New Client Information Form

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J. Scott Dick, CPA, PLLC
Certified Public Accountant
NEW CLIENT INFORMATION FORM
How did you hear about me?
Referred By:
PERSONAL CONTACT INFORMATION
Please Print
Full Name:______________________________________
Spouse: ______________________________________
Occupation: _____________________________________
Spouse Occupation: ____________________________
Address: Street: _____________________________________________________________________________________
City: _____________________________________
State: __________
Zip: ___ ___ ___ ___ ___
Home Phone: (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
Your E-mail:____________________________________
Cell Phone: (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
Work E-Mail: ___________________________________
Work Phone: (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
Spouse E-Mail: _________________________________
Primary contact person for tax-related matters?
Preferred PHONE and EMAIL to be used?
Best time to call?
Filing Status: Single _____
Head of Household _____
Married/Joint _____
Married/Separate ______
Your Date of Birth: _________ / ________ /_________
Spouse Date of Birth: _________ / ________ /_________
Your SS #:
___ ___ ___ - ___ ___ - ___ ___ ___ ___
Spouse SS#:
___ ___ ___ - ___ ___ - ___ ___ ___ ___
DEPENDENT INFORMATION
1. Full Name: _______________________________
4. Full Name: _______________________________
Date of Birth: _________ / ______ /___________
Date of Birth: _________ / ______ /___________
SS #:
___ ___ ___ - ___ ___ - ___ ___ ___ ___
SS #:
___ ___ ___ - ___ ___ - ___ ___ ___ ___
2. Full Name: _______________________________
5. Full Name: _______________________________
Date of Birth: _________ / ______ /___________
Date of Birth: _________ / ______ /___________
SS #:
___ ___ ___ - ___ ___ - ___ ___ ___ ___
SS #:
___ ___ ___ - ___ ___ - ___ ___ ___ ___
3 F ll N
3. Full Name: _______________________________
6 F ll N
6. Full Name: _______________________________
Date of Birth: _________ / ______ /___________
Date of Birth: _________ / ______ /___________
SS #:
___ ___ ___ - ___ ___ - ___ ___ ___ ___
SS #:
___ ___ ___ - ___ ___ - ___ ___ ___ ___
BUSINESS CLIENT INFORMATION
Company: ____________________________________________
EIN ___ ___ - ____ ____ ____ ____ ____ ____ ____
Business Address: Street: _______________________________________________________________________________
City: _________________________________________ State: __________ Zip: ___ ___ ___ ___ ___
Business Start Date: __________ /__________ /___________
Business Website: _________________________________________
Business Phone: (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
Business E-Mail: __________________________________________
Company Bookkeeper: _______________________________
Bookkeeper Contact Info: ____________________________________
Member/Partner: ____________________________
_____%
Social Security: ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Member/Partner: ____________________________
_____%
Social Security: ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Member/Partner: ____________________________
_____%
Social Security: ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Member/Partner: ____________________________
_____%
Social Security: ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Service(s) Requested:
Taxed as: Partnership _____
Corporation _____ S-Corp _____
Single Member LLC _____
Sole Proprietor _____
Nonprofit _____ Other _____
QuickBooks backup? YES _____ NO _______
QB Login name: ________________ QB Password: _______________
Are you interested in Remote Access options?
Yes _____
No _______
Notes: ___________________________________________________
GENERAL REMINDERS
Individuals and Businesses: please provide a complete copy (Federal, State, Local) of your prior year's tax return.
Businesses: please provide a copy of your Organizing Documents, referred to as your "Permanent File", including your Articles of Organization,
Official IRS Correspondence (EIN, S-Corp Election), and other initial business/employer registration filings (Fed, State, Local, Employment Tax
Registrations, etc.)
NOTES / COMMENTS
710 East Main Street
P:: (859) 433-1507
Lexington, KY 40502
F:: (502) 863-4639

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