Fax: 770.242.3729
Client Information Form
Your Name / Spouse Name
SSN (use dashes) / SSN (use dashes)
DOB (mm/dd/yy) / DOB (mm/dd/yy)
Address Line 1
Address Line 2
City
State
Zip
Dependents Name / MM/DD/YY / Dependents SSN
(Use dashes) / Relationship / Months Lived In your Home
Choose an item. / Choose an item. /
Choose an item. / Choose an item. /
Choose an item. / Choose an item. /
Choose an item. / Choose an item. /
Filing Status / Choose an item. /
Check box next to item you will supply your tax professional
☐ / Wages Statement – W2’s / ☐ / Received Interest / ☐ / Charity or religious contributions / ☐ / Own Rental Property☐ / 1099’s / ☐ / Received Dividends / ☐ / Property Tax / ☐ / Lottery or Gambling winnings
☐ / IRAs / ☐ / Pensions or Retirement Income / ☐ / Mortgage Interest / ☐ / Significant Loss or Theft
☐ / Sell Stocks or Bonds / ☐ / Social Security Income / ☐ / Mortgage points / ☐ / Buy or sell a home
☐ / Received Unemployment / ☐ / Tips / Other Income / ☐ / Tax Preparation Expenses / ☐ / Job Related Expenses or Training
☐ / Alimony (Paid or Received) / ☐ / Farm Income / ☐ / Union Dues
Would you like your refund directly deposited? If NO, leave blank. If YES, please provide:
Driver’s License No. / Spouse Driver’s License No.Issue Date: / Issue Date:
Expiration Date: / Expiration Date:
State issued in: / State issued in:
Bank Routing No. / Account No.
*If filing jointly, both driver’s info is needed. Only one bank account is necessary.
If you’re a new client, please provide your 2010’s tax return along with this form.