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Call Now: (713) 532-2844
FOR OFFICE USE ONLY
Preparer:
Assigned to:
Intake Date:
Completed Date:
Note:
Names must be spelled exactly as they appear on your Social Security Card.
PRIMARY TAX PAYER
First Name:
Last Name:
S. S. N.
Occupation:
D. O. B.
Deceased Date:
Home Ph. #
Work Ph. #
E-Mail:
Legally Blind:
Yes
No
Disabled:
Yes
No
SPOUSE
First Name:
Last Name:
S. S. N.
Occupation:
D. O. B.
Deceased Date:
Home Ph. #
Work Ph. #
E-Mail:
Legally Blind:
Yes
No
Disabled:
Yes
No
ADDRESS
Address:
Apt #:
City:
State:
Zip Code:
Documents:
List Items Provided:
1
2
3
4
5
6
FILING STATUS
Single
(must be unmarried on last day of tax year)
Head of Household
(must be unmarried or considered unmarried on last day of tax year and maintained a home for someone over 1/2 year)
Married Filing Jointly
(must be married on last day of tax year)
Home Loan (Purchase, Refinance, Cash-out, Construction)
CHILDREN & OTHER DEPENDENTS
First Name
Last Name
SSN
Relationship
Months In
D.O.B
Student
Yes
No
Yes
No
Yes
No
Yes
No
We also provideInsurance and Mortgage services. If interested please check the appropiate box:
Auto Insurance
Homeowners Insurance
Other Insurance
( Life, Health, Business, ect.)
Home Loan
(Purchase, Refinance, Cash-out, Construction)
WAGE & SALARY INCOME (enclude copies of W-2s)
Employers Name
Total Wage
Fed. Tax
State Tax
Local Tax
Soc Sec
Medicare
OTHER INCOME
Name of Payer:
Amount:
GENERAL INFORMATION
Yes
No
Have you ever filed a U.S. Tax Return in the past?
Yes
No
Do you have any interest earned?
Yes
No
Do you own any stock?
Yes
No
Do you own your own business? Or are self employeed.
Yes
No
Did you recieve alimony?
Yes
No
Did you recieve unemployment compensation?
Yes
No
Did you recieve social security income?
Yes
No
Did you have a casualty or theft loss? (Generally, the loss must exceed 10% of you income)?
Yes
No
Did you recieve a distribution from a pension plan, profit sharing plan,tax-shelterd annuity, deferred compensation plan, IRA or Keogh? If so provide Form 1099-R.
Yes
No
Do you own Life Insurance?
Yes
No
Do you own a home?
Yes
No
Do you have any rental properties or revenue?
Yes
No
Did you earn royalties?
Yes
No
Are you a member of a Partnership, LLC or Joint Venture?
Yes
No
Did you (or your spouse) receive alimony?
Yes
No
Did you receive revenue from a trust or estate?
Yes
No
Did you win any monies from gambling?
Yes
No
Did you receive any scholarships, grants or employer assistance for education?
GENERAL INFORMATION (DEDUCTIONS)
Yes
No
Did you pay home mortgage interest?
Yes
No
Did you make contributions to an IRA, ESA or SEP?
Yes
No
Did you do any improvements to your home?
Yes
No
Did you pay interest on student loans?
Yes
No
Do you have an adopted child dependent?
Yes
No
Did you make any donations to charities?
Yes
No
Any transportation or mileage for charitable work?
Yes
No
Did you or your spouse pay any alimony?
Yes
No
Did you have any unreimbursed employee expenses?
Yes
No
Did you have any investment expenses?
Yes
No
Do you have a safety deposit box?
Yes
No
Did you pay any professional fees (tax preparation, legal, accounting services)?
Yes
No
Did you pay any dues or subscriptions for any associations or unions?
Yes
No
Did you pay any travel expenses?
Yes
No
Did you pay any lodging, meals or auto rentals?
Yes
No
Do you move because of job change?
Yes
No
Did you or your dependants pay college tuition?
Yes
No
Did you incur any adoption expenses this year?
Yes
No
Did you use your car for business purposes?
Yes
No
Did you pay child care expenses?
Upon Completion; we will provide you with a copy of the Tax Return. Please select the appropiate format:
Printed copy
On a CD
Both ($10 extra)
SIGNATURE & CONFIRMATION OF INFORMATION
Print Name:
Signature:
D. L. #:
Exp Date:
Date:
Tel: (713) 532-2844
Toll Free: 1-800-239-8202
Email:
tax@786taxrefund.com
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