Customer Data Sheet
This form is to be completed by client
Preparer ID:
Tax Year:
Please choose which forms you want to file:
Federal
State
Primary Filer's Information
If Applicable
Name
First Name
Last Name
Date of Birth
Driver's License #
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Can someone else claim you as a dependent?
Yes
No
Dependent's Information
Name of Dependent
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Name of Dependent
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Name of Dependent
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Source of Income. Check the Income Items Which Pertain to You.
Wages or Salary (W2 Income)
Unemployment
Pension/Retirement Income
Rental Income
Farm Income
Dividend/Sale of Stocks
Interest Income 1099 INT
Self-Employment-Bus. Income (Sch.C)
Alimony Received
Lottery or Gambling Income W-2G
Public/State Aid Income
Social Security Income
Tips
Other Income
Source of Expenses. Check the Expenses Which Pertain to You
IRA's
Property Tax
Mortgage Points(closing points)
Business Owner/Self Employed
Tax Prep Expenses
Union Dues
Education Expense
Significant Loss or Theft
Charity of Religous Contributions
Mortgage Investment
Moving Expenses
Medical Expense
Alimony Paid
Buy or Sell Home
Job Related Expenses
Other
Child Care Information(Credit)
Provider Name
First Name
Last Name
Provider Phone Number
Format: (000) 000-0000.
Provider Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Tax Filing Products
Paper Filing (Fee Paid Upfront)
Yes
No
ETF Electronic Filing (Fee Paid Upfront)
Yes
No
Flex-Pay Refund (Ask Preparer for Details)
Yes
No
Bank Products
Yes
No
I give Financial permission to electronically deduct their final tax fee(s) from my IRS refund (Initial Below)
*
1
Rows
Not Important
Neutral
Very Important
How important is it for you to have a comfortable retirement
2
3
4
How important is it for you to fund the educational needs of your children, grandchildren, or others?
5
6
7
In the event of an untimely death, how important is it for you to provide financial resources for your family?
8
9
10
How important is it for you to eliminate debt?
11
12
13
May our financial advising department contact you regarding the financial concerns you have indicated above?
Yes
No
Client Signature
Date
-
Month
-
Day
Year
Date
Spouse Signature
Date
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: