Tax File Declaration Form

Tax File Declaration Form
Thank you for choosing Colibranna Financial Services to file your 2023 tax return. If you need to speak with a member of our team before completing the INTAKE FORM, please call 800-318-0775. You can also email at Colibrannafinancialservices@gmail.com
Type of Client
Tax Year Preparation Requested
Filing Status
Select Filing Status
Taxpayer

PLEASE ENTER IN ALL OF YOUR INFORMATION
Name

First NameMiddle NameLast NameSuffix
Date of Birth

MonthDayYear
Date
Social Security Number
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Occupation
Email
Have you ever been issued an IP PIN?
TAXPAYER IP PIN (issued from IRS yearly)
Spouse

YOUR SPOUSES INFORMATION, IF LEGALLY MARRIED OR PRESUMED MARRIED BY COMMON LAW STATUTE IN THE STATE YOU RESIDE IN
Name

First NameMiddle NameLast NameSuffix
Social Security Number
Please enter full social security number
Date of Birth

MonthDayYear
Date
Occupation
Phone Number
Email
SPOUSE IP PIN (issued from IRS yearly)
Number of Dependents
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

DUE DILIGENCE QUESTIONS
Did you receive a 1095A (Marketplace Health Insurance)
How many people live with you ?
HOW MANY ADULTS AND CHILDREN
Did anyone help support you during the year? If yes, who?
How Much?
In the case of audit can you prove financial responsibility and residency for any of the Dependents being claimed? Which document(s) can you provide? (i.e. copy of lease, medical records, school records, food stamps or benefit statements)
If Yes, why are the parents not claiming the child? (Please explain and list the child's name(s) if more than one listed on the return)
Are any of the dependents being claimed NOT your Son or Daughter? If Yes, why are the parents not claiming the child? (Please explain and list the child's name(s) if more than one listed on the return)

Were any of the credits disallowed or reduced in a previous year? YesNo If yes, please explain:
If yes, please explain
Did you have any other income during the year? (Child support, alimony) If yes, please specify
Are any of the dependents that you are claiming disabled?
If yes what type?
Does the dependent received social security/disability benefits ?
If yes what type?
Taxpayer Signature
Date

MonthDayYear
Date
Spouse Signature
Date

MonthDayYear
Date

How do you want your refund? (Check one of the following)
Cash Advance option (Check one of the following) * The loan of fered in amounts 25%, 50% or 75% of your expected tax refund to up to $6000. Some loans are interest bearing loan, and will have an annual APR. Please confirm the interest rates with your preparer. Cash Advance (RT Refund Transfer)
The Following products require fees paid at thetime of the service.
By signing below, I understand that I have received an explanation of all refund methods and cash advance options available to me and I have selected the option that I feel is the best delivery method for me.
Signature
Date

MonthDayYear
Date

Schedule C Income & Expense Form
TaxPayer

First NameLast Name
What is your business name?
Date Business Started

MonthDayYear
Date
Does any of the following apply to you?
Do you have an EIN?

Other
EIN NUMBER
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Income and Wages
Total amount of income received from your business in 2023?
1099 Income:
Total Sales Services:
Enter Amount
ADVERTISING:
Enter Amount
Auto Expense
Enter Amount
Commissions
Enter Amount
Depletion
Enter Amount
Insurance (Other than Health)
Enter Amount
Interest
Enter Amount
Mortgage
Enter Amount
Legal & Professional:
Enter Amount
Pension & Profit Sharing
Enter Amount
Rent or Lease
Enter Amount
a) Vehicles: b) Machinery: C) Other:
Enter Amount
Repair/ Maintenance
Enter Amount
Supplies
Enter Amount
Taxes/Licenses
Enter Amount
Travel
Enter Amount
Meals (Total):
Enter Amount
Utilities
Enter Amount
Other
Enter Amount
Net Income
Enter Amount
Total Income - Total Expenses = $ (Please attach any other supporting document(s) if available)
Enter Amount
If you do not have any business expenses, please explain why?
By signing below, I hereby certify the information given above is true and accurate.
Signature
Date

MonthDayYear
Date

AOTC Student Acknowledgement Form
Full name of the student

First NameMiddle NameLast NameSuffix
Name of school attended
What year did you attend college?
I certify that all the information found on this form is true and to the best of my knowledge. I understand that it is my responsibility to have all valid documents and or receipts, as required to claim any credit for attending a college or university. Below is a recap of all information, status, and expenses I have encountered
Room & Boarding $
Books
Tuition
Supplies On Campus
Supplies Off Campus
Other Expenses
Total
By signing below I certify all information is true, valid, and to the best of my knowledge. I accept full responsibility of the statements mentioned above. Any and all disputes regarding this matter shall be forwarded to me with the information found on my tax returns forms.
Signature
Date

MonthDayYear
Date

Head of Household Due Diligence
Name

First NameMiddle NameLast NameSuffix
Social Security Number
To Claim Head of Household can you provide a lease
Monthly Income: (wages, child support, other income)
Property Taxes
Rent
Mortgage Interest Expense
Utility Charges
Upkeep/Repair
Property/ Renters Insurance
Food Consumed on premises
TOTALS COST (GOVERNMENT ASSISTANCE)
Please do not count any money received under any governmental/public assistance/welfare/snap (Food Stamps) in the amounts that you paid. Include cost paid with the publuc assistance in the total cost

Taxpayer has provided all answers to the above questions to be true and correct to the best of the taxpayer's knowledge. Taxpayer has been informed that claiming a dependent for HOH or other can result in an audit, fines, and penalties if information provided to a prepare is incorrect.
Signature
Date

MonthDayYear
Date

CHILD DEPENDENT CARE
You may be able to claim the credit if you pay someone to care for your dependent who is under age 13 or for your spouse or dependent who is not able to care for himself or herself. The credit can be up to 35% of your expenses. To qualify, you must pay these expenses SO you can work or look for work.
Name of Dependent
Name of Provider
EIN
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Dependent
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Amount Paid
Name of Dependent
Name of Provider
EIN
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Amount Paid
By signing below I certify all information is true, valid, and to the best of my knowledge. I accept full responsibility of the statements mentioned above. Any and all disputes regarding this matter shall be forwarded to me with the information found on my tax returns forms.
Signature
Date

MonthDayYear
Date

Schedule A Deductions
Medical Expenses
Medical Insurance Premiums Paid (Other than Social Security Medicare Payments)
Long Term care Premiums
State & Local Income Taxes Paid (Other than those on W-2's, 1099's, etc Prior year Income Taxes paid in current year Real Estate Taxes
Prescription Drugs & Medications
Medical Miles Driven January 1 to June 30
Medical Miles Driven July 1 to December 31
July 1 to December 31
Prior year Income Taxes paid in current year
Real Estate Taxes
Home Mortgage Interest reported on Form 1098 Home Mortgage Interest paid to others Refinancing Points Paid Investment Interest (other than K-1)
Personal Property Taxes
Other taxes:
Qualified New Vehicle Taxes Additional State/ Local Taxes
Type a questionQualified New Vehicle Taxes
Qualified New Vehicle Taxes
Home Mortgage Interest reported on Form 1098
Additional State/ Local Taxes
Home Mortgage Interest paid to others
Refinancing Points Paid
Investment Interest (other than K 1)

CONTRIBUTIONS
Cash Contributions (If over $500 please provide detailed list)
Non Cash Contributions (If over $500 please provide detailed list)
Volunteer Mileage Driven
Unreimbursed Business Expenses
Union Dues
Tax Prep Fees (Paid for Previous Return)
Safe Deposit Rental
Investment Expenses (Other than K 1)
Gambling Losses (Due to extent of winnings)
If you had any casualty or theft losses during the year, please provide detail below, including date, description, amount of casualty or loss, any insurance reimbursement & basis in the property.
Signature
Date

MonthDayYear
Date
Should be Empty:

Tax File Declaration Form

Filing Status

Taxpayer

Spouse

DUE DILIGENCE QUESTIONS

Schedule C Income & Expense Form

Income and Wages

Schedule C Due Diligence Questions

Tax Credits

Dependent Information

Dependent 2

Dependent 3

AOTC Student Acknowledgement Form

Head of Household Due Diligence

CHILD DEPENDENT CARE

Schedule A Deductions

CONTRIBUTIONS