Client Sheet Information Fill Up Form – Fill Out and Use This PDF

ALLIANCE TAX SERVICE

65 Birchwood Lane, Crossville, TN 38555

Telephone: (931) 484-1004, Fax (931) 707- 2865

CLIENT INFORMATION FORM

Today’s Date:

Prepared by:

First Name

Middle Initial

Last Name

Suffix

Social Sec. No or ITIN

Date of Birth

-

-

/

/

Spouse First Name

Middle Initial

Spouse Last Name

Suffix

Social Sec. No or ITIN

Date of Birth

-

-

/

/

Please select the filing status you would like to use:

Single

Married Filing Jointly

Married Filing Separately

Head of Household

Qualifying Widow(er)

Your address and telephone number:

Mailing Address

Apt. #:

Best method and time to contact you?

Your e-mail address

City

State

ZIP Code

Home telephone number

(

)

Work information:

Your Occupation

Work telephone Number

Ext.

May we call you at work, if necessary?

(

)

Yes

No

Spouse Occupation

Work telephone Number

Ext.

May we call you at work, if necessary?

(

)

Yes

No

Dependent information:

Dependent 1:

First Name

MI

Last Name

Suffix

Social Sec. No or ITIN

DOB

Relationship to you

-

-

/

/

Number of months this person lived with you

Did you pay child or dependent care expenses for this person?

Yes

No

Dependent 2:

First Name

MI

Last Name

Suffix

Social Sec. No or ITIN

DOB

Relationship to you

-

-

/

/

Number of months this person lived with you

Did you pay child or dependent care expenses for this person?

Yes

No

Dependent 3:

First Name

MI

Last Name

Suffix

Social Sec. No or ITIN

DOB

Relationship to you

-

-

/

/

Number of months this person lived with you

Did you pay child or dependent care expenses for this person?

Yes

No

Dependent 4:

First Name

MI

Last Name

Suffix

Social Sec. No or ITIN

DOB

Relationship to you

-

-

/

/

Number of months this person lived with you

Did you pay child or dependent care expenses for this person?

Yes

No

Child/ dependent care provider information:

Name

SSN or Employer Identification Number

Total Amount Paid

Address

City

State

Zip code

Name

SSN or Employer Identification Number

Total Amount Paid

Address

City

State

Zip code

Did you or your spouse pay alimony?

Yes

No

If yes, enter the total amount that was paid:

Enter the Social Security Numbers for persons to whom alimony was paid:

-

-

-

-

-

-

Did you have expenses for post-high school education for someone in your family?

Yes

No

Did you or your spouse make a contribution to an Individual Retirement Account?

Yes

No

Did you have any personal or business losses or damage as a result of casualty or theft?

Yes

No

Taxes you paid:

Remarks

State/ Local

Property (main home)

Property (other real estate)

Personal property

Interest you paid:

Mortgage (combine interest from all mortgages)

Mortgage points

Charitable contributions:

Cash (cash, check, credit card, etc.)

Non-cash

Medical expenses:

Prescription medicines

Doctors, Dentists

Fees for hospitals, clinics

Lab and x-ray fees

Long-term care

Eyeglasses and contact lenses

Medical equipment and supplies

Health insurance premiums

Other (explain in Remarks)

Vehicle expenses:

Number of business miles driven

Number of personal miles driven

Total number of miles driven

Vehicle information:

Vehicle make and model (i.e. Chevy Blazer)

Type of vehicle (A: <6,000 lbs.; B: 6,000-13,000 lbs.;

C: >13,000 lbs.; D: tractor trailer for over-the-road use)

Date vehicle placed in service (i.e. 07/23/2003)

/

/

Business travel expenses:

Parking and local transportation

Travel away from home

Meals and entertainment

Other business related expenses:

Education

Professional publications

Licenses

Clothing and equipment

Dues for professional organizations

Other (explain in Remarks)