Part 1 Basic Information: PLEASE COMPLETE & SIGN

 Do you have health insurance  Y__  N___
 Did you purchase thru marketplace Y___ N___     SELF OR FAMILY
                    
    Primary: Occupation________________________________
    Name _____________________________ Date of Birth ______________
    Social Security____________________________
    Mailing Address _______________________ City/State _______________________
    Zip_________________
    Primary Phone _____________________________ Cell _____________________
    Email_________________
    Spouse: Occupation_________________________________________________________
    Name _____________________________ Date of Birth ______________
    Social Security___________________________
    Mailing Address ________________________ City/State _______________________
    Zip_________________
    Primary Phone _____________________________ Cell _____________________
    Email_________________
    Filing Status:     Single     Married filing joint __   Married Filing Separate__ Head of Household____
    If married filing separate please give spouse Name and SOCIAL _________________________________
    ___________________________________________________________________________________
    Married filing separate: Did spouse live with you: yes No
    Dependant Information: If you are a prior client please indicate if you are claiming same dependants
    First Name& Last Name                Social Security                         Date of Birth                            Lived with you-Total months this year 6/12
    1. ________________________ ______________________ _____________      Yes   No ___________
    2. ________________________ ______________________ _______________  Yes   No ___________
    3. ________________________ ______________________ _______________  Yes   No____________
    4. ________________________ ______________________ _______________  Yes   No____________
    5. ________________________ ______________________ _______________  Yes   No____________
    I HEREBY ACKNOWLEDGE THE INFORMATION GIVEN ON THIS FORM IS USED SOLELY FOR THE
    AID IN; INCOME TAX PREPARATION. UNDER PENALTY OF PERJURY, I UNDERSTAND THIS
    DECLARATION WILL BECOME PART OF THIS RETURN. I UNDERSTAND THAT IF MY RETURN IS
    REJECTED I MUST RESIGN PAPERWORK AND A FEE MAY BE CHARGED TO RETRANSMIT MY
    RETURN. I UNDERSTAND THIS INFORMATION WILL BE PROVIDED TO INTERNAL REVENUE
    SERVICE, SOLELY FOR THE PURPOSE OF TAX PREPARATION. I ACKNOWLEDGE THE
    INFORMATION IS TRUE AND CORRECT. INFORMATION I HAVE GIVEN VERBALLY TO THE
    BRADLEY TAX SERVICE IS IN CORRESPONDENCE TO DOCUMENTATION I POSSES AND WILL
    SUPPORT. I ACKNOWLEDGE THAT I HAVE GIVEN ALL W'2 DOCUMENTS & INCOME
    STATEMENTS, DEDUCTION FORMS, MORTGAGE INFORMATION (IF APPLICABLE), RETIREMENT
    INCOME STATEMENTS(IF APPLICABLE) AND ALL OTHER FORMS NEEDED TO BRADLEY TAX
    SERVICE TO PERFORM THE DUTY OF TAX PREPARATION FOR THE CURRENT YEAR OF______.

    Signature _________________________ Date _______________

    Signature __________________________ Date _______________

    Direct Monies to:        Direct Deposit(same account prior yr.)      Please call for new account info
    Rapid direct (acct info Routing# _________________Account#___________________)this takes my fee
    out automatically  OR  Mail box address ______________________ _______________
PART 2
PLEASE READ AND SIGN
 

I____________________________________ Acknowledge that Accurate Taxx has prepared my  taxes
and I to my knowledge owe no federal debts such as :
  •     Outstanding Child Support rearages
  •     Student Loans
  •     Federal Government loans
  • or any other offsets.
       In such case that I have a debt that I am unaware of and my taxes are Intercepted, I understand  
    that I am still liable to pay for the fees charged by Accurate Taxx and the processing fee of $68.00
    paid to the processing center.  I also understand that I will have 30 days from the time I am notified
    from IRS or Accurate Taxx to submit payment.


Primary Signature_______________________________  Date_________________________

Spouse Signature_______________________________  Date_________________________