Contact Us

Taxpayer Information:

Name: SSN:--

Date of Birth://

Day Phone #: ()-Evening #: ()-

Please check one of the above phone numbers for us to contact if we have any questions.

Address: Street # Street Name

City: State: Zip:

Spouse Information:

Name: SSN:--

Date of Birth://

Day Phone #: ()-Evening #: ()-

Child/Dependent # 1

(Additional dependents enter on page 2)

Name:

SSN:--

DOB://

Check One:

 Son Sister Daughter Niece Parent Nephew Grandparent Aunt Grandchild Uncle

Child/Dependent # 2

(Additional dependents enter on page 2)

Name:

SSN:--

DOB://

Check One:

 Son Sister Daughter Niece Parent Nephew Grandparent Aunt Grandchild Uncle

Do you have dependant care expenses? (Daycare) Yes No

Child Care Provider info: Name:

Address: City: State: Zip:

EIN or SSN: Amount Paid: $

General Questions

Can anyone else claim you or your dependents on their taxes? Yes No N/A

Are you or your spouse legally blind? Yes No

Are you, spouse, or any of your dependents disabled? Yes No

Are you, spouse, and dependents able to legally work in US? Yes No

Have you ever been denied EIC (earned income credit)? Yes No

Are any of your dependents married? Yes No N/A

Are any of your dependents over 18 and NOT in school? Yes No N/A

How would you like your Refund? Check one of the following for Federal Refund.
BANK PRODUCT *All bank and prep fees will be withheld from refund check. No upfront payment.

Direct Deposit- Personal Account 7-14 Days full refund

Diamond Card 7-14 Days full refund

Paper Check (Office pickup) 7-14 Days full refund

Please list any additional information below, such as additional dependents, if anyone is disabled, who, charitable contributions, college or trade school tuition paid, medical and dental expenses, uniforms or other work expenses, etc.

Taxpayer SignatureDate

Spouse Signature Date