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(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 #______________




How did you find out about us?___________________________________________________________________

Dependent Information: *if additional space needed put on back 

Full Name ______________________________     SS# __________________      Date of Birth________________

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