Jot Form – Empress Financial Services

Thank You for taking the time to complete the Empress Financial Services client intake form.

This information is important and will help complete a correct and accurate tax filing. Please don’t be in a rush to complete all questions and review all information before submitting. Please note if any documents are missing or incorrect this will result in a delay in processing your return.

Please wait until you have all your documents before submitting them.

Note: if claiming any dependents be sure to upload all documents such as Social security cards, Birth certificates School Records, etc, indicating the child is your dependent.

Filling Status *SingleHead Of HouseholdMarried Filling JointMarried Filling Single

Check All That Apply *W2Schedule CHousehold IncomeSchoolSection 8/ HousingMedicaidFood StampsOther

First Name *

Last Name *

Street Address *

Apartment, suite, etc *

City *

State/Province *

ZIP / Postal Code *

Phone *

Email Address *

Date Of Birth *

Date of the death if deceased

Social Security Number (SSN) *0 / 15

Are you a U.S Citizen? *YesNo

Tax Payer Occupation / Title *

Tax Payer Legally BlindYesNo

Can You Be Claimed as a Dependent? *YesNo

Did you receive last year tax return?YesNo

Upload documents Such As (ID, Socials, W2 statements) *

No file chosen

How did you hear about us? *

Are you the recipient of Obama Care or did you purchase Medical Insurance from the federal marketplace? If so, please provide a form 1095A. Your tax return will be rejected without this form. *YesNoI'm Not Sure

Were you previously issued an Identity Protection Pin( IP PIN) by the IRS?YesNo

Spoue Full Name

Spoue Date of Birth

Spoue Name E-mail Address

Spouse Name, Date Of Birth, Email Address and Social Security Number

Do you have full custody of the dependent children?

How many dependents?

Dependent 1 Name?

Dependent 1 Social Security Number

Sex Of 1st DependentMaleFemale

1st Dependent Date Of Birth

Is this child disabled?YesNo

If you are a single parent, where is the other parent of your children?

Do you provide more than 50% Support?YesNo

Has the dependent lived with you at least half of the year?YesNo

Dependent 2 Name?

Dependent 2 Social Security Number

2nd Dependent Date Of Birth

Sex Of 2nd DependentYesNo

Is this 2nd child disabled?YesNo

Do you provide more than 50% Support?YesNo

Dependent 3 Name?

Dependent 3 Social Security Number

3rd Dependent Date Of Birth

Sex Of 3rd DependentMaleFemale

Is this 3rd child disabled?YesNo

Do you provide more than 50% Support?YesNo

Did you pay any child care expenses last year?YesNo

How much did you pay in child care expenses?

Can anyone else claim your dependents? if yes, please explain

Please provide the name, address, and social security number or EIN # of your childcare. provider

Have you ever been disallowed EITC/AOTC/CTC? If so, when? *

Do you have any debts with the IRS, US TREASURY, CHILD SUPPORT, FEMA, OR ANY. GOVERNMENT ENTITY?" *YesNo

If so, With whom and what is the EXACT amount?

Please list documents you have provided for proof of loss/profit for business/self employment (Example: Receipts, P&L statement, bank statements, or written ledger (which is above spreadsheet)

Did you receive Unemployment? (Please upload 1099 G form)

No file chosen

How Would you like to recieve your Refund? Check one of the following7-14 Days (RT Refund Transfer: Check) In About 7-14 Days From The Date Your Return is Accepted Electronically By The IRS, You Receive A Check For The Amount Of Refund Less Filling Fees. (Checks will be available in our office)7-14 Days (RT Refund Transfer: Debit Card) in About 7-14 Days From The Date Your Refund Is Accepted Electronically By The IRS, For The Amount Of Your Refund Less. Filing Fees Will Be Deposited To The Debit Card We Issue You.7-14 Days (RT Refund Transfer: Direct Deposit) In About 7-14 Days From The Date Your Refund Is Accepted Electronically By The IRS, For The Amount Of Your Refund Less Filing Fees Will Be Deposited Into Your Bank Account

Would you like your refund deposited into your Checking or Savings Account?

Direct Deposit Routing Number: (Required if Direct Deposit was selected)

Direct Deposit Account Number: (Required if Direct Deposit was selected)

THE NECESSARY DOCUMENTS?

IF DOCUMENTS ARE NOT UPLOADED THIS FORM WILL BE VOIDED!!!!!!!

CLIENT NON-PAYMENT/OFFSET CLAUSE:

EMPRESS FINANCIAL SERVICES TAKES PRIDE IN ASSISTING ALL CLIENTS WITH THEIR INDIVIDUAL TAX NEEDS, HOWEVER, WE UNDERSTAND SITUATIONS WILL ARISE IF YOU HAVE ANY OFFSETS BY THE IRS, STUDENT LOANS, OR CHILD SUPPORT YOU ARE STILL OBLIGATED TO PAY OUR COMPANY FEES ASSOCIATED WITH FILING YOUR TAX RETURN.

BY SIGNING THIS AGREEMENT YOU ACKNOWLEDGE THAT IF PAYMENT IS NOT MADE IN FULL WITHIN 30 DAYS LEGAL ACTION WILL BE SOUGHT TO RESOLVE PAYMENT.

THANKS FOR YOUR BUSINESS

Any and all information has been filled out to the best of my knowledge. The data filled out by me (THE TAXPAYER) is accurate and truthful.* *

Printed First, Last Name

Date of Submission

For Tax Prep *AshleyAletraArielChayraGabrielleJasmineNicolePorcheBritneishaShavershia

Save as Draft

THE NECESSARY DOCUMENTS?

IF DOCUMENTS ARE NOT UPLOADED THIS FORM WILL BE VOIDED!!!!!!!

CLIENT NON-PAYMENT/OFFSET CLAUSE:

EMPRESS FINANCIAL SERVICES TAKES PRIDE IN ASSISTING ALL CLIENTS WITH THEIR INDIVIDUAL TAX NEEDS, HOWEVER, WE UNDERSTAND SITUATIONS WILL ARISE IF YOU HAVE ANY OFFSETS BY THE IRS, STUDENT LOANS, OR CHILD SUPPORT YOU ARE STILL OBLIGATED TO PAY OUR COMPANY FEES ASSOCIATED WITH FILING YOUR TAX RETURN.

BY SIGNING THIS AGREEMENT YOU ACKNOWLEDGE THAT IF PAYMENT IS NOT MADE IN FULL WITHIN 30 DAYS LEGAL ACTION WILL BE SOUGHT TO RESOLVE PAYMENT.

THANKS FOR YOUR BUSINESS

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