CLIENT INTERVIEW SHEET
Please fill in the required information below:
1. Taxpayer Name: _______________________ Spouse Name: _________________________
SSN: ________________________________ SSN: ________________________________
Occupation: __________________________ Occupation: ___________________________
Taxpayer Date of Birth: _____/_____/______ Spouse Date of Birth: _____/_____/________
Are you legally blind? ____ Yes ____ No Your Spouse? ____ Yes ____ No
Cell Phone:___________________________ Cell Phone: ___________________________
Home: _____________Work: ____________ Home: _____________Work: _____________
Did you attend college in 2009? ____ Yes ____ No Did your Spouse? ____ Yes ____ No
Address: _____________________________ Address: ______________________________
City St, Zip: ___________________________ City St, Zip: ____________________________
Email Address: _________________________ Email Address: __________________________
2. Please circle your Filing Status. All of the filing status categories below are based upon your status as of December 31 st (the
last day of the tax year).
1) Single – You are single if you were not married and you are claiming no dependents.
2) Married Filing Joint – You are MFJ if both you and your spouse have agreed to file a joint return.
3) Married Filing Separate – You are MFS if you would like to be responsible for your own tax.
4) Head of Household – You are not married (or are legally separated) and you are claiming at least one dependant.
5) Widow with dependent child – You can claim this filing status if your spouse died in 2008 or 2007 and you have not
remarried and you have a qualifying dependent.
3. Can anyone else claim you as a dependent on their tax return? ____ Yes ____ No Your Spouse? ____ Yes ____ No
4. Dependant Information:
First Name Last Name / Date of Birth/ Social Security Number/ Relationship/ # Months lived with you/ Child Care Expenses
5. Are any of your dependants legally disabled? ____ Yes ____ No
6. Did any of your dependents Attend College during 2008? ____ Yes ____ No
7. Child Care Provider Information
Provider’s Name, Address & Phone # SSN or Federal ID # (EIN) Amount Paid
8. Please indicate the Type of Refund you would prefer:
- RAL Refund Anticipation Loan: loan issued in 24 to 72 hours upon approval
- Bonus / Bank EFT: Refund available immediately upon receipt from IRS (Usually 9-16 days)
Direct Deposit Information: Bank Name:________________ RTN: ______________ Account #: _________________
Drivers License or State ID #: _____________________________ Issue Date: _____________ Expiration: ________________
Practitioner PIN Program:
9. Please select a 5 digit number to act as your electronic signature on your tax return TP __________ Spouse ___________
10. Please indicate if you have received any of the following: __ Unemployment __ Alimony __ S.S. Benefits __ Gambling
__ Self Employment Income __ Interest or Dividends __ 1099 Income __ Unreported Tip Income __ Other Income
11. Do you own a home? ____ Yes ____ No
If Yes please provide us with the total mortgage interest expense _________ Property Taxes Paid ______________
Did you make any Charitable Contributions? To Whom: ___________ How much did you donate:_______________
Did you have any Medical Expenses? ___________________ or Un-reimbursed business expenses? ___________
EARNED INCOME CREDIT DUE DILIGENCE WORKSHEET
Is your filing status “Married Filing Separate?” ____ Yes ____ No
Do you and your spouse have a Social Security Number that allows you to work? ____ Yes ____ No
Is your investment income less than $2,350? ____ Yes ____ No
Can anyone else claim you as a qualifying child? ____ Yes ____ No
Were you a U.S. Citizen or resident alien for the entire year? ____ Yes ____ No
This section to be filled out by taxpayers with dependents: Child 1 Child 2
Is your dependent: Your son, daughter, or adopted child or
A grandchild, a stepchild, or eligible foster child ____ Yes ____ No ____ Yes ____ No
Are any of your dependents filing their own return as Married Filing Joint? ____ Yes ____ No ____ Yes ____ No
At the end of the year was your child under 19 or a full-time student under 24yrs old? Or
Was your child any age and permanently and totally disabled? ____ Yes ____ No ____ Yes ____ No
Did your dependent live with you for over half the year or if a foster child(the entire year)? ____ Yes ____ No ____ Yes ____ No
Can any other taxpayer claim your dependent on their tax return? ____ Yes ____ No ____ Yes ____ No
If NO please continue, if YES, is your modified AGI higher than any other taxpayer
Who could claim your child as their dependent? ____ Yes ____ No ____ Yes ____ No
Does your dependant have a SSN that is valid for work or valid for EIC purposes? ____ Yes ____ No ____ Yes ____ No
This section to be filled out by taxpayers without dependents:
Was your main home in the United States for more than half the year? ____ Yes ____ No
Were you, or your spouse if filing Jointly, at least 25 but not more than 65 at the end of the year? ____ Yes ____ No
Are you eligible to be claimed as a dependent on anyone else’s tax return? ____ Yes ____ No
We will prepare your 2009 Form 1040-US Individual Income Tax Return & applicable State and local income tax returns if any ore
We understand that you will provide us with the basic information required for us to perform the services as described. You are
responsible for the accuracy and completeness of that information. As such, in connection with the preparation of your return, you
represent to us the following in your completed returns:
1. All information is complete and accurate.
2. All social security numbers and dates of birth for taxpayer, spouse and dependants are correct according to those
on file with the Social Security Administration and the IRS.
3. You have reported all income earned by you and/or spouse including income not reported to you by third parties.
4. You have not presented to us any fraudulent statements.
Due to the nature of our services we cannot guarantee that the IRS will not examine your return at some future date. We suggest
you retain all records and documents related to this return for a period of five (5) years should it ever be necessary for you to
substantiate any information reported on your return. Unless you purchase an Audit Protection Plan at the time of filing this return,
Nations Fast Tax assumes responsibility only for errors made on its part and does not assume responsibility for the information
provided. If any of this information is incorrect, I understand that a $10 fee will be charged per IRS rejection of this information. I f
you agree with this statement as outlined above, please sign at the bottom.
Taxpayer Signature:___________________________________________________ Date: ________________
Spouse Signature: ____________________________________________________ Date: ________________