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NEW CLIENT Information Form

Please complete so that we have your most current information on file  (Upload to your portal or bring in). Do not email!

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 pay for health insurance? Yes____(1095A) No____

Internet Virtual Currency (bitcoin) during _

tax year? Y____ N____

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

Scholarship amount included in your W2 income $__________________

How did you hear about us? _______________________________________________________

Claiming Dependents? Yes ___ or No ___ If yes, are they SAME dependents as last year? Yes ___ No___

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

Dependents name                                                                                  DOB & SS#                                  Relationship     #of Months   Student or

      First/Last                                                                                                                                                                            in Home       Disabled

_________________________________________        ___________________________________    ____________       _____            _____

_________________________________________        ___________________________________    ____________       _____            _____

_________________________________________        ___________________________________    ____________       _____            _____

_________________________________________        ___________________________________    ____________       _____            _____

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 state for the entire year? Yes___ No___

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

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

6. 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...? Yes___  No___

          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 _________________________________________________________________