Client Information Form - Charles Village Tax Service Inc

Personal Information

Taxpayer Name *

Spouse Name

Taxpayer SSN *

Spouse SSN

Taxpayer DOB

Spouse DOB

Contact Information

Home/Cell Phone

Spouse Home/Cell

Work Phone

Spouse Work Phone

Occupation

Spouse Occupation

Taxpayer E-mail

Spouse E-mail

Can we contact?YesNo

Address Information

Home Address *

City

State

Zip

Do You Rent or Own?RentOwn

Did you live at this address for all of the Tax Year?YESNO

If No, List Previous address

Did you reside in another state (for any length of time) during the Tax Year?YESNO

If Yes, Please list state(s) and length of time of residence

Identification Information

Taxpayer ID or Driver License #

State Issue/Date

Exp Date

Spouse ID or Driver License #

State Issue/Date

Exp Date

Are you or your spouse legally blind?YESNO

If Yes, Who?SelfSpouse

Did you or ANY of your dependents attend a college or university during the tax year?YESNO

What was the amount of your last year State refund?

Are you or your spouse Self Employed?YesNo

Who?

How do you want your refund back?MailMail w/ Direct DepositSimple E-File IRS issued checkSimple E-File W/ Direct Deposit into you bank account

Bank Products (our fees will be deducted)Prepaid Card/ Money Clip VisaBank Direct Deposit to your accountBank issued check in Office

Do you OWE any of the followingIRSChild SupportStudent LoansMVA Fines

Or any other Fines/Fees?

HOUSEHOLD/DEPENDENT INFORMATION

First

Last

SSN

Relationship

DOB

Any Childcare expenses?

Tuition or Fees paid?

DEPENDENT CARE INFORMATION

PROVIDER NAME / PHONE#

SSN/E.I.N

AMOUNT PAID

ADDRESS

STATE

ZIP

FINANCIAL INSTITUTION

BANK NAME

ROUTING #

ACCT# (If using direct deposit)

Was the taxpayer or spouse a member of the U.S. Armed Forces at any time during the tax year?YESNO

At any time in the tax year, did the taxpayer receive, sell, send, exchange, or acquire any financial interest in any virtual currency?YESNO

Did you buy, sell, or trade stock during the tax year?If yes, please send us your 1099-B or Form 8949.YESNO

Disclaimer

Taxpayer Signature / Date *

Spouse Signature / Date

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