Client Tax Information Sheet
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3Client Tax Information Sheet
Eva Smith & Associates, EA
PH510-889-8885
1290 B Street – Suite 114
FX 510-889-8765
Hayward, CA 94541
T
NOTE: New clients please fill in all boxes in top half of page – returning clients indicate only where there are changes.
TAXPAYER NAME:
SOC SEC NUMBER:
DATE OF BIRTH:
OCCUPATION:
DAYTIME PHONE:
FAX:
SPOUSE NAME:
SOC. SEC. NUMBER:
DATE OF BIRTH:
OCCUPATION:
DAYTIME PHONE:
FAX:
STREET ADDRESS:
CITY/STATE/ZIP:
HOME PHONE:
E-MAIL ADDRESS:
DEPENDENT NAME
DATE OF BIRTH
DEPENDENT’S
RELATIONSHIP
MONTHS
(First, Middle Initial, Last)
SOC. SEC. NUMBER
LIVED
IN YOUR
HOME
If any dependent child did not live with you, write child’s name here: ________________________
If another taxpayer can claim you or your spouse as a dependent, check this box.
CHECK ALL INCOME SOURCES YOU HAD IN 2009 - ENCLOSE DOCUMENTATION
Salary/Wages – W-2
SS/Railroad Retirement
Lottery/Gambling Winnings
Self-Employed/Business Income
Pension / Retirement Income
Interest – 1099-INT
Independent Contractor - 1099
IRA Distributions
Dividends – 1099-DIV
Commissions/Fees
Rental Property Income
Mutual Fund Distributions 1099
Cash Payments
Partnership/S-Corp – K-1
Municipal Bonds
Alimony Received
Estate/Trust – K-1
Farm Income
Unemployment $ __________
Military BAS/BAH $_______
Other Income (Enclose Details)
Tip Income
Did You Sell a Residence?
Installment Sale
Did You Sell Any Stocks/Bonds?
Did You Sell Other Real Estate?
Sell Any Business Assets?
(If yes, enclose 1099-B & cost info.)
(Enclose settlement statements.)
(Enclose sale and original cost info.)
IRA Contributions: Taxpayer $_____________
Spouse $_____________
Traditional
Roth
Traditional
Roth
SIMPLE/SEP/KEOGH Contributions: Taxpayer $
Spouse $
Alimony Paid $
Recipient:
SSN:
Federal Estimated Tax Payments $____________
Job-Related Moving Expenses
$____________
State Estimated Tax Payments
$____________
Lodging Expenses During Move $____________
State Tax Due Paid with 2006 Return $
Miles Traveled to New Home:
CHILD/DEPENDENT CARE EXPENSES (Match each provider to dependent.)
Dependent Cared For:
___________________________
Care Provider’s Name:
___________________________
Provider’s SSN/EIN: __________
Provider’s Address
___________________________
Amt Paid: $_________
Dependent Cared For:
___________________________
Care Provider’s Name:
___________________________
Provider’s SSN/EIN: __________
Provider’s Address
___________________________
Amt Paid: $_________
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