CLIENT INFORMATION FORM

CLIENT INFORMATION FORM
Name*

First NameLast Name
Social Security Number (please add spaces between the numbers. Ex. 000-00-0000)*
Date of Birth*

MonthDayYear
Date
Occupation (Job Title) *
Cellphone Number (please add spaces between numbers. Ex. 000-000-0000)*
Cellphone Provider (Who is your phone service with?)*
Email Address*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
License/State ID Information
Driver License Number*
State *
Issue Date*
Expiration Date*
Filing Status
Filing Status*
If Filing Head of Household, Can provide PROOF? Utility Bill, Rent Statement, etc.)
If YES, Please submit proof of documentation along with other tax documents
PLEASE THOROUGHLY READ!

YOU MAY USE FILING STATUS HEAD OF HOUSEHOLD ONLY IF, YOU PAY MORE THAN HALF OF THE BILLS. If you CANNOT provide PROOF of Head of Household ( UTILITY BILL IN YOUR NAME, RENT STATEMENT OR RECEIPTS IN YOUR NAME, ETC., you will need to file SINGLE. If you file using Head of Household and you are LEGALLY MARRIED AND LIVING IN THE SAME HOUSE; If audited, you will pay a fine to the IRS. IF you agree and understand all terms, Please Sign below
Signature

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Spouse Name ( ONLY IF FILING JOINT OR SEPARATE)

First NameLast Name
Social Security Number
Date of Birth

MonthDayYear
Date
Occupation
Cellphone Number
Cellphone Provider
License/State ID Information (FOR SPOUSE IF FILING JOINTLY)
Driver License Number
Issue Date
State
Expiration Date
Spouse Address (ONLY IF FILING SEPARATE)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Did you receive Healthcare through the Marketplace? If YES, Please provide form 1095-A. If unsure, Please call 1-800-318-2596. Returns are rejected even if you applied but didn't use it.*

YESNoUNSURE

DEPENDENT(S) INFORMATION
DEPENDENT NAME

First NameLast Name
Date of Birth

MonthDayYear
Date
Social Security Number
Relationship of Dependent
How Many Months did Dependent Live with You? (Type Number of Months)
DEPENDENT NAME

First NameLast Name
Date of Birth

MonthDayYear
Date
Social Security Number
Relationship of Dependent
How Many Months did Dependent Live with You? (Type Number of Months)
DEPENDENT NAME

First NameLast Name
Date of Birth

MonthDayYear
Date
Social Security Number
Relationship of Dependent
How Many Months did Dependent Live with You? (Type Number of Months)
DEPENDENT NAME

First NameLast Name
Date of Birth

MonthDayYear
Date
Social Security Number
Relationship of Dependent
How Many Months did Dependent Live with You? (Type Number of Months)
Did Any of Your Dependents Receive Childcare or Dependent Care? If YES, Please Provide Documentation.

YesNo
Do You Have any Offsets or Obligations that would affect your refund? *
If you are unsure of any tax offsets, Do we have permission to call the IRS Tax OFFSET Number? If YES, Please sign.*

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How did you here about us?*

REFERRALFacebookInstagramWALK-INOTHER
If Referred, List Name of Person that Referred You:
PLEASE READ!

Upon completion of all electronic forms, please send all required tax documentation via email uniquetaxprofessionals@gmail.com. We also have an app that you can download to your device (Tax Business Manager). When emailing documents, PLEASE make sure they are clear to ensure we are able to input the correct information. Also, if you are filing Head of Household, please submit proof that has been listed above.

If you have any additional questions, Please contact us at 678-688-6191 or via email at uniquetaxprofessionals@gmail.com.
Signature*

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Date*

MonthDayYear
Date
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CLIENT INFORMATION FORM

License/State ID Information

Filing Status

License/State ID Information (FOR SPOUSE IF FILING JOINTLY)

DEPENDENT(S) INFORMATION