Taxpayer Interview Form

Taxpayer Information

Social Security#

Date of Birth

U.S. Citizenship?

Name:
Spouse:
Address:
City:
State:
Zip:

Occupation

Taxpayer Occupation:
ARE YOU?
Legally Blind?
Spouse's Occupation:
Totally and Permanently Disabled?

Contact Information

Taxpayer Phone:
Taxpayer Cell:
Taxpayer Email:
Spouse's Phone:
Spouse's Cell:
Spouse's Email:

Banking Information

Routing Number:
Acct. Number:

Filing Status

Dependant Name

Soc. Sec #

D.O.B

Relationship

Full Time Student

Unemployment Income

Did you receive any unemployment insurance last year?

Social Security Benefit

Taxpayer
Benefit Amount:   $
Spouse
Benefit Amount:   $
Estimate Taxes Paid
1st Quarter: $
2nd Quarter: $
3rd Quarter: $
4th Quarter: $
Daycare (Under Age 13)
Education

Name:

Address:

City

SS#/EIN#:

Other:

State
Zip
Amount
Amount

Educational Institution Name:

Address:

City

Tuition Paid:

State
Zip
Fed Tax ID
Books:
Did you receive form 1098-T from this institution?
Do you have plans to purchase a house in 2021?

1st Time Home Buyer Credit

Did you buy a home last year and claimed 1st Time Home Buyer Credit?
Due Diligence Requirements

To comply with the EIC knowledge requirement, you must not know or have reason to know that any information used to determine the taxpayer's and the amount of, the EIC is incorrect. You may not ignore the implications of information furnished to or known by you, and you must take reasonable eligibility for, inquires if the information furnished appears to be incorrect, inconsistent, or incomplete. At the time you make these inquires, you must document in your files the inquires made and the taxpayers responses.

The above information is true and correct, and I/we understand that the information given on this questionnaire will be used to complete my/our tax return(s). I/We agree to hold this company harmless for any errors that they may make on my/our tax return. I/We also understand that error on my/our return will cause a delay in the processing of the return and the receipt of the return and the receipt of the refund, if any. All expenses listed above are true and I have documentations to show proof if needed by IRS. 

Date:
Date:
Medical Expenses
Amount
Charitable Contributions
Insurance Premium
Hosp./Nursing Home
Co Payment
Prescription Drugs
Dental
Glasses/Hearing Aid
Other:
$
$
$
$
$
$
$
Church   Name:
Red Cross
United Way
Goodwill
Fair market value of goods donated
Charitable miles
Other:
$
$
$
$
$
$
$
Household Income:
Wages earned as a household employee (Not on W-2):
Do you have clear records?
Business Profit and Loss for Independent Contractor and Self-Employed
Taxpayer Name:
Business Address
Tax ID#:
Business Name:
City:
Occupation:
State:
Zip:
Gross Receipts or Sales
1st Quarter: $
2nd Quarter: $
3rd Quarter: $
4th Quarter: $
Expenses
Accounting
Advertising
Answering Service
Bad Debts
Bank Charges
Car and Truck Expenses
Commissions
Contract Labor
Delivery and Freight
Dues and Subscriptions
Insurance (other than health)
Mortgage Interest
Other Interest
Uniforms
Utilities
Other
Other
Other
Other
Business Miles
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Expenses
Laundry and Cleaning
Legal and Professional
Miscellaneous
Office Expenses
Parking and Tolls
Tools
Travel
Postage
Printing
Rent - vehicles, machinery, equipment
Rent - other
Repairs
Security
Supplies
Taxes - real estate
Taxes - payroll
Total Meals and Entertainment
Outside Services
Required Telephone
Commuting Miles
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Energy Efficency
Did you make energy efficiency improvements to your home?
If yes, provide:
Type:
Amount Paid:
Type:
Amount Paid:
Type:
Amount Paid:
Due Diligence Requirements

To comply with the EIC knowledge requirement, you must not know or have reason to know that any information used to determine the taxpayer's and the amount of, the EIC is incorrect. You may not ignore the implications of information furnished to or known by you, and you must take reasonable eligibility for, inquires if the information furnished appears to be incorrect, inconsistent, or incomplete. At the time you make these inquires, you must document in your files the inquires made and the taxpayers responses.

The above information is true and correct, and I/we understand that the information given on this questionnaire will be used to complete my/our tax return(s). I/We agree to hold this company harmless for any errors that they may make on my/our tax return. I/We also understand that error on my/our return will cause a delay in the processing of the return and the receipt of the return and the receipt of the refund, if any. All expenses listed above are true and I have documentations to show proof if needed by IRS. 

Date:
Date:

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