Certified Tax Preparer Self-Assisted Tax Return Questionnaire Please Fill Out This Entire Questionnaire

Transcription

1 2012 Certified Tax Preparer Self-Assisted Tax Return Questionnaire Please Fill Out This Entire Questionnaire Taxpayer, Spouse, and Dependent Information 1. Your Filing Status Single Married Filing Jointly Married Filing Separately Head of Household Widow(er) Taxpayer Birth Date Spouse Birth Date 2. Are you filing with an ITIN (and not with a SSN)? Yes No A) Number of exemptions Include "1" for yourself unless you are claimed by your parents and "1" for your spouse and "1" for each dependent (max 9). B) Can you be claimed as a dependent on another return? Yes No 3. C) Can the spouse be claimed as a dependent on another return? Yes No A) Amount paid for child care expenses $ B) Number of children cared for C) Spouse Disability or School Attendance* Enter the number of children included in line 2(A) above, that are under age 17 A) Number of Children under age 19 at the end of 2010 B)Number of Children over the age of 18 and under the age of 24 (age 19 to 23) that are full time students C)Number of Children not included in A or B above that are Disabled Total number of eligible children $ *Spouse Diablity or School Attendance Your spouse was a student if he/she was enrolled as a full-time student at a school during any 5 months of A school does not include an on-the-job training course, correspondence school, or a school offering courses only through the Internet. Your spouse was disabled if he or she was not capable of self-care. For each month or part of a month a spouse was a student or was disabled, his or her earned income is considered to be $250 ($500 per month if more than one qualifying person was cared for). For example, if a spouse meets the requirements above to be classified as a student and attended school for 9 months in 2010 the earned income placed on line 3C would be $2250 for a single child or $4500 for two or more children. Last Name: SSN Last 4: Page 1 of 9

2 Income 6. A) Taxpayer (Enter the Wages and Federal Tax Withheld as reported on W2's) Wages $ Withholding $ Wages $ Withholding $ Wages $ Withholding $ B) Spouse (Enter the Wages and Federal Tax Withheld as reported on W2's) Wages $ Withholding $ Wages $ Withholding $ Wages $ Withholding $ 8. Schedule C - Business Income/Loss A) Taxpayer Amount $ B) Spouse Amount $ 10. Unemployment Compensation 11. A) Taxpayer Amount Gross Amount $ B) Spouse Amount Gross Amount $ Social Security Income $ Withholding $ Withholding $ Last Name: SSN Last 4: Page 2 of 9

3 22. Exemptions, Deductions, Credits and Other Taxes Check the box if you are Itemizing Deductions A) Medical Expenses $ B) State Income or State Sales Tax Paid $ C) Real Estate Tax $ D) New Motor Vehicle Deduction (2010 purchases paid in 2011) Total Taxes Paid on Vehicle(s) $ Vehicle(s) Purchase Price $ Taxes Paid on First $49,500 of Purchase Price $ E) Interest Paid $ F) Gifts to Charity $ G) Job Expenses $ Include Form Employee Business Expenses H) Other Miscellaneous Deductions $ 27. Include Form Non cash Charitable Contributions Education Credits A) American Opportunity Credit qualified expenses $ 40. B) Lifetime Learning qualified expenses $ State Returns Resident State Non-Resident State Last Name: SSN Last 4: Page 3 of 9

4 Taxpayer Information Full Name Social Security Number Occupation Daytime Phone Evening Phone Cell Phone Address Mailing Address County School District Spouse Information Full Name Social Security Number Occupation Daytime Phone Evening Phone Cell Phone Address Taxpayer Detail Is the taxpayer blind? Is the taxpayer active-duty military? Was the taxpayer s main home, and the taxpayer s spouse if filing jointly, in the U.S. for more than half of the year? Was the taxpayer a nonresident for any part of the year 2011? Yes No Last Name: SSN Last 4: Page 4 of 9

5 Dependent Information Full Name SSN Months in Home Date of Birth Relation Other Disabled Please answer the following questions to the best of your knowledge: Yes No Do you own a home? Did you pay any childcare expenses? Do you have any children in college? Are you self-employed? Do you have any delinquent child support? Alimony? Student Loans? Back taxes? All children are unmarried? Married children, can be claimed as the taxpayer s dependent, and is not filing a joint return (except to claim a refund)? Did the children live with the taxpayer in the U.S. for more than half of the year? Could another person qualify to claim this child? If the tiebreaker rules apply, would the child be treated as the taxpayer s qualifying child? *If the children are not the taxpayer s son or daughter, what documents does the taxpayer have that provies their relationship? Last Name: SSN Last 4: Page 5 of 9

6 ADMINISTRATIVE SERVICES COMPANY OF AMERICA, LLC ( ASCA ) CONSENT TO DISCLOSURE OF TAX RETURN INFORMATION Federal law requires this consent form be provided to you. Unless authorized by law, we cannot disclose, without your consent, your tax return information to third parties for purposes other than the preparation and filing of your tax return. If you consent to the disclosure of your tax return information, Federal law may not protect your tax return information from further use or distribution. You are not required to complete this form. Because our ability to disclose your tax return information to another tax return preparer affects the service that we provide to you and its cost, we may decline to provide you with service or change the terms of service that we provide to you if you do not sign this form. If you agree to the disclosure of your tax return information, 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. In order to process your return, we must disclose all of your 2011 tax return information to another tax professional in connection with the preparation of your tax return, as well as VBS Franchising, LLC ( VBS ), any franchisee of VBS, any affiliate of ASCA or VBS, or any person or any entity operating as a third party data collection contractor working on behalf of such entities. You have indicated that you are interested in obtaining and applying for a Refund Loan, Refund Transfer, Refund Deposit, and related card services and banking services. These products are made available through arrangements that we have with financial institutions and their partners. To apply for and obtain any of these products or services, we must forward your information to these companies and/or their affiliates. If you check the boxes below, you authorize ASCA to disclose your 2011 Tax Return for the designated purpose. You may direct a more limited disclosure of your tax return information. Insert a checkmark in the corresponding box if you consent to the disclosure described. I authorize ASCA to disclose my entire 2011 Tax Return to VBS, any VBS franchisee, any person or entity operating as a third party data collection point on behalf of either ASCA, VBS, or any VBS franchisee, in order to provide me with certain products and services in the future. I authorize ASCA to disclose my entire 2011 Tax Return to determine the availability of bank accounts, loan products, card services, and related banking services from a number of different providers, including but not limited to, Santa Barbara Tax Product Group ( SBTPG ). I authorize ASCA to disclose my entire 2010 Tax Return to ensure that any bank products, loan products, card services, and related banking services that I obtain or apply for can be issued, processed, underwritten, and serviced. The foregoing activities and related services may be performed by a number of different providers, including but not limited to, SBTPG. Taxpayer Signature: Date: Taxpayer Name (print): Taxpayer Spouse Signature: Date: Taxpayer Spouse Name (print): 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 , or by at complaints@tigta.treas.gov. CONSENT TO DISCLOSE Document: ASCA 2011 Page 1 of 1 Last Name: SSN Last 4: Page 6 of 9

7 ADMINISTRATIVE SERVICES COMPANY OF AMERICA, LLC ( ASCA ) CONSENT TO USE OF TAX RETURN INFORMATION Federal law requires this consent form be provided to you. Unless authorized by law, we cannot use, without your consent, your tax return information for purposes other than the preparation and filing of your tax return. You are not required to complete this form. If we obtain your signature on this form by conditioning our services on your consent, your consent will not be valid. Your consent is valid for the amount of the time that you specify. If you do not specify the duration of your consent, your consent is valid for one year. For your convenience, we have entered into arrangements with certain financial institutions and their partners regarding the provision of loan products, permanent bank accounts, card services, and related banking services. To determine whether these services may be of interest to you, we will need to use your tax return information. If you sign this form and check the boxes below, you authorize ASCA to use your 2011 Tax Return for the designated purpose. You may direct a more limited use of your tax return information. Insert a checkmark in the corresponding box if you consent to the use described. I authorize ASCA to use my entire 2011 Tax Return to ensure that my taxes are adequately processed. The foregoing activity may be performed by one of the following companies and/or affiliates: VBS, any VBS franchisee, another tax professional, or any person or entity operating as a third party data collection point on behalf of either ASCA, VBS, or any VBS franchisee, in order to provide me with certain products and services in the future. I authorize ASCA to use my entire 2011 Tax Return to determine the availability of bank accounts, loan products, card services, and related banking services from a number of different providers, including but not limited, to Santa Barbara Tax Product Group ( SBTPG ). I authorize ASCA to use my entire 2011 Tax Return to ensure that any bank products, loan products, card services, and related banking services that I obtain or apply for can be issued, processed, underwritten, and serviced. The foregoing activities and related services may be performed by a number of different providers, including but not limited to, SBTPG. Taxpayer Signature: Date: Taxpayer Name (print): Taxpayer Spouse Signature: Date: Taxpayer Spouse Name (print): 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 , or by at complaints@tigta.treas.gov. CONSENT TO USE Document: ASCA 2011 Page 1 of 1 Last Name: SSN Last 4: Page 7 of 9

8 ADMINISTRATIVE SERVICES COMPANY OF AMERICA TAX RETURN PREPARER DISCLOSURE ACKNOWLEDGEMENT This Tax Return Preparer Disclosure Acknowledgement ( Disclosure ) is provided on behalf of Administrative Services Company of America, LLC ( we, us, and our ). This Disclosure Form describes the various business entities and their roles in the preparation and processing of income tax returns for our present and former customers ( you and your ). Our Collection of Taxpayer Information through Independent Contractors We collect nonpublic personal information about you on applications, other forms, and information about your transactions with us, our affiliates, or others. This information is initially collected with your permission from third party, data collection contractors ( Contractors ), such as insurance agencies and similar businesses. These Contractors are not affiliated with us or our affiliates, nor do they have the right to act on our behalf. Contractors do not prepare tax returns nor do they render any tax advice or exercise any discretion or independent judgment with regard to your tax position. Contractors merely input client tax information into the data fields of the tax preparation software and exercise judgment regarding which data fields to use. Contactors are STRICTLY PROHIBTED from: Rendering any tax advice or exercising any discretion or independent judgment with regard to tax positions; Preparing any IRS tax form; Creating taxpayer supporting documents or schedules; Assuming primary responsibility for preparing and filing any tax returns; Collecting fees from tax payer clients, other than obtaining authorization from tax payer clients for us to (a) deduct fees from refund or (2) charge the client s credit card for such fees; Electronic Return Originator IRS Revenue Procedure defines an Electronic Return Originator (or ERO ) as the party that originates the electronic submission of tax returns. Pursuant to IRS Publication 3112, we require ERO s to have an Electronic Filing Identification Number ( EFIN ) for every Contractor location whereby taxpayer data is collected. ERO s then forward the taxpayer data to us for processing, preparation, and filing on their EFIN for that specific Contractor location. Below, you will find the contact information for the ERO who originated your tax return: (To be filled in out by ERO or Contractors):. You may also contact the Intermediate Service Provider (contact information below) with questions regarding the ERO who originated your return. Intermediate Service Provider IRS Revenue Procedure defines an Intermediate Service Provider as the party that receives tax return information from an ERO (or from a taxpayer or tax exempt organization that files electronically using a personal computer, modem or the Internet, and commercial tax preparation software), processes the return information, and either forwards the information to a Transmitter, or sends the information back to the ERO (or taxpayer or taxexempt organization). We provide processing, tax preparation, e-filing, and refund fulfillment services ( Services ) for ERO s who work with Contractors, such as insurance agencies and similar businesses, to collect taxpayer data and information. Contractors forward the taxpayer data and information to us for processing and preparation of the tax returns on behalf of the ERO s. After we have completed the Services, we forward the tax return to the Transmitter (defined below) for transmitting to the IRS. Due to the nature of the business relationship and the Services provided, we serve as an Intermediate Service Provider in the preparation of your tax return. Our contact information is as follows: Administrative Services Company of America, LLC; 1055 St. Paul Place, Cincinnati, Ohio 45202; Attn: Tax Division; Phone (513) ; compliance@ascaservices.com Last Name: SSN Last 4: Page 8 of 9

9 Tax Return Preparer IRS Circular 230, Section 7701(a)(36) defines a Tax Return Preparer as any person who [1] prepares [2] for compensation, or who employs one or more persons to prepare for compensation, [3] any return of tax imposed by this title or any claim for refund of tax imposed by this title. For purposes of the preceding sentence, the preparation of a substantial portion of a return or claim for refund shall be treated as if it were the preparation of such return or claim for refund. In addition to being the Intermediate Service Provider, we are the Tax Return Preparer for your tax return. Any questions pertaining to the amount and character of entries on the tax returns or the sufficiency of the information to prepare the return should be addressed to us. We do not issue refunds on tax preparation fees under any circumstances. Our Refund policy is as follows: If your tax return was improperly filed and was the result of our error, we will amend the return at no additional charge. All customers are given the option of purchasing insurance to protect against the possibility of tax preparer error. Therefore, we do not reimburse customers for tax penalties or interest under any circumstances. Our contact information is as follows: Administrative Services Company of America, LLC; 1055 St. Paul Place, Cincinnati, Ohio 45202; Attn: Tax Division; Phone (513) ; compliance@ascaservices.com Transmitter IRS Revenue Procedure defines a Transmitter as the party that transmits electronic return information directly to the Service. Below, you will find the contact information for the Transmitter: Petz Enterprises, Inc.; 7575 W. Linne Road; Tracey, CA 95304; (800) By signing below, I acknowledge and agree that I have read and understand this Disclosure in its entirety. I understand that the Intermediate Service Provider and Tax Return Preparer are Administrative Services Company of America, LLC and the Contractor collecting this Disclosure is merely a drop off location for the collection of my taxpayer information. Taxpayer Signature: Date: Taxpayer Name (print): Taxpayer Spouse Signature: Date: Taxpayer Spouse Name (print): *If you believe your tax return information has been disclosed or used improperly in a manner unauthorized by law or without your permission, or If you have you questions or concerns related to the processing or preparation of your income tax return, please contact Administrative Services Company of America, LLC by telephone at (513) or by at compliance@ascaservices.com. Last Name: SSN Last 4: Page 9 of 9

10 Tax Refund Small Loan Checklist These Documents Below Are Required Last Two Paycheck Stubs Last Two Bank Statements Last Year s Tax Return -or- Last Year s Tax Refund Amount or AGI to review to get confirmation of last year s return Picture ID A VOIDED check (if customer has checking account) A CHECK used as security for Loan (ONLY IF NEEDED OR REQUESTED-HOME OFFICE WILL MAKE YOU AWARE IF NEEDED TO COMPLETE) 2011/2012 Customer Tax Data Entry Forms and signatures A Bill with the same Address as the Borrower s with his name listed LOAN SUPPLEMENT TWO see other given for copy of such Bring these documents in and present them to a teller at any of our locations and they will process your loan application. You are inquiring about obtaining a small loan from A+ Financial Services, Inc. and in establishing a customer/business relationship with A+ Financial Services, Inc. and each of its affiliated corporations, A+ Auto Insurance Agency, Inc., A+ Title Pawn, Inc., and A+ Contracting Services, Inc. (collectively, A+ or we or our ). In order for A+ to process your application for a small loan and to provide you with information about our other financial products and services, we require the following information from you, which you hereby agree to furnish to A+ in consideration of the small loan offered and (if your application is accepted) lent by A+ to you and any other products and services offered to you. Applicant s Signature: Date: Teller s Signature: Date: Manager s Signature: Date: Last Name: SSN Last 4: Page 1 of 4

11 A+ Financial Services, Inc. Tax Refund Small Loan Application and Agreement The undersigned Applicant ( you or your ) has inquired about obtaining a small loan from A+ Financial Services, Inc. and in establishing a customer/business relationship with A+ Financial Services, Inc. and each of its affiliated corporations, A+ Auto Insurance Agency, Inc., A+ Title Pawn, Inc., and A+ Contracting Services, Inc. (collectively, A+ or we or our ). In order for A+ to process your application for a small loan and to provide you with information about our other financial products and services, we require the following information from you, which you hereby agree to furnish to A+ in consideration of the small loan offered and (if your application is accepted) lent by A+ to you and any other products and services offered to you. References Information (you must supply two references below) Full Name Home Phone Mobile Phone Address Address Relationship Full Name Home Phone Mobile Phone Address Address Relationship Bank Account Information Name on Account Account Type Checking Savings Direct Deposit? Yes No Routing Number Account Number Last Name: SSN Last 4: Page 2 of 4

12 Employer Information Employer Name Employer Address Phone Ext. Position Shift 1st 2nd 3rd Supervisor s Name Supervisor s Direct Phone & Extension Ext. Date of Hire What address do you report to? Your Direct Phone & Extension Ext. FCRA Disclosure Regarding Account Information: From time to time A+ Financial Services, Inc. ( A+ ) may share certain of your information with its other A+ affiliates. You may prohibit A+ from doing so, except for information pertaining solely to transactions or experiences between A+ and you by providing written notice to A+. Such notice will include your account/loan number, name of account holder, address, and telephone number, and will be mailed to A+, as follows: Compliance Officer, A+ Financial Services, Inc., P.O. Box , Lawrenceville, GA Further, if you believe that any information relating to you and held by A+ is inaccurate, you will notify A+ promptly of the specific information that is inaccurate. Disclosure of Information; Assignment; Validity: The information that you have stated in this application is complete and correct, and no material debts have been omitted. You acknowledge that A+ is relying upon the completeness and accuracy of the information submitted and that any intentionally false or misleading information may constitute an attempt to defraud A+. You hereby authorize A+ to obtain, verify and confirm any information about you or your credit history and employment history, from credit reporting agencies, directly from my creditors, my landlord or other businesses or individuals, and my current and former employers. You consent to such persons or entities providing such information directly to A+; and you hereby authorize A+ to furnish the information that you have provided to A+, as well as your payment history with A+, to those businesses with whom A+ believes that you have a credit account or are opening a credit account. You understand that A+ may assign your contract, entered into by you, as a result of this credit application. you hereby agree that your signature on any A+ form or document, whether original or electronic, shall constitute your valid and legally binding signature and that this signed form, if stored on electronic media, will have the same validity and legal effect as the original signed form. Last Name: SSN Last 4: Page 3 of 4

13 Tax Refund Small Loan Conditions Your loan is being approved based upon A+ Financial Services, Inc. s usual liberal underwriting rules. This Loan is not in connection with your Federal or State Income Tax Refund and is not a RAL (Rapid Anticipation Loan) and is due and payable under the terms of your Loan Agreement. Your Loan is a regulated Loan under the Georgia Industrial Loan Act. You are hereby further agreeing that you will repay the proceeds of your Loan from the RAC Check issued by your Tax Preparer as a convenience. In case a RAC Check is not issued for any reason by your Tax Preparer and/or the Issuing Bank for any reason you still will owe the balance on your Loan Promissory Note. Your RAC Tax Check will print at the location where you originally submitted your tax information for collection and remittance to the Tax Preparer and the location agrees that they will print your check for you, cash your check at the usual and customary 3% fee, and collect the balance due on your Loan Promissory note at date of printing. You hereby agree to these services & terms with your tax collection location in addition to your Loan Promissory Note by A+ Financial Services, Inc. including any optional services or products agreed upon to be paid in connection with your Loan proceeds see Loan Promissory Note for details. You agree to provide an ACH/EFT Authorization to your current checking or debit card account for your payment(s) in case the RAC Check is not issued, cashed, or your loan balance remains unpaid. We will remit your ACH/EFT by this authorization after your loan due date if not paid in full. Applicant s Signature: Date: Witness Signature: Date: Last Name: SSN Last 4: Page 4 of 4