H&B Tax Services

How Did You Hear About Us?

FULL NAME:

SOCIAL SECURITY#:

SPOUSE FULLNAME:

SPOUSE SOCIAL SECURITY#:

STATUS:

IF YOU ARE HEAD OF HOUSEHOLD, DO YOU COVER 50% OF THE COST OF LIVING IN YOUR HOUSEHOLD?

YES

NO

IF YES, DO YOU HAVE EVIDENCE TO PROVE THAT?

YES

NO

DATE OF BIRTH:

SPOUSE DOB:

ADDRESS:

CITY:

STATE:

ZIPCODE:

PHONE:

EMAIL:

DEPENDENT #1 FULLNAME:

DEPENDENT #1 SOCIAL SECURITY#:

RELATIONSHIP WITH DEPENDENT#1:

DEPENDENT #2 FULLNAME:

DEPENDENT 2 SOCIAL SECURITY#:

RELATIONSHIP WITH DEPENDENT #2:

DEPENDENT #3 FULLNAME:

DEPENDENT #3 SOCIAL SECURITY#:

RELATIONSHIP WITH DEPENDENT #3:

HAVE YOU LIVED MORE THAN 6 MONTHS WITH YOUR DEPENDENT?

YES

NO

DO YOU HAVE DOCUMENTS TO PROVE THAT? (LETTER FROM SCHOOL, BIRTH CERTIFICATE, SOCIAL CERTIFICATE, ETC)

YES

NO

INCOME/CREDIT:

WERE YOU DENIED OR REDUCED ANY CREDIT IN THE PREVIOUS YEARS?

YES

NO

DO YOU HAVE ANY DOCUMENT THAT PROVES YOUR INCOME?

STATEMENT

OTHER

DO YOU HAVE ANY WORK EXPENSES?

YES

NO

IF YES, DO YOU HAVE EVIDENCE TO PROVE THAT?

YES

NO

Opt-In

I, CERTIFY THAT ALL OF THE ABOVE INFORMATION WAS PROVIDED BY ME AND I CERTIFY THAT THIS INFORMATION IS CORRECT AND ACCURATE. I ALSO AM RESPONSIBLE FOR ANY FALSE STATEMENT ON MY PART AND I WILL BE RESPONSIBLE FOR ANY AUDIT CONDUCTED BY THE

IRS OR THE STATE. I AUTHORIZE AND GIVE MY PREPARER PERMISSION TO PREPARE MY TAXES.

I ALSO UNDERSTAND THAT I WILL BE CHARGED A FEE FOR BANK PRODUCTS ON MY RETURN.

FIRST & LAST INITIAL SIGNATURE:

DATE:

FIRST & LAST INTIAL SIGNATURE:

DATE:

FRONT OF ID PHOTO:

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BACK OF ID PHOTO:

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SOCIAL SECURITY CARD FRONT:

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SOURCE OF INCOME: (W2, 1099, ETC):

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IF MORE SOURCES OF INCOME

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IF MORE SOURCES OF INCOME: IF YOU HAVE MORE THEN 3, EMAIL US THE REST

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DEPENDENT #1 SS CARD PHOTO:

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DEPENDENT #1 BIRTH CERTIFICATE OR PASSPORT PHOTO:

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DEPENDENT #2 SS CARD PHOTO:

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DEPENDENT #2 BIRTH CERTIFICATE OR PASSPORT PHOTO:

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DEPENDENT #3 SS CARD PHOTO:

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DEPENDENT #3 BIRTH CERTIFICATE OR PASSPORT PHOTO:

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COMPLETE FORM BELOW: IF YOU HAVE ANY QUESTIONS, CALL US AT 212-871-8794