2024 TaxAbility Client Data

Client Data Sheet
Tax Payer Name*

First NameLast Name
Social Security Number*
Date of Birth*
Take a selfie*
Occupation*
Did you attend College in 2023?*
Have you received your 1098-T?*
Did you want to apply for up to $9,000 cash advance?*
Tax Payer Spouse Name if any

First NameLast Name
Social Security Number
Date of Birth
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Did you file with this same address last year?*
Email*
example@example.com
Phone Number*

Area CodePhone Number
Marital Status*

SingleHead of HouseholdMarried Filing SeperateMarried Filing JointlyWidow
Did you ever need an IP Pin to file your taxes?*
If yes, Please upload a copy of your new IP Pin

Browse Files

Cancelof
Do you have Any Dependents*

YesNo
if yes! How many months did the dependent live with you in 2023?*
N/A if this does not apply.
What is your relationship to your dependents?*
N/A if this does not apply.
Did you pay for daycare last year?*
If yes, how much?
Why is the other parent of the dependent(s) not claiming the dependent on his or her tax return?*
Dependents Name (s), Birthday (s), and Social(s), Sex and Months Lived with you?
Dependents Name (s), Birthday (s), and Social(s), Sex and Months Lived with you?
Dependents Name (s), Birthday (s), and Social(s), Sex and Months Lived with you?
Do you have Child Care Expenses*

YesNo
Did you have Health Insurance?*

YesNo
Do you or your dependent have Medicaid/Medicare?*

YesNo
Insurance Carrier*
Insurance Identification #*
Please Upload Front and Back of ALL Medicaid Cards *

Browse Files

Cancelof
Driver's License(s)*

Browse Files

Cancelof
Social Security Cards*

Browse Files

Cancelof
Birth Certificates?

Browse Files

Cancelof
All Tax Forms- Ws, 1099R, 1099G, 1099 Misc, 1098T, Sch C Receipts, etc, *

Browse Files

Cancelof
Did you have another forms? Social Security, Disability Etc

Browse Files

Cancelof
Are you self employed or do you additional self employed income?*

YesNo
Did you receive Unemployment in any state?*

YesNo
What State did you have Unemployment? If none, Please type NONE.*
Would you like direct deposit?*
What is the name of your bank?*
Type N/A if your answered no to direct deposit
Bank Account Number*
Type N/A if you answered no to direct deposit
Routing Number*
Type N/A if you answered no to direct deposit
How did your hear about TaxAbility Tax Services?*
Referred By:
Use of Data - We collect your personal information in order to fulfill your order, comply with the law, and assess your eligibility. Your data will not be sold to or shared with unaffiliated third parties.

Electronic Communication Acknowledgment - I agree and consent to be contacted through the use of email and/or telephone calls and/or SMS text messages to my mobile phone number I have provided in conjunction with my account, including the use of automatic telephone dialing systems. I acknowledge that message and date rates may apply.

I agree to OPT IN to start receiving your Covid prevention and Support Services.
By completing this form I am enrolling in the Medicaid/Medicare COVID-19 home testing offered to me as a Medicaid/ Medicare Member. Which will continue until I opt out by contacting PerfectRx Pharmacy.

I confirm that I have read and agree to the above disclaimers and I agree that all of the information that I provided is truthful and Correct.
Signature*

Clear

Client Data Sheet