Client Form
Tax Year
Today's Date
-
Month
-
Day
Year
Date
Have you used DBE services before?
Yes
No
If so, what year?
Back
Next
Primary Taxpayer Full Name (from Social Security Card)(This person will be listed first on the tax return)
First Name
Last Name
Has name changed? ( Past Year)
Yes
No
If Yes, Please List Former Name
First Name
Last Name
Social Security Number
Date of Birth
-
Month
-
Day
Year
Date
Occupation
Email Address
example@example.com
Are you currently serving in the military on Active Duty?
Yes
No
Do you want $3 to go to the Presidential Campaign Fund?
Yes
No
Back
Next
Spouse Full Name
First Name
Last Name
Has name changed? ( Past Year)
Yes
No
If Yes, Please List Former Name
First Name
Last Name
Social Security Number
Date of Birth
-
Month
-
Day
Year
Date
Occupation
Email Address
example@example.com
Are you currently serving in the military on Active Duty?
Yes
No
Do you want $3 to go to the Presidential Campaign Fund?
Yes
No
Back
Next
Marital Status
Single
Married
Separated
Divorced
Widowed
If Widowed, Date of Spouse's Death
-
Month
-
Day
Year
Date
If Separated Date of Separation
-
Month
-
Day
Year
Date
If Separated, Spouse's SSN
Are you or can you be claimed as a dependant on someone else's tax return?
Yes
No
Back
Next
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Physical Street Address(if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Daytime Phone *Preferred
Please enter a valid phone number.
Evening Phone *Preferred
Please enter a valid phone number.
Cell Phone *Preferred
Please enter a valid phone number.
Text Message Number
(if different than cell)
Best time to call
Hour Minutes
AM
PM
AM/PM Option
How did you hear about DBE?
If "friend", Friend's Name
First Name
Last Name
Interested in our Fall Tax School?
Interested in receiving our Client Newsletter
Dependant First Name
(from Social Security Card)
Last Name
(in different)
SSN
Relationship
Months in Home
(this year)
Date of Birth
Full Time Student?
Disabled?
Back
Next
Live in any other states? And/or Work in any other states?
If yes, list the states and dates you lived or work there:
City / Country of resident of Workplace
School District
Did you purchase a home in 2020?
Have you ever claimed the First time Home Buyer's Credit?
Purchased qualified residential energy products for your home?
Back
Next
Receive wages, salaries, or any other employer compensation?
Receive W-2 forms from ALL employers your worked for last year?
Receive unemployment compensation?
Receive alimony
Receive Social Security Income?
Pay alimony?
If yes, Name of Recipient
First Name
Last Name
SSN of Recipient
Pay Daycare expenses? (Name, address and SSN (or EIN) of provider is required) Receive winnings from gambling? (lottery, race track, casinos, raffles, etc.) Receive any miscellaneous income? (prizes, awards,jury duty, etc.)Amount and description are required
Pay interest on student loans?
Receive a state tax refund?
Pay real estate taxes?
Have a Home Mortgage?
Have medical expenses or pay for health insurance?
Contribute to charity, church, etc?
Receive pension, annuity, ROTH, IRA or retirement income? Receive interest on savings, cash, US bonds, stock dividends? Have a Health Saving Account (HSA)
Have out-of-pocket expenses, use personal vehicle on the job, etc?
Have a loss from casualty? (fire, theft, natural disaster, etc.)
Employer Name
Wages
Have a job-related move?
Simple Retirement Plan $
Did you take a distribution from any retirement account?
2019 Amount
2020 Amount
Pay college tuition expenses?
Are you enrolled as a: FT Student or PT Student
Was the Earned Income Credit ever disallowed for you?
Do you currently have health insurance coverage?
Are you receiving health insurance coverage through an ACA Marketplace?
Back
Next
Sold stock, mutual fund, or other securities?
Receive any 1099s (e.g. 1099-SSA, 1099-C, 1099-Misc)?
Own your own business or work as self-employed?
Use a portion of your home exclusively for business?
Did You Sell your home? Did Sell any other property? (equipment, land, etc.
Make estimated tax payments?
Business Name
First Name
Last Name
Proprietor Name
First Name
Last Name
Date of Business Start
-
Month
-
Day
Year
Date
Back
Next
Own rental property or convert rental property to personal use?
Receive royalties?
Operate a farm?
Receive installment payments on property sold?
Have an interest in a partnership, S-corporation, estate or trust?
Have income as a minister?
Receive housing allowance?
Back
Next
If I’m due a refund, I would like the convenience of having fees taken out of my refund instead of paying DBE out of my pocket.
Back
Next
All information I have given is true and correct to the best of my knowledge.
Client's Signature
Spouse's Signature
Date
-
Month
-
Day
Year
Date
Prep Id (DBE Employee)
Submit
Should be Empty: