Client-Data-Sheet 2020

2023 Client Data Sheet for the 2022 Tax Year

This form is to assist you in gathering your income tax information.
TAXPAYER FULL NAME*
OCCUPATION
SSN
DATE OF BIRTH*

MonthDayYear
Date
EMAIL*
example@example.com
SPOUSE FULL NAME
OCCUPATION
SSN
DATE OF BIRTH

MonthDayYear
Date
EMAIL
example@example.com
ADDRESS
CITY
STATE
ZIP
APT #(if applicable)
TAXPAYER PHONE
SPOUSE PHONE
Dependents 1: Name (first, middle initial and last name)

First NameLast Name
Dependents 2: Name (first, middle initial and last name)

First NameLast Name
Date of Birth ( Dependent 1)

MonthDayYear
Date
Date of Birth (Dependent 2)

MonthDayYear
Date
Dependent’s(1) SSN
Dependent’s(2) SSN
Relationship to you (Dependent 1)
Relationship to you (Dependent 2)
Months lived in home (Dependent 1)
Months lived in home (Dependent 2)
Paid ChildCare for this Dependent(1)?

YesNo
Paid ChildCare for this Dependent(2)?

YesNo
CITIZENSHIP

If you are a not a citizen of the United States you would be considered a nonresident alien, unless you meet one of the two tests(Green Card Test and Substantial Presence Test), you then would be considered a resident alien for tax purposes.
Are you a citizen of the United States?

YesNo (If yes, this section is complete, please proceed)
Are you considered a Non-Resident Alien?

YesNo
If you are in the United States on a VISA, please enter the type of VISA you have here.
CHECK ALL THAT APPLY

Someone else can claim you as a dependent.You paid estimated Federal (Form 1040ES) or State taxes last year.
Federal $
State$
YOUR SOURCES OF INCOME

Wage Statement – W-2sMiscellaneous Income – 1099sPension, Retirement IncomeInterestUnemploymentStock SalesCombat Zone PayTips / Other IncomeDividendsMunicipal BondsSocial SecurityRailroad RetirementAlimony ReceivedLottery or Gambling WinningsBusiness/Self-employed incomeStock SalesRental IncomeSold a PropertyCrypto Currency
MARKETPLACE HEALTH INSURANCE QUESTIONNAIRE
Did you purchase health insurance through Marketplace (commonly know as Obama Care)?

YesNo
No(If yes then please provide us with a 1095A. If no, then please check the months in which everyone inyour household had health insurance coverage. )

JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
DIRECT DEPOSIT INFORMATION/AUTHORIZATION
Would you like your refund direct deposited into your bank account?

YesNo
Type

CheckingSavings
Routing Number
Account Number
I CERTIFY THAT I WOULD LIKE MY TAXES PREPARED ACCORDING TO THE INFORMATION I HAVE SUPPLIED ABOVE IN ADDITION TO
DOCUMENTATION ATTACHED.
Taxpayer’s Signature

Clear
Date

MonthDayYear
Date
Spouse’s Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

CITIZENSHIP

MARKETPLACE HEALTH INSURANCE QUESTIONNAIRE

DIRECT DEPOSIT INFORMATION/AUTHORIZATION