TAX DOCTORS

2600 SOUTH LOOP WEST SUITE 215

HOUSTON, TX 77054
Office: (713) 377-6954

AMANDA HOLT
17435 IMPERIAL VALLEY DR APT 2106
HOUSTON, TX 77060
2017 INCOME TAX RETURN
 TAX DOCTORS
2600 SOUTH LOOP WEST SUITE 215
HOUSTON TX 77054
(713) 377-6954

"
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
&
"AMANDA T HOLT &
"17435 IMPERIAL VALLEY DR APT 2106 & Preparer No.: 995
"HOUSTON TX 77060 & Client No. : XXX-XX-4365
"(409) 333-7395 & Invoice Date: 04/23/2018
" &
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
" &

INVOICE
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
"
########################################################################
" "
"
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Description " Amount "
"
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
########################################################################
" "
" "
$$$$$$$$$$$$$$$$"
"PREPARATION OF 2017 FEDERAL/STATE FORMS & WORKSHEETS: " $$$$$$$$$$$$$$$$"
" "
$$$$$$$$$$$$$$$$"
"FORM 1040 "
$$$$$$$$$$$$$$$$"
"SCHEDULE C-EZ "
$$$$$$$$$$$$$$$$"
"SCHEDULE EIC (EARNED INCOME CREDIT) "
$$$$$$$$$$$$$$$$"
"SCHEDULE SE (SELF-EMPLOYMENT TAX) "
$$$$$$$$$$$$$$$$"
"FORM W-2 (WAGES AND TAX) (2) "
$$$$$$$$$$$$$$$$"
"FORM 8879 (E-FILE SIGNATURE AUTHORIZATION) "
$$$$$$$$$$$$$$$$"
"FORM 8812 (CHILD TAX CREDIT) "
$$$$$$$$$$$$$$$$"
"FORM 8867 (DUE DILIGENCE CHECKLIST) "
$$$$$$$$$$$$$$$$"
"MISCELLANEOUS STATEMENTS "
$$$$$$$$$$$$$$$$"
"AUDIT MAINTENANCE PRO "
$$$$$$$$$$$$$$$$"
" "
$$$$$$$$$$$$$$$$"
" "
$$$$$$$$$$$$$$$$"
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$$$$$$$$$$$$$$$$"
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$$$$$$$$$$$$$$$$"
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$$$$$$$$$$$$$$$$"
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!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
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$$$$$$$$$$$$$$$$"
" " " "
" These are charges for services rendered !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
" Total Invoice " $624.99 "
" and do not include any Bank fees. " " "
" !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
" Amount Paid " $0.00 "
" " " "
"
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
" Balance Due " $624.99 "
 TAX YEAR: 2017 PROCESS DATE: 04/23/2018

CLIENT : 449-53-4365 AMANDA T HOLT BIRTH DATE : 01/09/1981 / Age: 36

ADDRESS : 17435 IMPERIAL VALLEY DR APT 2106 PREPARER : 995

: HOUSTON TX 77060

Home : (409) 333-7395 PREPARER FEE: 585.00

Work : - ELECTRONIC :
Cell : - AUDIT FEE : 39.99
TOTAL FEES : 624.99
STATUS : 4
FED TYPE: Advantage ERD
ST TYPE : Regular Tax
E-MAIL :
_____________________________________________________________________________________
DEPENDENT NAME
__________________________________________________________________________________
BIRTH DATE AGE SSN RELATIONSHIP MONTHS
ISAAC SOSTAND 02/04/2002 15 634-80-9545 SON 12
ISIAH POULLARD 06/13/2007 10 643-08-9275 SON 12
_____________________________________________________________________________________

LISTING OF FORMS FOR THIS RETURN

________________________________
FORM 1040
FORM W-2
SCHEDULE C-EZ (BUSINESS INCOME)
SCHEDULE EIC (EARNED INCOME CREDIT)
SCHEDULE SE (SELF EMPLOYMENT TAX)
FORM 8812 (ADDITIONAL CHILD TAX CREDIT)
FORM 8867 (DUE DILIGENCE CHECKLIST)
FORM 8879 (E-FILE SIGNATURE AUTHORIZATION)
MISCELLANEOUS STATEMENTS

_____________________________________________________________________________________
* QUICK SUMMARY *
__________________________________________________________________________
SUMMARY FEDERAL
FILING STATUS 4
TOTAL INCOME 16148
TOTAL ADJUSTMENTS 998
ADJUSTED GROSS INCOME 15150
DEDUCTIONS 9350
EXEMPTIONS 12150
TAXABLE INCOME 0
TAX 0
CREDITS 0
PAYMENTS 1881
OTHER TAXES 1996
EARNED INCOME CREDIT 5616
REFUND 5501
AMOUNT DUE 0
 CLIENT : AMANDA HOLT 449-53-4365

PREPARER : 995 DATE : 04/23/2018

_____________________________________________________________________________________
* W-2 INCOME FORMS SUMMARY *
_____________________________________________________________________________________

____________________________________________________________________________
T/S EMPLOYER WAGES FED WITH FICA MED TAX STATE WITH ST
1. T 2 MEN HOUSTON 892 58 55 13 0
2. T SERENITY ASSIS 1126 0 70 16 0

TOTALS...... 2018 58 125 29 0

 a Employee’s social security number Safe, accurate, Visit the IRS website at
OMB No. 1545-0008 FAST! Use www.irs.gov/efile
449-53-4365
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld

75-1243053 892 58
c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld

2 MEN HOUSTON LLC 892 55

1 GEOFFREY WAY 5 Medicare wages and tips 6 Medicare tax withheld

HOUSTON TX 77035 892 13

7 Social security tips 8 Allocated tips

d Control number 9 Verification code 10 Dependent care benefits

e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box 12
C
o
AMANDA T HOLT d
e

100 UNIVERSITY DR PRAIRIE VIEW 13 Statutory

employee
Retirement Third-party 12b
plan sick pay C
o
HOUSTON TX 77047 d
e

14 Other 12c
C
o
d
e

12d
C
o
d
e

f Employee’s address and ZIP code

15 State Employer’s state ID number 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name

W-2 Wage and Tax Department of the Treasury—Internal Revenue Service

Form Statement 2017
a Employee’s social security number Safe, accurate, Visit the IRS website at
OMB No. 1545-0008 FAST! Use www.irs.gov/efile
449-53-4365
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld

84-1622269 1126
c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld

SERENITY ASSISTANT LIVING 1126 70

1945 PENNSYLVANIA AVE 5 Medicare wages and tips 6 Medicare tax withheld

BEAUMONT TX 77701 1126 16

7 Social security tips 8 Allocated tips

d Control number 9 Verification code 10 Dependent care benefits

e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box 12
C
o
AMANDA T HOLT d
e

17435 IMPERIAL VALLEY DR 13 Statutory

employee
Retirement Third-party 12b
plan sick pay C

HOUSTON TX 77060 o
d
e

14 Other 12c
C
o
d
e

12d
C
o
d
e

f Employee’s address and ZIP code

15 State Employer’s state ID number 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name

W-2 Wage and Tax Department of the Treasury—Internal Revenue Service

Form Statement 2017
Form 8879 IRS e-file Signature Authorization
OMB No. 1545-0074

Department of the Treasury

Return completed Form 8879 to your ERO. (Do not send to IRS.)
2017
Internal Revenue Service Go to www.irs.gov/Form8879 for the latest information.

Submission Identification Number (SID)

Taxpayer’s name Social security number

AMANDA T HOLT 449-53-4365

Spouse’s name Spouse’s social security number

Part I Tax Return Information — Tax Year Ending December 31, 2017 (Whole dollars only)
1 Adjusted gross income (Form 1040, line 38; Form 1040A, line 22; Form 1040EZ, line 4; Form 1040NR,
line 37) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 15150
2 Total tax (Form 1040, line 63; Form 1040A, line 39; Form 1040EZ, line 12; Form 1040NR, line 61) . . 2 1996
3 Federal income tax withheld from Forms W-2 and 1099 (Form 1040, line 64; Form 1040A, line 40;
Form 1040EZ, line 7; Form 1040NR, line 62a) . . . . . . . . . . . . . . . . . . . 3 58
4 Refund (Form 1040, line 76a; Form 1040A, line 48a; Form 1040EZ, line 13a; Form 1040-SS, Part I, line 13a;
Form 1040NR, line 73a) . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 5501
5 Amount you owe (Form 1040, line 78; Form 1040A, line 50; Form 1040EZ, line 14; Form 1040NR, line 75) 5
Part II Taxpayer Declaration and Signature Authorization (Be sure you get and keep a copy of your return)
Under penalties of perjury, I declare that I have examined a copy of my electronic individual income tax return and accompanying schedules and statements
for the tax year ending December 31, 2017, and to the best of my knowledge and belief, it is true, correct, and accurately lists all amounts and sources of income
I received during the tax year. I further declare that the amounts in Part I above are the amounts from my electronic income tax return. I consent to allow my
intermediate service provider, transmitter, or electronic return originator (ERO) to send my return to the IRS and to receive from the IRS (a) an acknowledgement
of receipt or reason for rejection of the transmission, (b) the reason for any delay in processing the return or refund, and (c) the date of any refund. If applicable, I
authorize the U.S. Treasury and its designated Financial Agent to initiate an ACH electronic funds withdrawal (direct debit) entry to the financial institution
account indicated in the tax preparation software for payment of my federal taxes owed on this return and/or a payment of estimated tax, and the financial
institution to debit the entry to this account. This authorization is to remain in full force and effect until I notify the U.S. Treasury Financial Agent to terminate the
authorization. To revoke (cancel) a payment, I must contact the U.S. Treasury Financial Agent at 1-888-353-4537. Payment cancellation requests must be
received no later than 2 business days prior to the payment (settlement) date. I also authorize the financial institutions involved in the processing of the electronic
payment of taxes to receive confidential information necessary to answer inquiries and resolve issues related to the payment. I further acknowledge that the
personal identification number (PIN) below is my signature for my electronic income tax return and, if applicable, my Electronic Funds Withdrawal Consent.

Taxpayer’s PIN: check one box only

X I authorize TAX DOCTORS to enter or generate my PIN 1 4 3 6 5
ERO firm name Enter five digits, but
as my signature on my tax year 2017 electronically filed income tax return. don’t enter all zeros

I will enter my PIN as my signature on my tax year 2017 electronically filed income tax return. Check this box only if you are
entering your own PIN and your return is filed using the Practitioner PIN method. The ERO must complete Part III below.
Your signature Date 04/23/2018
Spouse’s PIN: check one box only
I authorize to enter or generate my PIN
ERO firm name Enter five digits, but
as my signature on my tax year 2017 electronically filed income tax return. don’t enter all zeros

I will enter my PIN as my signature on my tax year 2017 electronically filed income tax return. Check this box only if you are
entering your own PIN and your return is filed using the Practitioner PIN method. The ERO must complete Part III below.

Spouse’s signature Date

Practitioner PIN Method Returns Only—continue below

Part III Certification and Authentication — Practitioner PIN Method Only

ERO’s EFIN/PIN. Enter your six-digit EFIN followed by your five-digit self-selected PIN. 6 1 6 9 5 9 5 9 7 9 0
Don’t enter all zeros
I certify that the above numeric entry is my PIN, which is my signature for the tax year 2017 electronically filed income tax return for
the taxpayer(s) indicated above. I confirm that I am submitting this return in accordance with the requirements of the Practitioner PIN
method and Pub. 1345, Handbook for Authorized IRS e-file Providers of Individual Income Tax Returns.
ERO’s signature TAX DOCTORS Date 04/23/2018
KATRINA EDWARDS
ERO Must Retain This Form — See Instructions
Don’t Submit This Form to the IRS Unless Requested To Do So
For Paperwork Reduction Act Notice, see your tax return instructions. QNA Form 8879 (2017)
Form
1040 Department of the Treasury—Internal Revenue Service

U.S. Individual Income Tax Return

(99)
2017 OMB No. 1545-0074 IRS Use Only—Do not write or staple in this space.

For the year Jan. 1–Dec. 31, 2017, or other tax year beginning , 2017, ending , 20 See separate instructions.
Your first name and initial Last name Your social security number

AMANDA T HOLT 449-53-4365

If a joint return, spouse’s first name and initial Last name Spouse’s social security number

Home address (number and street). If you have a P.O. box, see instructions. Apt. no. Make sure the SSN(s) above
17435 IMPERIAL VALLEY DR 2106 and on line 6c are correct.
City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions). Presidential Election Campaign
HOUSTON, TX 77060 Check here if you, or your spouse if filing
jointly, want $3 to go to this fund. Checking
Foreign country name Foreign province/state/county Foreign postal code
a box below will not change your tax or
refund. You Spouse

Filing Status 1 Single 4 x Head of household (with qualifying person). (See instructions.)
2 Married filing jointly (even if only one had income) If the qualifying person is a child but not your dependent, enter this
Check only one 3 Married filing separately. Enter spouse’s SSN above child’s name here.
box. and full name here. 5 Qualifying widow(er) (see instructions)

Exemptions 6a
b
X Yourself. If someone can claim you as a dependent, do not check box 6a .
Spouse . . . . . . . . . . . . . . . . . . . .
.
.
.
.
.
.
.
.
} Boxes checked
on 6a and 6b
No. of children
1
c Dependents: (2) Dependent’s (3) Dependent’s (4) if child under age 17 on 6c who:
social security number relationship to you qualifying for child tax credit • lived with you 2
(1) First name Last name (see instructions) • did not live with
you due to divorce
ISAAC SOSTAND 634-80-9545 SON X or separation
If more than four ISIAH POULLARD 643-08-9275 SON X (see instructions) 0
dependents, see Dependents on 6c
instructions and not entered above 0
check here Add numbers on
d Total number of exemptions claimed . . . . . . . . . . . . . . . . . lines above 3
Income 7 Wages, salaries, tips, etc. Attach Form(s) W-2 . . . . . . . . . . . . 7 2018
8a Taxable interest. Attach Schedule B if required . . . . . . . . . . . . 8a
b Tax-exempt interest. Do not include on line 8a . . . 8b
Attach Form(s)
9a Ordinary dividends. Attach Schedule B if required . . . . . . . . . . . 9a
W-2 here. Also
attach Forms b Qualified dividends . . . . . . . . . . . 9b
W-2G and 10 Taxable refunds, credits, or offsets of state and local income taxes . . . . . . 10
1099-R if tax 11 Alimony received . . . . . . . . . . . . . . . . . . . . . 11
was withheld.
12 Business income or (loss). Attach Schedule C or C-EZ . . . . . . . . . . 12 14130
13 Capital gain or (loss). Attach Schedule D if required. If not required, check here 13
If you did not 14 Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . . . 14
get a W-2,
see instructions. 15a IRA distributions . 15a b Taxable amount . . . 15b
16a Pensions and annuities 16a b Taxable amount . . . 16b
17 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E 17
18 Farm income or (loss). Attach Schedule F . . . . . . . . . . . . . . 18
19 Unemployment compensation . . . . . . . . . . . . . . . . . 19
20a Social security benefits 20a b Taxable amount . . . 20b
21 Other income. List type and amount 21
22 Combine the amounts in the far right column for lines 7 through 21. This is your total income 22 16148
23 Educator expenses . . . . . . . . . . . 23
Adjusted 24 Certain business expenses of reservists, performing artists, and
Gross fee-basis government officials. Attach Form 2106 or 2106-EZ 24
Income 25 Health savings account deduction. Attach Form 8889 . 25
26 Moving expenses. Attach Form 3903 . . . . . . 26
27 Deductible part of self-employment tax. Attach Schedule SE . 27 998
28 Self-employed SEP, SIMPLE, and qualified plans . . 28
29 Self-employed health insurance deduction . . . . 29
30 Penalty on early withdrawal of savings . . . . . . 30
31a Alimony paid b Recipient’s SSN 31a
32 IRA deduction . . . . . . . . . . . . . 32
33 Student loan interest deduction . . . . . . . . 33
34 Tuition and fees. Attach Form 8917 . . . . . . 34
35 Domestic production activities deduction. Attach Form 8903 35
36 Add lines 23 through 35 . . . . . . . . . . . . . . . . . . . 36 998
37 Subtract line 36 from line 22. This is your adjusted gross income . . . . . 37 15150
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. QNA Form 1040 (2017)
 HOLT 449-53-4365
Form 1040 (2017) Page 2
38 Amount from line 37 (adjusted gross income) . . . . . . . . . . . . . . 38 15150
Tax and
Credits
39a Check
if:
{ You were born before January 2, 1953,
Spouse was born before January 2, 1953,
Blind.
Blind.
} Total boxes
checked 39a 0
b If your spouse itemizes on a separate return or you were a dual-status alien, check here 39b
Standard 40 Itemized deductions (from Schedule A) or your standard deduction (see left margin) . . 40 9350
Deduction
for— 41 Subtract line 40 from line 38 . . . . . . . . . . . . . . . . . . . 41 5800
• People who 42 Exemptions. If line 38 is $156,900 or less, multiply $4,050 by the number on line 6d. Otherwise, see instructions 42 12150
check any
box on line 43 Taxable income. Subtract line 42 from line 41. If line 42 is more than line 41, enter -0- . . 43 0
39a or 39b or 44 Tax (see instructions). Check if any from: a Form(s) 8814 b Form 4972 c 44
who can be
claimed as a 45 Alternative minimum tax (see instructions). Attach Form 6251 . . . . . . . . . 45
dependent,
see 46 Excess advance premium tax credit repayment. Attach Form 8962 . . . . . . . . 46
instructions. 47 Add lines 44, 45, and 46 . . . . . . . . . . . . . . . . . . . 47
• All others:
48 Foreign tax credit. Attach Form 1116 if required . . . . 48
Single or
Married filing 49 Credit for child and dependent care expenses. Attach Form 2441 49
separately,
$6,350 50 Education credits from Form 8863, line 19 . . . . . 50
Married filing 51 Retirement savings contributions credit. Attach Form 8880 51
jointly or
Qualifying 52 Child tax credit. Attach Schedule 8812, if required . . . 52
widow(er), 53 Residential energy credits. Attach Form 5695 . . . . 53
$12,700
Head of 54 Other credits from Form: a 3800 b 8801 c 54
household, 55 Add lines 48 through 54. These are your total credits . . . . . . . . . . . . 55
$9,350
56 Subtract line 55 from line 47. If line 55 is more than line 47, enter -0- . . . . . . 56 0
57 Self-employment tax. Attach Schedule SE . . . . . . . . . . . . . . . 57 1996
Other 58 Unreported social security and Medicare tax from Form: a 4137 b 8919 . . 58
59 Additional tax on IRAs, other qualified retirement plans, etc. Attach Form 5329 if required . . 59
Taxes 60a Household employment taxes from Schedule H . . . . . . . . . . . . . . 60a
b First-time homebuyer credit repayment. Attach Form 5405 if required . . . . . . . . 60b
61 Health care: individual responsibility (see instructions) Full-year coverage
X . . . . . 61
62 Taxes from: a Form 8959 b Form 8960 c Instructions; enter code(s) 62
63 Add lines 56 through 62. This is your total tax . . . . . . . . . . . . . 63 1996
Payments 64 Federal income tax withheld from Forms W-2 and 1099 . . 64 58
65 2017 estimated tax payments and amount applied from 2016 return 65
If you have a
qualifying
66a Earned income credit (EIC) . . . . . . . . . . 66a 5616
child, attach b Nontaxable combat pay election 66b
Schedule EIC. 67 Additional child tax credit. Attach Schedule 8812 . . . . . 67 1823
68 American opportunity credit from Form 8863, line 8 . . . 68
69 Net premium tax credit. Attach Form 8962 . . . . . . 69
70 Amount paid with request for extension to file . . . . . 70
71 Excess social security and tier 1 RRTA tax withheld 71 . . . .
72 Credit for federal tax on fuels. Attach Form 4136 72 . . . .
73 Credits from Form: a 2439 b Reserved c 8885 d 73
74 Add lines 64, 65, 66a, and 67 through 73. These are your total payments . . . . . 74 7497
Refund 75 If line 74 is more than line 63, subtract line 63 from line 74. This is the amount you overpaid 75 5501
76a Amount of line 75 you want refunded to you. If Form 8888 is attached, check here . 76a 5501
Direct deposit? bRouting number 1 1 1 9 0 0 6 5 9 c Type: X Checking Savings
See dAccount number 8 4 1 8 1 6 0 9 9 3
instructions.
77 Amount of line 75 you want applied to your 2018 estimated tax 77
Amount 78 Amount you owe. Subtract line 74 from line 63. For details on how to pay, see instructions 78
You Owe 79 Estimated tax penalty (see instructions) . . . . . . . 79
Third Party Do you want to allow another person to discuss this return with the IRS (see instructions)? X Yes. Complete below. No
Designee’s Phone Personal identification
Designee name KATRINA EDWARDS no. 713-377-6954 number (PIN) 5 9 7 9 0
Sign Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct, and
accurately list all amounts and sources of income I received during the tax year. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Here Your signature Date Your occupation Daytime phone number
Joint return? See
instructions. 04/23/18 409-333-7395
Keep a copy for Spouse’s signature. If a joint return, both must sign. Date Spouse’s occupation If the IRS sent you an Identity Protection
your records. PIN, enter it
here (see inst.)
Print/Type preparer’s name Preparer’s signature Date PTIN
Paid Check if
Preparer
KATRINA EDWARDS 04/23/2018 self-employed P01836685
Firm’s name TAX DOCTORS Firm’s EIN 82-0913880
Use Only
Firm’s address 2600 SOUTH LOOP WEST SUITE 215 HOUSTON TX 77054 Phone no. 713-377-6954
Go to www.irs.gov/Form1040 for instructions and the latest information. QNA Form 1040 (2017)
SCHEDULE C-EZ Net Profit From Business OMB No. 1545-0074
(Form 1040)
Department of the Treasury
(Sole Proprietorship)
Partnerships, joint ventures, etc., generally must file Form 1065 or 1065-B.
2017
Attachment
Internal Revenue Service (99) Attach to Form 1040, 1040NR, or 1041. See instructions on page 2. Sequence No. 09A
Name of proprietor Social security number (SSN)

AMANDA T HOLT 449-53-4365

Part I General Information

• Had business expenses of $5,000 or • Had no employees during the year,

less, • Do not deduct expenses for business
You May Use • Use the cash method of accounting, use of your home,
Schedule C-EZ • Did not have an inventory at any time • Do not have prior year unallowed
Instead of during the year,
And You: passive activity losses from this
business, and
Schedule C • Did not have a net loss from your
• Are not required to file Form 4562,
Only If You: business,
Depreciation and Amortization, for
• Had only one business as either a sole this business. See the instructions for
proprietor, qualified joint venture, or Schedule C, line 13, to find out if you
statutory employee, must file.

A Principal business or profession, including product or service B Enter business code (see page 2)
BEAUTY SALONS 8 1 2 1 1 2
C Business name. If no separate business name, leave blank. D Enter your EIN (see page 2)
HAIR BY AMANDA
E Business address (including suite or room no.). Address not required if same as on page 1 of your tax return.

City, town or post office, state, and ZIP code

F Did you make any payments in 2017 that would require you to file Form(s) 1099? (see the Instructions for
Schedule C) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes X No
G If “Yes,” did you or will you file required Forms 1099? . . . . . . . . . . . . . . . . . Yes No
Part II Figure Your Net Profit
1 Gross receipts. Caution: If this income was reported to you on Form W-2 and the “Statutory
employee” box on that form was checked, see Statutory employees in the instructions for
Schedule C, line 1, and check here . . . . . . . . . . . . . . . . . . 1 15179

2 Total expenses (see page 2). If more than $5,000, you must use Schedule C . . . . . . . 2 1049

3 Net profit. Subtract line 2 from line 1. If less than zero, you must use Schedule C. Enter on both
Form 1040, line 12, and Schedule SE, line 2, or on Form 1040NR, line 13, and Schedule SE,
line 2 (see page 2). (Statutory employees do not report this amount on Schedule SE, line 2.)
Estates and trusts, enter on Form 1041, line 3 . . . . . . . . . . . . . . . . . 3 14130
Part III Information on Your Vehicle. Complete this part only if you are claiming car or truck expenses on line 2.
4 When did you place your vehicle in service for business purposes? (month, day, year) .

5 Of the total number of miles you drove your vehicle during 2017, enter the number of miles you used your vehicle for:

a Business b Commuting (see page 2) c Other

6 Was your vehicle available for personal use during off-duty hours? . . . . . . . . . . . . . Yes No

7 Do you (or your spouse) have another vehicle available for personal use? . . . . . . . . . . . Yes No

8a Do you have evidence to support your deduction? . . . . . . . . . . . . . . . . . . Yes No

b If “Yes,” is the evidence written? . . . . . . . . . . . . . . . . . . . . . . . . Yes No

For Paperwork Reduction Act Notice, see the separate instructions for Schedule C (Form 1040). Schedule C-EZ (Form 1040) 2017

QNA
Schedule SE (Form 1040) 2017 Attachment Sequence No. 17 Page 2
Name of person with self-employment income (as shown on Form 1040 or Form 1040NR) Social security number of person
AMANDA T HOLT with self-employment income 449-53-4365
Section B—Long Schedule SE
Part I Self-Employment Tax
Note: If your only income subject to self-employment tax is church employee income, see instructions. Also see instructions for the
definition of church employee income.
A If you are a minister, member of a religious order, or Christian Science practitioner and you filed Form 4361, but you
had $400 or more of other net earnings from self-employment, check here and continue with Part I . . . . . .
1a Net farm profit or (loss) from Schedule F, line 34, and farm partnerships, Schedule K-1 (Form 1065),
box 14, code A. Note: Skip lines 1a and 1b if you use the farm optional method (see instructions) 1a
b If you received social security retirement or disability benefits, enter the amount of Conservation Reserve
Program payments included on Schedule F, line 4b, or listed on Schedule K-1 (Form 1065), box 20, code Z 1b ( )
2 Net profit or (loss) from Schedule C, line 31; Schedule C-EZ, line 3; Schedule K-1 (Form 1065),
box 14, code A (other than farming); and Schedule K-1 (Form 1065-B), box 9, code J1.
Ministers and members of religious orders, see instructions for types of income to report on
this line. See instructions for other income to report. Note: Skip this line if you use the nonfarm
optional method (see instructions) . . . . . . . . . . . . . . . . . . . . 2 14130
3 Combine lines 1a, 1b, and 2 . . . . . . . . . . . . . . . . . . . . . . 3 14130
4a If line 3 is more than zero, multiply line 3 by 92.35% (0.9235). Otherwise, enter amount from line 3 4a 13049
Note: If line 4a is less than $400 due to Conservation Reserve Program payments on line 1b, see instructions.
b If you elect one or both of the optional methods, enter the total of lines 15 and 17 here . . 4b
c Combine lines 4a and 4b. If less than $400, stop; you don't owe self-employment tax.
Exception: If less than $400 and you had church employee income, enter -0- and continue 4c 13049
5a Enter your church employee income from Form W-2. See
instructions for definition of church employee income . . . 5a
b Multiply line 5a by 92.35% (0.9235). If less than $100, enter -0- . . . . . . . . . . 5b
6 Add lines 4c and 5b . . . . . . . . . . . . . . . . . . . . . . . . 6 13049
7 Maximum amount of combined wages and self-employment earnings subject to social security
tax or the 6.2% portion of the 7.65% railroad retirement (tier 1) tax for 2017 . . . . . . 7 127,200 00
8a Total social security wages and tips (total of boxes 3 and 7 on
Form(s) W-2) and railroad retirement (tier 1) compensation.
If $127,200 or more, skip lines 8b through 10, and go to line 11 8a 2018
b Unreported tips subject to social security tax (from Form 4137, line 10) 8b
c Wages subject to social security tax (from Form 8919, line 10) 8c
d Add lines 8a, 8b, and 8c . . . . . . . . . . . . . . . . . . . . . . . 8d 2018
9 Subtract line 8d from line 7. If zero or less, enter -0- here and on line 10 and go to line 11 . 9 125182
10 Multiply the smaller of line 6 or line 9 by 12.4% (0.124) . . . . . . . . . . . . . 10 1618
11 Multiply line 6 by 2.9% (0.029) . . . . . . . . . . . . . . . . . . . . . 11 378
12 Self-employment tax. Add lines 10 and 11. Enter here and on Form 1040, line 57, or Form 1040NR, line 55 12 1996
13 Deduction for one-half of self-employment tax.
Multiply line 12 by 50% (0.50). Enter the result here and on
Form 1040, line 27, or Form 1040NR, line 27 . . . . . . 13 998
Part II Optional Methods To Figure Net Earnings (see instructions)
Farm Optional Method. You may use this method only if (a) your gross farm income1 wasn't more
than $7,800, or (b) your net farm profits2 were less than $5,631.
14 Maximum income for optional methods . . . . . . . . . . . . . . . . . . 14 5,200 00
15 Enter the smaller of: two-thirds (2/3) of gross farm income1 (not less than zero) or $5,200. Also
include this amount on line 4b above . . . . . . . . . . . . . . . . . . . 15
Nonfarm Optional Method. You may use this method only if (a) your net nonfarm profits3 were less than $5,631
and also less than 72.189% of your gross nonfarm income,4 and (b) you had net earnings from self-employment
of at least $400 in 2 of the prior 3 years. Caution: You may use this method no more than five times.
16 Subtract line 15 from line 14 . . . . . . . . . . . . . . . . . . . . . . 16
17 Enter the smaller of: two-thirds (2/3) of gross nonfarm income4 (not less than zero) or the
amount on line 16. Also include this amount on line 4b above . . . . . . . . . . . 17

1 3
From Sch. F, line 9, and Sch. K-1 (Form 1065), box 14, code B. From Sch. C, line 31; Sch. C-EZ, line 3; Sch. K-1 (Form 1065), box 14, code
2
From Sch. F, line 34, and Sch. K-1 (Form 1065), box 14, code A—minus the A; and Sch. K-1 (Form 1065-B), box 9, code J1.
amount you would have entered on line 1b had you not used the optional 4
From Sch. C, line 7; Sch. C-EZ, line 1; Sch. K-1 (Form 1065), box 14, code
method. C; and Sch. K-1 (Form 1065-B), box 9, code J2.
QNA Schedule SE (Form 1040) 2017
SCHEDULE EIC Earned Income Credit OMB No. 1545-0074
(Form 1040A or 1040) 1040A
Qualifying Child Information
Complete and attach to Form 1040A or 1040 only if you have a qualifying child.
..........

1040 2017
Department of the Treasury
Go to www.irs.gov/ScheduleEIC for the latest information.
EIC Attachment
Internal Revenue Service (99) Sequence No. 43
Name(s) shown on return Your social security number

AMANDA HOLT 449-53-4365

• See the instructions for Form 1040A, lines 42a and 42b, or Form 1040, lines 66a and 66b, to make
Before you begin: sure that (a) you can take the EIC, and (b) you have a qualifying child.
• Be sure the child’s name on line 1 and social security number (SSN) on line 2 agree with the child’s social security card.
Otherwise, at the time we process your return, we may reduce or disallow your EIC. If the name or SSN on the child’s
social security card is not correct, call the Social Security Administration at 1-800-772-1213.

• You can't claim the EIC for a child who didn't live with you for more than half of the year.
!
CAUTION
• If you take the EIC even though you are not eligible, you may not be allowed to take the credit for up to 10 years. See the instructions for details.
• It will take us longer to process your return and issue your refund if you do not fill in all lines that apply for each qualifying child.

Qualifying Child Information Child 1 Child 2 Child 3

1 Child’s name First name Last name First name Last name First name Last name
If you have more than three qualifying
children, you have to list only three to get
the maximum credit. ISIAH POULLARD ISAAC SOSTAND

2 Child’s SSN
The child must have an SSN as defined in
the instructions for Form 1040A, lines 42a
and 42b, or Form 1040, lines 66a and 66b,
unless the child was born and died in
2017. If your child was born and died in
2017 and did not have an SSN, enter
“Died” on this line and attach a copy of
the child’s birth certificate, death
certificate, or hospital medical records
showing a live birth. 643-08-9275 634-80-9545
3 Child’s year of birth
Year 2 0 0 7 Year 2 0 0 2 Year
If born after 1998 and the child is If born after 1998 and the child is If born after 1998 and the child is
younger than you (or your spouse, if younger than you (or your spouse, if younger than you (or your spouse, if
filing jointly), skip lines 4a and 4b; filing jointly), skip lines 4a and 4b; filing jointly), skip lines 4a and 4b;
go to line 5. go to line 5. go to line 5.

4 a Was the child under age 24 at the end of

2017, a student, and younger than you (or Yes. No. Yes. No. Yes. No.
your spouse, if filing jointly)?
Go to Go to line 4b. Go to Go to line 4b. Go to Go to line 4b.
line 5. line 5. line 5.

b Was the child permanently and totally

disabled during any part of 2017? Yes. No. Yes. No. Yes. No.
Go to The child is not a Go to The child is not a Go to The child is not a
line 5. qualifying child. line 5. qualifying child. line 5. qualifying child.

5 Child’s relationship to you

(for example, son, daughter, grandchild,
niece, nephew, eligible foster child, etc.) SON SON
6 Number of months child lived
with you in the United States
during 2017

• If the child lived with you for more than

half of 2017 but less than 7 months,
enter “7.”
• If the child was born or died in 2017 and 12 months 12 months months
your home was the child’s home for more
than half the time he or she was alive Do not enter more than 12 Do not enter more than 12 Do not enter more than 12
during 2017, enter “12.” months. months. months.
For Paperwork Reduction Act Notice, see your tax Schedule EIC (Form 1040A or 1040) 2017
return instructions.
QNA
SCHEDULE 8812 OMB No. 1545-0074
Child Tax Credit 1040
(Form 1040A or 1040)
Attach to Form 1040, Form 1040A, or Form 1040NR.
1040A
1040NR 2017
Department of the Treasury Go to www.irs.gov/Schedule8812 for instructions and the latest 8812 Attachment
Internal Revenue Service (99) information. Sequence No. 47
Name(s) shown on return Your social security number

AMANDA HOLT 449-53-4365

Part I Filers Who Have Certain Child Dependent(s) with an Individual Taxpayer Identification Number (ITIN)

CAUTION
! Complete this part only for each dependent who has an ITIN and for whom you are claiming the child tax credit.
If your dependent is not a qualifying child for the credit, you cannot include that dependent in the calculation of this credit.

Answer the following questions for each dependent listed on Form 1040, line 6c; Form 1040A, line 6c; or Form 1040NR, line 7c, who has an
Individual Taxpayer Identification Number (ITIN) and that you indicated is a qualifying child for the child tax credit by checking column (4) for that
dependent.
A For the first dependent identified with an ITIN and listed as a qualifying child for the child tax credit, did this child meet the substantial
presence test? See separate instructions.
Yes No

B For the second dependent identified with an ITIN and listed as a qualifying child for the child tax credit, did this child meet the substantial
presence test? See separate instructions.
Yes No

C For the third dependent identified with an ITIN and listed as a qualifying child for the child tax credit, did this child meet the substantial
presence test? See separate instructions.
Yes No

D For the fourth dependent identified with an ITIN and listed as a qualifying child for the child tax credit, did this child meet the substantial
presence test? See separate instructions.
Yes No

Note: If you have more than four dependents identified with an ITIN and listed as a qualifying child for the child tax credit, see separate instructions
and check here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

}
Part II Additional Child Tax Credit Filers
1 If you file Form 2555 or 2555-EZ, stop here; you cannot claim the additional child tax credit.

If you are required to use the worksheet in Pub. 972, enter the amount from line 8 of the Child Tax
Credit Worksheet in the publication. Otherwise:
1040 filers: Enter the amount from line 6 of your Child Tax Credit Worksheet (see the 1 2000
instructions for Form 1040, line 52).
1040A filers: Enter the amount from line 6 of your Child Tax Credit Worksheet (see the
instructions for Form 1040A, line 35).
1040NR filers: Enter the amount from line 6 of your Child Tax Credit Worksheet (see the
instructions for Form 1040NR, line 49).
2 Enter the amount from Form 1040, line 52; Form 1040A, line 35; or Form 1040NR, line 49 . . . . . 2
3 Subtract line 2 from line 1. If zero, stop here; you cannot claim this credit . . . . . . . . . . . 3 2000
4a Earned income (see separate instructions) . . . . . . . . . . . 4a 15150
b Nontaxable combat pay (see separate
instructions) . . . . . . . . . . . 4b
5 Is the amount on line 4a more than $3,000?
No. Leave line 5 blank and enter -0- on line 6.
X Yes. Subtract $3,000 from the amount on line 4a. Enter the result . . . 5 12150
6 Multiply the amount on line 5 by 15% (0.15) and enter the result . . . . . . . . . . . . . . 6 1823
Next. Do you have three or more qualifying children?
X No. If line 6 is zero, stop here; you cannot claim this credit. Otherwise, skip Part III and enter the
smaller of line 3 or line 6 on line 13.
Yes. If line 6 is equal to or more than line 3, skip Part III and enter the amount from line 3 on line 13.
Otherwise, go to line 7.
For Paperwork Reduction Act Notice, see your tax return instructions. Schedule 8812 (Form 1040A or 1040) 2017
QNA
 AMANDA HOLT 449-53-4365
Schedule 8812 (Form 1040A or 1040) 2017 Page 2
Part III Certain Filers Who Have Three or More Qualifying Children
7 Withheld social security, Medicare, and Additional Medicare taxes from
Form(s) W-2, boxes 4 and 6. If married filing jointly, include your spouse’s
amounts with yours. If your employer withheld or you paid Additional

}
Medicare Tax or tier 1 RRTA taxes, see separate instructions . . . . . . 7
8 1040 filers: Enter the total of the amounts from Form 1040, lines
27 and 58, plus any taxes that you identified using code
“UT” and entered on line 62.
1040A filers: Enter -0-. 8
1040NR filers: Enter the total of the amounts from Form 1040NR,
lines 27 and 56, plus any taxes that you identified using
code “UT” and entered on line 60.

}
9 Add lines 7 and 8 . . . . . . . . . . . . . . . . . . . 9
10 1040 filers: Enter the total of the amounts from Form 1040, lines
66a and 71.
1040A filers: Enter the total of the amount from Form 1040A, line
42a, plus any excess social security and tier 1 RRTA 10
taxes withheld that you entered to the left of line 46
(see separate instructions).
1040NR filers: Enter the amount from Form 1040NR, line 67.
11 Subtract line 10 from line 9. If zero or less, enter -0- . . . . . . . . . . . . . . . . . 11
12 Enter the larger of line 6 or line 11 . . . . . . . . . . . . . . . . . . . . . . 12
Next, enter the smaller of line 3 or line 12 on line 13.
Part IV Additional Child Tax Credit
13 This is your additional child tax credit . . . . . . . . . . . . . . . . . . . . . 13 1823
Enter this amount on
1040 Form 1040, line 67,
Form 1040A, line 43, or
1040A Form 1040NR, line 64.
1040NR

QNA Schedule 8812 (Form 1040A or 1040) 2017

 8867 Paid Preparer’s Due Diligence Checklist OMB No. 1545-1629

2017
Form Earned Income Credit (EIC), American Opportunity Tax Credit (AOTC), Child Tax Credit (CTC),
and Additional Child Tax Credit (ACTC)
Department of the Treasury To be completed by preparer and filed with Form 1040, 1040A, 1040EZ, 1040NR, 1040SS, or 1040PR. Attachment
Internal Revenue Service Go to www.irs.gov/Form8867 for instructions and the latest information. Sequence No. 70
Taxpayer name(s) shown on return Taxpayer identification number

AMANDA T HOLT 449-53-4365

Enter preparer’s name and PTIN

KATRINA EDWARDS P01836685

Part I Due Diligence Requirements

Please check the appropriate box for the credit(s) claimed on this return and EIC CTC/ACTC AOTC
complete the related Parts I–IV for the credit(s) claimed (check all that apply). X X
1 Did you complete the return based on information for tax year 2017 provided
by the taxpayer or reasonably obtained by you? . . . . . . . . . . X Yes No
2 Did you complete the applicable EIC and/or CTC/ACTC worksheets found in
the Form 1040, 1040A, 1040EZ, 1040SS, 1040PR, or 1040NR instructions,
and/or the AOTC worksheet found in the Form 8863 instructions, or your own
worksheet(s) that provides the same information, and all related forms and
schedules for each credit claimed? . . . . . . . . . . . . . . X Yes No
3 Did you satisfy the knowledge requirement? To meet the knowledge
requirement, you must do both of the following:
• Interview the taxpayer, ask questions, and document the taxpayer’s
responses to determine that the taxpayer is eligible to claim the credit(s)
• Review information to determine that the taxpayer is eligible to claim the
credit(s) and for what amount . . . . . . . . . . . . . . . . X Yes No
4 Did any information provided by the taxpayer, a third party, or reasonably
known to you, in connection with preparing the return, appear to be incorrect,
incomplete, or inconsistent? (If “Yes,” answer questions 4a and 4b. If “No,”
go to question 5.) . . . . . . . . . . . . . . . . . . . . Yes X No
a Did you make reasonable inquiries to determine the correct, complete, and
consistent information? . . . . . . . . . . . . . . . . . . Yes No
b Did you document your inquiries? (Documentation should include the
questions you asked, whom you asked, when you asked, the information that
was provided, and the impact the information had on your preparation of the
return.) . . . . . . . . . . . . . . . . . . . . . . . . Yes No
5 Did you satisfy the record retention requirement? To meet the record
retention requirement, you must keep a copy of your documentation
referenced in 4b, a copy of this Form 8867, a copy of applicable worksheets,
a record of how, when, and from whom the information used to prepare Form
8867 and worksheet(s) was obtained, and a copy of any document(s)
provided by the taxpayer that you relied on to determine eligibility or to
compute the amount for the credit(s) . . . . . . . . . . . . . . X Yes No
List those documents, if any, that you relied on.
TAXPAYER PROVIDED DOCS FOR DEPENDENTS AND
SELF

6 Did you ask the taxpayer whether he/she could provide documentation to
substantiate eligibility for and the amount of the credit(s) claimed on the
return if his/her return is selected for audit? . . . . . . . . . . . . X Yes No
7 Did you ask the taxpayer if any of these credits were disallowed or reduced in
a previous year? . . . . . . . . . . . . . . . . . . . .
(If credits were disallowed or reduced, go to question 7a; if not, go to question 8.) X Yes No

a Did you complete the required recertification Form 8862? . . . . . . . Yes No N/A
8 If the taxpayer is reporting self-employment income, did you ask questions to
prepare a complete and correct Form 1040, Schedule C? . . . . . . . X Yes No N/A
For Paperwork Reduction Act Notice, see separate instructions. Form 8867 (2017)
QNA
 HOLT 449-53-4365
Form 8867 (2017) Page 2

Part II Due Diligence Questions for Returns Claiming EIC (If the return does not claim EIC, go to Part III.)

EIC CTC/ACTC AOTC

9a Have you determined that this taxpayer is, in fact, eligible to claim the EIC for
the number of children for whom the EIC is claimed, or to claim EIC if the
taxpayer has no qualifying child? (Skip 9b and 9c if the taxpayer is claiming
EIC and does not have a qualifying child.) . . . . . . . . . . . . X Yes No
b Did you explain to the taxpayer that he/she may not claim the EIC if the
taxpayer has not lived with the child for over half the year, even if the
taxpayer has supported the child? . . . . . . . . . . . . . . . X Yes No
c Did you explain to the taxpayer the rules about claiming the EIC when a child X Yes No
is the qualifying child of more than one person (tie-breaker rules)? . . . . N/A
Part III Due Diligence Questions for Returns Claiming CTC and/or ACTC (If the return does not claim CTC or ACTC, go to
Part IV.)

10a Did all children for whom the taxpayer is claiming the CTC/ACTC reside with
the taxpayer? (If “Yes,” go to question 10c; if “No,” go to question 10b.) . . X Yes No
b Did you ask if there is an active Form 8332, Release/Revocation of Claim to
Exemption for Child by Custodial Parent, or a similar statement in place and, Yes No
if applicable, did you attach it to the return? . . . . . . . . . . . N/A
c Have you determined that the taxpayer has not released the claim to another X Yes No
person? . . . . . . . . . . . . . . . . . . . . . . . N/A
Part IV Due Diligence Questions for Returns Claiming AOTC (If the return does not claim AOTC, go to Part V.)

11 Did the taxpayer provide substantiation such as a Form 1098-T and/or

receipts for the qualified tuition and related expenses for the claimed AOTC? Yes No
Part V Credit Eligibility Certification

You have complied with all due diligence requirements with respect to the credits claimed on the return of the
taxpayer identified above if you:
A. Interview the taxpayer, ask adequate questions, document the taxpayer’s responses on the return or in your notes, review
adequate information to determine if the taxpayer is eligible to claim the credit(s) and in what amount(s);
B. Complete this Form 8867 truthfully and accurately and complete the actions described in this checklist for all credits
claimed;
C. Submit Form 8867 in the manner required; and
D. Keep all five of the following records for 3 years from the latest of the dates specified in the Form 8867 instructions under
Document Retention.
1. A copy of Form 8867,
2. The applicable worksheet(s) or your own worksheet(s) for any credits claimed,
3. Copies of any taxpayer documents you may have relied upon to determine eligibility for and the amount of the credit(s),
4. A record of how, when, and from whom the information used to prepare this form and worksheet(s) was obtained, and
5. A record of any additional questions you may have asked to determine eligibility for and amount of the credits, and the
taxpayer’s answers.
If you have not complied with all due diligence requirements for all credits claimed, you may have to pay a $510
penalty for each credit for which you have failed to comply.
12 Do you certify that all of the answers on this Form 8867 are, to the best of
your knowledge, true, correct, and complete? . . . . . . . . . . . X Yes No
Form 8867 (2017)

QNA
 AMANDA HOLT 449-53-4365

Before you begin: Figure the amount of any credits you are claiming on Form 5695, Part II, line 30*;
Form 8910; Form 8936; or Schedule R.
• To be a qualifying child for the child tax credit, the child must be under age 17 at the end of 2017 and meet the other
requirements listed earlier under Qualifying Child. Also see Taxpayer identification number needed by due date of return, earlier.
CAUTION
• If you do not have a qualifying child, you cannot claim the child tax credit.
*See the Form 5695 instructions to see if line 30 (nonbusiness energy property credit) applies for 2017.

Part 1 1. Number of qualifying children: 2 $1,000. Enter the result. 1 2000

2. Enter the amount from Form 1040, line 38;

Form 1040A, line 22; or Form 1040NR, line 37. 2 15150
3. 1040 Filers. Enter the total of any—
• Exclusion of income from Puerto Rico, and
• Amounts from Form 2555, lines 45 and 50;
Form 2555-EZ, line 18; and Form 4563, line 15. 3
1040A and 1040NR Filers. Enter -0-.

4. Add lines 2 and 3. Enter the total. 4 15150

5. Enter the amount shown below for your filing status.
• Married filing jointly - $110,000
• Single, head of household, or
5 75000
qualifying widow(er) - $75,000
• Married filing separately - $55,000

6. Is the amount on line 4 more than the amount on line 5?

X No. Leave line 6 blank. Enter -0- on line 7.
Yes. Subtract line 5 from line 4. 6
If the result is not a multiple of $1,000,
increase it to the next multiple of $1,000.
For example, increase $425 to $1,000,
increase $1,025 to $2,000, etc.

7. Multiply the amount on line 6 by 5% (0.05). Enter the result. 7 0

8. Is the amount on line 1 more than the amount on line 7?

No. STOP
You cannot take the child tax credit on Form 1040, line 52; Form 1040A,
line 35; or Form 1040NR, line 49. You also cannot take the additional
child tax credit on Form 1040, line 67; Form 1040A, line 43; or
Form 1040NR, line 64. Complete the rest of your Form 1040, Form 1040A,
or Form 1040NR.
X Yes. Subtract line 7 from line 1. Enter the result. 8 2000
Go to Part 2 on the next page.

QNA
 AMANDA HOLT 449-53-4365

Part 2 9. Enter the amount from Form 1040, line 47; Form 1040A, line 30; or 9 0
Form 1040NR, line 45.

10. Add the following amounts from:

Form 1040 or Form 1040A or Form 1040NR
Line 48 Line 46 +
Line 49 Line 31 Line 47 +
Line 50 Line 33 +
Line 51 Line 34 Line 48 +
Form 5695, line 30* +
Form 8910, line 15 +
Form 8936, line 23 +
Schedule R, line 22 +

Enter the total. 10 0

*See the Form 5695 instructions to see if line 30 (nonbusiness energy property
credit) applies for 2017.
11. Are you claiming any of the following credits?
interest credit, Form 8396.
Adoption credit, Form 8839.
energy efficient property credit, Form 5695, Part I.
of Columbia first-time homebuyer credit, Form 8859.
X No. Enter the amount from line 10.

Yes. If you are filing Form 2555 or 2555-EZ, enter the amount from 11 0
line 10. Otherwise, complete the Line 11 Worksheet, later, to figure
the amount to enter here.

12. Subtract line 11 from line 9. Enter the result. 12 0

13. Is the amount on line 8 of this worksheet more than the amount on line 12?

No. Enter the amount from line 8.

This is your
child tax credit. 13
X Yes. Enter the amount from line 12. 0
See the TIP below. Enter this amount on
Form 1040, line 52;
Form 1040A, line 35;
or Form 1040NR, line
49.

1040
A
1040 R
1 0 4 0 N
You may be able to take the additional child tax credit on
Form 1040, line 67; Form 1040A, line 43; or Form 1040NR,
TIP line 64, only if you answered “Yes” on line 13.
complete your Form 1040 through line 66a (also
complete line 71), Form 1040A through line 42a, or Form
1040NR through line 63 (also complete line 67).
use Parts II IV of Schedule 8812 to figure any
additional child tax credit.

QNA
 Form 8867 Due Diligence Notes
Taxpayer: AMANDA HOLT 449-53-4365

________________________________________________________________________________

Dependent Information:
_____________________

Name....: ISAAC SOSTAND

SSN.....: 634-80-9545 Relationship......: SON
Student.: NO School Attended...:
Disabled: NO Type of Disability:
Notes...:

Dependent Information:
_____________________

Name....: ISIAH POULLARD

SSN.....: 643-08-9275 Relationship......: SON
Student.: NO School Attended...:
Disabled: NO Type of Disability:
Notes...:

________________________________________________________________________________
Due Diligence Notes:
_______________________
 Paid Preparer's Earned Income Credit Checklist

Taxpayer name(s) shown on return Taxpayer's social security number

AMANDA T HOLT 449-53-4365
For the definitions of Qualifying Child and Earned Income, see Pub. 596.

Part I All Taxpayers

1 Enter preparer's name and PTIN KATRINA EDWARDS P01836685

2 Is the taxpayer’s filing status married filing separately? . . . . . . . . . . . . . . . Yes X No

If you checked “Yes” on line 2, stop; the taxpayer cannot take the EIC. Otherwise, continue.

3 Does the taxpayer (and the taxpayer’s spouse if filing jointly) have a social security number (SSN)
that allows him or her to work and is valid for EIC purposes? See the instructions before
answering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X Yes No

If you checked “No” on line 3, stop; the taxpayer cannot take the EIC. Otherwise, continue.

4 Is the taxpayer (or the taxpayer's spouse if filing jointly) filing Form 2555 or 2555-EZ (relating to the
exclusion of foreign earned income)? . . . . . . . . . . . . . . . . . . . . . Yes X No

If you checked “Yes” on line 4, stop; the taxpayer cannot take the EIC. Otherwise, continue.

5a Was the taxpayer (or the taxpayer's spouse) a nonresident alien for any part of 2017 ? . . . . Yes X No

If you checked “Yes” on line 5a, go to line 5b. Otherwise, skip line 5b and go to line 6.

b Is the taxpayer’s filing status married filing jointly? . . . . . . . . . . . . . . . . Yes No

If you checked “Yes” on line 5a and “No” on line 5b, stop; the taxpayer cannot take the EIC.
Otherwise, continue.

6 Is the taxpayer’s investment income more than $3,400? See the instructions before answering. Yes X No

If you checked “Yes” on line 6, stop; the taxpayer cannot take the EIC. Otherwise, continue.

7 Could the taxpayer be a qualifying child of another person for 2017 ? If the taxpayer's filing status is
married filing jointly, check “No.” Otherwise, see instructions before answering . . . . . . . Yes X No

If you checked “Yes” on line 7, stop; the taxpayer cannot take the EIC. Otherwise, go to Part II
or Part III, whichever applies.
 HOLT 449-53-4365

Part II Taxpayers With a Child

Caution: If there is more than one child, complete lines 8 through 14 for Child 1 Child 2 Child 3
one child before going to the next column. ISIAH ISAAC
8 Child’s name . . . . . . . . . . . . . . . . . . . . . POULLARD SOSTAND
9 Is the child the taxpayer’s son, daughter, stepchild, foster child, brother, sister,
stepbrother, stepsister, half brother, half sister, or a descendant of any of them? X Yes No X Yes No Yes No
10 Was the child unmarried at the end of 2017 ?
If the child was married at the end of 2017 , see the instructions before
answering . . . . . . . . . . . . . . . . . . . . . X Yes No X Yes No Yes No
11 Did the child live with the taxpayer in the United States for over half of 2017 ?
See the instructions before answering . . . . . . . . . . . . X Yes No X Yes No Yes No
12 Was the child (at the end of 2017 )—
• Under age 19 and younger than the taxpayer (or the taxpayer’s spouse,
if the taxpayer files jointly),
• Under age 24, a student (defined in the instructions), and younger than
the taxpayer (or the taxpayer’s spouse, if the taxpayer files jointly), or
• Any age and permanently and totally disabled? . . . . . . . . X Yes No X Yes No Yes No
If you checked “Yes” on lines 9, 10, 11, and 12, the child is the
taxpayer’s qualifying child; go to line 13a. If you checked “No” on line 9,
10, 11, or 12, the child is not the taxpayer’s qualifying child; see the
instructions for line 12.
13a Do you or the taxpayer know of another person who could check “Yes”
on lines 9, 10, 11, and 12 for the child? (If the only other person is the
taxpayer's spouse, see the instructions before answering.) . . . . . Yes X No Yes X No Yes No
If you checked “No” on line 13a, go to line 14. Otherwise, go to
line 13b.
b Enter the child’s relationship to the other person(s) . . . . . . . .
c Under the tiebreaker rules, is the child treated as the taxpayer’s qualifying Yes No Yes No Yes No
child? See the instructions before answering . . . . . . . . . . Don’t know Don’t know Don’t know
If you checked “Yes” on line 13c, go to line 14. If you checked “No,” the
taxpayer cannot take the EIC based on this child and cannot take the EIC for
taxpayers who do not have a qualifying child. If there is more than one child,
see the Note at the bottom of this page. If you checked “Don’t know,”
explain to the taxpayer that, under the tiebreaker rules, the taxpayer’s EIC
and other tax benefits may be disallowed. Then, if the taxpayer wants to take
the EIC based on this child, complete lines 14 and 15. If not, and there are no
other qualifying children, the taxpayer cannot take the EIC, including the EIC
for taxpayers without a qualifying child; do not complete Part III. If there is
more than one child, see the Note at the bottom of this page.
14 Does the qualifying child have an SSN that allows him or her to work and is
valid for EIC purposes? See the instructions before answering . . . . X Yes No X Yes No Yes No
If you checked “No” on line 14, the taxpayer cannot take the EIC
based on this child and cannot take the EIC available to taxpayers
without a qualifying child. If there is more than one child, see the Note at
the bottom of this page. If you checked “Yes” on line 14, continue.
15 Are the taxpayer’s earned income and adjusted gross income each less
than the limit that applies to the taxpayer for 2017 ? See instructions . . X Yes No
If you checked “No” on line 15, stop; the taxpayer cannot take the
EIC. If you checked “Yes” on line 15, the taxpayer can take the EIC.
Complete Schedule EIC and attach it to the taxpayer’s return. If there
are two or three qualifying children with valid SSNs, list them on
Schedule EIC in the same order as they are listed here. If the taxpayer’s
EIC was reduced or disallowed for a year after 1996, see Pub. 596 to see
if Form 8862 must be filed. Go to line 20.
Note: If there is more than one child, complete lines 8 through 14 for the
other child(ren) (but for no more than three qualifying children).
 EIC Due Diligence Notes
Taxpayer: AMANDA HOLT 449-53-4365

EIC Due Diligence Notes:

_______________________
TAXPAYER PROVIDED DOCS FOR DEPENDENTS AND SELF SHE CARRIES HER KIDS
WHICH SHE TAKES CARE OF THEM AND THEY LIVE WITH HER
 !"#$%&'()%#"*"+,-./0%112%2.3%114
AMANDA HOLT 449-53-4365

Worksheet A—2017 EIC—Lines 66a and 66b Keep for Your Records

Before you begin: Be sure you are using the correct worksheet. Use this worksheet only if you
answered “No” to Step 5, question 2. Otherwise, use Worksheet B.

Part 1 1. Enter your earned income from Step 5. 1

All Filers Using

2. Look up the amount on line 1 above in the EIC Table (right after
Worksheet A Worksheet B) to find the credit. Be sure you use the correct column 2
for your filing status and the number of children you have. Enter the
credit here.
STOP
If line 2 is zero, You can’t take the credit.
Enter “No” on the dotted line next to line 66a.

3. Enter the amount from Form 1040, line 38. 3

4. Are the amounts on lines 3 and 1 the same?

Yes. Skip line 5; enter the amount from line 2 on line 6.

No. Go to line 5.

5. If you have:
Part 2 ● No qualifying children, is the amount on line 3 less than $8,350
($13,950 if married filing jointly)?
Filers Who ● 1 or more qualifying children, is the amount on line 3 less than

Answered $18,350 ($23,950 if married filing jointly)?

“No” on Yes. Leave line 5 blank; enter the amount from line 2 on line 6.
Line 4
No. Look up the amount on line 3 in the EIC Table to find the
credit. Be sure you use the correct column for your filing
status and the number of children you have. Enter the credit 5
here.
Look at the amounts on lines 5 and 2.
Then, enter the smaller amount on line 6.

6. This is your earned income credit. 6

Part 3
Enter this amount on
Your Earned Form 1040, line 66a.

Income Credit
Reminder—
1040 1040
If you have a qualifying child, complete and attach Schedule EIC.
EIC

If your EIC for a year after 1996 was reduced or disallowed, see
Form 8862, who must file, earlier, to find out if you must file Form 8862 to take the
CAUTION credit for 2017.

!"#! !""#$%&'"$()*&'%+,(&)$&'$*&'%-.$/(-(,$01234&53
!"#$%&'()%#"*"+,-./0%112%2.3%114
AMANDA HOLT

Worksheet B—2017 EIC—Lines 66a and 66b Keep for Your Records
Use this worksheet if you answered “Yes” to Step 5, question 2.
Complete the parts below (Parts 1 through 3) that apply to you. Then, continue to Part 4.
If you are married filing a joint return, include your spouse’s amounts, if any, with yours to figure the amounts to
enter in Parts 1 through 3.

Part 1 1a. Enter the amount from Schedule SE, Section A, line 3, or
1a 14130
Section B, line 3, whichever applies.
Self-Employed, + 1b
b. Enter any amount from Schedule SE, Section B, line 4b, and line 5a.
Members of the
Clergy, and c. Combine lines 1a and 1b. = 1c 14130
People With d. Enter the amount from Schedule SE, Section A, line 6, or
Church Employee Section B, line 13, whichever applies.
– 1d 998
Income Filing
e. Subtract line 1d from 1c. = 1e 13132
Schedule SE

2. Don’t include on these lines any statutory employee income, any net profit from services performed as a
Part 2 notary public, any amount exempt from self-employment tax as the result of the filing and approval of Form
4029 or Form 4361, or any other amounts exempt from self-employment tax.
Self-Employed
NOT Required a. Enter any net farm profit or (loss) from Schedule F, line 34, and from
2a
farm partnerships, Schedule K-1 (Form 1065), box 14, code A*.
To File
Schedule SE b. Enter any net profit or (loss) from Schedule C, line 31; Schedule C-EZ,
line 3; Schedule K-1 (Form 1065), box 14, code A (other than farming);
For example, your + 2b
and Schedule K-1 (Form 1065-B), box 9, code J1*.
net earnings from
self-employment
were less than $400. c. Combine lines 2a and 2b. = 2c
*If you have any Schedule K-1 amounts, complete the appropriate line(s) of Schedule SE, Section A.
Reduce the Schedule K-1 amounts as described in the Partner’s Instructions for Schedule K-1. Enter
your name and social security number on Schedule SE and attach it to your return.

Part 3
Statutory Employees 3. Enter the amount from Schedule C, line 1, or Schedule C-EZ, line 1, that
3
Filing Schedule you are filing as a statutory employee.
C or C-EZ

Part 4 4a. Enter your earned income from Step 5. 4a 2018

All Filers Using

4b 15150
Worksheet B b. Combine lines 1e, 2c, 3, and 4a. This is your total earned income.
Note. If line 4b STOP
includes income on If line 4b is zero or less, You can’t take the credit. Enter “No” on the dotted line next to line 66a.
which you should 5. If you have:
have paid self- ● 3 or more qualifying children, is line 4b less than $48,340 ($53,930 if married filing jointly)?
employment tax but
● 2 qualifying children, is line 4b less than $45,007 ($50,597 if married filing jointly)?
didn’t, we may
● 1 qualifying child, is line 4b less than $39,617 ($45,207 if married filing jointly)?
reduce your credit by
the amount of ● No qualifying children, is line 4b less than $15,010 ($20,600 if married filing jointly)?
self-employment tax x Yes. If you want the IRS to figure your credit, see Credit figured by the IRS, earlier. If you want to
not paid. figure the credit yourself, enter the amount from line 4b on line 6 of this worksheet.
STOP
No. You can’t take the credit. Enter “No” on the dotted line next to line 66a.

!""#$%&'"$()*&'%+,(&)$&'$*&'%-.$/(-(,$01234&53 !"#!
 !"#$%&'()%#"*"+,-./0%112%2.3%114

Worksheet B —2017 EIC—Lines 66a and 66b—Continued Keep for Your Records

Part 5
6. Enter your total earned income from Part 4, line 4b. 6 15150
All Filers Using
Worksheet B 7. Look up the amount on line 6 above in the EIC Table to find
the credit. Be sure you use the correct column for your filing status 7 5616
and the number of children you have. Enter the credit here.

If line 7 is zero, STOP You can’t take the credit.

Enter “No” on the dotted line next to line 66a.

8. Enter the amount from Form 1040, line 38. 8 15150

9. Are the amounts on lines 8 and 6 the same?

x Yes. Skip line 10; enter the amount from line 7 on line 11.

No. Go to line 10.

10. If you have:

Part 6
● No qualifying children, is the amount on line 8 less than $8,350
($13,950 if married filing jointly)?
Filers Who
● 1 or more qualifying children, is the amount on line 8 less than $18,350
Answered ($23,950 if married filing jointly)?
“No” on
Yes. Leave line 10 blank; enter the amount from line 7 on line 11.
Line 9
No. Look up the amount on line 8 in the EIC Table to find the
credit. Be sure you use the correct column for your filing
status and the number of children you have. Enter the credit 10
here.
Look at the amounts on lines 10 and 7.
Then, enter the smaller amount on line 11.

Part 7 11. This is your earned income credit. 11 5616

Enter this amount on
Your Earned Reminder— Form 1040, line 66a.
Income Credit
If you have a qualifying child, complete and attach Schedule EIC. 1040

EIC 1040

If your EIC for a year after 1996 was reduced or disallowed, see
Form 8862, who must file, earlier, to find out if you must file Form
CAUTION 8862 to take the credit for 2017.

!"#! !""#$%&'"$()*&'%+,(&)$&'$*&'%-.$/(-(,$01234&53
Supporting Statement for TAX SUMMARY
Taxpayer: HOLT SSN: 449-53-4365
________________________________________________________________________________
TAXPAYER PROVIDED DOCS FOR DEPENDENTS AND SELF SHE CARRIES HER KIDS
WHICH SHE TAKES CARE OF THEM AND THEY LIVE WITH HER
 616959
EFIN_____________

IMPORTANT DISCLOSURES RELATED TO THE REFUND DISBURSEMENT SERVICE

PLEASE READ THESE BEFORE YOU SIGN THE APPLICATION
If you are owed a federal tax refund, you have the right to choose how you will receive the refund. There are several options
available to you. Some options require you to pay fees for the Tax Refund Disbursement Service and some options are free.
Please read about these options below.

You can file your tax return electronically or by paper and obtain your refund directly from the IRS for free. The IRS can send
your refund either by check mailed directly to you by U.S. Mail, or by direct deposit to your bank/credit union account. Options available
to you to receive your refund directly from the IRS include:

Filing Method Disbursement Estimated Availability Of Funds * Tax Preparation Fees

Paper Return IRS Issued Check 5 to 7 weeks You Pay Preparer Directly
Paper Return IRS Direct Deposit 5 to 7 weeks You Pay Preparer Directly
E-File IRS Issued Check 21 to 28 days You Pay Preparer Directly
E-File IRS Direct Deposit Less than 21 days You Pay Preparer Directly
* The estimates shown above do not include any additional time that may be required for your bank to make the funds available to you after the refund
is deposited to your account, or for IRS mail delivery.

You can file your tax return electronically and obtain your refund through our Refund Disbursement Service. If you choose to
receive your refund through our Refund Disbursement Service (the “Disbursement Service” or “Service”), your tax refund will be sent by
the government to a temporary special purpose deposit account at a bank, from which we will send you the refund amount after we have
made all deductions authorized by you. For comparison, the table below contains information about the Service:

Filing Method Disbursement Options Available Estimated Availability Of Funds Tax Preparation Fees
E-File Check, Direct Deposit*, Prepaid Card** Less than 21 days Can be Deducted from Refund
* Please allow additional time for direct deposit processing at your bank. ** Check with your tax preparer for availability.

Fees related to this Service: If you decide to use our Service, fees vary based upon the disbursement option you select. These options
and fees are set out in the chart below. Only the 1st disbursement fee is charged if you receive just one tax refund (whether federal or
state). Both the 1st and 2nd disbursement fees are charged if you receive more than one tax refund. The 2nd disbursement fee is charged
only once for any refund after the 1st Refund, regardless of how many refunds are received. If you use our Service, the disbursement fees
charged will be deducted from the tax refund proceeds you receive and can reduce the amount you can expect from your tax refund.
Disbursement Options and Costs (Fees vary) Disbursement Fees
FasterMoney® Visa® Prepaid Card (previously enrolled for at www.myfastermoney.com). No fees for in-network ATM 1st Refund: $39.00
withdrawals. See Cardholder Agreement for complete details, including all other fees, related to use of the prepaid card. 2nd Refund: $10.00
New FasterMoney Visa Prepaid Card (obtained from your Tax Preparer). No fees to use the card at merchants to
1st Refund: $39.00
purchase goods or services during the first 30 days after issuance. Card will be issued to Primary Applicant in the case of a
2nd Refund: $10.00
joint return. See Cardholder Agreement for complete details including all other fees.
Paper Check. By selecting the paper check option, you authorize and direct us to issue a check payable to you and deliver it 1st Refund: $39.00
to your Tax Preparer or to your address. 2nd Refund: $10.00
ACH Credit (direct deposit) to existing bank account or other prepaid card. Advance disbursements not available. 1st Refund: $39.00
Rejected disbursements will be disbursed via paper check and the paper check fees will apply. 2nd Refund: $10.00

Other important information:

No one can guarantee whether, when or in what amount a tax refund will be issued. The IRS does not guarantee a specific date that
a tax refund will be received by mail or deposited to a bank account, whether or not you use this Service.
The use of our Service will not provide a speedier payment of your refund than you can obtain for yourself through electronic filing and
requesting the direct deposit to your own bank or credit union account.
Consult with tax advisor for tax planning advice. By changing your tax withholding in future years, you may be able to lower refund
amounts you may receive but increase your wage income during those years.
For information on opening a low-cost bank account, or to access financial education resources, go to www.eta-find.gov.
Once your tax return is filed, you may visit www.irs.gov and click on ‘Where’s My Refund’ to learn information about the processing of
your refund.

O931.20171023 RT Important Disclosures - RT - O - 2017/18  

 
Refund Disbursement Service Agreement
1. GENERAL INFORMATION ABOUT THE REFUND DISBURSEMENT SERVICE: As used in this agreement for the Refund
Disbursement Service (“Agreement”), as well as the attached Refund Disbursement Application (“Application”), or collectively, the
“Application and Agreement”, the terms “you” and “your” mean the person signing as the “Applicant” (or, if a joint return is being filed,
both “Primary Applicant” and “Joint Applicant”). The term “Bank” means The Ohio Valley Bank Company, a FDIC insured depository
institution. The term “Servicer” refers to Refund Advantage, a division of MetaBank who acts as a third-party processor for your return.
The terms “we,” “us,” and “our” mean Bank and Servicer. By completing this Agreement, you hereby authorize Bank to receive your
income tax refund(s) on your behalf and to make disbursements from your refund(s) as authorized by this Agreement (“Service”). You
authorize Bank to receive a direct deposit of your refund(s) from the Internal Revenue Service (“IRS”) and/or state taxing authorities, on
your behalf and to be held temporarily in escrow for your benefit, until Bank disburses any amounts, fees and charges authorized by this
Agreement to be disbursed from your refund(s), including but not limited to any Refund Disbursement Fee (as set forth in this Agreement),
and your tax preparation fees and any other amounts, fees and charges authorized by this Agreement from your Account. After deducting
all fees and charges as provided for in this Agreement, we will disburse the remaining balance of your tax refund(s), if any, in accordance
with your direction. You understand that you have the ability to pay your tax preparation fees and file your tax return(s) without
using the Service.

2. TEMPORARY SPECIAL PURPOSE DEPOSIT ACCOUNT: By signing this Agreement, you authorize Bank to (i) receive the direct
deposit of your federal and/or state tax refund(s) into a special purpose deposit account (the “Account”) used by Bank solely for the receipt
of tax refunds, (ii) make any authorized deductions specified by you on the attached itemization of Refund Disbursement Fees and
Authorized Deductions and disburse them to third parties as authorized by this Agreement, and (iii) cause the remainder of your refund(s)
received into the Account to be disbursed to you as directed by you in this Agreement. The Bank will hold your refund(s) in this Account
solely for your benefit and only until your tax refund(s) have been fully disbursed. You will not be able to make any further deposits into
or withdrawals from this Account, to close the Account, or to take any other action with respect to the Account. The Account is non-
interest bearing, so you will receive no interest on your refund(s) while the Bank holds your refund(s). The Account is intended for use
for the direct deposit and disbursement of tax refunds received by Bank. Once your tax refunds for the 2017 tax year have been fully
disbursed from the Account, your interest in the Account will be terminated.

3. RECEIPT AND APPLICATION OF TAX REFUND(S): By signing the Application you authorize your Tax Preparer and Servicer to
make arrangements with the IRS (and state taxing authority, if applicable) to remit your tax refund to the Bank by direct deposit for the
2017 tax year. You authorize Tax Preparer to submit the Application on your behalf. You appoint Servicer as your agent for all purposes
necessary to carrying out the Service, including assisting you with obtaining an electronic payment of your federal and/or state tax
refund(s), making arrangements for your tax refund to be received into the Account and providing for the payments from this Account as
described herein. You acknowledge that your refund may be delayed or returned to the IRS if fraud or identity theft is suspected.

4. REFUND DISBURSEMENT OPTIONS AND FEES: Enrolling in the Disbursement Service allows you to direct your refund proceeds
to multiple entities from whom you have chosen to obtain various services. The Disbursement Service is an optional service and is not
required in order to file your taxes or receive a tax refund. For your convenience, we offer multiple options for refund disbursements.
You will select the option in which you wish to receive the proceeds that are to be provided to you under this Agreement. Please review
the options carefully as the fees associated with refund disbursements vary depending on the option you select. If the account
information supplied by you or your representative to us is inaccurate or incorrect, you will be responsible for any loss as a consequence
of any funds transfer made using such erroneous information. In addition, if the transfer is rejected by your financial institution, or if
transfer cannot be accomplished for any other reason, then your net tax refund proceeds will be delivered by paper check, and the
applicable check fees will apply.

5. SHARING INFORMATION: You authorize your 2017 tax return and refund information to be shared with and among: the IRS,
applicable state taxing authority, Tax Preparer, applicable service bureau, transmitter, Servicer, and Bank. You also authorize Servicer
and Bank to share such information with (i) your Tax Preparer, (ii) any applicable service bureau, transmitter, and third parties involved
in the Service, and/or (iii) others (including the government) as necessary for the Service and to detect or report suspicious or fraudulent
tax returns and/or possible fraudulent activity, as permitted by law. You authorize us to provide your Tax Preparer and any applicable
service bureau and/or transmitter information regarding the status of your account and to perform any actions they deem necessary to
verify the accuracy of information contained in this Agreement. You authorize Servicer to inquire of the IRS as to the status of your tax
refund. You also authorize Servicer to inquire of the Treasury Offset Program Call Center to determine whether your tax refund may be
offset. You may not revoke any of the foregoing authorizations except as permitted by applicable law. You may authorize us to share
information with certain of our affiliates and non-affiliates by your separate agreement. For more information about our privacy
policies, see the Privacy Policies at the end of this Agreement.

6. ACKNOWLEDGEMENT REGARDING TAX PREPARER: You have the right to complete and submit your own tax return(s) to the
IRS (or state taxing authority) without the use of this Service or without the employment of a Tax Preparer. If you elect to use the Service,
only returns transmitted to Servicer by a Tax Preparer acceptable to us will be eligible for the Service. Your Tax Preparer is solely
responsible for preparing and/or filing your tax returns, and you affirm that you have chosen the Tax Preparer for your own reasons and/or
convenience, without the recommendation or endorsement of Bank or Servicer. Bank and Servicer will not verify the Tax Preparer’s
returns for accuracy, compliance, completeness or filing errors. You agree that your Tax Preparer is fully authorized to act as your agent
for all purposes necessary to effect the purpose of this Agreement and has so acted as your agent in connection with the completion and
transmission to Bank and Servicer of this Agreement, and is acting as your agent to arrange and/or accept delivery of your check(s) or
Prepaid Card as selected by you under this Agreement, if any. You authorize us to rely upon information communicated on your behalf
by the Tax Preparer. You absolve and will not hold Bank or Servicer liable should your Tax Preparer negligently or intentionally fail to
deliver accurate information about yourself, should the Tax Preparer make a mistake in the computation of your tax return(s) or make any
other error or omission in submitting the same, or should the Tax Preparer fail to deliver a check or Prepaid Card to you. You also agree
that if Bank or Servicer is legally required to give you any specific notices or disclosures, Bank or Servicer may deliver such information
to your Tax Preparer as your agent.

O932.20171023 RT Application & Agreement - RT - O - 2017/18 Page 1 of 8 

 
7. QUESTIONS AND CONCERNS: If you have a question regarding the temporary account or Refund Disbursement Service, or
believe an unauthorized transaction has been made, contact us IMMEDIATELY by telephone at (866) 876 - 6648, or write to Refund
Advantage, 9000 Wessex Place, Suite 101, Louisville, KY 40222 (“Notice Address”). Please include your name and account number,
and a brief description of the issue, including the amount and date of the transaction in question. We will look into your question or your
claim. You agree to cooperate with us. If you do not contact us within a reasonable time, it may affect our ability to help.

8. MISCELLANEOUS: No one can, and Servicer does not, guarantee the amount of your tax refund, if any, or the date on which it
may be received. Furthermore, you understand that your requests made in the Application and Agreement may be denied for any reason.
By signing this Application and Agreement, you agree that Servicer may assign, sell, or transfer all or part of its rights arising under this
Agreement, in whole or in part, to a third party or to an affiliate. You may not assign your rights and responsibilities under this Agreement.
You agree that any document completed and/or signed by you that is sent to us by facsimile or electronic means will be valid and binding
as the original of the document in question. This Agreement shall be governed by the laws of the State of Ohio and applicable federal
laws; except that the Waiver of Right to Trial by Jury and Arbitration Provision (“Dispute Clause”) contained in Section 10 below
shall be governed solely by federal law. The provisions of this Agreement, including but not limited to Section 10, shall survive the
termination of this Agreement and/or the completion of the transactions contemplated herein, including the disbursement to you of your
net tax refund proceeds and/or the filing for protection of the bankruptcy courts by any party to this Agreement. If any provision of this
Agreement is deemed invalid or prohibited by applicable law, such provision shall be ineffective to the extent of such invalidity or
prohibition; but the remainder of such provisions or the remaining provisions of this Agreement will remain enforceable. Any headings or
captions are intended solely for convenience or reference purposes and shall not constitute part of this Agreement.

9. LIABILITY RELEASE AND DAMAGE LIMITATION: You agree by signing this Application and Agreement that Servicer and
Bank (collectively, the “Released Parties”) are not responsible to you for any payment or disbursement which is made in
accordance with this Agreement, and you hereby release Released Parties from any such liability for having made such payment
or disbursement. You agree that Released Parties are not liable or responsible to you or joint recipients of your tax refunds,
for: (a) a taxing authority’s failure to make a refund payment, failure to make a refund in a complete or timely fashion, claiming
a right in the nature of off-set against any refund to which you may be otherwise entitled, or paying the refund to an improper
taxpayer or account; or (b) any act, error or omission of the Tax Preparer in preparing and/or filing your return, or in the handling
or disbursement of any check or Prepaid Card, or complying with its duties under this Agreement. Subject to the foregoing,
Released Parties will not be liable to you under the Agreement or Service, except for Released Parties’ own and unilateral failure to
exercise ordinary care in carrying out the Service expressly assumed under this Agreement and except for violations of law where you
are granted a private right of action by the controlling law. Released Parties shall not be in violation of their obligation of “ordinary care”
by a mistake in fact or judgment based upon Released Parties’ honesty-in-fact reasoned belief and conduct. You further agree that clerical
error, inadvertence or oversight, absent proven willful intent, will not be oppression, fraud or malice or a wrongful, intentional or grossly
negligent act, error or omission. In any event where or when Released Parties are found to have breached this Agreement or otherwise
acted negligently with respect to the Service, you will be entitled to recover your direct losses and damages; but in no event will you be
entitled to recover from the Released Parties any indirect, consequential, punitive, reliance, exemplary or special damages, including but
not limited to attorney fees or court costs, even if the same damage(s) were reasonably foreseeable or we had been advised in advance
by you of its possibility. Released Parties will not be liable for physical or legal circumstances beyond their control (such as fire, flood,
intervening conduct of others, etc.), or for delay that results if the contemplated transfer to you is delayed because of defect or interruption
of any system associated with the transfer.

10. WAIVER OF RIGHT TO TRIAL BY JURY AND ARBITRATION PROVISION:

YOU AND WE ACKNOWLEDGE THAT THE RIGHT TO TRIAL BY JURY IS A CONSTITUTIONAL RIGHT BUT MAY BE WAIVED IN
CERTAIN CIRCUMSTANCES. TO THE EXTENT PERMITTED BY LAW, YOU AND WE KNOWINGLY AND VOLUNTARILY WAIVE
ANY RIGHT TO TRIAL BY JURY IN THE EVENT OF LITIGATION ARISING OUT OF OR RELATED TO THIS AGREEMENT.

We have put this arbitration provision (“Dispute Clause”) in question and answer form to make it easier to follow. However, this Dispute
Clause is part of this Agreement and is legally binding.
Background and Scope
Short
Question Further Detail
Answer
An
What is
alternative In arbitration, a third party arbitrator (“Arbitrator”) solves Disputes in an informal hearing.
arbitration?
to court
Is it different
The hearing is private. There is no jury. It is usually less formal, faster and less expensive than a
from court
Yes lawsuit. Pre-hearing fact finding is limited. Appeals are limited. Courts rarely overturn arbitration
and jury
awards.
trials?
Can you opt- If you do not want this Dispute Clause to apply, you must send us a signed notice within 60 calendar
out of this Yes, within days after your first disbursement. You must send the notice in writing (and not electronically) to our
Dispute 60 days Notice Address indicated above, Attn: General Counsel. Provide your name and address. State that
Clause? you “opt out” of the dispute clause.
The parties'
What is this
agreement Unless prohibited by applicable law and unless you opt out, you and we agree that you or we
Dispute
to arbitrate may elect to arbitrate or require arbitration of any "Dispute" as defined below.
Clause about?
Disputes

O932.20171023 RT Application & Agreement - RT - O - 2017/18 Page 2 of 8 

 
You, us and This Dispute Clause governs you and us. It also covers certain "Related Parties": (1) our parents,
Who does the
certain subsidiaries and affiliates; (2) our employees, directors, officers, shareholders, members and
Dispute
"Related representatives; and (3) any person or company that is involved in a Dispute you pursue at the same
Clause cover?
Parties" time you pursue a related Dispute with us.
This Dispute Clause governs all “Disputes” that would usually be decided in court and are between
All Disputes us (or any Related Party) and you. In this Dispute Clause, the word “Disputes” has the broadest
(except reasonable meaning. It includes all claims even indirectly related to your Application, this Agreement,
What
certain the Disbursement Service or our relationship with you. It includes claims related to collections,
Disputes does
Disputes privacy, data security and customer information. It includes claims related to the validity in general
the Dispute
about this of this Agreement. However, it does not include disputes about the validity, coverage or scope
Clause cover?
Dispute of this Dispute Clause or any part of this Dispute Clause. (This includes a Dispute about the
Clause) rule against class arbitration.) All such disputes are for a court and not an Arbitrator to
decide.
Arbitrations are conducted under this Dispute Clause and the rules of the arbitration administrator
in effect when the arbitration is started. However, arbitration rules that conflict with this Dispute
Clause do not apply. The arbitration administrator will be either:
The American Arbitration Association ("AAA"), 1633 Broadway, 10th Floor, New York, NY
10019, www.adr.org.
Who handles Usually
JAMS, 620 Eighth Avenue, 34th Floor, New York, NY 10018, www.jamsadr.com
the AAA or
arbitration? JAMS Any other company picked by agreement of the parties.
If all the above options are unavailable, a court will pick the administrator. No arbitration may be
administered without our consent by any administrator that would permit a class arbitration
under this Dispute Clause. The arbitrator will be selected under the administrator's rules. However,
the arbitrator must be a lawyer with at least ten years of experience or a retired judge unless you
and we otherwise agree.
Either party may bring a lawsuit if the other party does not demand arbitration. We will not demand
Can Disputes arbitration of any lawsuit you bring as an individual action in small-claims court. However, we may
Sometimes
be litigated? demand arbitration of any appeal of a small-claims decision or any small-claims action brought on a
class basis.
For Disputes subject to this Dispute Clause, you give up your right to:
1. Have juries decide Disputes.
2. Have courts, other than small-claims courts, decide Disputes.
Are you
3. Serve as a private attorney general or in a representative capacity.
giving up any Yes
4. Join a Dispute you have with a dispute by other consumers.
rights?
5. Bring or be a class member in a class action or class arbitration.
We also give up the right to a jury trial and to have courts decide Disputes you wish to
arbitrate.
Can you or
The Arbitrator is not allowed to handle any Dispute on a class or representative basis. All
another
Disputes subject to this Dispute Clause must be decided in an individual arbitration or an individual
consumer No
small-claims action. This Dispute Clause will be void if a court rules that the Arbitrator can decide a
start a class
Dispute on a class basis and the court's ruling is not reversed on appeal.
arbitration?
This Agreement and the Service involve interstate commerce. Thus, the FAA governs this Dispute
The Federal
What law Clause. The Arbitrator must apply substantive law consistent with the FAA. The Arbitrator must
Arbitration
applies? honor statutes of limitation and privilege rights. Punitive damages are governed by the constitutional
Act (“FAA”)
standards that apply in judicial proceedings.
Will anything I
do make this
This Dispute Clause stays in force even if: (1) you or we end this Agreement; (2) we transfer or
Dispute No
assign our rights under this Agreement; or (3) you go into or through bankruptcy.
Clause
ineffective?
Process
Before starting a lawsuit or arbitration, the complaining party must give the other party written notice
Send a
What must a of the Dispute. The notice must explain in reasonable detail the nature of the Dispute and any
written
party do supporting facts. If you are the complaining party, you must send the notice in writing (and not
Dispute
before electronically) to our Notice Address, Attn: General Counsel. You or an attorney you have personally
notice and
starting a hired must sign the notice and must provide your name and a phone number where you (or your
work to
lawsuit or attorney) can be reached. A letter from us to you will serve as our written notice of a Dispute. Once
resolve the
arbitration? a Dispute notice is sent, the complaining party must give the other party a reasonable opportunity
Dispute
over the next 30 days to resolve the Dispute on an individual basis.
   

O932.20171023 RT Application & Agreement - RT - O - 2017/18 Page 3 of 8 

 
If the parties do not reach an agreement to resolve the Dispute within 30 days after notice of the
Dispute is received, the complaining party may commence a lawsuit or an arbitration, subject to the
How does an terms of this Dispute Clause. To start an arbitration, the complaining party picks the administrator
Mailing a
arbitration and follows the administrator's rules. If one party begins or threatens a lawsuit, the other party can
notice
start? demand arbitration. This demand can be made in court papers. It can be made if a party begins a
lawsuit on an individual basis and then tries to pursue a class action. Once an arbitration demand is
made, no lawsuit can be brought and any existing lawsuit must stop.
Will any The Arbitrator may decide that an in-person hearing is unnecessary and that he or she can resolve
hearing be Yes a Dispute based on written filings and/or a conference call. However, any in-person arbitration
held nearby? hearing must be held at a place reasonably convenient to you.
Appeal rights under the FAA are very limited. Except for FAA appeal rights and except for Disputes
involving more than $50,000 (including Disputes involving requests for injunctive relief that could
cost more than $50,000), the Arbitrator’s award will be final and binding. For Claims involving more
What about
Very limited than $50,000, any party may appeal the award to a three-arbitrator panel appointed by the
appeals?
administrator, which will reconsider from the start anything in the initial award that is appealed. The
panel's decision will be final and binding, except for any FAA appeal right. Any appropriate court
may enter judgment upon the arbitrator's award.
Arbitration Fees and Awards
Who bears
We will pay all filing, administrative, hearing and Arbitrator fees if you act in good faith, cannot get
arbitration Usually, us.
a waiver of such fees and ask us to pay.
fees?
When will we If you win an arbitration, we will pay the reasonable fees and costs for your attorneys, experts and
cover your witnesses. We will also pay these amounts if required under applicable law or the administrator's
If you win
legal fees and rules or if payment is required to enforce this Dispute Clause. The Arbitrator shall not limit his or
costs? her award of these amounts because your Dispute is for a small amount.
Will you ever
owe us for The Arbitrator can require you to pay our fees if (and only if): (1) the Arbitrator finds that you have
Only for
arbitration or acted in bad faith (as measured by the standards set forth in Federal Rule of Civil Procedure
bad faith
attorneys' 11(b)); and (2) this power does not make this Dispute Clause invalid.
fees?
You are entitled to an arbitration award of at least $7,500 if: (1) you give us notice of a Dispute on
Can our your own behalf (and not on behalf of any other party) and comply with all of the requirements of
failure to this Dispute Clause (including the requirements described in response to the question reading
resolve a "What must a party do before starting a lawsuit or arbitration?”); and (2) the Arbitrator awards you
Dispute money damages greater than the last amount you requested at least ten days before the
informally Yes arbitration commenced. This is in addition to the attorneys' fees and expenses (including expert
result in a witness fees and costs) to which you are otherwise entitled. This $7,500 minimum award is a
larger single award that applies to all Disputes you have raised or could have raised in the arbitration.
recovery for Multiple awards of $7,500 are not contemplated by this Dispute Clause. Settlement demands and
you? offers are strictly confidential. They may not be used in any proceeding by either party except to
justify a minimum recovery of $7,500.
Can an award A party may request details from the Arbitrator, within 14 days of the ruling. Upon such request,
Yes
be explained? the Arbitrator will explain the ruling in writing.
 

   

O932.20171023 RT Application & Agreement - RT - O - 2017/18 Page 4 of 8 

 
Refund Disbursement Service Application
In accordance with the attached Agreement and as indicated in this Application, upon receipt of your federal and/or state refund(s), you
authorize The Ohio Valley Bank Company and Refund Advantage, a division of MetaBank, to disburse your refund(s) as indicated below:

APPLICANT SELECTION:
Disbursement Selection – Please check one box on left to indicate your selection. Disbursement Fees
® ®
FasterMoney Visa Prepaid Card (previously enrolled for at www.myfastermoney.com). Refund Disbursement 1st Refund: $39.00
Fees apply. No fees for Advance disbursements and no fees for in-network ATM withdrawals. Refund proceeds will 2nd Refund: $10.00
be disbursed to the account identified. See Cardholder Agreement for complete details, including all other fees, related
to use of the prepaid card.

Bank Routing Number: ________________________________

Account Number: ____________________________________
New FasterMoney Visa Prepaid Card (obtained from your Tax Preparer). Refund Disbursement Fees apply. No 1st Refund: $39.00
fees for Advance disbursements and No fees to use the card at merchants to purchase goods or services during the 2nd Refund: $10.00
first 30 days after issuance. Card will be issued to Primary Applicant in the case of a joint return. See Cardholder
Agreement for complete details, including all other fees, related to use of the prepaid card.

Card Envelope Number: ________________________________

Paper Check. Refund Disbursement Fees apply. No fees for Advance disbursements. By selecting the paper 1st Refund: $39.00
check option, you authorize and direct us to issue a check payable to you and deliver it to your Tax Preparer or to 2nd Refund: $10.00
your address.
ACH Credit (direct deposit) to existing bank account or other prepaid card. Refund Disbursement Fees apply. 1st Refund: $39.00
Advance disbursements not available. If disbursement is rejected for any reason such as incorrect account information 2nd Refund: $10.00
provided by you, we will disburse via paper check and the paper check fees will apply.
111900659
Bank Routing Number: ________________________________
8418160993
Account Number: ____________________________________ Type of Account: Checking Savings

FEES AND AUTHORIZED DEDUCTIONS:

Expected Refund Amount* $ 5,501.00
(1) Tax Preparation Fees paid to Tax Preparer $ 585.00
- Tax Preparation fees $ 585.00
- E-File fees $ 0.00
(2) Service Bureau Fee paid to Service Bureau $ 35.00
(3) Transmitter Fee paid to Transmitter $ 68.00
(4) Disbursement Fee(s)† $ 39.00
(5) Audit Fee paid to AMP $ 39.99
(6) Other Authorized Deductions $___________
0.00
Estimated Total Deductions** [(1)+(2)+(3)+(4)+(5)+(6)] 766.99
- $___________
Estimated Refund Amount Paid to You †† 4,734.01
$___________
Please Note: If you apply and are approved for an Advance, your Estimated Refund Amount Paid to You will be
reduced by the amount of the Advance. You may consult your Refund Advance Loan Disclosure and Agreement for
more information.
* Expected Refund Amount is based upon the tax information to be filed with the IRS and/or state taxing authority by your Tax Preparer. If the actual
refund amount is lower, the Estimated Refund Amount Paid to You will also be lower.
†
Disbursement Fee(s) include the applicable fees in connection with your disbursement option. This amount may be higher if you receive a second
tax refund, and we only anticipated one tax refund (in which case the fees for a second disbursement in connection with your disbursement selection
will apply).

** The Estimated Total Deductions are a good faith estimate of associated fees. Fees will be due upon commencement of disbursement services.
††
The Estimated Refund Amount Paid to You equals the Expected Refund Amount less the Estimated Total Deductions and may be made in
multiple disbursements. The actual amount paid directly to you may be higher or lower if the actual amount of your refund received from the IRS
or state taxing authorities is different than the Expected Refund Amount set forth above.

(Certifications and signature lines continued on the next page.)

O932.20171023 RT Application & Agreement - RT - O - 2017/18 Page 5 of 8 

 
CERTIFICATIONS:

By signing this Application, I, the Primary Applicant (and Joint Applicant if applicable), hereby certify:
1. The information I have provided is true and accurate.
2. I am at least eighteen (18) years old, and I have supplied my Tax Preparer with one of the following valid forms of Picture ID: Driver’s
License, BMV/DMV State ID, Military ID, Passport, Resident Alien ID, or other Government-Issued Picture ID.
3. I understand that the Refund Disbursement Service is not a loan or an extension of credit and that the Refund Disbursement Service
is an optional product and is not required in order to file my taxes or receive a tax refund.
4. I have received a separate listing of fees relating to tax preparation services and tax return filing.
5. I received a completed copy of (i) this Application and Agreement and (ii) disclosure page titled “Important Disclosures related to the
Refund Disbursement Service”. I have carefully read and considered all of the provisions of this Application and Agreement.
6. I authorize the deductions of each of the amounts specified above prior to the proceeds of my tax refund being disbursed to me, and
I have selected my disbursement option above.
7. I have read, understand, and agree to all of the terms of this Application and Agreement, including the WAIVER OF RIGHT TO TRIAL
BY JURY AND ARBITRATION PROVISION.
8. By using Refund Advantage for disbursement, I understand and agree to be bound by the terms of the Refund Disbursement Service
Agreement.
9. I have authorized my tax preparer to submit this Application on my behalf. I acknowledge that the services provided by my Tax
Preparer and/or others are not complete and the fees for such services are not due until disbursement of my refund proceeds in
accordance with this Agreement.

616959
EFIN____________

APPLICANT(S) INFORMATION AND SIGNATURE(S): Joint Applicant information required if filing joint return.

AMANDA T HOLT
Primary Applicant: ________________________________________________________ XXX-XX-4365
SSN: ___________________________________________

Joint Applicant: __________________________________________________________ SSN: ___________________________________________

409 __________
Daytime Phone: (_________) 333 - ____________________
7395 Cell Phone (optional): (_________) __________ - _____________________

x _______________________________________ _______________ x _____________________________________ _______________

Primary Applicant Signature Date Joint Applicant Signature Date
(Joint Applicant signature required if filing joint return.)

USA PATRIOT ACT DISCLOSURE: IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT: In an effort to protect
you and our country, the USA PATRIOT Act was signed into law. To help the government fight the funding of terrorism and money laundering activities,
federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens a new account. As such, we
ask for your name, address, date of birth, and other information that will allow us to identify you. We may ask for a driver’s license or other identifying
documents. We will share certain of this information with third parties as necessary to fulfill our obligations and as disclosed in this Application and
Agreement.

For questions, complaints and concerns, call toll free at 1-866-876-6648.

   

O932.20171023 RT Application & Agreement - RT - O - 2017/18 Page 6 of 8 

 
     Rev. 03/2016

FACTS  WHAT DOES METABANK DO WITH YOUR 
PERSONAL INFORMATION? 
   
Financial companies choose how they share your personal information.  Federal 
Why?  law gives consumers the right to limit some but not all sharing.  Federal law also 
requires us to tell you how we collect, share, and protect your personal 
information.  Please read this notice carefully to understand what we do. 
   
The types of personal information we collect and share depend on the product 
What?  or service you have with us.  This information can include: 
Social Security number and Income 
Account balances and Transaction history 
Credit history and Assets 
When you are no longer our customer, we continue to share your information 
as described in this notice. 
   
All financial companies need to share customers’ personal information to run 
How?   their everyday business.  In the section below, we list the reasons financial 
companies can share their customers’ personal information; the reasons 
MetaBank chooses to share; and whether you can limit this sharing. 
  

Reasons we can share your personal  Does MetaBank  Can you limit 

information  share?  this sharing? 
For our everyday business purposes – such as to  Yes  No 
process your transactions, maintain your 
account(s), respond to court orders and legal 
investigations, or report to credit bureaus 
For our marketing purposes ‐ to offer our products  Yes  No 
and services to you 
For joint marketing with other financial companies  Yes  No 
For our affiliates' everyday business purposes‐  No  We do not share 
Information  about your transactions and 
experiences 
For our affiliates' everyday business purposes‐  No  We do not share 
Information  about your creditworthiness 
For our affiliates to market to you  No  We do not share 
For nonaffiliates to market to you  No  We do not share 
 
Questions?   Go to www.metabank.com. 
   

O932.20171023 RT Application & Agreement - RT - O - 2017/18 Page 7 of 8 

 
Page 2 
 
        
Who we are 
Who is providing this  This privacy policy is provided by MetaBank and applies to MetaBank 
notice?  products and services.  
  

What we do 
How does MetaBank  To protect your personal information from unauthorized access and use, 
protect my personal  we use security measures that comply with federal law.  These measures 
information?  include computer safeguards and secured files and buildings. 
How does MetaBank  We collect your personal information, for example when you 
collect my personal  Open an account or Apply for a loan 
information?   Make deposits or withdrawals from your account or Provide 
account information  
Make a wire transfer 
We also may collect your personal information from others, such as credit 
bureaus, affiliates, or other companies. 
Why can't I limit all  Federal law gives you the right to limit only 
sharing?  Sharing for affiliates’ everyday business purposes – information 
about your creditworthiness 
Affiliates from using your information to market to you 
Sharing for nonaffiliates to market to you 
State law and individual companies may give you additional rights to limit 
sharing.  [See below for more on your rights under state law.] 
  

Definitions 
Affiliates  Companies related by common ownership or control.  They can be 
financial and nonfinancial companies. 
MetaBank does not share with our affiliates. 
Nonaffiliates  Companies not related by common ownership or control.  They can be 
financial and nonfinancial companies. 
MetaBank does not share with nonaffiliates so they can market to 
you.  
Joint Marketing  A formal agreement between nonaffiliated financial companies that 
together market financial products or services to you. 
Our joint marketing partner(s) include nonaffiliated financial 
companies that we may partner with to jointly market financial 
products or services to you.  

Other important information
Special Notice for State Residents 
Residents of California or Vermont: We will not share with nonaffiliates except for our own 
marketing purposes, our everyday business purposes, or with your consent. 
 
Residents of Nevada: We are providing this notice pursuant to Nevada law. 
 

O932.20171023 RT Application & Agreement - RT - O - 2017/18 Page 8 of 8 

449-53-4365 AMANDA HOLT 04/23/2018
Audit!Maintenance!Pro!Service!Agreement!

Audit!Maintenance!Pro,!L.L.C.!(herein!referred!to!as!“AMP”)!is!a!tax!audit!assistance!program!that!provides!you!with!all!the!support!you!
need!in!the!event!your!Federal!tax!return!is!ever!selected!for!an!Internal!Revenue!Service!(IRS)!audit.!Audit!Maintenance!Pro!will!provide!
the! Customer/Taxpayer! (herein! referred! to! as! “Customer”)! with! a! licensed! Enrolled! Agent! or! C.P.A! who! will! personally! assist! you! in! the!
resolution! of! your! case.! We! will! work! with! Customer! in! every! phase! of! Customer’s! audit! and! we! will! work! to! protect! Customer’s! rights!
under!the!Federal!Tax!Code,!as!more!specifically!itemized!below.!
!
AMP’s!primary!objective!is!to!resolve!to!Customer’s!satisfaction!any!items!covered!in!the!scope!of!the!audit!and!to!eliminate!or!reduce!any!
increases!in!Customer’s!tax!liability.!Under!qualified!circumstances,!this!agreement!will!also!provide!for!reimbursement!of!certain!assessed!
penalties!and!interest!up!to!$2,500.00**!(please!see!section!on!reimbursement!policy).!
!
What’s!Included!
!
1. 36!months!of!protection!on!each!covered!return!
2. Assistance!from!an!Enrolled!Agent!or!C.P.A.!during!the!audit!process.!Specifically,!this!assistance!includes:!
a. Explanation!of!Customer’s!claim!rights!and!options!available!under!this!agreement!
b. Complete!review!of!all!IRS!correspondence!or!notices!
c. Help!with!document!organization!and!presentation!
d. Compiling!any!letters!or!communication!necessary!to!respond!to!IRS!requests!
e. Direct!communication!(by!e"mail!or!telephone)!with!any!IRS!representative!assigned!to!Customer’s!audit!
3. Coverage!for!Federal!tax!returns!with!all!major!forms!including!Schedules!C,!E!and!F.!
4. Reimbursement!of!certain!assessed!penalties!and!interest!up!to!$2,500.00**!(please!see!section!on!reimbursement!policy)!
5. AMP’s!100%!Money!Back!Guarantee!–!If!at!any!time!during!AMP’s!assistance!with!an!audit,!Customer!is!not!satisfied!with!the!
audit!assistance!being!provided,!AMP!will!refund!the!Customer’s!enrollment!fee.!
!
What’s!Excluded!
!
1. Returns!excluded!from!coverage:!
a. Corporate!or!partnership!returns!(Forms!1120,!1120S,!1065)!
b. Trust,!estate,!gift!tax!or!franchise!returns!
c. State!or!local!returns!!
d. Amended!returns!
e. Non"resident!federal!returns!
f. Returns!containing!items!or!positions!disallowed!by!the!IRS!
g. Additional!appeals!once!an!examination!has!been!closed!
2. Any!returns!containing!Schedules!C,!E!or!F!with!gross!receipts!exceeding!$500,000!
3. Criminal!Investigation!Audits!–!Audits!for!returns!that!have!been!or!are!currently!being!investigated!for!IRS!or!any!other!criminal!
investigations!
4. Audits!that!cover!any!period!preceding!the!date!of!coverage!for!this!agreement!!
!
Limitations!
!
1. Agreement!does!not!include!face!to!face!consultations!or!an!AMP!representative!physically!being!present!at!any!audit!sessions!or!
meetings.!
2. Agreement!only!covers!the!return!for!the!tax!year!of!purchase!and!does!not!cover!any!other!tax!year!or!previously!filed!returns.!
3. Return!must!be!timely!filed!(including!extensions).!
4. Coverage!period!ends!36!months!after!purchase!date.!
5. AMP!does!not!guarantee!favorable!results!or!outcomes!related!to!any!audit.!
6. AMP!does!not!cover!or!assist!with!returns!not!accepted!by!the!IRS.!
7. Coverage!does!not!provide!any!legal!representation!or!legal!advice!as!part!of!this!Agreement.!
8. Coverage!does!not!include!any!face!to!face!audit!representation!or!appeals!in!any!court!of!law.!
9. Coverage!does!not!include!audit!reconsiderations!or!offers!in!compromise.!
10. Coverage!does!not!include!responding!to!notices!or!correspondence!from!audits!not!covered!under!this!Agreement.!
11. Coverage!does!not!include!assistance!for!collection!notices.!Collection!notices!from!the!IRS!are!not!considered!audits!or!inquiry!
notices!and!are!thereby!excluded.!
12. Coverage!does!not!include!compiling!records,!receipts,!journals,!reconciling!bank!records,!or!any!other!related!clerical!tasks.!
13. Coverage!will!be!rendered!null!and!void!if!it!is!determined!that!any!of!the!following!items!or!actions!have!occurred:!
a. Incomplete,!incorrect!or!fraudulent!information!knowingly!provided!by!Customer!or!Customer’s!representatives!to!the!
return!preparer!for!the!preparation!of!the!return;!
b. Incomplete,!incorrect!or!fraudulent!information!filed!by!the!return!preparer!either!with!or!without!the!Customer’s!
knowledge!or!consent;!
c. Customer’s!failure!to!provide!any!and!all!records!or!data!requested!by!either!the!IRS!or!AMP!within!the!thirty!day!period!
following!the!date!of!the!claim;!
449-53-4365 AMANDA HOLT 04/23/2018
d. Customer!taking!a!position!on!the!return!that!is!unrealistic,!unsupported!or!that!is!in!direct!conflict!with!tax!laws!or!IRS!
guidelines;!
e. Any!failure!to!disclose!material!facts!by!either!the!Return!Preparer!or!Customer!that!are!pertinent!or!relevant!to!the!audit;!
f. The!tax!preparer!or!taxpayer!did!not!comply!with!the!Due!Diligence!Requirements!as!set!forth!on!Form!8867;!or!
g. Customer!does!not!notify!AMP!in!writing!within!fifteen!(15)!days!of!receipt!of!IRS!correspondence!or!notification.!
!
Claims!Process!
!
1. Upon!receiving!any!IRS!notice!or!correspondence,!Customer!shall!notify!AMP!immediately,!but!in!no!event!later!than!15!days!
following!receipt!of!IRS!notice!or!correspondence.!Customer’s!failure!to!timely!respond!could!impact!the!resolution!of!Customer’s!
audit!and!void!the!coverage!provided!in!this!Agreement.!
2. Customer!shall!provide!AMP!with!copies!of!all!IRS!notices!or!correspondence!related!to!the!audit!or!assessment!by!fax,!email!or!
standard!mail!to!the!address!provided!at!the!bottom!of!this!agreement.!
3. Customer!shall!provide!AMP!with!a!Form!2848!Power!of!Attorney!and!Declaration!of!Representative!which!can!be!accessed!on!
AMP’s!website.!Once!AMP!has!this!tax!Power!of!Attorney,!Customer!can!request!that!the!IRS!agent!speak!to!AMP!directly!as!
Customer’s!representative.!
4. Upon!review,!an!AMP!representative!will!be!assigned!to!Customer’s!case!and!will!communicate!with!Customer!the!scope!and!
details!of!the!audit!and!the!steps!necessary!to!resolve!it.!AMP!will!explain!Customer’s!rights!as!a!taxpayer!and!AMP!will!develop!a!
strategy!for!the!best!possible!outcome.!
5. Based!on!this!review,!Customer’s!assigned!representative!will!provide!Customer!with!a!list!of!documents!that!will!be!required!in!
order!to!favorably!support!Customer’s!claim.!If!one!or!more!of!these!documents!are!not!available,!AMP!will!suggest!alternative!
documents!or!data!that!may!be!accepted!in!the!absence!of!the!requested!documents.!
6. AMP!will!assist!Customer!in!collecting!and!organizing!these!documents!and!presenting!them!to!the!IRS!on!Customer’s!behalf.!
AMP!will!continue!to!consult!with!Customer!throughout!the!entire!process!until!the!audit!is!closed.!
7. If!required,!AMP!may,!in!its!sole!discretion,!provide!a!licensed!tax!professional!to!accompany!Customer!or!attend!the!audit!in!
Customer’s!place.!This!would!result!in!an!additional!charge!of!$150!per!hour!plus!travel!costs!that!will!be!the!sole!responsibility!of!
the!Customer.!
!
Customer’s!failure!to!comply!with!requests!or!instructions!from!the!IRS!or!its!representatives!during!the!assessment!or!audit,!may!result!in!
a! negative! or! adverse! decision.! Customer’s! failure! to! comply! with! actions! recommended! by! AMP’s! representative! may! also! negatively!
impact! the! outcome! as! well.! AMP! will! not! be! held! responsible! in! either! scenario! and! reserves! the! right! to! terminate! this! Agreement! if!
Customer!does!not!comply!with!all!such!requests!or!instructions!from!the!IRS,!its!representatives!or!AMP.!
!
Reimbursement!Policy!Guidelines!
!
Reimbursement! for! any! assessed! interest! and! penalties! will! be! determined! on! an! individual! case! basis! in! AMP’s! sole! discretion.! These!
reimbursements!will!be!determined!by!AMP’s!underwriting!department!and!are!subject!to!any!and!all!limitations!and!exclusions!as!outlined!
in!this!Agreement.!!Any!disputed!item!for!which!Customer!fails!to!produce!the!proper!valid!documents!as!required!by!the!IRS!to!support!
the!items!in!question!shall!not!be!eligible!for!reimbursement.!It!will!be!up!to!the!assigned!AMP!representative!to!determine!the!validity!of!
the! supporting! documents! prior! to! submission! to! the! IRS.! ! Reimbursements! will! be! made! provided! that! all! criteria! outlined! in! this!
Agreement! are! satisfied! and! only! after! all! tax! obligations! have! been! paid! in! full! to! the! IRS.! All! reimbursements! will! be! assessed! on! an!
individual! line! item! basis.! No! reimbursement! will! be! given! on! any! return! that! is! found! to! contain! incomplete,! inaccurate! or! fraudulent!
information!or!that!is!in!direct!conflict!with!IRS!tax!laws!or!code.!
!
Indemnification!
!
Customer! shall! indemnify,! hold! harmless! and! reimburse! AMP,! its! affiliates,! and! their! officers,! directors,! and! employees,! for! all! costs,!
including!without!limitation,!attorney’s!fees,!judgments,!penalties,!and!other!direct!expenses!and!payments!in!settlement!or!disposition!of,!
or!in!connection!with,!any!claims,!disputes!or!litigation!arising!out!of!the!actual!or!alleged!breach!by!User!of!its!duties!and!obligations!under!
this! agreement.! Customer! may! retain,! in! Customer’s! sole! discretion,! attorneys! of! Customer’s! own! selection! to! represent! Customer! at!
Customer’s!own!expense.!!Customer!shall!direct!the!defense!of!the!claim,!provided,!however,!that!said!Customer!does!not!compromise!or!
settle!any!claim!or!action!without!prior!approval!from!AMP.!!If!AMP!is!named!a!party!to!any!action!or!proceeding!for!which!Customer!has!a!
duty!of!indemnification,!AMP!shall!have!the!right!to!directly!defend!any!such!action!or!proceeding!by!retaining!attorneys!of!AMP’s!own!
selection! to! represent! it! at! Customer’s! reasonable! expense,! provided,! however,! AMP! shall! not! compromise! or! settle! any! such! claim! or!
action!without!prior!approval!from!Customer.!

Taxpayer!Signature:_________________________!Date:__________!!Spouse!Signature:_________________________!Date:__________!
!
Call!us!at!1"706"364"1267!or!visit!www.auditmp.com!for!more!information!
Address!for!Notices:!3422!Wrightsboro!Road,!Suite!200,!Augusta,!Georgia!30909!
!
*The! signature! and! date! on! this! Service! Agreement! signify! that! the! tax! preparer! has! explained! Audit! Maintenance! Pro’s! services! to! the! taxpayer,! the!
taxpayer!agrees!to!the!AMP!Terms,!and!the!taxpayer!has!chosen!to!purchase!AMP.!!It!is!the!responsibility!of!the!tax!preparer!to!furnish!each!taxpayer!that!
purchases!AMP!with!a!copy!of!the!Audit!Maintenance!Pro!Service!Agreement.!!!
 Consent to Use Of Tax Return Information

____________________________________________
TAX DOCTORS ("we," "us" and "our")
Printed name of tax preparer

Federal law requires this consent form be provided to you (“you” refers to each taxpayer, if
more than one). Unless authorized by law, we cannot use your tax return information for
purposes other than the preparation and filing of your tax return without your consent.

You are not required to complete this form to engage our tax return preparation services. If we
obtain your signature on this form by conditioning our tax return preparation services on your
consent, your consent will not be valid. Your consent is valid for the amount of time that you
specify. If you do not specify the duration of your consent, your consent is valid for one year
from the date of signature.

For your convenience, we have entered into an arrangement with certain companies to offer an
Electronic Refund Disbursement Service and/or Loan product. To determine whether these
offerings may be of interest to you, we will need to use your tax return information.
If you would like us to use your tax return information to determine whether these offerings are
relevant to you while we are preparing your return, please sign and date this consent to the use
of your tax return information.

By signing below, you authorize us to use the information you provide to us during the
preparation of your 2017 tax return to determine whether to offer you an opportunity to apply for
the Electronic Refund Disbursement Service and/or Loan product.

Printed Name of Taxpayer:_________________________________________________

AMANDA T HOLT

Taxpayer Signature:_____________________________________ Date:____________

Printed Name of Joint Taxpayer: ____________________________________________

Joint Taxpayer Signature:_________________________________ Date:____________

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
Inspector General for Tax Administration (TIGTA) by telephone at 1-800-366-4484, or by
email at [email protected].
 CONSENT TO USE

Federal law requires this consent form be provided to you. Unless authorized by law, we cannot
use, without your consent, your tax return information for purposes other than the preparation
and filing of your tax return. If you consent to the use 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. 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, your consent is valid for one year.

Duration of consent: Calendar year 2017 through Calendar year 2021

Pursuant to Reg §301.7216-3, I (we), ___________________________________________

AMANDA T HOLT
authorize ____________________________to
TAX DOCTORS use any and all tax return information,
forms, schedules, documents and attachments for the purpose of offering a tax audit
assistance, support and representation service, provided by Audit Maintenance Pro, L.L.C.

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 Inspector
General for Tax Administration (TIGTA) by telephone at 1-800-366-4484, or by email at
[email protected].

____________________________________________ ________________
Taxpayer Signature: Date:

____________________________________________ ________________
Spouse Signature: Date:
 Consent to Disclosure Of Tax Return Information

____________________________________________
TAX DOCTORS ("we," "us" and "our")
Printed name of tax preparer

Federal law requires this consent form 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 our tax return preparation services. If we
obtain your signature on this form by conditioning our tax return preparation 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, your consent is valid for one year from the date of signature.

You have indicated that you are interested in utilizing the Electronic Refund Disbursement Service
and/or Loan product from Refund Advantage. To provide you with the opportunity to apply for and/
or receive the Electronic Refund Disbursement Service and/or Loan product, we must disclose all
of your 2017 tax return information to Refund Advantage. You may request a more limited
disclosure of tax return information, but you will not be eligible to submit an application for the
Electronic Refund Disbursement Service and/or Loan product.
If you would like us to disclose your 2017 tax return information to Refund Advantage for this
purpose, please sign and date your consent to the disclosure of your tax return information.

By signing below, you authorize us to disclose to Refund Advantage all of your 2017 tax return
information so that it can evaluate and process your application for the Electronic Refund
Disbursement Service and/or Loan product. You understand that if you are not willing to authorize
us to share your tax information with Refund Advantage, you will not be able to obtain the
Electronic Refund Disbursement Service and/or Loan product, but you can still choose to have
your tax return prepared and filed by us for a fee.

Printed Name of Taxpayer:_________________________________________________

AMANDA T HOLT

Taxpayer Signature:_____________________________________ Date:____________

Printed Name of Joint Taxpayer: ____________________________________________

Joint
Taxpayer Signature:_______________________________________ Date:____________

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 Inspector
General for Tax Administration (TIGTA) by telephone at 1-800-366-4484, or by email at
[email protected].
 CONSENT TO DISCLOSURE

Federal law requires this consent form be provided to you. Unless authorized by law, we cannot
disclose, without your consent, your tax return information to third parties for purposes other
than the preparation and filing of your tax return. 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. 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, your consent is valid for one year.

Duration of disclosure: Calendar year 2017 through Calendar year 2021

Pursuant to Reg §301.7216-3, I (we), ___________________________________________

AMANDA T HOLT
authorize _______________________________________to
TAX DOCTORS disclose 2017 tax return
information, forms, schedules, documents and attachments to Audit Maintenance Pro, L.L.C.
for the purpose of providing tax audit assistance, support and representation.

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 Inspector
General for Tax Administration (TIGTA) by telephone at 1-800-366-4484, or by email at
[email protected].

____________________________________________ ________________
Taxpayer Signature: Date:

____________________________________________ ________________
Spouse Signature: Date: