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  • Client Intake Form

    20913 Gratiot Ave. Eastpointe, MI 48021 Ph: 586-241-5300 Ph: 586-200-5743 www.profusetaxsvc.com
  • PLEASE READ BEFORE YOU START

    You must upload All Documents every
    Tax Season ** NO EXCEPTION **

    List of Important Items.
    Please Bring or Upload One Item from Each BULLET Point For Each Dependent.

    • Taxpayer(s): Driver License or State (you may upload the child(ren) ID or license)
    • Taxpayer(s): Any form of Bill Ex: Gas, Lights, Water Etc., if applicable
    • All Dependents Birth Certificate(s) (Substitution: Certificate of Birth) OR   Any Legal Document
    • All Dependents Social Security Cards (Substitution: 1095-B from the S of M)
    • ·Medical Records from PCP (No Shot Records) OR School Progress OR Report Card
    • Login to MI Bridges & download the FAP OR Health Approval Letter with your Child(ren) OR P-EBT Cards OR Rental Lease Agreement
    • Insurance Statement (if applicable) 1095-A, 1095-B OR 1095-C
  • **Your return will be Completed and Submitted with some but not all items.

    Note: If you do not have all but some items listed you must at the email below; email the other documents within 1-2 weeks. If we DO NOT receive your missing documents, your return will be NONCOMPLIANCE with the IRS Due Diligence requirements. Which may put you at risk of receiving

     A CP75 or CP75A notice.

    Note: If you are a New Client Email A Copy of your last year tax return to mytaxinfo888@yahoo.com

    Subject: Last Name, First Name Tax Year

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  • Client Intake Form

  • Personal Information

  •  - -
  •  - -
  • Direct Deposit Information

  • Dependents

    • Dependent1 
    • Dependent 1

    • This must be filled out If the dependent is other than your Son or Daughter
      Must bring a copy or upload the legal parents ID ** NO EXCEPTION **

    • Letter for Family Funds Support/ Letter of Affidavit

    • To whom this may concern:

      I    am the     Of            

      I give permission for      the duration of     years to claim my child(ren) as a dependent. Currently, I am unable to care for my child(ren) on my own due to financial hardship. I will provide financial support as much as I can towards living and other expenses for the child(ren) during their period at                  (Address of the child(ren) residency).

      If you have any questions, please contact me at
            (Legal Parents phone number).

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    •  - -
    • Dependent Care Provider’s Identification and Certification

      For Informational Purposes Only
    • Part I - Dependent Care Provider’s Identification

    • If the childcare provider refuses to give you his or her social security number you can still claim the credit.

    • Clear
    •  - -
    • Part II - Name, Address, & Telephone Number of Company Requesting

    • Profuse Tax & Notary Service, LLC 20913 Gratiot Ave. Eastpointe, MI 48021 586-241-5300

    • Dependent2 
    • Dependent 2

    • This must be filled out If the dependent is other than your Son or Daughter
      Must bring a copy or upload the legal parents ID ** NO EXCEPTION **

    • Letter for Family Funds Support/ Letter of Affidavit

    • To whom this may concern:

      I    am the     Of            

      I give permission for      the duration of     years to claim my child(ren) as a dependent. Currently, I am unable to care for my child(ren) on my own due to financial hardship. I will provide financial support as much as I can towards living and other expenses for the child(ren) during their period at                  (Address of the child(ren) residency).

      If you have any questions, please contact me at
            (Legal Parents phone number).

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    •  - -
    • Dependent Care Provider’s Identification and Certification

      For Informational Purposes Only
    • Part I - Dependent Care Provider’s Identification

    • If the childcare provider refuses to give you his or her social security number you can still claim the credit.

    • Clear
    •  - -
    • Part II - Name, Address, & Telephone Number of Company Requesting

    • Profuse Tax & Notary Service, LLC 20913 Gratiot Ave. Eastpointe, MI 48021 586-241-5300

    • Dependent3 
    • Dependent 3

    • This must be filled out If the dependent is other than your Son or Daughter
      Must bring a copy or upload the legal parents ID ** NO EXCEPTION **

    • Letter for Family Funds Support/ Letter of Affidavit

    • To whom this may concern:

      I    am the     Of            

      I give permission for      the duration of     years to claim my child(ren) as a dependent. Currently, I am unable to care for my child(ren) on my own due to financial hardship. I will provide financial support as much as I can towards living and other expenses for the child(ren) during their period at                  (Address of the child(ren) residency).

      If you have any questions, please contact me at
            (Legal Parents phone number).

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    •  - -
    • Dependent Care Provider’s Identification and Certification

      For Informational Purposes Only
    • Part I - Dependent Care Provider’s Identification

    • If the childcare provider refuses to give you his or her social security number you can still claim the credit.

    • Clear
    •  - -
    • Part II - Name, Address, & Telephone Number of Company Requesting

    • Profuse Tax & Notary Service, LLC 20913 Gratiot Ave. Eastpointe, MI 48021 586-241-5300

    • Dependent4 
    • Dependent 4

    • This must be filled out If the dependent is other than your Son or Daughter
      Must bring a copy or upload the legal parents ID ** NO EXCEPTION **

    • Letter for Family Funds Support/ Letter of Affidavit

    • To whom this may concern:

      I    am the     Of            

      I give permission for      the duration of     years to claim my child(ren) as a dependent. Currently, I am unable to care for my child(ren) on my own due to financial hardship. I will provide financial support as much as I can towards living and other expenses for the child(ren) during their period at                  (Address of the child(ren) residency).

      If you have any questions, please contact me at
            (Legal Parents phone number).

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    •  - -
    • Dependent Care Provider’s Identification and Certification

      For Informational Purposes Only
    • Part I - Dependent Care Provider’s Identification

    • If the childcare provider refuses to give you his or her social security number you can still claim the credit.

    • Clear
    •  - -
    • Part II - Name, Address, & Telephone Number of Company Requesting

    • Profuse Tax & Notary Service, LLC 20913 Gratiot Ave. Eastpointe, MI 48021 586-241-5300

    • Dependent5 
    • Dependent 5

    • This must be filled out If the dependent is other than your Son or Daughter
      Must bring a copy or upload the legal parents ID ** NO EXCEPTION **

    • Letter for Family Funds Support/ Letter of Affidavit

    • To whom this may concern:

      I    am the     Of            

      I give permission for      the duration of     years to claim my child(ren) as a dependent. Currently, I am unable to care for my child(ren) on my own due to financial hardship. I will provide financial support as much as I can towards living and other expenses for the child(ren) during their period at                  (Address of the child(ren) residency).

      If you have any questions, please contact me at
            (Legal Parents phone number).

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    •  - -
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    •  - -
    • Dependent Care Provider’s Identification and Certification

      For Informational Purposes Only
    • Part I - Dependent Care Provider’s Identification

    • If the childcare provider refuses to give you his or her social security number you can still claim the credit.

    • Clear
    •  - -
    • Part II - Name, Address, & Telephone Number of Company Requesting

    • Profuse Tax & Notary Service, LLC 20913 Gratiot Ave. Eastpointe, MI 48021 586-241-5300

    • Dependent6 
    • Dependent 6

    • This must be filled out If the dependent is other than your Son or Daughter
      Must bring a copy or upload the legal parents ID ** NO EXCEPTION **

    • Letter for Family Funds Support/ Letter of Affidavit

    • To whom this may concern:

      I    am the     Of            

      I give permission for      the duration of     years to claim my child(ren) as a dependent. Currently, I am unable to care for my child(ren) on my own due to financial hardship. I will provide financial support as much as I can towards living and other expenses for the child(ren) during their period at                  (Address of the child(ren) residency).

      If you have any questions, please contact me at
            (Legal Parents phone number).

    • Clear
    •  - -
    • Browse Files
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    •  - -
    • Dependent Care Provider’s Identification and Certification

      For Informational Purposes Only
    • Part I - Dependent Care Provider’s Identification

    • If the childcare provider refuses to give you his or her social security number you can still claim the credit.

    • Clear
    •  - -
    • Part II - Name, Address, & Telephone Number of Company Requesting

    • Profuse Tax & Notary Service, LLC 20913 Gratiot Ave. Eastpointe, MI 48021 586-241-5300

    • Rest of the Form 
  • PLEASE ANSWER ALL OF THE QUESTIONS TO AVOID SLOWING UP THE PROCESS OF YOUR RETURN.

  • YOU MAY NOW RECEIVE IT DIRECT DEPOSIT.

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  •  
  •  
  • If you didn’t receive you Letters 1444 A-C &/or Letter(s) 6416 or 6417 Please create an account on IRS.GOV/GETMYPAYMENTS save the detail information and upload with the rest of your tax documents.

  • State of Michigan Information

    Homeowners Only
  • Renters Only

  • Direct Deposit Information

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  • EITC Due Diligence Client Worksheet

  • HEAD OF HOUSEHOLD (HOH)

  • IN ORDER TO BE CONSIDERED HOH, YOU MUST PROVIDE OVER HALF THE COST OF KEEPING UP THE HOME & YOUR TAX LIABILITY CAN NOT BE AT ZERO. ONLY ONE TAXPAYER PER HOME CAN QUALIFY FOR HOH. 

    CAN YOU PROVIDE DOCUMENTATION PROVING YOUR HOH STATUS?

    IF YES, CIRCLE &/OR CHECK ANY OR ALL OF THE APPROPRIATE ITEMS.

  • Child & Other Dependent QUESTIONAIRRE

  • GENERAL MISCELLANEOUS QUESTIONS

  •  
  • APPROXIMATELY HOW MUCH?

  • 7216 Consent to Use of Tax Return Information

  • Profuse Tax & Notary Services, LLC

    Printed name of Tax Company

     

    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 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 an arrangement with Santa Barbara Tax Products Group, LLC (“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 CURRENT TAX PERIOD tax return to determine whether to present you with the opportunity to apply for refund processing services through Processor.

  • Duration of consent: N/a                

     
    Printed Name of Taxpayer:       
    Taxpayer Signature:   Date:   Pick a Date   
     
    Printed Name of Joint Taxpayer:       
    Joint Taxpayer Signature:   Date: Pick a Date   
     

  • 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.

  • 7216 Consent to Disclosure of Tax Return Information

  • Profuse Tax & Notary Services, LLC 

    Print name of Preparer

     

    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 disclose your tax return information to third parties for purposes other than the preparation and filing of your tax return without your consent. If you consent to the disclosure of your tax return information, Federal law may not protect your tax return information from further use or distribution.

    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. If you agree to the disclosure of your tax return information, your consent is valid for 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.

    You have indicated that you are interested in applying for a Refund Transfer (“RT”) product from Santa Barbara Tax Products Group, LLC (“Processor”) using banking services of Civista Bank (“Bank”). To have your refund processed by and through Processor, we must disclose all your CURRENT TAX PERIOD tax return information to Processor and Bank.

    If you would like us to disclose your CURRENT TAX PERIOD tax return information to Processor and Bank for this purpose, please sign and date your consent to the disclosure of your tax return information.

    By signing below, you (including each of you if there is more than one taxpayer) authorize us to disclose to Processor and Bank all your CURRENT TAX PERIOD tax return information so that Processor can evaluate and process your application and Bank can provide banking services for the RT product. You understand that if you are not willing to authorize us to share your tax information with Processor and Bank, you will not be able to obtain an RT product from Processor, but you can still choose to pay us directly to have your tax return prepared and filed.

  • Duration of consent: N/a                

     
    Printed Name of Taxpayer:       
    Taxpayer Signature:   Date:   Pick a Date   
     
    Printed Name of Joint Taxpayer:       
    Joint Taxpayer Signature:   Date: Pick a Date   
     

  • 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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