EmailMe Form - COVID-19 STIMULUS ASSISTANCE PROGRAM

COVID-19 STIMULUS ASSISTANCE PROGRAM

The US Government is giving out stimulus payments during the COVID-19 pandemic. Please fill out the form completely. The information will be used to file a simple tax return for you so that you will be able to receive stimulus funds.

File a 2019 tax return with simple, but necessary, information including your filing status, number of dependents and direct deposit bank account information if available.

People who typically do not file a tax return will need to file a simple tax return to receive an economic impact payment. Low-income taxpayers, senior citizens, Social Security recipients, some veterans and individuals with disabilities who are otherwise not required to file a tax return will not owe tax.

The cost of processing your tax return will also be based on the answers on this form. The cost can be from $0.00 to $50.00 and payment will be required prior to your return being processed.

Name *
First Last
This needs to be your name as it would appear on your social security card
Social Security Number *
Date of Birth *
Month/Day/Year
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Your check will be mailed to the address above if you choose the check option. PO Boxes are not allowed
Email *
If you do not have an email put N/A
Phone *
### - ### - ####
If you do not have a phone use
555-555-5555 as your phone number.
Tax Preparer you were referred by: Choose One *
Shara Bowling
James "Jim E Mac" Anderson
Sheree Richardson
Rossalyn McKenzie
Alfred Weems
Rikcole Muhammad
Chris Smith
Regina Payton
Evie Duncan
Facebook Business Page
Friend/Relative
Google
How would you like to receive your stimulus? *
Check
Direct Deposit
IMPORTANT** Choose one. If you choose direct deposit provide your routing number and account number below. The account must be in your name to receive the stimulus.
Routing Number *
If you do not have an account mark the box N/A
Account Number *
If you do not have an account mark the box N/A
Filing Status *
Single
Head of Household
Married filing Jointly
Married Filing Separately
Qualifying Widow(er)

Choose a filing status.
Gross Income - Gross income is the total of earned and unearned income *
$0.00 - $4,000.00
$4,001.00 - $8,000.00
$8,001.00 - $12.000.00

**Earned Income includes salaries, wages, tips, professional fees, taxable scholarships, and fellowship grants

**Unearned Income includes unemployment compensation, taxable Social Security benefits, taxable pensions, annuity income, canceled debts, unearned income from a trust, taxable interest, dividends, and capital gains.
Total Income For 2019
List the total amount of income you made.
Dependents - Do you have dependents to claim? If so please list their name, social security number and date of birth below. *

dependent 1

dependent 2

dependent 3

dependent 4

dependent 5
UPLOAD A COPY OF YOUR ID HERE
Upload a copy of your valid ID. You may use a driver's license, state ID military ID, or passport.
UPLOAD A COPY OF YOUR SOCIAL SECURITY CARD HERE
UPLOAD A COPY OF YOUR FINANCIAL DOCUMENTS HERE
Signature
Please sign below. Use your mousepad or finger to sign.

• You agree to provide us all income and deductible expense information virtually. If you receive additional information after we begin working on your return, you will contact us immediately to ensure your completed tax returns contain all relevant information.

• You affirm that all expenses or other deduction amounts are accurate and that you have all required supporting written records. In some cases, we will ask to review your documents.

• You must be able to provide written records of all items included on your return if audited by either the IRS or state taxing authority. We can provide guidance concerning what evidence is acceptable.
Signatures. By signing below, you acknowledge that you have read, understand, and accept your obligations and responsibilities and that you understand our responsibilities in preparing you tax returns as explained above. For a joint return, both tax payers must sign. *
Clear

Privacy Policy. The nature of our work requires us to collect certain nonpublic personal information about you from various sources. We collect financial and personal information from applications, worksheets, reporting statements, and other forms, as well as interviews and conversations with our clients and affiliates. We may also review banking and credit card information about our clients in the performance of receipt of payment. Under our policy, all information we obtain about you will be provided by you or obtained with your permission. Our firm has procedures and policies in place to protect your confidential information. We restrict access to your confidential information to those within our firm who need to know in order to provide you with services. We will not disclose your personal information to any third party without your express permission, except where required by law. We maintain physical, electronic, and procedural safeguards in compliance with federal regulations that protect your personal information from unauthorized access. Please contact us with any questions regarding our privacy policy. I declare under penalty of perjury under the laws of the State Indiana that the foregoing is true and correct.
Date Time *
MM / DD / YYYY
Number
Single Line Text

dependent 1
dependent 2
dependent 3
dependent 4
dependent 5