CLIENT DATA SHEET
Referred By
Are you a return client?
Yes
Today's Date
/
Month
/
Day
Year
Date
Tax year
Primary Name
Spouse/Partner Name
SSN or Tax ID (ITIN): Spouse SSN or Tax ID (ITIN)
SSN or Tax ID (ITIN): Spouse SSN or Tax ID (ITIN)
Occupation: Spouse’s Occupation
Occupation: Spouse’s Occupation
Date of Birth: Spouse’s Date of Birth
/
Month
/
Day
Year
Date
Date of Birth: Spouse’s Date of Birth
/
Month
/
Day
Year
Date
Address
Home Address
Street Address Line 2
City
State
Zip
State
Cell Phone
Home
Phone
Mail
Did you and your dependents have health insurance
Yes
No
Partial
Did you have any education expenses?
Yes
No
If you selected yes on the previous question, do you have a 1098T?
Yes
No
Bank Name
Routing Number
Account Number
DEPENDANT INFORMATION (Please list youngest first)
Rows
Name *As it appears on the SSN Card
SSN
D.O.B. MM/DD/YY
RELATIONSHIP
MONTHS DEPENDENT LIVED W/YOU
CHILD CARE INFORMATION (REQUIRED FOR EACH PROVIDER) Provider's Name
Provider's SSN/EIN
Provider's Address
Provider's Address
Amount Paid to Provider
Type of ID
ID Number
Date Issued
Expiration
Spouse Type of ID
Spouse ID Number
Spouse ID Date Issued
Spouse ID Expiration
Signature
Spouse’s Signature
Date
/
Month
/
Day
Year
Date
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