CLIENT INTERVIEW SHEET



CLIENT INTERVIEW SHEETPlease fill in the required information below:Taxpayer Name: _______________________Spouse Name: _________________________SSN: ________________________________SSN: ________________________________Occupation: __________________________Occupation: ___________________________Taxpayer Date of Birth: _____/_____/______Spouse Date of Birth: _____/_____/________Are you legally blind? ____ Yes ____ No Your Spouse? ____ Yes ____ No Or Permanently Disabled?____Yes _____NoYour Spouse? ____ Yes ____ No Cell Phone:___________________________Cell Phone: _____________________________Home: _____________Work: ____________Home: _____________Work: _______________Did you or your spouse attend college in 2012? ____ Yes Tuition & Books _________ Other ___________Address: _____________________________Address: ______________________________City St, Zip: ___________________________City St, Zip: ____________________________Email Address: _________________________Email Address: __________________________Please circle your Filing Status. All of the filing status categories below are based upon your status as of December 31st (the last day of the tax year).Single – You are single if you were not married and you are claiming no dependents.Married Filing Joint – You are MFJ if both you and your spouse have agreed to file a joint return.Married Filing Separate – You are MFS if you would like to be responsible for your own tax. Head of Household – You are not married (or are legally separated) and you are claiming at least one dependent.Widow with dependent child – You can claim this filing status if your spouse died in 2010 or 2009 and you have not remarried and you have a qualifying dependent.Can anyone else claim you as a dependent on their tax return? ____ Yes ____ No Your Spouse? ____ Yes ____ No Dependent Information:First Name Last Name / Date of Birth/ Social Security Number/ Relationship/ # Months lived in home/ Child Care Expenses___________________________/___________/___________________/____________/___________/______________________________________________/___________/___________________/____________/___________/______________________________________________/___________/___________________/____________/___________/______________________________________________/___________/___________________/____________/___________/___________________Are any of your dependents legally disabled? ___ Yes Did any of your dependents Attend College during 2011? ___ Yes Child Care Provider InformationProvider’s Name, Address & Phone #SSN or Federal ID # (EIN) Amount Paid____________________________________________________________________________________________________________________________________________________________________________________________________________Please indicate the Type of Refund you would prefer Direct Deposit____ or Paper Check ____Direct Deposit Information:Bank Name:________________RTN: ______________ Account #: _________________Drivers License or State ID #: _____________________________ Issue Date: _____________ Expiration: ________________Practitioner PIN Program: 7. Please select a 5 digit number to act as your electronic signature on your tax return TP __________ Spouse ___________8. Please indicate if you have received any of the following: ___ Unemployment ___ Alimony ___ S.S. Benefits ___ Gambling ___ Self Employment Income ___ Interest or Dividends ___ 1099 Income ___ Unreported Tip Income ___ Other Income9. Itemized Deductions: Do you own a home? ____ Yes (please provide us with mortgage interest and property taxes paid in 2012); Did you make any Charitable Contributions? yes ____ $______; Did you have any Medical Expenses? yes ____ $______; or Un-reimbursed business expenses? yes ____ please provide details.NOTES:EARNED INCOME CREDIT DUE DILIGENCE WORKSHEETIs your filing status “Married Filing Separate?”____ Yes ____ No Do you and your spouse have a Social Security Number that allows you to work?____ Yes ____ No Is your investment income less than $3,200?____ Yes ____ No Can anyone else claim you as a qualifying child?____ Yes ____ No Were you a U.S. Citizen or resident alien for the entire year?____ Yes ____ No This section to be filled out by taxpayers with dependents: Child 1 Child 2 Child 3Is your dependent: Your son, daughter, stepchild, foster child, brother, sister, stepbrother, stepsister, half brother, half sister, or a descendant of any of them?___ Yes ___ No ___ Yes ___ No ___ Yes ___ No Are any of your dependents filing their own return as Married Filing Joint?___ Yes ___ No ___ Yes ___ No ___ Yes ___ No Did your dependent live with you for over half the year? ___ Yes ___ No ___ Yes ___ No ___ Yes ___ No Can any other taxpayer claim your dependent on their tax return?___ Yes ___ No ___ Yes ___ No ___ Yes ___ No If NO please continue, if YES, is your modified Adjusted Gross Income (AGI) higher than any other taxpayerWho could claim your child as their dependent?___ Yes ___ No ___ Yes ___ No ___ Yes ___ No Does your dependent have a SSN that is valid for work or valid for EIC?___ Yes ___ No ___ Yes ___ No ___ Yes ___ No This section to be filled out by taxpayers without dependents:Was your main home in the United States for more than half the year? ____ Yes ____ No Were you, or your spouse if filing Jointly, at least 25 but not more than 65 at the end of the year? ____ Yes ____ No Are you eligible to be claimed as a dependent on anyone else’s tax return?____ Yes ____ No We will prepare your 2012 Form 1040-US Individual Income Tax Return & applicable State and local income tax returns if any ore required.We understand that you will provide us with the basic information required for us to perform the services as described. You are responsible for the accuracy and completeness of that information. As such, in connection with the preparation of your return, you represent to us the following in your completed returns:All information you have provided is complete and accurate.All social security numbers and dates of birth for yourself, your spouse and all dependents are correct according to those on file with the Social Security Administration and the IRS.You have reported all income earned and any expenses incurred by you and/or your spouse including income not reported to you by third parties.You have not presented to us any fraudulent or misleading statements or information.Due to the nature of our services we cannot guarantee that the IRS will not examine your return at some future date. We suggest you retain all records and documents related to this return for a period of five (5) years should it ever be necessary for you to substantiate any information reported on your return. Unless you purchase an Audit Protection Plan at the time of filing this return, Tax Masters of America assumes responsibility only for errors made on its part and does not assume responsibility for any of the information provided. If any of this information is incorrect, you understand that a $10 fee will be charged per IRS rejection of this information. If you agree with this statement as outlined above, please sign at the bottom. Thank you for trusting Tax Masters of America with your 2012 Tax return.Taxpayer Signature:___________________________________________________ Date: ________________Spouse Signature: ____________________________________________________ Date: ________________ ................
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