Income Tax Data Form

Customer Data Sheet

This form is to be completed by client
Tax Year:
Primary Filer's Information
Name*

First NameLast Name
Date of Birth*
Social Security Number*
xxx-xx-xxxx
Driver's License #*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Can someone else claim you as a dependent?*

YesNo
Spouse Filer's Information
Name

First NameLast Name
Date of Birth
Social Security Number
xxx-xx-xxxx
Driver's License #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dependent's Information
Name of Dependent
Date of Birth
Name of Dependent
Date of Birth
Name of Dependent
Date of Birth
Source of Income. Check the Income items which pertain to you:
Select all that's applied:*

Wages or Salary (W2 Income)UnemploymentPension/Retirement IncomeRental IncomeFarm IncomeDividend/Sale of Stocks
Select all that's applied:

Interest Income 1099 INTSelf-Employment-Bus. Income (Sch.C)Alimony ReceivedLottery or Gambling Income W-2GPublic/State Aid IncomeSocial Security IncomeTipsOther Income
Source of Expenses. Check the Expenses items which pertains to you:
Select all that's applied:

IRA'sProperty TaxMortgage Points(closing points)Business Owner/Self EmployedTax Prep ExpensesUnion DuesEducation ExpenseSignificant Loss or Theft
Select all that's applied:

Charity of Religous ContributionsMortgage InvestmentMoving ExpensesMedical ExpenseAlimony PaidBuy or Sell HomeJob Related ExpensesOther
Child Care Information(Credit)
Provider Name
Provider Phone Number

Area CodePhone Number
Provider Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Tax Filing Products
Paper Filing

YesNo
ETF Electronic Filing

YesNo
Bank Products

YesNo
I give Banks Financial Services permission to electronically deduct their final tax fee(s) from my IRS refund.
Primary Filer's Signature*

Clear
Date

MonthDayYear
Date
Spouse Signature

Clear
Date

MonthDayYear
Date
If a tax return needs to be re-transmitted to the Internal Revenue Service due to incorrect or incomplete information provided by the tax filer, and additional re-processing fee may be applied.
Should be Empty:

Customer Data Sheet

Primary Filer's Information

Spouse Filer's Information

Dependent's Information

Source of Income. Check the Income items which pertain to you:

Source of Expenses. Check the Expenses items which pertains to you:

Child Care Information(Credit)

Tax Filing Products