INCOME TAXES

Client Profile Form

New Customer

Income Taxes Client Profile Form

Were you our Tax customer last year?

How did you hear about us?

1. Filing Status

2. Personal Information

First name

Last Name

Social Security #

Date of Birth (DD/MM/YYYY)

Address

City

State

Zip Code

Work Phone #

Home Phone #

Cell Phone #

Occupation

Email Address

IRS PIN (if IRS Assigned you a PIN enter here, if not leave blank)

Type of Identification

Passport Country

Id State

Identification #

Issue Date (DDMMYYYY)

Expiration Date (DD/MM/YYYY)

3. Spouse Information

First name

Last Name

Social Security #

Date of Birth (DD/MM/YYYY)

Work Phone #

Home Phone #

Cell Phone #

Occupation

Email

IRS PIN (if IRS Assigned a PIN enter here, if not leave blank)

Type of Identification

Id State

Passport Country

Identification #

Issue Date (DDMMYYYY)

Expiration Date (DDMMYYYY)

4. How Many Dependents do you have?

4.1 Dependent Name

4.1 Relationship

4.1 Date of Birth (DD/MM/YYYY)

4.1 Social Security #

4.2 Dependent Name

4.2 Relationship

4.2 Date of Birth (DD/MM/YYYY)

4.2 Social Security #

4.3 Dependent Name

4.3 Relationship

4.3 Date of Birth (DD/MM/YYYY)

4.3 Social Security #

4.4 Dependent Name

4.4 Relationship

4.4 Date of Birth (DD/MM/YYYY)

4.4 Social Security #

Daycare/Qualified after schooI Program/Camp

Dependents not living with you but supported by at least 6 months

Did you receive a 3rd Stimulus? $

Is dependent your child?

Dependents Supporting Documents Dependents Supporting Documents Social Security Card Insurance enrollment School Verification Letter Physical form Child Care Letter Place of Worship Social Service Records Lease agreement Employer Statement

Do you know where the child's parents are?

Did one the parents live with you?

Did anyone else live with you?

Can anyone else claim the child?

Is there an active 8332 Release/Revocation form in place?

5. Homeowner

How many Properties

# of Units - Condominium (Complete Real Estate Property Form)

6. Self Employed

W2 Employee - How Many W2?

Business Name

EIN

Business address

City

State

Zip

Phone

Email

Select from the list...

Bank Interest?

Unemployment Comp?

Citizen

Resident Alien

IRA, Pension or annuity distribution?

Health Insurance

Type of Health Insurance

FID or EIN #

Member #

Insurance Name

Purchase through the exchange marketplace

Purchase through employer

Covered the whole year

How many months

Do you have the insurance card with you?

Do you have form 1095-A

Did you make contributions to HSA Acct?

Did you purchase or sell any Virtual currency last year?

Did you sell Stocks?

Signatures Signatures Client's Signature Spouse's Signature By signing this form, I hereby certify that all information provided to Qualitech Professional Services is true, correct to the best of my knowledge and belief (I/we) understand that any assessments, penalties or audits by the IRS due to omissions or erroneous information provided to Qualitech (I/we) waive the right to pursue legal action against Qualitech. (I/we) will seek proper legal representation if necessary outside Qualitech Professional Service and agree to pay all document preparation at time of service.

7. PAYMENT METHOD

Bank Name

Routing #

Account #

5 + 3 =

****Filling fees are due at the time of service

Email us attaching a copy of picture I.D Social Card and Insurance card

Office use Only

• Please attach a copy of picture I.D. Social Card, Insurance card and Original W-2 forms
• No typewritten SS Cards. All typewritten W- 2’s must be verified
• When Claiming EIC dependents information must be verified
• All Self employed clients must submit accurate business income & expenses records at the time of filing
• Additional copies for previous tax return have additional fee of $50.00 per tax year

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