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4418 Bluebonnet Drive, Suite 202
Stafford, TX 77477
(281) 491-1235
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Client Information
First Name
Last Name
SS#/ITIN#:
Date of Birth
Profession
Cell#
Email
Spouse’s First Name:
Last Name
SS#/ITIN#:
Date of Birth
Profession
Cell#
Home Address
City
State
Zip
Filling Status: (check one ✓)
Single
Married Filling Jointly
Married Filling Saparately
Head of household
Can you or spouse be claimed as a dependent on anyone else tax return
Yes
No
Name of Dependent/Child #1
Date of Birth of Dependent
Social Security #/ ITIN
Relationship
Select
Son
Daughter
Mother
Father
Name of Dependent/Child #2
Date of Birth of Dependent
Social Security #/ ITIN
Relationship
Select
Son
Daughter
Mother
Father
Name of Dependent/Child #3
Date of Birth of Dependent
Social Security #/ ITIN
Relationship
Select
Son
Daughter
Mother
Father
Name of Dependent/Child #4
Date of Birth of Dependent
Social Security #/ ITIN
Relationship
Select
Son
Daughter
Mother
Father
Do you owe taxes from previous years or have deliquent Child Support or Alimony?
Yes
No
Did you have Obama Care Health (ACA)Insurance Last year?
Yes (Provide 1095-A Form)
No Not at all
Advance Child Tax Credit Payment in 2021:
How Much Stimulus Payment did you receive in 2021:
Did you Buy or Sell Crypto Currency in 2021:
Yes
No
How would you like your Refund
Direct Deposit
Cheque
Direct Deposit:
Bank Name
Routing
Account#
Tax Payer DL # / ID
Issue Date
Expire Date
Spouse DL # / ID
Spouse DL Issue Date
Spouse DL Expire Date
Taxpayer DL/ID card Scan copy upload (Max 1 file - front only)
Spouse DL/ID card Scan copy upload (Max 1 file - front only)
Tax Payer Status:
US Citizen
Other
(If other, please enter Country Name)
Spouse:
US Citizen
Other
(If other, please enter Country Name)
Disclaimer
Disclaimer:
This is to certify that all the information above is correct according to my best knowledge and the prepare will not be held responsible for any rejections/audits or refunds on my Tax Return.
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