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 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 # _____________________________
Date
--------------------------------------------------------------------------------------------------------------------------------------
NEW CLIENTS ONLY
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)