Form – Diverse Tax Services

Name *

Social Security Number *

Can You Be Claimed As A Dependent By Someome Else? *YESNO

Date Of Birth (D.O.B.)

Date Of Death ( If Applicable )

Phone# *

Job Title *

If You Are Disabled, Please Give The Date Disability Began

Email *

Address*

If you are filling *MARRIED FILING JOINT* Please Provide Your Spouse Information BELOW.

Spouse/First Name

Spouse/Last Name

Spouse/SS#

Can You Be Claimed As A Dependent By Someome Else? *YESNO

Date Of Birth (D.O.B.)

Date Of Death ( If Applicable )

Spouse/Phone Number

What is your JOB Title?

If You Are Disabled, Please Give The Date Disability Began

Spouse Email Address *

1.Do you owe the IRS? *YESNO

2.Do you owe a STUDENT LOAN? *YESNO

3.Do you owe CHILD SUPPORT? *YESNO

4.Did you have Healthcare.gov/Marketplace Insurance? *YESNO

5.Did you go to College in 2021? *YESNO

5B. If Yes Where?

5c. Identity Protection PIN (If Applicable)

6. Did your address change from last year's Tax Return? ? *YESNO

7. Are you claiming any dependent child(ren)? *YESNO

7B. The child(ren) you are claiming are they yours? *YESNO

7C. If NO how are you related?

7D. Where are the parent(s)?

7E. Are you the legal guardian? *YESNO

7F. Can someone else claim child(ren)? *YESNO

Can You Prove Your Right To Claim The Child(Ren) On Your Return? *YESNO

7I. If so what proof do you have?

How Do You Want Your Money *CHECKDIRECT DEPOSITCARD

NEED ( A ) BANK NAME, ( B ) ROUTING NUMBER ( C ) ACCOUNT NUMBER

Please enter dependents information

A. Dependent Full Name

A. Dependent SS#

A. Dependent D.O.B.

A. How many months lived at home with tax payer

B. Dependent Full Name

B. Dependent SS#

B. Dependent D.O.B.

B. How many months lived at home with tax payer

C. Dependent Full Name

C. Dependent SS#

C. Dependent D.O.B.

C. How many months lived at home with tax payer

D. Dependent Full Name

D. Dependent SS#

D. Dependent D.O.B.

D. How many months lived at home with tax payer

E. Dependent Full Name

E. Dependent SS#

E. Dependent D.O.B.

E. How many months lived at home with tax payer

8. Do you have a HOME BASED BUSINESS?YESNO

8B. If yes what type and/or name of said business?

9. Do you have a NON-W2 INCOME?YESNO

9B. If yes what type of income and monthly amount?

10. ) DID YOU RECEIVE UNEMPLOYMENT LAST YEAR?YESNO

Please Upload All Applicable Documents Below.

NOTE: the red X indicates your file has been uploaded successfully.

1. VALID PICTURE I.D./DL

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2. PICTURE - SOCIAL SECURITY CARD

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3. PICTURE - SOCIAL SECURITY CARD

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*Supporting Documentation/Explanation if filing Head of House Hold: TP can provide proof if requested by IRS.*

1. LEASE AGREEMENT PICTURE

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2. MORTGAGE STATEMENT PICTURE

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3. UTILITY STATEMENT PICTURE

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4. OTHER PICTURE

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Income

1A. W-2's PICTURE(S)

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1B. W-2's PICTURE(S)

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1C. W-2's PICTURE(S)

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1D. W-2's PICTURE(S)

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2A. 1099's PICTURE(S)

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2B. 1099's PICTURE(S)

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2C. 1099's PICTURE(S)

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3. SSA (Social Security Benefits) PICTURE

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4. UNEMPLOYMENT INCOME PICTURE

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5. SELF EMPLOYMENT INCOME (business expenses/receipts & documentation) PICTURE

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6. COLLEGE (1098-T) FORM *INCOME*

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7. ALL OTHER FORMS OF INCOME (Any & All Other Tax Documentation)

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Printed Name of Taxpayer

Date

Printed Name of Joint Taxpayer

Date

Fill. Upload. Submit.

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