Client Information

Print this page and fill out before you get to our office.
Taxpayer Information

SSN#                                                                      DOB                                            Name                                                                                                   

Occupation                                                                    Dependent of someone else?                    Blind? _______   Disabled? __________

Home Phone ________________________ Work Phone ________________________ Cell Phone ________________________

Cell Phone Carrier ________________________________   Email__________________________________________________

Driver’s License/State ID #                                                                                      Date issued                                 Date Expired_                 

Spouse Information

SSN#                                                                      DOB                                            Name                                                                                                   

Occupation                                                                    Dependent of someone else?                    Blind? _______   Disabled? __________

Home Phone ________________________ Work Phone ________________________ Cell Phone ________________________

Cell Phone Carrier ________________________________   Email__________________________________________________

Driver’s License/State ID #                                                                                      Date issued                                 Date Expired_                 

Address:

Mailing Address                                                                                                            City                                                             Zip                                

Physical Address                                                                                                            City                                                           Zip                         

Filing Status

  1. Single (not married with no dependents, or have dependents but do not pay 50% of bills)
  2. Married filing jointly (if you are married, you must file married filing separate or joint
  3. Married filing separately (both spouses MUST list this status and neither can be SINGLE or HOH)
  4. Head of Household (means you are not married, have dependents, pay more than 50% of household bills)
  5. Widower (spouse must have died during the year of which you are filing)
   Direct Deposit for your refund?

 
Bank Name_                                                           Routing #                                                            Account #_                                                                                      __

Dependent Information

  1. Name___________________________DOB______________ SSN#__________________ Relationship________________ Disabled? Yes/No  Student? Yes/No  Months in home?_____________
  2. Name___________________________DOB______________ SSN#__________________Relationship________________ Disabled? Yes/No  Student? Yes/No  Months in home?_____________
  3. Name___________________________DOB______________ SSN#__________________Relationship________________ Disabled? Yes/No  Student? Yes/No  Months in home?_____________
  4. Name___________________________DOB______________ SSN#__________________Relationship________________ Disabled? Yes/No  Student? Yes/No  Months in home?_____________
Referral Credit                    
We pay $20 to each person that refers a new client to us!
If you are a new client to us, who referred you here?___________________________________

 

Health Expenses:
  • Health Insurance Premiums Total $______________
  • Out of pocket medical payments $______________
  • Out of pocket vision & dental payments $______________
  • Hospital, lab, radiology etc $______________
  • Medical miles driven______________
  • Prescription Drugs Copay $______________
  • Home medical equipment $______________
  • Long Term Care Premiums $______________
Charitable Donations:             
  • Church/Charitable Donations  * cash/check $______________
  • Non-cash charitable Donations, Value $______________
  • Charitable Miles Driven ______________
Other Tax Credits
  • IRA Contribution $______________
  • Daycare Expense $______________
  • Educator Expense $______________
  • 2017 State Refund (if you itemized) $______________
  • Alimony Paid $______________
  • Alimony Received  $______________
  • Childcare $______________
  • College Tuition * 1098-T $______________
  • Student Loan Interest $______________
  • Reservist, Performing Artist Expense $______________
  • First Time Home buyer Repayment $______________
Taxes &Mortgage: 
  • Real Estate Tax $______________
  • Sales Tax- Vehicle,Home, RV, Boat $______________
  • Vehicle, Boat, RV, Mobile Home Tax $______________
  • Mortgage Interest $______________
  • Mortgage Insurance (not homeowner’s) $______________
  • SC Fuel Credit  Gallons __________
  • Maintenance $______________
Under penalty of perjury, I declare all information listed above is true and correct to the best of my knowledge. I understand it is my responsibility to report accurate figures and information to my tax preparer and I further assume all responsibility if any information I provide to my preparer is incomplete or incorrect. I understand that I must keep a copy of my tax return and all supporting documents used to prepare my return for a minimum of 3 years.

Taxpayer Signature                                                                                         Date                                        

Marketplace Insured – Blue Cross

  1. If you have health insurance through the Marketplace, also known as Consumer’s Choice, you must have Form 1095-A to file your tax return!  If you have an exemption, what is the certificate #? ________________________
   Other Insured
  1. Did you and your household listed on the return have Employer/Private Insurance for the entire year? YES / NO
  2. Did you and/or your household have Medicare or Medicaid? YES / NO
NO Health Insurance for all or part of the year
Circle each month you, your spouse or children did not have health insurance.
  1. Name ________________________ Jan/Feb/Mar/Apr/May/June/July/Aug/Sept/Oct/Nov/Dec
  2. Name ________________________ Jan/Feb/Mar/Apr/May/June/July/Aug/Sept/Oct/Nov/Dec
  3. Name ________________________ Jan/Feb/Mar/Apr/May/June/July/Aug/Sept/Oct/Nov/Dec
  4. Name ________________________ Jan/Feb/Mar/Apr/May/June/July/Aug/Sept/Oct/Nov/Dec
I certify that my tax preparer has reviewed my State and Federal Tax Returns along with all corresponding schedules and statements in full with me and I fully understand and agree with all the figures, incomes, deductions and credits contained within it.

I understand that if upon further inspection, if there is something that I do not understand on my return, or agree with; it is my responsibility to notify my preparer or return to the office for further explanation and/or necessary corrections. I understand it is my responsibility to make sure corrections are made if in fact, an error or omission has occurred. I understand that if my return contains an error or omission which is later discovered by the IRS, it is my responsibility to pay the adjusted tax, penalty, interest and other fees assessed by the government.

I have received a full copy of my tax returns and understand that if I need additional copies, a $10 fee will be charged. I also understand that if I need to make a change to my tax return once this return has been filed, a

$25 amendment fee will be charged.

I understand that I am paying to have my income tax returns prepared on my behalf regardless if I am due or receive an income tax refund. I understand the fees charged to prepare my income tax return do not include any fee in regards to the amount of time it takes for the government to issue the refund, if any. If I am having my tax prep fees withheld from my refund, and my refund is not issued due to a prior debt placed against me, or audit that my tax prep fee has not been paid and is still owed to Brinson’s Tax Service.

Taxpayer Signature                                                                                  Date                                              

Spouse Signature                                                                                     Date                                              

SELF EMPLOYMENT ORGANIZER

*** Please report the amounts that pertain to you unless you have brought your own detailed statement ***

2018 Business Income & Expense Report

Total Income reported 1099 MISC $____________ Other Business Income $____________

Expenses:

  • Office Expense $____________  Rent/Lease $____________  Rent/Lease/Other $_____________
  • Taxes & License $_____________ Travel $_____________ Business Meals $_____________
  • Utilities $_____________ Advertising $_____________ Commissions & Fees $_____________
  • Contract Labor $_____________ Wages $_____________ Legal & Professional Services $_____________
  • Last yr tax prep SCH C $_____________ Pension/Profit Sharing $_____________
  • Supplies $_____________ Returns & Allowances $_____________ Insurance (not health) $_____________
  • Phone $_____________  Mortgage Interest $_____________ Other Interest $_____________  MISC $_____________

Cost of Goods Sold:

  • Beginning Inventory at wholesale value $_____________ Purchases at wholesale cost $_____________
  • Materials & Supplies $_____________Cost of labor, shipping $_____________  Other costs $_____________
  • Ending Inventory at wholesale value $_____________

Business Vehicle Information:

Property tax $_____________ Gas,oil,repairs $_____________

Total miles driven in 2018 _____________ Business miles driven in 2018 __________Other miles, commuting etc ________

Equipment, Office equipment, Computers, Vehicles, Tools, Fixtures Used for Business Purposes, Etc:

Description of Asset_________________________ Date Placed in Service____________ Cost of Asset $_________________ 
I, the taxpayer, have reviewed all figures recorded in this document and under penalty of perjury, declare all information is true, correct and complete.

Taxpayer Signature__________________________________________ Date ______________________