CUSTOMER DATA SHEET

Please PRINT your personal information to assist us in the preparation of your income tax return

REFFERED BY ( NAME / PHONE )

Full Name

Mailing Address

Birth Date

Drivers License

Contact

Yes

No

Full Name

Birth Date

Drivers License

Contact

Dependent 1

Dependent 2

Dependent 3

Dependent 4

Dependent 5

Dependent 6

Did you have minimum essential health coverage for the full year?

Did you have insurance purchased through the market place?

Did your dependent(s) minimum essential health coverage for the full year?

Did your dependent(s) have insurance purchased through the market place?

Yes

No

Yes

No

Yes

No

No

Yes