(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 e-mail:            ____________________________ _________________________________

                          (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 $50 fee)?    (Yes)       (No)


Desired Completion Date: __________________________________

Desired method of pick-up or mailing:  Mail _____  Pickup _____ Email as PDF & your email: _____________


          (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_____

Did you receive a stimulus check after March 11, 2021, which should have been about $1,400/person in household?
Yes____ No____         Date __________  Amount _______________
Did any dependents receive it as well?
Yes____ No____         Date __________  Amount________________


Did you receive any Advanced Child Tax Credits from July - Dec  2021?   Yes___ No___

Attach letter #6419 from the IRS or list by month the amount received.


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:

Full Name ________________________________ SS# _______________  Date of Birth _________________

1. ______________________________________________________________________ M/F

2.  _____________________________________________________________________  M/F

3. _____________________________________________________________________   M/F

                                           (Write on back of page if needed)