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(Please click the PDF to download this document)


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 a refund, if any, directly deposited at no fee? You still need to mail your return yourself. (Yes)  ___   (No) ___

Bank: ___________________Routing#____________________ Account# _____________________

Do you want to E-file your return (at an add’l $100 minimum fee. Larger returns can be more)?   (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)

Do you want a hard paper copy or pdf when completed or hard copy today and a pdf copy in May or June at an additional charge of $25-50. 


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 not, I can’t finish your taxes.


Do you have a HSA (Health Savings Account)? Yes____ or 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 Reminder Checklist for completion of my tax return and that it is complete.

___________________________________                 __________________________________________

Burchett Financial Service Agent                                           Client


Dropped off and signed on: _______________________        Log #______________




How did you find out about us?___________________________________________________________________

Dependent Information: *if additional space needed put on back. 

Full Name ________________________________________   SS#  ____________    Date of Birth________________

_____________________________________________________________________________________________  M/F

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