Accelerated Tax & Insurance Services Tax Application

Taxpayer Name *

Taxpayer Date of Birth * +

Taxpayer SSN *

Spouse Name *

Spouse Date of Birth * +

Spouse SSN *

Taxpayer Occupation *

Spouse Occupation *

Street Address *

Address Line 2

City *

State *

Zip Code *

Cell # *

Home #/ 2nd Contact *

Email Address *

FILING STATUS

What is your filing status *

Are you claimed as a dependent on another tax return? *

Yes

No

Have you received the 2020? ( 1st Stimulus)? *

Yes

No

If yes, what was the amount? *

Have you received the 2021? ( 2nd Stimulus)? *

Yes

No

If yes, what was the amount? *

DEPENDENT

DEPENDENT NAME

	Answer Below
1	Answer Below
2	Answer Below
3	Answer Below
4	Answer Below

DEPENDENT SSN

	Answer Below
1	Answer Below
2	Answer Below
3	Answer Below
4	Answer Below

DEPENDENT DATE OF BIRTH

	Answer Below
1	Answer Below
2	Answer Below
3	Answer Below
4	Answer Below

DEPENDENT RELATIONSHIP

	Answer Below
1	Answer Below
2	Answer Below
3	Answer Below
4	Answer Below

IN THE HOUSEHOLD MORE THAN 6 MONTHS?

	Answer Below
1	Answer Below
2	Answer Below
3	Answer Below
4	Answer Below

Childcare Provider Name *

EIN or SSN *

Childcare Provider Street Address *

City *

State *

Zip Code *

Amount Paid to Childcare Provider *

How Often? Choose One. *

SOURCES OF INCOME

Check all that apply *

Do you have any of the following? *

Do you have health insurance through the Marketplace/Exchange? *

If yes, provide form 1095A

Were you a student last year? *

If yes, provide form 1098T from school

Do you have any unpaid IRS or State debt? *

Do you owe any UNPAID CHILD SUPPORT, STUDENT LOANS, DEFAULTED LOANS, or filed BANKRUPTCY? *

Do you RENT or OWN your HOME? *

Are the BILLS and UTILITIES in your name for HEAD of HOUSEHOLD purposes? *

Would you be interested in a HOME, AUTO, RENTERS, or BUSINESS INSURANCE quote? *

Want your TAX PREPARATION FEES to come out of your refund? *

How would you like to receive your refund? *

BANKING INFORMATION

Bank Account Name *

Account Type *

Account Number *

Confirm Account Number *

Routing Number *

Confirm Routing Number *

I, the undersigned, hereby certify that all of the information provided above is true and correct to the best of my knowledge. I further certify that ALL of the documents and information provided to my Tax Preparer are everything needed to efficiently prepare my tax return. Iunderstand that the IRS, STATE, DEPARTMENT of EDUCATION, OFFICE of CHILD SUPPORT, and or any other Government Agency may hold back a portion or my entire REFUND due to UNPAID FEDERAL or STATE DEBT. I will not hold the Tax Preparer liable for these holdbacks.

Taxpayer Signature *

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Date *

Spouse Signature *

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Date *

CONSENT TO DISCLOSURE OF TAX RETURN INFORMATION

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

ACCELERATED TAX SERVICES INC.

(Printed name of Tax Preparer)

Federal law requires this consent from to be provided to you (“you” refers to each taxpayer, if more than one)Unless authorized by law, we cannot disclose your tax return information to third parties for purposes other than the preparation and filing of your tax return without your consent.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 to engage in our tax preparation services. If we obtain your signature on this form by conditioning our services on your consent, your consent will not be valid. 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, yourconsent is valid for one year from the date of signature.You have indicated that you are interested in receiving an Electronic Disbursement Service from Refund Advantage, a division of MetaBank. In order to provide you with the opportunity to apply for one of these Products orServices, we must disclose all of your 2020tax return information necessary for evaluating the request to Refund Advantage.If you request a more limited disclosure of tax return information, you will not be eligible to submit anapplication request for these Products or Services. If youwould like us to disclose your 2020tax return information for this purpose, please sign and date your consent to the disclosure of your tax return information.By signing below, you authorize usto disclose to Refund Advantage all of your 2020tax return information necessary for the evaluation and processing of your request for a Product or Service.Youunderstand that if you are unwilling to authorize the disclosure and sharing of your tax return information with Refund Advantage, you will not be able to obtain a Product or Service, but you may still choose to have your tax return prepared and filed by us for a fee.

Printed Name of Taxpayer *

Date *

Taxpayer Signature *

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Printed Name of Joint Taxpayer *

Date *

Joint Taxpayer Signature *

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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 InspectorGeneralforTaxAdministration(TIGTA)bytelephoneat1-800-366-4484,orbye-mailatcomplaints@tigta.treas.gov.