Filing Status (only check one)
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Single
Married Filing Jointly
Married Filing Separately
Head of Household
Qualifying Widow
Taxpayer first name and middle initial
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Taxpayer last name
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Taxpayer date of birth
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Taxpayer social security #
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If joint return, spouse first name and middle initial
Spouse last name
Spouse date of birth
Spouse social security #
Home address (number and street)
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Apt #
City
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State
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Zip Code
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Taxpayer phone number
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Taxpayer email address
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Spouse phone number
Spouse email address
Taxpayer driver's license #
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Taxpayer driver's license issue state
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Taxpayer driver's license issue date
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Taxpayer driver's license expiration date
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Taxpayer job title
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Last year, were you:
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Full-time student
Totally and permanently disabled
Legally blind
None of the above
Spouse driver's license #
Spouse driver's license issue state
Spouse driver's license issue date
Spouse driver's license expiration date
Spouse job title
Spouse date of death (widowed only)
Last year, was your spouse:
Full-time student
Totally and permanently disabled
Legally Blind
None of the above
Can anyone claim your or your spouse as a dependent?
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Yes
No
Unsure
List your dependents
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If no dependent's please type NO
Dependent #1 First Name and M.I.
Dependent #1 Last Name
Dependent #1 DOB
Dependent #1 SSN
Dependent #1 Relationship to you
Dependent #1 Number of months lived with you
Was Dependent #1 a full-time student last year (yes/no)
Is Dependent #1 totally or permanently disabled (yes/no)
Dependent #2 First Name and M.I.
Dependent #2 Last Name
Dependent #2 DOB
Dependent #2 SSN
Dependent #2 Relationship to you
Dependent #2 Number of months lived with you
Was Dependent #2 a full-time student last year (yes/no)
Is Dependent #2 totally or permanently disabled (yes/no)
Dependent #3 First Name and M.I.
Dependent #3 Last Name
Dependent #3 DOB
Dependent #3 SSN
Dependent #3 Relationship to you
Dependent #3 Number of months lived with you
Was Dependent #3 a full-time student last year (yes/no)
Is Dependent #3 totally or permanently disabled (yes/no)
Business Name
Business EIN#
Business address (number and street)
Business city
Business state
Business zip code
Is your business a Sole Proprietorship, LLC, S Corp or C Corp?
Car Make
Car Model
Did you file a tax return for 2024?
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Yes
No
Did you receive a refund on your 2024 tax return?
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Yes
No
What was the amount of the refund your received for your 2023 tax return?
Did you owe taxes in 2024?
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Yes
No
If you owed taxes in 2024, what was the amount?
Do you have a debt with the IRS, Child Support or any other Government Agency (yes/no)?
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Did you or your spouse attend a college or university full-time in 2024 (yes/no)?
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Were you or your spouse a resident of another state or earned income in another state (yes/no)?
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Did you have health insurance last year (yes/no)?
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Did you and or your dependents have Obamacare (Healthcare Marketplace yes/no)?
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Did you use a personal vehicle for work in 2024?
Yes
No
If yes, did you receive reimbursement for the use of your personal vehicle?
Yes
No
Are you interested in Business Funding (yes/no)?
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Bank information for refund purposes
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Account Type (checking, savings)
Routing Number
Re-enter Routing Number
Account Number
Re-enter Account Number
Check all that apply that you will upload for review
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Business Tax Questionnaire
W2
1099
Buy or Sold a home (HUD or Closing Form)
Form 1098 for refinanced home
Form 1098 Rental Mortgage Interest Statement
Form 1098 Primary Mortgage Interest Statement
Form 1098-T Tuition Statement
Childcare Provider Statement
Form SSA-1099 SS Income
Form 1099-R Pension or Retirement
Form 1099-G Received Unemployment
1099-NEC Non-Employee Compensation
Form 1099-INT Sold Stocks or Bonds
Form 1099-INT Received Interest (ex. bank or insurance interest)
Form 1099-R IRA Withdrawal
Form 1099-DIV Received Dividends
Charitable Donations
Moving Expenses
Alimony
Tips/Other Income
Medical Expenses (paid out of pocket)
Form W2G Lottery/Gambling
Out of Pocket Work Expenses
Home Office Expenses
Career Educational Expenses
Cash Payments for Business
Previous Year Tax Return (new clients only)
How many W2's are you providing?
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Did you work in a different state than you reside
Yes
NO
Did you have health insurance for 2024?
YES
NO
What type of insurance did you have?
Private insurance from my job
Marketplace (Obamacare) Insurance
Covered by another family members insurance
No Insurance
How many 1099's are you providing?
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Childcare Provider Information (Required for each provider)
Provider's Name
Provider's SS or EIN
Provider's Address (number and street)
City
State
Zip Code
Provider's Phone Number
Provider's Name
Provider's SS or EIN
Provider's Address (number and street)
City
State
Zip Code
Provider's Phone Number
Provider's Name
Provider's SS or EIN
Provider's Address (number and street)
City
State
Zip Code
Provider's Phone Number
Who referred you to The Proxy Place?
What is your preferred method of communication?
Text
Call
E-mail
The Proxy Place, LLC is not responsible if taxpayer provides us with incorrect information (i.e., social security numbers for self, spouse, or dependents, last names, birth dates, etc.). This may delay your refund. Customer Initials
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The Proxy Place, LLC is not responsible for any IRS audits. All information obtained from the taxpayer and/or spouse must be presentable if the IRS audits your tax return. Customer Initials
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The Proxy Place, LLC is not responsible for any incorrect tax figures provided by the taxpayer and/or spouse. If your tax figures change you will need to do an Amendment. Prices vary. Customer Initials
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If you have any federal or government debts (ex. school loans, child support, etc.) there is a chance that your refund will be applied towards your debt. Customer Initials
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The Proxy Place, LLC is not responsible for any discussions or changes the IRS or bank may make on disbursement dates, filing status or any other required information from the IRS. Customer Initials
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The Proxy Place, LLC is not responsible for any IRS glitch problems or IRS problems that may cause a delay in your tax refund. We DO NOT reimburse any bank fees in the event of this occurrence. Customer Initials
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The Proxy Place, LLC provides the taxpayer with ONE complimentary copy of their tax return. Should you need any additional copies, there is a $25 fee per copy (federal and state included). The information contained in this office or on this website is of a general nature. It should not be used for legal advice. Customer Initials
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You will be invoiced the fee when your taxes are totally completed at the end of our services. We do not accept payment from your tax returns. Customer Initials
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I/we understand the terms and conditions and that all information contained in this income tax return was obtained from the taxpayer or spouse. Please sign your name in the box below.
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