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4100 E. Bill Mallory Blvd. · Bloomington, IN 47401 phone: (812) 325-9165 · fax: (812)334-2718 |
| 2009-2010 Tax Year | ® |
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New Client Data Sheet |
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| Full Name: _______________________________________________ Social Security Number: _________________________ Date of Birth: ____________________________ Spouse's Full Name (if married): ___________________________________________ Spouse's Social Security Number: _________________________ Spouse's Date of Birth: ___________________________ Your Current Address (including zip code): ___________________________________________________________________________ Current Home Phone Number: ________________________ What County did you and your spouse live in as of January 1, 2009? ________________ (Indiana Residents only) What County did you and your spouse work in as of January 1, 2009? Taxpayer_______________________ Spouse ________________________
(Indiana Residents only) Name of your Indiana School District as of January 1, 2009? ___________________________________ Your Current Occupation: ______________________________________________________ Spouse's Current Occupation: __________________________________________________ Can you be claimed as a dependant on someone else's taxes? (Ex. Parents) ____YES ____NO
Will you claim any dependants? ____YES ____NO Dependant #1 Full Name: ___________________________________________________ Relationship to Taxpayer: _______________________________________ Social Security Number: ___________________________ Date of Birth: _________________________ Dependant #2 Full Name: ___________________________________________________ Relationship to Taxpayer: _______________________________________ Social Security Number: ___________________________ Date of Birth: _________________________
Will you claim the CHILD DEPENDANT CARE DEDUCTION for 2009? ____YES ____NO
Are you a homeowner? ____YES ____NO
Did you pay Real Estate Taxes in 2009? ___YES___NO
Did you purchase a new vehicle after February 16, 2009 ?___YES___NO
Did you purchase your first home in 2009?___YES___NO
Did you make any Energy Improvements to your main home in 2009?___YES___NO
Will you be filing more than 1 State Return? ____YES ____NO If yes, which State? _______________________________
Will you be claiming any educational expenses? ____YES ____NO
Will you be claiming any interest paid on student loans? ____YES ____NO
(Indiana Residents only) Did you rent? ____YES ____NO If yes, how many months did you rent in 2009? ____________
(Indiana Residents only) If renter, how much was your monthly rent? $_____________
(Indiana Residents only) If rented, what is the full name and address of your landlord? ___________________________________________________________________________
Any personal Property Taxes? (Ex. Vehicle taxes) ____YES ____NO Any unearned income? (Ex. Dividends, Bank Interest) ____YES ____NO Did you have any significant Medical and/or Dental expenses in 2009? ____YES ____NO Any cash or non-cash contributions to charity in 2009? ____YES ____NO Did you contribute to an IRA in 2009 or will you before 4/15/2010? ____YES ____NO Did you have any 1099-Retirement Distributions in 2009? ____YES ____NO Did you have any self-employment income in 2009? ____YES ____NO Did you sell any stocks or bonds in 2009? ____YES ____NO Did you have any rental income property in 2009? ____YES ____NO Did you have any Social Security income in 2009? ____YES ____NO
Print out & Bring to Appt or Fax to 812-334-2718
__________________________________ _____________________ Signature of Taxpayer Date |
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