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Referral

Previous Client

Website

Client Type *

Returning Client

New Client

Name of Tax Preparer: *

Referred By:

First Name *

Last Name *

Address *

City *

State *

Postal code *

Email *

Phone *

Occupation *

Does any of the following apply? *

Deceased

Blind

Can Be Claimed As a Dependent

None of these apply

Taxpayer's SSN *

Filing Status

Date of birth

Date of Death

Spouse First Name

Spouse Last Name

Spouse SSN

Spouse Phone Number

Spouse Email Address

Spouse Date of Birth

Do you currently have dependents? *

If so, how many dependents do you have?

Would you like to apply for a refund advance? *

Are you filing a business/self employed/ side job/cash job? *

Yes

No

Did you or your family have health insurance at any time in 2023 from the MARKETPLACE? HEALTHCARE.GOV *

Yes

No

Do you owe student loans, taxes, or any other entity that at might offset your refund? *

Yes

No

Out-of-Pocket Expenses

Insurance premiums you paid (medical, dental, vision)

Amount paid to providers (doctors, dentists, etc.) Prescriptions

X-rays, lab work, etc.

Nursing services (in-home or at a care facility)

Hospital care (including meals and lodging)

Alcohol and drug rehabilitation

Medical aids (hearing aids, crutches, wheelchairs, etc.)

Dependent First Name

Dependent Last Name

Dependent Date of Birth

Dependent SSN

What is Dependent #1's Relationship to you (son, daughter, etc.)?

How many months did Dependent #1 live with you in 2024? (If all year, enter 12)

Dependent #2 First Name

Dependent #2 Last Name

Dependent #2 Date of Birth

Dependent #2 SSN

What is Dependent #2's Relationship to you (son, daughter, etc.)?

How many months did Dependent #2 live with you in 2023? (If all year, enter 12)

Dependent #3 First Name

Dependent #3 Last Name

Dependent #3 Date of Birth

Dependent #3 SSN

What is Dependent #3's Relationship to you (son, daughter, etc.)?

How many months did Dependent #3 live with you in 2023? (If all year, enter 12)

Name of Bank

Routing #

Account Number

How would you like your refund?

Paper Check Printed in Office

Prepaid debit Card

Direct Deposit

I am the custodial parent for the dependent(s) for whom the tax credit(s) will be requested, and I released the dependency deduction to my former spouse for 2023 by signing Form 8332( release / Revocation of claim to exemption for Child by Custodial Parent).

Yes

No

I certify that the child(ren) for whom the tax credit(s) will be requested can be claimed as my dependent(s), as per the information provided at the end this questionnaire.

Yes

No

I or my child(ren) , have documentation to substantiate the credit(s) being claimed , such as form 1098-T , bills, statements, and receipts for college tuition,fees, books, and material cost (you are responsible for keeping this documentation and providing it to the IRS if you are audited or questioned).

Yes

No

The child(ren) for whom the tax credit(s) will be requested has lived with me for the entire year of 2023.

Yes

No

Was a child Tax Credit, Additional Child Tax Credit, or American Opportunity Credit claimed by you disallowed or reduced by the IRS on a past tax return?

Yes

No

I am unmarried or seperated, support a qualifying person as your dependent, and pay more than half the cost of maintaining your household.

Yes

No

Are you on Section 8?

Yes

No

Do you get Government Assistance?

Yes

No

Does your yearly income exceed $17k/ year?

Yes

No

Do You Pay For 50% or More for the Upkeeping of Your Home?

Yes

No

Are you claiming your own dependents?

Yes

No

If you selected No, please provide the reason you are claiming someone else dependent.

I AGREE, The information contained in this office or on this website is of a general nature. It should not be construed as legal advice nor should it be acted upon in your specific situation without further details and/or professional assistance. Any use of information contained in this office or on our web site is done so at the risk of the user, and TDA Communications Services LLC is not responsible for the result or outcome of its use TDA Communications Services LLC does not guarantee and is not liable for the truthfulness, accuracy, effectiveness, or any resulting effects of the use of any information contained in this office or on the web site. It is advised and it is the responsibility of the visitor of this office or web site to seek proper instruction and/or seek professional assistance in all matters regarding taxes and the IRS. TDA Communications Services LLC is thus held harmless, released of, and users of information contained in this office or on this web site assume full responsibility for, any violation of Tax laws and/or IRS procedure, and any other legal liability resulting from use of any information contained in this office or on this web site. I attest that all information contained in this income tax return was obtained from the taxpayer or spouse and is true and correct to the best of his/her knowledge. *

Yes

No

I, "Tax Client", give and express full written and verbal permission over to "TDA Communications Services LLC" and it's employees/agents/representatives to contact the American Offset Debt Line/Treasury Offset Program on behalf of myself to determine if I have any non-tax debt that could potentially offset my current tax return. The Offset Debt Line contact number is 1-800-304-3107. *

Yes

No

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