National Insurance & Tax Service, Inc. PO Box 6373 Aurora, IL. 60598. PH 630 499-7877 FX 630-499-7810 Taxpayer Questionnaire & DISCLOSURE / AGREEMENT I/we further agree to pay any additional collection agency fees, down payments, tax preparation fees, court costs and reasonable attorney fees should my account be placed with your outside collection agency and/or law firm in order to collect the outstanding balance owed to National Insurance & Tax Service, Inc. under this Agreement. The collection agency fee will be thirty-five (35) percent and will be based on the percentage of the balance of the debt being turned over to the collection agency at that time. Additionally, I/we agree to pay simple interest at the rate of 1 ½ % per month on the outstanding principal balance of my account starting from the final date of service or final statement date whichever is most current. If the phone number(s) I/we am providing include my cell number(s), I/we consent to receiving auto dialed or prerecorded message calls from your outside collection agency and/or law firm who may call when attempting to collect on any past due accounts your office has placed with them. _____________________________________________ Client Signature _____________________________________________ Date

Vivian L. Durham Address: P O BOX 6373, Aurora, IL. 60598 Phone: 630-499-7877 Fax: 630-499-7810 Email: taxinfo@mynits.com Website: mynits.com

Taxpayer Questionnaire

PERSONAL INFORMATION Primary Taxpayer

First Name: Last Name: M.I:

S.S.N: Birth date: Taxpayer’s PIN:

Home Phone: Work Phone: Cell Phone:

Occupation: Dependent on another return? Yes No

Legally Blind? Disabled?

Email Address: Text Message: Yes No

Cell Phone Carrier:

ID Number: State: Issue Date: Expiry Date:

Spouse First Name: Last Name: M.I:

S.S.N: Birth date: Taxpayer’s PIN:

Home Phone: Work Phone: Cell Phone:

Occupation: Dependent on another return? Yes No

Legally Blind? Disabled?

Email Address: Text Message: Yes No

Cell Phone Carrier:

ID Number: State: Issue Date: Expiry Date:

Filling Status Filling Status (Select the Checkbox, which Status number applies) Notes

1 = Single 2 = Married Filing Joint

3 = Married Filing Separate 4 = Head of Household

5 = Qualified Widow(er)

Referred by (New Client only): Referring Client:

Address Street Address: Apt. #.

City: State: Zip Code:

Military Address Info: (1 = APO/FPO, 2 = Stateside, 3 = Foreign or Blank) Combat Zone:

Bank Information (for Direct Deposit into Taxpayers Personal Acct.)

Bank Name: Account Type: Saving Checking

Routing Number: Account Number:

Will this refund go to an account outside of the US? Yes No

DEPENDENTS

First Name Last Name Birth Date SSN Relationship # of

Months

CHILD CARE CREDIT A. If married, did both, Taxpayer and Spouse work during the time of dependent care? Yes No

B. If no to A, was Taxpayer or Spouse disabled or a full-time student for more than 5 months? No Yes, Disabled

Yes, Student

If no to A and B, this return is not eligible for dependent care credit

CARE PROVIDER # 1 INFORMATION Name SSN or EN

Address Total Amount Paid $

CARE PROVIDER # 2 INFORMATIONName SSN or EN

Address Total Amount Paid $

WAGES AND SALARIES (Use Actual Form W-2 for Data Entry)

Taxpayer Employer’s Name Wages Federal Withholding St Withholding

Spouse Employer’s Name Wages Federal Withholding St Withholding

Other Income (Use Actual Form 1098, 1099B, 1099-INT, 1099-DIV, 1099R, 1099G, 1099C, W2G, etc.)

Payer’s Name Income Withholdings Dividends

ADJUSTMENTS AND CREDITS Student Loan Interest Deduction – 1098E

IRA Contributions

Tuition and Fees Deduction, Education Credit, American Opportunity Credit - 1098T, Lifetime Education Qualified Expense

ITEMIZED EXPENSES Sch-A Medical and Dental Expenses Miles

Number of Miles driven to Doctor / Dental Visits during the year

Medical / Dental Expense Description Amount

Taxes Paid Amount

Real Estate Property Taxes Paid

Personal Property Taxes Paid (i.e. vehicle registration)

Interest Paid Amount

Home Mortgage Interest, from Form 1098

Gifts to Charity Miles

Number of Miles driven to Volunteer Work with Charitable Organization

Charitable Cash or Check Contributions Amount

Description

Description

Non-Cash Charitable Contributions (if more than $500 must attach Form 8283) Amount

Description

Description

Description

Job Expenses and Other Miscellaneous Expenses Amount

Un-reimbursed employee expenses (i.e. union dues, uniforms, tools specific to work) Prep Note: all other Un-reimbursed employee expenses must be filed on Form 2106

Tax Preparation Fees

Other Expenses (safe deposit box, attorney fees for production of income, gambling losses, etc.)

Description

Other Expenses Amount

Description

Description

With the IRS removing the Debit Indicator (DI), there is a chance that a RAC/RT will not be refunded in full.

Some reasons for not getting a complete RT refund:

IRS says you owe back taxes IRS says you have a current garnishment IRS is auditing your Earned Income Credit Earned Income Tax Credit (EITC) is claimed and an EITC qualifying child is a foster child You have an outstanding debt with any bank that provides RAC/RT

PLEASE NOTE – WE DO NOT HAVE ANY CONTROL OVER THE ABOVE REASONS!

Taxpayer Initial _____________________ Spouse Initial _____________________ I understand that all information I have provided on this form is true. If any of this information is incorrect, I understand that a formal letter will be sent if the refund is not paid in full. In addition, I understand that my refund may be provided to me in more than 1 check.

Taxpayer Signature: _______________________________________________ Date: ____________________________

Spouse Signature: ________________________________________________ Date: ____________________________

Check any of the Following which describes how you (and other family members on this return) received health care coverage:

A. Received health care coverage through employer for the entire year (including Cobra Coverage)

B. Received health care coverage from the Government such a Medicaid, Medicare, VA benefits, and other governmental health care

programs for the entire year

C. Purchased health insurance (not through the (“Marketplace”) for the entire year

D. Purchased health insurance through the “Marketplace” (Form 1095-A)

E. At least one family member (including taxpayer) did not have health care coverage at any time during the year.

FOR OFFICE USE ONLY

Process Checklist (to be included in customer file)

Make copies of form of ID and Social Security cards

Interview sheet filled out

One copy of tax return, W-2s and/or 1099 (Taxpayer & Spouse, if applicable)

Signature on 8879/Pin # and Bank application