Collier’s Tax Practitioner Service 15 W. National Rd. Englewood, OH | Ofc: 937-279-6369 Email: Ctaxldy@gmail.com | Fax: 937-867-3695 Intake Information Date: Filing Status: * Taxpayer DOB: TAXPAYER DRIVER’S LICENSE: Spouse DOB: SPOUSE DRIVER’S LICENSE: Home Address & Contact: ARE YOU SELF-EMPLOYED? No Yes DEPENDENT INFO: Provide copies of ID (SS Card and Birth Certificate). For over 18 in School, provide 1098-T. Number of Dependents: 0 1 2 3 4 5 6 Dependant Name DOB SSN Relationship Banking Info: