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Welcome to

Charlesworth Financial Services, LLC


New clients, please fill out the following new client information sheet if you will be having us prepare your tax return.



Thank you for your interest in Charlesworth Financial Services and having us prepare your income tax returns and/or other services.  Our basic return prep fees start at $195 and include federal and Indiana efling as well as audit cost and identity theft protection.  Additional charges will apply for states other than Indiana, forms other than basic and additional time spent on the return based on the organization of your information.

Please complete this form and, if applicable for your spouse any dependents. After we receive this form from you, we will send you a link to our secure portal SmartVault. When submitting info through SmartVault or in person, make sure to include all social security number(s), copy of driver's license(s) and bank account and routing number for direct deposit or electronic tax payments.  Please remove all forms from envelopes and recycle the non-essential fillers.


First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

Occupation Title *
  
Please upload a copy of your driver's license here.
Valid file types: JPG, GIF, PNG, and PDF

County of Residence *

County of Employment
Would a possible extension be acceptable if necessary?*
No
Yes

Spouse First Name

Spouse Last Name

Spouse Date of Birth

Spouse Phone Number

Spouse Email
  
Please upload a copy of spouse driver's license here.
Valid file types: JPG, GIF, PNG, and PDF

Spouse Occupation Title

Spouse County Work In

Dependent Name #1
Please select one

Dependent #1 Date of Birth

Dependent Name #2
Please Select One

Dependent #2 Date of Birth

Dependent Name #3
Please Select One

Dependent #3 Date of Birth

Comments
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information

Occupation Title *
  
Please upload a copy of your driver's license here.
Valid file types: JPG, GIF, PNG, and PDF

County of Residence *

County of Employment
Would a possible extension be acceptable if necessary?*
No
Yes

Spouse First Name

Spouse Last Name

Spouse Date of Birth

Spouse Phone Number

Spouse Email
  
Please upload a copy of spouse driver's license here.
Valid file types: JPG, GIF, PNG, and PDF

Spouse Occupation Title

Spouse County Work In

Dependent Name #1
Please select one

Dependent #1 Date of Birth

Dependent Name #2
Please Select One

Dependent #2 Date of Birth

Dependent Name #3
Please Select One

Dependent #3 Date of Birth

Comments
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information

Occupation Title *
  
Please upload a copy of your driver's license here.
Valid file types: JPG, GIF, PNG, and PDF

County of Residence *

County of Employment
Would a possible extension be acceptable if necessary?*
No
Yes

Spouse First Name

Spouse Last Name

Spouse Date of Birth

Spouse Phone Number

Spouse Email
  
Please upload a copy of spouse driver's license here.
Valid file types: JPG, GIF, PNG, and PDF

Spouse Occupation Title

Spouse County Work In

Dependent Name #1
Please select one

Dependent #1 Date of Birth

Dependent Name #2
Please Select One

Dependent #2 Date of Birth

Dependent Name #3
Please Select One

Dependent #3 Date of Birth

Comments
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information

Occupation Title *
  
Please upload a copy of your driver's license here.
Valid file types: JPG, GIF, PNG, and PDF

County of Residence *

County of Employment
Would a possible extension be acceptable if necessary?*
No
Yes

Spouse First Name

Spouse Last Name

Spouse Date of Birth

Spouse Phone Number

Spouse Email
  
Please upload a copy of spouse driver's license here.
Valid file types: JPG, GIF, PNG, and PDF

Spouse Occupation Title

Spouse County Work In

Dependent Name #1
Please select one

Dependent #1 Date of Birth

Dependent Name #2
Please Select One

Dependent #2 Date of Birth

Dependent Name #3
Please Select One

Dependent #3 Date of Birth

Comments
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information

Occupation Title *
  
Please upload a copy of your driver's license here.
Valid file types: JPG, GIF, PNG, and PDF

County of Residence *

County of Employment
Would a possible extension be acceptable if necessary?*
No
Yes

Spouse First Name

Spouse Last Name

Spouse Date of Birth

Spouse Phone Number

Spouse Email
  
Please upload a copy of spouse driver's license here.
Valid file types: JPG, GIF, PNG, and PDF

Spouse Occupation Title

Spouse County Work In

Dependent Name #1
Please select one

Dependent #1 Date of Birth

Dependent Name #2
Please Select One

Dependent #2 Date of Birth

Dependent Name #3
Please Select One

Dependent #3 Date of Birth

Comments
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information

Occupation Title *
  
Please upload a copy of your driver's license here.
Valid file types: JPG, GIF, PNG, and PDF

County of Residence *

County of Employment
Would a possible extension be acceptable if necessary?*
No
Yes

Spouse First Name

Spouse Last Name

Spouse Date of Birth

Spouse Phone Number

Spouse Email
  
Please upload a copy of spouse driver's license here.
Valid file types: JPG, GIF, PNG, and PDF

Spouse Occupation Title

Spouse County Work In

Dependent Name #1
Please select one

Dependent #1 Date of Birth

Dependent Name #2
Please Select One

Dependent #2 Date of Birth

Dependent Name #3
Please Select One

Dependent #3 Date of Birth

Comments
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information

Occupation Title *
  
Please upload a copy of your driver's license here.
Valid file types: JPG, GIF, PNG, and PDF

County of Residence *

County of Employment
Would a possible extension be acceptable if necessary?*
No
Yes

Spouse First Name

Spouse Last Name

Spouse Date of Birth

Spouse Phone Number

Spouse Email
  
Please upload a copy of spouse driver's license here.
Valid file types: JPG, GIF, PNG, and PDF

Spouse Occupation Title

Spouse County Work In

Dependent Name #1
Please select one

Dependent #1 Date of Birth

Dependent Name #2
Please Select One

Dependent #2 Date of Birth

Dependent Name #3
Please Select One

Dependent #3 Date of Birth

Comments
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information

Occupation Title *
  
Please upload a copy of your driver's license here.
Valid file types: JPG, GIF, PNG, and PDF

County of Residence *

County of Employment
Would a possible extension be acceptable if necessary?*
No
Yes

Spouse First Name

Spouse Last Name

Spouse Date of Birth

Spouse Phone Number

Spouse Email
  
Please upload a copy of spouse driver's license here.
Valid file types: JPG, GIF, PNG, and PDF

Spouse Occupation Title

Spouse County Work In

Dependent Name #1
Please select one

Dependent #1 Date of Birth

Dependent Name #2
Please Select One

Dependent #2 Date of Birth

Dependent Name #3
Please Select One

Dependent #3 Date of Birth

Comments
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information

Occupation Title *
  
Please upload a copy of your driver's license here.
Valid file types: JPG, GIF, PNG, and PDF

County of Residence *

County of Employment
Would a possible extension be acceptable if necessary?*
No
Yes

Spouse First Name

Spouse Last Name

Spouse Date of Birth

Spouse Phone Number

Spouse Email
  
Please upload a copy of spouse driver's license here.
Valid file types: JPG, GIF, PNG, and PDF

Spouse Occupation Title

Spouse County Work In

Dependent Name #1
Please select one

Dependent #1 Date of Birth

Dependent Name #2
Please Select One

Dependent #2 Date of Birth

Dependent Name #3
Please Select One

Dependent #3 Date of Birth

Comments
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information

Occupation Title *
  
Please upload a copy of your driver's license here.
Valid file types: JPG, GIF, PNG, and PDF

County of Residence *

County of Employment
Would a possible extension be acceptable if necessary?*
No
Yes

Spouse First Name

Spouse Last Name

Spouse Date of Birth

Spouse Phone Number

Spouse Email
  
Please upload a copy of spouse driver's license here.
Valid file types: JPG, GIF, PNG, and PDF

Spouse Occupation Title

Spouse County Work In

Dependent Name #1
Please select one

Dependent #1 Date of Birth

Dependent Name #2
Please Select One

Dependent #2 Date of Birth

Dependent Name #3
Please Select One

Dependent #3 Date of Birth

Comments
Parent or Guardian's Email Address

Email*

Confirm Email*
.
How did you hear about Charlesworth Financial Services?*
Family, friend or colleague referral (let us know who)
Attended event at Pennsy Depot Room and saw sign
Facebook
Internet search
Fingerprint client
Other (let us know)
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Occupation Title *
  
Please upload a copy of your driver's license here.
Valid file types: JPG, GIF, PNG, and PDF

County of Residence *

County of Employment
Would a possible extension be acceptable if necessary?*
No
Yes

Spouse First Name

Spouse Last Name

Spouse Date of Birth

Spouse Phone Number

Spouse Email
  
Please upload a copy of spouse driver's license here.
Valid file types: JPG, GIF, PNG, and PDF

Spouse Occupation Title

Spouse County Work In

Dependent Name #1
Please select one

Dependent #1 Date of Birth

Dependent Name #2
Please Select One

Dependent #2 Date of Birth

Dependent Name #3
Please Select One

Dependent #3 Date of Birth

Comments
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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