63 E Montauk Hwy
Hampton Bays, NY 11946

Call Now : 631.723.1777

Taxpayer Name:

Spouse Name:

SSN:

Birth date:

SSN:

Birth date:

Address:

City:

State:

Zip:

Phone:

Alt. Phone:

Email:

Alt. Email:

Dependents: (list youngest first)

Name (first, initial, last)	Dependent’s SSN	Relationship to Taxpayer	Months lived in your home	Date of Birth

Has the IRS issued you an Identity Theft PIN?

Yes

Are you a “Dependent of Another” taxpayer?

Yes

What Form 1095 did you receive to verify last year’s health insurance coverage?

1095-A

1095-B

1095-C

N/A

Please enter your bank information for refund direct deposit or ACH direct debit of tax balance owed:

Bank Name:

Account Type:

Routing Number:

Account Number:

I certify that I would like my taxes prepared according to the information I/we supplied above and I/we give Hamptons Tax & Advisory Services, LLC permission to use the above email address(es) for informational and promotional purposes. All other info contained in the form shall be kept confidential and only used for preparing the taxpayer’s tax returns.

Taxpayer Signature:

Date:

Spouse Signature:

Date:

REQUEST A FREE CALL BACK

Provide discussion information and we’ll get back to you as soon as possible.

Dependents: (list youngest first)

Please select any item that applies or you would like to discuss:

Income

Expenses

Credits

Please enter your bank information for refund direct deposit or ACH direct debit of tax balance owed:

REQUEST A FREE CALL BACK