Date __________________

NEW CLIENT QUESTIONNAIRE

Name: ___________ Social Security #

Date of Birth: ___________________

Spouse’s Name: ___________________________ Social Security # ____________________________

Date of Birth: ___________________

Address: ____________________________________________________________________________

City/State/Zip Code: __________________________________________________________________

Phone: _____________________ Beeper/Cell: (His) _________________ (Hers) _________________

Email: (His)_______________________________ Email: (Hers)___________________________

Occupation: ______________________________________ Office # ____________________________

Spouse’s Occupation: ______________________________ Office # ___________________________

No. of Dependents: _____________

Dependent Information

Name DOB Soc. Security # Relationship

_________________________________ _________ _______________________ ______________

_________________________________ _________ _______________________ ______________ (Please List Additional Dependents on Separate Sheet)

Referred By: _____________________________________

I/We, __________________________________ (taxpayer(s), acknowledge that all information provided here for the preparation and completion of my Federal and State taxes is complete and accurate to the best of my knowledge. I/We also understand & agree that a 50% deposit is due when work is accepted and that payment in full is due when work is completed.

I/We have read all the information furnished and agree to all terms and conditions.

____________________________________ ______________________________

Taxpayer’s Signature Social Security #