Nichole Maly Income Tax Services
New Client Intake Form
How did you hear about us?
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Referred by a Friend
A Facebook Post/Group
Internet Search
Other (Please specify...)
Other
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Who referred you?
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What is your filing status for the tax year you are filing?
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Married Filing Joint
Married Filing Separate
Single
Head of Household
Qualifying Widow/er
I don't know / Help me clarify this
Taxpayer Name (You)
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Taxpayer Date of Birth
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Month
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Day
Year
Taxpayer Phone Number
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Format: (000) 000-0000.
Taxpayer Occupation Title
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Spouse Name
Spouse Date of Birth
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Month
-
Day
Year
Spouse Phone Number
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Format: (000) 000-0000.
Spouse Occupation Title
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Mailing Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is your physical address the same as your mailing address?
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Yes
No
Physical address if different from Mailing address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
At any point did you buy / sell / trade Bitcoin, Crypto, or any online currency during the tax year we are filing?
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Yes (Please specify)
No
Please specify your crypto dealings
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Dependents?
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Please Select
None
One
Two
Three
Four
Five
Six
1st Dependent Name
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First Name
Middle Name
Last Name
1st Dependent Date of Birth
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Month
-
Day
Year
2nd Dependent Name
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First Name
Middle Name
Last Name
2nd Dependent Date of Birth
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-
Month
-
Day
Year
Date
3rd Dependent Name
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First Name
Middle Name
Last Name
3rd Dependent Date of Birth
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-
Month
-
Day
Year
Date
4th Dependent Name
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First Name
Middle Name
Last Name
4th Dependent Date of Birth
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-
Month
-
Day
Year
Date
5th Dependent Name
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First Name
Middle Name
Last Name
5th Dependent Date of Birth
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-
Month
-
Day
Year
Date
6th Dependent Name
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First Name
Middle Name
Last Name
6th Dependent Date of Birth
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-
Month
-
Day
Year
Date
Did you have a child/children born in the tax year you are filing?
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Yes
No
Do Your Dependents Live With You?
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Yes
No
Some Do, Some Don't
Please list the dependents that lived with you in the tax year you are filing, and how many months they did.
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Please list the dependents that DID NOT live with you in the tax year you are filing. (List the dependents here that lived with you for 0 months.)
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Current Place of Employment
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Please list your places of employment in the tax year you are filing:
Do you own a home or rent?
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Own a home
Rent
Have you ever been audited by the IRS?
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Yes
No
How many months were you covered under health insurance during the tax year you are filing?
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Please Select
None
12
11
10
9
8
7
6
5
4
3
2
1
Valid documentation or proof of coverage is required. Examples include 1095-B, 1095-C, etc
Do you provide a home for your parents?
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Yes
No
Do your parents live with you or at a separate residence?
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With me
Separate residence
Did you collect unemployment?
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Yes
No
Did you collect Social Security benefits?
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Yes
No
Did you move?
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Yes
No
Did you work out of state?
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Yes
No
Did you start/own a business?
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Yes
No
Have you ever owned a business?
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Yes
No
Did you file bankruptcy?
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Yes
No
List any deaths in the tax year you are filing and DOD:
Do you have a 401K through work?
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Yes
No
What company sponsors your work 401k plan?
Do you have a Traditional IRA?
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Yes
No
Do you have a Roth IRA?
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Yes
No
Do you own any stocks/bonds separate from IRAs?
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Yes
No
Email Address
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Would you be willing to recommend us?
Yes
Maybe
Please give reference of anyone who you feel can benefit from expert tax help!
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