Sign Form

Name*

First NameLast Name

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Date of Birth *

SSN *

Occupation*

Date*

Date

Spouse's Name - **IF FILING JOINTLY**

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Spouse's Date of Birth

Spouse's SSN

Date

Dependent 1 - Name

First NameLast Name

Dependent 1 - Date of Birth

Dependent 1 - Social Security Number

Relationship

Dependent 2 - Name

First NameLast Name

Dependent 2- Date of Birth

Dependent 2 - Social Security Number

Relationship

Dependent 3 - Name

First NameLast Name

Dependent 3- Date of Birth

Dependent 3 - Social Security Number

Relationship

Dependent 4 - Name

First NameLast Name

Dependent 4 - Date of Birth

Dependent 4 - Social Security Number

Relationship

YesNo

IP PIN

YesNo

Tip Type

Tip Documentation

YesNo

Overtime Details

Tax Documents - W-2*

Form 1095-A

Head of Household - (Lease or Proof of Address)*

Child / Dependent Birth Certificate or Medical Records

Social Security Cards*

ID / Driver's License*

Other Documents (Receipts, Mile Logs, Profit & Loss Sheets ETC)

Bank Name*

Routing Number*

Account Number*

1. I understand that The Tax Clinic charges a preparation fee for filing my tax return.

2. I Understand that if my tax refund is intercepted or offest by the IRS, U.S Treasury , or any other government agency due to prior debts (including but not limited to back taxes, student loans, child support, unemployment overpayments, or state obligations), I am still responsible for paying the full prepration fees.

3. I agree to notify The Tax Clinic if I am aware of any existing debts that could result in my refund being offset.

4. If my refund is seized or reduced and The Tax Clinic does not receive their prepration fee through the refund transfer , I agree to: - Pay the full fee dircetly within 10 business days, OR - Enter into a payment plan of $100 per month untillegal action by the balance is paid in full.

5. I understand that failure to pay the agreed fee may result in collection efforts and/ or legal action by The Tax Clinic to recover unpaid preparation fees. The Tax Clinic will prepare your 2025 Tax individual return from the information you provided to us.

You, the tax payer, are ultimately responsible for the prepartation and filing of your tax return. I , the Tax payer named above, have provided to (Business NAME HERE) the attached tax information and to the best of my knowledge this information is true, correct and complete.

* ARE ALL THE ANSWERS YOU PROVIDED TRUE AND CORRECT TO THE BEST OF YOUR KNOWLEDGE?

YesNo

Date*

Date

Tax Payer Signature*

Tax Payers Spouse's Signature

Interview Type

Filing Status Explanation

Explain how the filing status was determined

Dependents and Credit Eligibility

Explain how dependents and credits (ETIC, CTC, AOTC, ACTC) were verified

Verification Notes

Explain income source reviewed and verification obtained

Schedule C Reasons (If Applicable)

Red Flags / Special Circumstances

Note any inconstancies, previous audits, low income , high credits, or special occurrences

I Agree

Date - **FOR PREPARE'S ONLY**

FOR PREPARERS ONLY

THE TAX CLINIC

Please Read

AFFIDAVIT OF TAX PREPATION FEES

Sign Form

For Preparer's ONLY- Due Diligence Interview Notes

THE TAX CLINIC

*Please Read*

AFFIDAVIT OF TAX PREPATION FEES

Sign Form

***For Preparer's ONLY- Due Diligence Interview Notes***

Please Read

For Preparer's ONLY- Due Diligence Interview Notes