NEW CLIENT INFORMATION/UPDATE/DROP-OFF SHEET
(Click the PDF symbol on the right to download & print this form)
TAXPAYER SPOUSE
Full Name: _______________________________ __________________________________
SS# _______________________________ __________________________________
Date of Birth: ____________________________ __________________________________
Home Address: ____________________________________________________________________
____________________________________________________________________
Home Phone: ____________________________ __________________________________
Work Phone: ____________________________ __________________________________
Cell Phone: ____________________________ __________________________________
(Please check which phone number is the best to reach you during reg. business hours)
E-mail Address:___________________________ Other email:_____________________________
(Please mark which e-mail we can send notices and newsletters to)
Do you want to have refund, if any, directly deposited at no fee? (Yes) (No)
Bank: ___________________Routing#____________________ Account# _____________________
Do you want to E-file your returns (at an additional $100 fee)? (Yes) (No)
------------------------------------------------------------------------------------------------------------------------------
Desired Completion Date: _______________ Mail____ Pickup____ Email as pdf file & you mail ____
(If you choose to have it mailed, we charge between $5-15 depending on the size and weight)
Did you purchase, trade, or sell virtual currency? Yes____ or No_____
I have health insurance thru the marketplace (Obamacare) Yes____ or No_____
If yes, I have attached/included the 1095A for the completion of my taxes. Yes____ or No_____
If no, I can’t finish your taxes.
Do you have a HSA (Health Savings Account)? ____Yes _____No If Yes, attach your 1099SA.
I understand that my desired pickup date will be the targeted completion time and when the return is completed and ready for pickup, the office will call/e-mail me and let me know of its completion. Please do not call the office before that desired date.
I certify that I have reviewed and have completed the Required Checklist for completion of my tax return and that it is complete.
___________________________________ __________________________________________
Burchett Financial Service Agent Client
Dropped off and signed on: _______________________ Log #______________
Date
------------------------------------------------------------------------------------------------------------------------------
NEW CLIENTS ONLY
How did you find out about us?___________________________________________________________________
Dependent Information: *if additional space needed put on back
Full Name ______________________________ SS# __________________ Date of Birth________________