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Welcome to

Charlesworth Financial Services, LLC


We strive to be the only Financial Advisor you and your family will ever need.

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 efiling as well as 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. Returns will be available to you in your personal secure portal. Upon completion, you will be sent via email a DocuSign request for your signature and an invoice that may be paid online.

Please complete this form and, if applicable for your spouse and dependents. After we receive this form from you, we will send you a link to our secure portal SmartVault as well as a retainer invoice of the $195 minimum. When submitting info through SmartVault, by texting 219.531.9519 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.


Parent or Guardian's Email Address

Email*

Confirm Email*
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 as of 1/1/2023. *

County of Employment as of 1/1/2023
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 as of 1/1/2023. *

County of Employment as of 1/1/2023
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 as of 1/1/2023. *

County of Employment as of 1/1/2023
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 as of 1/1/2023. *

County of Employment as of 1/1/2023
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 as of 1/1/2023. *

County of Employment as of 1/1/2023
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 as of 1/1/2023. *

County of Employment as of 1/1/2023
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 as of 1/1/2023. *

County of Employment as of 1/1/2023
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 as of 1/1/2023. *

County of Employment as of 1/1/2023
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 as of 1/1/2023. *

County of Employment as of 1/1/2023
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 as of 1/1/2023. *

County of Employment as of 1/1/2023
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
Click to customize section title
How did you hear about Charlesworth Financial Services?*
Investment client
Attended event at Pennsy Depot Banquet Room and saw sign
Referred by family, friend or colleague (let us know who)
Internet search
Facebook
Fingerprint client
Other (let us know)

Referred by:
I (We) agree to an up front retainer fee of $195 and that at completion we will promptly pay any additional charges *
I (We) agree
I (We) agree to open all tax form envelopes, remove non-essential fillers and organize our tax papers *
We agree to discard empty envelopes before submitting information
Have you (and spouse) texted "ACCEPT" to 219.531.9519 to exchange encrypted information with us?*
No, we will do so upon completion of this engagement letter
Yes
No, we do not text

Thank you and welcome to Charlesworth Financial Services.

Julianne M. Charlesworth, CPA/PFS

Justene R. Charlesworth, MBA

219-531-9519 ~ Charlesworth.CPA

College & Retirement Planning, Income Tax Planning & Preparation

Small Business Consulting, Financial Services

Fixed and Variable Annuities*, Life, Disability and Long Term Care Insurance

Securities offered through Avantax Investment ServicesSM, Member FINRA, SIPC. Investment advisory services offered through Avantax Advisory ServicesSM. Insurance services offered through an Avantax affiliated insurance agency.

 

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 as of 1/1/2023. *

County of Employment as of 1/1/2023
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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