EMPRESS FINANCIAL SERVICES

Thank You for taking the time to complete the Empress Financial Services client intake form.

This information is important and will help complete a correct and accurate tax filing. Please don't be in a rush to complete all questions and review all information before submitting. Please note if any documents are missing or incorrect this will result in a delay in processing your return.

Please wait until you have all your documents before submitting them.

Note: if claiming any dependents be sure to upload all documents such as Social security cards, Birth certificates School Records, etc, indicating the child is your dependent.
Filling Status*

SingleHead Of HouseholdMarried Filling JointMarried Filling Single
Check All That Apply*

W2Schedule CHousehold IncomeSchoolSection 8/ HousingMedicaidFood StampsOther
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Date of the death if deceased

MonthDayYear
Date
Social Security Number (SSN)*
Are you a U.S Citizen?*

YESNO
Tax Payer Occupation / Title
Tax Payer Legally Blind

YesNo
Can You Be Claimed as a Dependent?*

YesNo
Did you receive last year tax return?

YesNo
How did you hear about us?*
Are you the recipient of Obama Care or did you purchase Medical Insurance from the federal marketplace? If so, please provide a form 1095A. Your tax return will be rejected without this form.*

YesNoI'm Not Sure
Were you previously issued an Identity Protection Pin( IP PIN) by the IRS?

YesNo
Spoue Full Name
Spoue Date of Birth
Spoue Name E-mail Address
Spouse Name, Date Of Birth, Email Address and Social Security Number
Do you have full custody of the dependent children?
How many dependents?
Dependent 1 Name?
Dependent 1 Social Security Number
Sex Of 1st Dependent

MaleFemale
1st Dependent Date Of Birth

MonthDayYear
Date
Is this child disabled?

YesNo
If you are a single parent, where is the other parent of your children?
Do you provide more than 50% Support?

YesNo
Has the dependent lived with you at least half of the year?

YesNo
Dependent 2 Name?
Dependent 2 Social Security Number
2nd Dependent Date Of Birth

MonthDayYear
Date
Sex Of 2nd Dependent

MaleFemale
Is this 2nd child disabled?

YesNo
Do you provide more than 50% Support?

YesNo
Dependent 3 Name?
Dependent 3 Social Security Number
3rd Dependent Date Of Birth

MonthDayYear
Date
Sex Of 3rd Dependent

MaleFemale
Is this 3rd child disabled?

YesNo
Do you provide more than 50% Support?

YesNo
Did you pay any child care expenses last year?

YesNo
How much did you pay in child care expenses?
Can anyone elsa claim your dependents? if yes, please explain
Please provide the name, address, and social security number or EIN # of your childcare. provider
Have you ever been disallowed EITC/AOTC/CTC? If so, when?*
Do you have any debts with the IRS, US TREASURY, CHILD SUPPORT, FEMA, OR ANY. GOVERNMENT ENTITY?"*

YesNo
If so, With whom and what is the EXACT amount?
Please list documents you have provided for proof of loss/profit for business/self employment (Example: Reciepts, P&L statement, bank statements, or written ledger (which is above spreadsheet)
Did you receive Unemployment? (Please upload 1099 G form)

Cancelof
How Would you like to recieve your Refund? Check one of the following

7-14 Days (RT Refund Transfer: Check) In About 7-14 Days From The Date Your Return is Accepted Electronically By The IRS, You Receive A Check For The Amount Of Refund Less Filling Fees. (Checks will be available in our office)7-14 Days (RT Refund Transfer: Debit Card) in About 7-14 Days From The Date Your Refund Is Accepted Electronically By The IRS, For The Amount Of Your Refund Less. Filing Fees Will Be Deposited To The Debit Card We Issue You.7-14 Days (RT Refund Transfer: Direct Deposit) In About 7-14 Days From The Date Your Refund Is Accepted Electronically By The IRS, For The Amount Of Your Refund Less Filing Fees Will BeDeposited Into Your Bank Account
Would you like your refund deposited into your Checking or Savings Account?
Direct Deposit Routing Number: (Required if Direct Deposit was selected)
Direct Deposit Account Number: (Required if Direct Deposit was selected)
THE NECESSARY DOCUMENTS?

IF DOCUMENTS ARE NOT UPLOADED THIS FORM WILL BE VOIDED!!!!!!!
CLIENT NON-PAYMENT/OFFSET CLAUSE:
EMPRESS FINANCIAL SERVICES TAKES PRIDE IN ASSISTING ALL CLIENTS WITH THEIR INDIVIDUAL TAX NEEDS, HOWEVER, WE UNDERSTAND SITUATIONS WILL ARISE IF YOU HAVE ANY OFFSETS BY THE IRS, STUDENT LOANS, OR CHILD SUPPORT YOU ARE STILL OBLIGATED TO PAY OUR COMPANY FEES ASSOCIATED WITH FILING YOUR TAX RETURN.

BY SIGNING THIS AGREEMENT YOU ACKNOWLEDGE THAT IF PAYMENT IS NOT MADE IN FULL WITHIN 30 DAYS LEGAL ACTION WILL BE SOUGHT TO RESOLVE PAYMENT.
THANKS FOR YOUR BUSINESS
Any and all information has been filled out to the best of my knowledge. The data filled out by me (THE TAXPAYER) is accurate and truthful.*

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Printed First, Last Name
Date of Submission

MonthDayYear
Date
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THE NECESSARY DOCUMENTS?

THANKS FOR YOUR BUSINESS