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Tax Client Intake Form
Tax Payer Name
*
First Name
Last Name
Spouse Name
First Name
Last Name
Tax Payer SSN
Spouse SSN
Tax Payer Occupation
Spouse Occupation
Tax Payer Phone Number
-
Area Code
Phone Number
Spouse Phone Number
-
Area Code
Phone Number
Tax Payer Email Address
example@example.com
Spouse Email Address
example@example.com
Tax Payer Date of Birth
-
Month
-
Day
Year
Date
Spouse Date of Birth
-
Month
-
Day
Year
Date
Are you new to our firm?
Yes
No
Tax Payer Address
Street Address
County
City
State / Province
Postal / Zip Code
Tax Payer Phone Number
-
Area Code
Phone Number
Spouse Phone Number
-
Area Code
Phone Number
Tax Payer Driver's License Information
Spouse Driver's License Information
Marital Status at 12/31/2021
Single
Married
Separated
Widow(er)
Unsure
Were you divorced or separated during the year?
Yes
No
Have you received any notices from the IRS or state revenue department within the past year?
Yes
No
Dependent 1
Dependent 2
Did any of the children have income above $1,050 for the 2021 tax year?
Yes
No
Do any of the children have a disability
Yes
No
Is it anticipated that a different taxpayer will seek to claim a child listed above as their dependent for tax year 2021?
Yes
No
VIRTUAL CURRENCY:At any time during 2021, did you receive, sell, send, exchange, or otherwise acquire any financial interest in any virtual currency?
Yes
No
If you are due a refund, would you like it directly deposited into your bank?
Lifestyle and Taxes- Foreign Country Bank & Income-Select all that apply
Children and Education- Select all that apply
Investments- Select all that apply
Deductions- Select all that apply
Business- Select all that apply
State of residence during 2021 and dates
School District
Do you rent or own your home
Rent
Own
State Information- Not required for Alaska, Florida, Nevada, South Dekota, Texas, Washington, Wyoming, New Hampshire, and Tennessee
Full-Year Resident
Part-Year Resident
Nonresident (You worked in one of the states not listed above, but did not live there)
Self-Employed Income
List Self-Employed expenses with amounts for 2021- If business is home based, please include amount of rent and utilities. If vehicle used for business purposes, please include amount of car note, insurance, maintenance and any repairs.
If you need to itemize deductions, please provide amounts and/or receipts to your Tax Specialist. These amounts can include, but are not limited to, Medical Expenses, Taxes Paid, Interest Paid, Charitable Contributions, Casualty and Theft Losses and other Miscellaneous Itemized Deductions.
Please provide to your Tax Specialist all forms W2, 1099-INT, 1099-DIV, 1099-R, 1099-MISC, and other income reporting statements.
PRIVACY POLICY
The nature of our work requires us to collect certain nonpublic information. We collect financial and persoanl information from applications, worksheets, reporting statements, and other forms, as well as interviews and conversations with our clients and affiliates. We mat also review banking and credit card information about our clients int he performance of receipt of payment. Under our policy, all information we obtain about you will be provided by you or obtained with your permission. Our firm has procedures and policies in pklace to protect your confidential information. We restrict access to your confidential information to those within our firm who need to know in order to provide you with services. We will not disclose your personal information to a third party without your permission, except where required by law. We maintain physical, electronic, and procedural safeguards in compliance with federal regulations that protect your personal infromation from unauthorized access
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I agree that all information provided is true and factual. I understand that falsifying information is against the law. I agree that upon completion of my tax return, if my return is intercepted and not paid, I am responsible for all preparation fees to be paid to my Tax Specialist
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