CLIENT DATA COLLECTION & CHANGE FORM – INDIVIDUAL
DEMOGRAPHIC INFORMATION
Client First Name
Client Last Name
Spouse First Name
Address 1
Address 1
Address 2
Address 2
City/State/Zip
City/State/Zip
Telephone #
Telephone #
Email
Email
Social
Security #
Birth
Date
Social
Security #
Birth
Date
DEPENDENT INFORMATION
First Name
1
2
3
4
5
Spouse Last Name
***[CHECK ALL THAT APPLY]
Last Name
Birth Date
Social Security #
Age
Relationship
Months
@ Home
Child
Who
Lived
With
You
Child
Who
Didn’t
Live
With
You
Disabled
Student
[19-23]
Other
DOMICILE/RESIDENCY INFORMATION
Yes ☐
Have you lived in the state indicated in your address during ALL of the current tax year?
IF “NO”:
No ☐
List dates & states you lived in during the current tax year_____________________________________________________
EARNED WAGES INFORMATION
**If you are self-employed skip this section**
Yes ☐
Did you earn all of your wages for the current tax year in PA?
IF “NO”:
No ☐
List each state you earned wages from or in ___________________________________________________________________________________
**This would be each state listed on your W-2 Form, OTHER than wages earned in your state of residence
SELF-EMPLOYMENT INFORMATION
Indicate your business structure:
**Skip this section if your self-employment is from a corporation**
☐ Sole Proprietor
☐ Partnership
☐ Sole Member LLC
Business Name or D/B/A Name:_______________________________________________________
Address:_____________________________________________________
_____________________________________________________
City/State/Zip:________________________________________________
Phone #:______________________________
Federal Tax ID # or Social Security #:___________________________________
If Partnership or Multi-Member LLC list all business partners and their share of ownership:
First Name
Last Name
Share of Ownership
Partner 1
__________________________________________________________
Partner 2
__________________________________________________________
Partner 3
__________________________________________________________
Partner 4
__________________________________________________________
☐ Multi-Member LLC
ANNUAL TAX RELATED INFORMATION OR DOCUMENTION
1.
2.
3.
4.
Please provide us with all W2’s
Please provide us with all K-1, 1065/1120S schedules
Please provide us with a copy of your previous years; Federal, State & Local tax returns
Did you receive any interest payments during the current tax year?
5.
6.
7.
8.
Did you purchase, sell or realize and gains, losses or dividends from investments during the current tax year?
Do you receive any pension and/or annuity payments?
Do you receive any Social Security or Railroad retirement benefits?
Do you receive any “other” income such as unemployment comp, independent contractor fees?
No ☐
No ☐
12.
13.
14.
15.
No ☐ Yes ☐
No ☐ Yes ☐ [Form 1099-R]
No ☐ Yes ☐ [Form SSA-1099]
Yes ☐ [Form UC-1099G, 1099-MISC, 1099-C
No ☐
9. Do you have any gambling winnings or losses for the current tax year?
10. Do you maintain a home office?
11. Do you have any UNREIMBURSED employee business expenses for the current tax year?
No ☐
No ☐
Yes ☐ [Form 1099-INT, DIV, B]
Yes ☐ [Form W-2G]
Yes ☐
Yes ☐
Do you have any UNREIMBURSED employee vehicle expenses for the current tax year?
No ☐ Yes ☐
Do you have any Student loan, tuition fee or education costs for the current tax year?
No ☐ Yes ☐ [Form 1098-T, 1098-E, 1099-Q]
Do you have any Traditional or Roth IRA accounts?
No ☐ Yes ☐
Did you make any conversions or cash out any retirement account; IRA, 401K etc… during the current tax year?
No ☐ Yes ☐
No ☐
16. Did you buy or sell a home or land during the current tax year?
17. Did you make any estimated Federal, State or Local tax payment during the current tax year?
No ☐
Yes ☐
Yes ☐
****For any question you answered “YES” to, please provide us with all notices, statements or IRS forms you may have received. We will also review this information prior
to your scheduled appointment
E-FILE INFORMATION
Would you like your FEDERAL AND/OR STATE TAX RETURNS filed electronically?
☐ Yes
☐ No
If you would like your Federal Tax Returns filed electronically, please provide the following information and provide a copy of a VOIDED CHECK:
Bank Name:___________________________
Checking Account Routing #:_______________________
Checking Account #__________________________
****Not all states accept electronic filing