Client Data Sheet

Client Data Sheet
Name

First NameLast Name
Occupation*
Social Security Number*
Date of Birth*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse Name
Name

First NameLast Name
Spouse Occupation
Spouse Social Security Number
Spouse Date of Birth
Spouse Email
Spouse Phone Number
yesno
How Did you hear about us.
Dependents Name(s), Social Security Number(s), DOB(s), Relationship(s) to you, Months lived in your home this tax year (Type N/A if not applicable)
Child Care Information (include provider name, address, ein, and amount paid)
You and (if applicable) all your dependents have medical insurance.Someone else can claim you as a dependent.You and your spouse lived apart during the year.You paid estimated Federal or State taxes last year.You itemized last year.You or your spouse were a resident of another state or earned income in another state during last year.You purchased a home in 2008 and received the up to $7,500 First-Time Home Buyers credit.You were a student, had education expenses, or made student loan payments.
Did you work in 2019 but was unable to work in 2021 due to Covid 19?
YesNo
YesNo
Did you receive your 3rd stimulus checks? If so, specify amount received. *
Did you receive any child tax advance payments? If so, specify the amount received and how many dependents.
Do You have an IPIN number?
Would you like your refund direct deposited into your bank account?
If yes, please provide bank account number and routing number.
CheckTaxpayer Debit Card
Would you like to apply for a tax advance loan up to $6,000? (rate may apply)
would You like to apply for a Tax Advance for $500 up to $2,000? (no additional rates)
You have 1 or more Wage Statement(s) (W2s)Self EmployedTips/other income1099sReceived InterestReceived InterestSold Stocks or BondsPension or Retirement IncomeReceived Unemployment (1099-G)Alimony (paid or received)Bought or sold a homeOwn a rental propertyMortgage InterestMortgage Points (ie closing points)Paid real estate taxesProperty taxSold a business assetFarm IncomePaid qualified education expenseMedical ExpensesLottery or Gambling WinningsCancellation of DebtCharity or Religious ContributionsSignificant loss or theft (federally declared disaster areas)Have foreign bank account, trust, or businessGave a gift of more than $15,000Gave a gift of more than $15,000
Upload Your Id *

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Upload Social Security for Taxpayers *

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Upload Social Security cards for dependents.*

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Upload Tax Forms

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Take A selfie of Yourself For Identity purposes only( Don't forget to say cheese)
Taxpayers Drivers LicenseTaxpayers Social Security Cards.All Dependents Social Security CardsProof Of residence (Ex: lease agreement, current mail with mailing address)Healthcare Card for Taxpayer/DependentsIncome (Ex: W-2, 1099/Self Employment Expense log or summery of income, Business License, Bank Statements)
TYPE NAME: TO CERTIFY ALL INFORMATION IS ACCURATE AND YOU WOULD LIKE YOUR TAXES PREPARED BASED ON THE INFORMATION YOU HAVE PROVIDED.*
Signature*

Consent to Use of Tax Return Information

Sherita Scott (“we”, “us” and “our”)

Federal law requires this consent form be provided to you (“you” refers to each taxpayer, if
more than one). Unless authorized by law, we cannot use your tax return information for
purposes other than the preparation and filing of your tax return without your consent.
You are not required to complete this form to engage our tax return preparation services. If we
obtain your signature on this form by conditioning our tax return preparation services on your
consent, your consent will not be valid. Your consent is valid for the amount of time that you
specify. If you do not specify the duration of your consent, your consent is valid for one year
from the date of signature.
For your convenience, we have entered into an arrangement with Santa Barbara Tax Products
Group, LLC, a division of Green Dot Corporation, a Delaware corporation (“Processor”), using
banking services of Civista Bank, to provide qualifying taxpayers with the opportunity to apply
for refund processing services offered by and through Processor. To determine whether these
services may be available to you, we will need to use your tax return information by analyzing it
and calculating the amount of your anticipated refund.
If you would like us to use your tax return information to determine whether these services
may be available to you while we are preparing your return, please sign and date this consent
to the use of your tax return information.
By signing below, you (including each of you if there is more than one taxpayer) authorize us to
use the information you provide to us during the preparation of your 2021 tax return to
determine whether to present you with the opportunity to apply for refund processing services
through Processor.
Taxpayer Name *

First NameLast Name
Date*

MonthDayYear
Date
Taxpayer Signature*
Name

First NameLast Name
Date

MonthDayYear
Date
Signature
If you believe your tax return information has been disclosed or used improperly in a manner
unauthorized by law or without your permission, you may contact the Treasury Inspector
General for Tax Administration (TIGTA) by telephone at 1-800-366-4484, or by email at
complaints@tigta.treas.gov.
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