No___

2. Do you have a copy of your previous year tax return with you? Yes___ No___

3. Did you live and work in one stat for the entire year? Yes___ No___

4. Did you receive the Earned Income (EIC) last year? Yes___ No___

5. Are you claiming the same dependents you claimed last year? Yes___ No___

6. Is there anyone else who can or will try to clan you or your dependents? Yes___ No___

7. Did you receive any income that you may have forgotten about? Yes___ No___

(i.e unemployment, short term jobs, etc)

8. Did you have any tax refund problems last year? Yes___ No___ If yes, describe______________________________________________________________________________________

9. Do you owe any prior year taxes, child support, unemployment,

          If yes, or unsure call the IRS at 1-800-304-3107 (offsets), and 800-829-1954 (hotline) and let us know immediately.

10. How did you hear about us? 


            Last year client___ Drive By/Office Sign____ Referred by__________________ 

            Other? Please specify _________________________________________________________________