Client Intake Form
Important: Fill out this for for each client. Tax return will NOT be transmitted without form completion.
Taxpayer Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Are you a U.S. citizen?
*
Yes
No
Have you, your spouse, or dependents been a victim of tax related identity theft or been issued an Identity Protection PIN?
*
Yes
No
Filing Status?
*
Single
Head of Household
Married Filing Jointly
Married Filing Separately
Proof of Head of Household (Check all that apply) Note: In order to qualify for head of head of household, taxpayer must provide proof of the following (Must select 3 proofs):
Medical Insurance
Medical Records
School Demographic Sheet
SNAP Benefits
Proof of utility service for address on tax return
Dependents birth certificate (Required)
Court records (if applicable)
Lease with address on tax return and dependents listed as occupants
Are you a full time student?
*
Yes
No
Are you permanently disabled?
*
Yes
No
Are you legally blind?
*
Yes
No
Is your spouse a full time student?
Yes
No
Are you legally married, separated, or divorced?
*
Yes
No
Is your spouse permanently disabled?
Yes
No
Is any of your dependents over the age of 18 and are full time college students?
*
Yes
No
Was the listed dependents claimed on your tax return last year?
*
Yes
No
Can anyone claim you or your spouse as a dependent?
*
Yes
No
Is any of your dependents permanently disabled?
*
Yes
No
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Wage/Income Information (Check all that apply. Taxpayer must provide documentation for all items selected.)
*
W-2 Wages
Tuition Statement (1098-T)
Interest/Dividends from: checking/savings accounts, bonds, CDs, brokerage (1099-INT, 1099-DIV)
Refund of state/local income taxes (1099-G)
Alimony income or separate maintenance payments
Self employment income (1099-MISC, 1099-NEC, 1099-K, cash, digital assets or real estate) (including your home 1099-S, 1099-B)
Income (or loss) from the sale or exchange of stocks, bonds, digital assets (1099-S, 1099-B)
Disability Income from pensions, annuities, IRA (1099-R, W2)
Retirement Income (1099-R)
Unemployment Compensation (1099-G)
Social Security or Railroad Retirement Benefits (SSA-1099, RRB-1099)
Income (or loss) rental property (Sch E)
Other Income (gambling W2-G, lottery, prizes, awards, jury duty, digital assets, Sch K-1, royalties, foreign income, etc.)
If you are self employed or have a business, enter your EIN.
Business name
Type of business
Business Entity (sole proprietor, LLC, 1065-Partnership, Trust, S-Corp, C-Corp)
Expenses (Check all that apply. Taxpayer must provide documentation for all items selected.)
Alimony or separate maintenance payments
Contributions or repayments to a retirement account
College or postsecondary educational expenses for yourself, spouse, or dependents
Medical and Dental (including insurance premiums)
Taxes (state, real estate, personal property, sales)
Mortgage interest (1098)
Charitable contributions
Child or dependent care expenses such as daycare
For supplies used as an eligible educator such as a teacher, teacher's aide, counselor
Expenses related to self employment income or any other income you received
Student loan interest (1098-E)
Additional Information (Check all that apply. Taxpayer must provide documentation for all items selected.)
Have a Health Savings account (5498-S, 1099-SA, W2 with code W in box 12)
Have a credit card, student loan or mortgage debt cancelled/forgiven by a lender or have a home foreclosure
Have Earned Income Credit, Child Tax Credit or American Opportunity Credit disallowed in a prior year
Adopt a child
Purchase and install energy efficient home items (windows, furnace, insulation, solar panels)
Received the First Time Homebuyers Credit in 2008
Make estimated tax payments or apply last year's refund to this year's tax
File a federal return last year containing a "capital loss carryover" on Form 1040 schedule D
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Have you received any notices from the IRS or state agencies?
*
Yes
No
Have you ever had a tax return audited, rejected, or adjusted by the IRS?
*
Yes
No
Do you owe the IRS?
*
Yes
No
Do you owe state taxes?
*
Yes
No
Do you owe student loans?
*
Yes
No
Do you owe child support?
*
Yes
No
Did you have Marketplace Health Insurance/Obamacare (1095-A)?
*
Yes
No
Are you applying for the Refund Advance?
*
Yes
No
Tax Professional
Please Select
Latiffany
Quantia
Kimberlie
Olivia Y
Michael
Courtney
Kidz Koture
Latravior
Mercedes
Notes
*
Signature
Date:
*
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Month
-
Day
Year
Date
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