New Client Data Request

Date

Tax Payer Information

Your Name (required)

Address (required)

City (required)

State (required)

Zip Code (required)

Home Phone (required)

Work Phone

Mobile Phone

Fax Number

Your E-mail Address (required)

Your Birth Date

Spouse Information

Spouse Name

Spouse Home Phone

Spouse Work Phone

Spouse Mobile Phone

Spouse Fax Number

Spouse E-mail Address

Spouse Birth Date

School District

County

Referred By

Dependents

Dependent 1 Name

Dependent 1 Birth Date

Dependent 2 Name

Dependent 2 Birth Date

Dependent 3 Name

Dependent 3 Birth Date

Dependent 4 Name

Dependent 4 Birth Date

Dependent 5 Name

Dependent 5 Birth Date

1. Do you owe any outstanding fees to your prior tax professional?
YesNo

2. Did you have any disagreements with your prior tax professional regarding reporting of income or allowable tax deductions?
YesNo

If yes, please describe those disagreements

3. Why did you leave your prior tax professional?

4. Are you interested in or would you like to discuss any of the following services?
Asset preservation planningBusiness succession planningOutsourcing your payrollMonthly external CFO servicesOutsourcing your recordkeepingConsulting Services (ex. internal controls over your financial activities, business growth strategies, cost analysis)

Attachment:

Your Signature