COOLIDGE

Client Interview Form

Full Name *

Address

Street Address

City *

State *

Country *

Postal Code *

Phone *

3. Tax Preparer *

4. DO YOU HAVE AN ID.ME ACCOUNT? *

5. HAVE YOU RECEIVED ANY LETTERS FROM THE IRS OR STATE OF MICHIGAN? *

6. List ALL sources of income (including SSI benefits, W-2’s, self-employment, Unemployment Income or others) and how are you supporting yourself and your dependent(s) Unemployment? *

7. Do you receive state assistance? Yes No If yes, write down the type of assistance and the amount you receive each month. Example: Cash assistance, Food assistance or housing assistance? How much do you pay? *

8. Indicate the total number of people living in your household: *

9. HAVE YOU RECEIVED NOTIFICATION FROM THE IRS THAT ANY CREDITS HAS BEEN DISALLOWED? *

10. Did you or any dependents attend any educational institution that may qualify for the American Opportunity Credit or the Lifetime Learning Credit? *

11. Did you pay for student loans and did you receive form 1098 E (Student Loan Interest paid) *

12. Do you have any garnishments such as IRS debt, child support, student loans, medical bills. MIWAM state that you owe for overpayment? *

13a. Do you own or rent? *

Own

Rent

13b. If you rent, what do you pay per month? If you own, how much did you pay for property taxes? *

14. ⁠Are you currently receiving Section 8 housing assistance? *

15. Did you have any gambling winnings or win money from the lottery, including platforms like FanDuel, BetMGM, or similar? *

16. Did you withdraw funds early from your retirement accounts? *

17. Do you have an IRS Identity Protection (IP) PIN? *

18. Did you have health insurance through the Health Insurance Marketplace and/or are you expecting to receive a Form 1095-A for this tax year? *

19. Is ALL the information you provided accurate and complete to the best of your knowledge? *

20. Do you understand that you are responsible for providing truthful and correct documentation? *

21. Did you earn any overtime or tips? *

22. If yes, how much?

I agree to terms & conditions provided by the company. I confirm everything stated in the form is the truth to the best of my knowledge.

Signature *

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