Tax Preparation Client Intake Form

Tax Preparation Client Intake Form
Filing Status *

Single Head of Household Married Filing Separate Married Filing Joint Qualifying Widower

Taxpayer Information
Name *

First Name Last Name
Age *
Date of Birth *

Month Day Year
Date
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Occupation *
SSN *
Are you a full-time student? *

Yes No
Are you totally and permanently disabled? *

Yes No
Are you legally blind? *

Yes No
Is this individual dependent of other? *

Yes No

Spouse Information
Name

First Name Last Name
Age
Date of Birth

Month Day Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Occupation
SSN
Are you a full-time student?

Yes No
Are you totally and permanently disabled?

Yes No
Are you legally blind?

Yes No
Is this individual dependent of other?

Yes No

Dependents

Enter your dependents here

	Name	SSN	Date of Birth	Relationship
1
2
3
4
5
6

Does you, your spouse, and your dependents have health insurance within 12 months last year? If yes, who covers for it?

	Yes/No	Employer	Spouse Ins	Exchange/ Marketplace	Direct with Insurer	Medicare	Medicaid
Taxpayer
Spouse
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5

Employment Status *

Employed Unemployed Self-employed Fixed Income Other
Copy of your ID *

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Expenses
Please fill-up the information within the current year only.

General Expenses *

	Amount
Medical Expenses
Dental Expenses
Insurance Premiums paid
Long Term Care Premiums
Prescription Drugs and Medications
Home Mortgage
Investment Interest
Cash Contributions
Non-Cash Contributions
Unreimbursed Business Expenses
Union Dues
Tax Preparation Fees
Investment Expenses

Total Expenses
Additional comments

Acknowledgment & Signature
I confirmed that all information I entered here is accurate and true. I allow ABC Financial to capture my sensitive data like personal id, government id, social security number (SSN), and other information. I have read the terms and conditions and privacy policy of ABC Financial. By signing below, you acknowledge that you have read and understood your responsibilities and our responsibilities in doing this tax return.
Date Signed *

Month Day Year
Date
Taxpayer Signature *

Clear
Date Signed

Month Day Year
Date
Spouse Signature

Clear
Should be Empty: