Client Intake and Interview Sheet 2009

CLIENTINTAKEANDINTERVIEW SHEET 2010

TAX PROFESSIONAL SERVICES

TaxpayerInformation

YOURINFORMATION:

FirstNameMILastNameSSN/ITIN(LastFourDigitsRequired)

SPOUSEINFORMATION:

FirstNameMILastName

- / -

SSN/ITIN(LastFourDigitsRequired)

StreetAddressApt.CityStateZip

EmailAddress:_

YOUSPOUSEOCCUPATION DaytimePhone:

Evening Phone:Cell Phone:

DateofBirth:

Age:

YourOccupation#Jobsin2009

SpouseOccupation#Jobsin2009

LegallyBlind?Yes☐No☐Yes☐No☐

Disabled?Yes☐No☐Yes☐No☐

Areyou aU.S.Citizen?Yes☐No☐Yes☐No☐

Areyou (oryourspouse)inthe UnitedStatesonanF,J,M,orQVisa?Yes☐No☐

MARITALSTATUSon12/31/09: Single☐Married☐Divorced☐, since(year)

Widowed,☐ since (year)Married,☐livingseparatelysince (date)

Doesanyoneelsecontributeto yourhouseholdexpenses?Yes☐No☐

FAMILYINFORMATION:Pleaselisteveryonewholivedin yourhomeduring2009. Alsolist anyoneelsethat yousupported during2009.Isthereanagreement,such asadivorcedecreeorIRSForm8332,thatallowsomeoneelsetoclaimamemberofyourfamily? Yes☐ No☐
Name
(First,Last) / Birth
Date / SSN/ITIN (Last four Digits Required) / Relationship / Months lived with
youin
2009? / US Citizen, ResidentofUS, Canadaor Mexico
(Yesor No) / Didthis person haveany income? / Was the dependenta full time student? / Didyouprovide morethan50% of support for this person? / Did the dependent file ajoint return? / Isthis person disabled?

DURING 2009:

Canyour parent or someoneelse claimyouroryour spouse as a dependent?Yes☐No☐

Didyou pay forchildcare?Yes☐No☐

Didyour or anyone inyour familyearnincome thatwas not reported on a W-2? Yes☐No☐

Didyou receive Social Securitypayments?Yes☐No☐

Didyou receive unemployment payments?Yes☐No☐

Didyou have anyother income such as lotterywinnings, pensions, alimony, disability, interest, or tips?Yes☐No☐

Didyou receive a State Tax Refund?Yes☐No☐(may be taxable ifyou itemized lastyear) Didyou receive income based on sale of stock, bonds or real estate?Yes☐ No☐

Didyou or anyone inyour familyattend college or vocational school?Yes☐No☐

Didyou pay interest on a student loan?Yes☐No☐

Didyou put money in anykindof retirement plan? Yes☐No☐

Didyou have anyunreimbursed medical expense or make any charitablecontributions?Yes☐No☐

Didyou receive a letter from the IRS?Yes☐No☐

Didyou receive any alimonypayments?Yes☐No☐ (ifyes,you must provide the name and SSN ofthe recipient) Anyestimatedtax payments for thisyear?Yes☐ No☐

Was the EITCpreviouslydisallowed? Yes☐No☐

Didyou ownyour home? Yes☐No☐

If yes, howmuch didyou payin propertytaxes? $_

CLIENTINTAKEANDINTERVIEW SHEET 2010

TAX PROFESSIONAL SERVICES

Theinformationin thisclientintakesheetistrueandcorrect.I understandthatthe (tax professional services) willretain thisinformation fortaxpreparationpurposesintheeventI returnnext year.I realizethattheabovetax professional serviceswilluse thisinformationtoimprovetaxassistance servicestome,speedpreparationoftaxreturns,andofferotherservices.Mypersonal informationiskeptconfidentialandisnotsharedwith orsoldto anyotherorganizationorcompany.Information willbe properlystoredandwhennolongerneeded,informationwillbeproperlydisposed.

Wewillprovidebothphysicalandelectronicprotectionfortheinformationwhileit’scare.Informationcollectedontheintakeand interviewsheetwillnotbesoldorsharedwithanyoneelse.Electronicrecordswillbemaintainedfor7 yearsasrequiredbyIRS E-fileregulationandaggregatedataisretainedbytheprogrampurposes. Suchinformationwillnotincludespecificinformation aboutthetaxpayer.Serviceswillnotbedeniedif you donotagree with thisstatement.Contact

usat 347-651-1033(tax professional servicesphonenumber) if need any further questions or concerns.

ClientSignature:Date: