CLIENT INTAKE FORM

MIDWEST SOUTH SERVICES

WELCOME TO MIDWEST SOUTH SERVICES!

Our Client Intake Form is the key to unlocking personalized tax solutions. This essential document empowers us to comprehensively assess your tax needs, financial goals, and unique circumstances. By providing us with the details in this form, you're taking the first step towards a seamless tax experience. We'll use this information to craft a tailored strategy that maximizes your returns and minimizes your stress. Your financial well-being is our priority, and it all begins with your responses on the Client Intake Form. Let's work together to achieve your tax success!

We will prepare your 2023 federal and requested state income tax returns from information that you will furnish us. We will not audit or otherwise verify the data you submit, although it may be necessary to ask you for clarification of some of the information. We will furnish you with questionnaires or worksheets to guide you in gathering the necessary information. Your use of such forms will assist in keeping pertinent information from being overlooked.

This letter is to confirm and specify the terms of our engagement with you and to clarify the nature and extent of the services we will provide. In order to ensure an understanding of our mutual responsibilities, we ask all clients for whom returns are prepared to confirm the following arrangements.

It is your responsibility to provide all the information required for the preparation of complete and accurate returns. You should retain all the documents, canceled checks and other data that form the basis of income and deductions. These may be necessary to prove the accuracy and completeness of the returns to a taxing authority. You have the final responsibility for the income tax returns, and, therefore, you should review them carefully before you sign them.

Our work in connection with the preparation of your income tax returns does not include any procedures designed to discover defalcations or other irregularities, should any exist. We will render such accounting and bookkeeping assistance as determined to be necessary for preparation of the income tax returns.

We will use professional judgment in resolving questions where the tax law is unclear, or where there may be conflicts between the taxing authorities' interpretations of the law and other supportable positions. Unless otherwise instructed by you, we will resolve such questions in your favor whenever possible.

The law provides various penalties that may be imposed when taxpayers understate their tax liability. If you would like information on the amount or the circumstances of these penalties, please contact us. Your returns may be selected for review by the taxing authorities. Any proposed adjustments by the examining agent are subject to certain rights of appeal. In the event of such government tax examination, we will be available upon request to represent you and will render additional invoices for the time and expenses incurred.

Our fee for these services will be based upon the amount of time required at standard billing rates plus out-ofpocket expenses. All invoices are due and payable upon presentation. If the foregoing fairly sets forth your understanding, please sign the enclosed copy of this letter in the space indicated and return it to our office. However, if there are other tax returns you expect us to prepare, such as gift or property tax returns, please inform us by noting so just below your signature at the end of the returned copy of this letter.

We want to express our appreciation for this opportunity to work with you.

Signature *

Clear

Date Signed *

For the purposes of this consent form, “we,” “us,” and “our” mean.

Federal law requires this consent form to be provided to you. Unless authorized by law, we cannot use your tax return information for purposes other than the preparation and filing of your tax return without your consent. You are not required to complete this form to engage in our tax return preparation services. If we obtain your signature on this form by conditioning our tax preparation services on your consent, your consent will not be valid. Your consent is valid for the amount of time that you specify. If you do not specify the duration of your consent, your consent is valid for one year from the date of signature. If you do not consent, you may still have your tax return prepared and electronically filed by us for a fee. For your convenience, we have entered into an arrangement with third parties to provide qualifying taxpayers with the opportunity to apply for an Electronic Refund Disbursement Service and/or Loan product. To determine whether these products may be available to you, we will need to use your tax return information in order to calculate the amount of your anticipated refund. If you would like us to use your tax return information to determine whether these products may be available to you while we are preparing your return, please sign and date this consent to the use of your tax return information.

By signing below, you authorize us to use the information you provide to us during the preparation of your 2023 tax return to determine whether to present you with the opportunity to apply for these products and services.

If you believe your tax return information has been disclosed or used improperly in a manner unauthorized by law or without your permission, you may contact the Treasury Inspector General for Tax Administration (TIGTA) by telephone at 1-800-366-4484, or by e-mail at [email protected]

Tax Payer Signature *

Clear

Spouse Signature

Clear

Date Signed *

How many people live with you? Please list the number of adults and children. *

Did anyone help support you through the year? If so, please list how much. *

In the case of audit can you prove financial responsibility and residency for any of the Dependents being claimed? Which document(s) can you provide? (i.e. copy of lease, medical records, school records, food stamps or benefit statements) *

Are any of the dependents listed on this return not your biological son or daughter? If yes, why are the parents not claiming the child? (Please explain and list the child’s name(s) if more than one listed on the return). *

Has any credits been disallowed in a previous year? Please explain. *

Are any of the dependents being claimed disabled? Please list the nature of the disability. Does the dependent receive Social Security benefits? If so, what type?

By signing below, I hereby certify the information given above is true and correct to the best of my knowledge. I have been informed if the information provided to preparer is incorrect the audit, fines, and penalties. associated.

Signature

Clear

Date Signed

Taxpayer Name

Monthly Income

Property Taxes

Amount You Paid
Actual Expenses

Rent

Amount You Paid
Actual Expenses

Mortgage Interest Expense

Amount You Paid
Actual Expenses

Utilities

Amount You Paid
Actual Expenses

Food Consumed in Home

Amount You Paid
Actual Expenses

Other Expenses

Amount You Paid
Actual Expenses

Total

Amount You Paid
Actual Expenses

Please do not count any money received under any governmental/public assistance/welfare/SNAP (food stamps) in the amount that you paid. But include costs paid with the public assistance in the total cost.

Taxpayer has provided all answers to the above questions to be true and correct to the best of the taxpayer’s knowledge. Taxpayer has been informed that claiming a dependent for HOH or other can result in an audit, fines, and penalties if information provided to a prepare is incorrect.

Signature

Clear

Date Signed

Taxpayer Name *

Business Name (if any)

Business Address

Date Business Started

Business EIN

Total Sales & Services

1099 Income

Advertising
Auto Expenses
Commissions
Depletion
Mortgage Interest
Rent (Vehicles)
Rent (Machinery)
Office Expenses
Repairs
Supplies
Taxes & Licenses
Travel
Meals
Utilities
Legal/Professionals
Other:
TOTAL EXPENSES

If you do not have any business expenses, please explain why?

Taxpayer has provided all answers to the above questions to be true and correct to the best of the taxpayer’s knowledge.

Signature

Clear

Date Signed

Dependent(s) Information

Dependent

Relationship

Amount Paid

.

Dependent

Relationship

Amount Paid

Childcare Provider(s) Information

Daycare/Nanny

Relationship

Amount Paid

SSN/EIN/ITIN

Phone Number

Address

.

Daycare/Nanny

Relationship

Amount Paid

SSN/EIN/ITIN

Phone Number

Address

By signing below I certify all information is true, valid, and to the best of my knowledge. I accept full responsibility of the statements mentioned above. Any and all disputes regarding this matter shall be forwarded to me with the information found on my tax returns forms.

Signature

Clear

Date Signed

I , (Full Name) was a student during the 2023 school year and attended (Name of the Institution) . I certify that all the information found on this form is true and to the best of my knowledge. I understand that it is my responsibility to have all valid documents and or receipts, as required to claim any credit for attending a college or university. Below is a recap of all information, status, and expenses I have encountered.

Full Name

Name of the Institution

My Scholar Status:

Full-Time

Part-Time

Expenses
Tuition
Room & Boarding
Books
Supplies (on campus)
Supplies (off-campus)
Other expenses
Total

By signing below I certify all information is true, valid, and to the best of my knowledge. I accept full responsibility of the statements mentioned above. Any and all disputes regarding this matter shall be forwarded to me with the information found on my tax returns forms.

Signature

Clear

Date Signed

Taxpayer Name

MEDICAL EXPENSES

Medical & Dental
Medical Premiums Paid
Long Term Care Premiums
Prescription Drugs & Medicine
Medical Miles Driven Jan1-Jun 30
Medial Miles Driven July1-Dec30

INTEREST EXPENSES

Home Mortgage Interest
Refinancing Points Paid
Investment Income

CONTRIBUTIONS

Cash Contributions
Non-Cash Contributions
volunteer Mileage Driven

TAX EXPENSES

State & Local Income Taxes
Prior year Income Taxes Paid
Real Estate Taxes
Personal Property Taxes
Qualified New Vehicle Taxes
Additional State /Local Taxes