Client Intake Form

Dependent #1 Full Name

First NameLast Name
Dependent's Date of Birth
mm/dd/yyyy
Dependent's Social Security Number
XXX-XX-XXXX
Dependent #2 Full Name

First NameLast Name
Dependent's Date of Birth
mm/dd/yyyy
Dependent's Social Security Number
XXX-XX-XXXX
Dependent #3 Full Name

First NameLast Name
Dependent's Date of Birth
mm/dd/yyyy
Dependent's Social Security Number
XXX-XX-XXXX
Can you or any dependents be claimed by anyone else?*

YesNo
If yes, which dependent can be claimed by someone else?
Name
Did you or your spouse pay any daycare expenses for any dependents, for the filing year?*

YesNo
Which dependent did you pay daycare for? (If Applicable)
Name(s)

BUSINESS OWNER/SELF-EMPLOYMENT
Do you have an IRS Federal EIN Number (Tax ID Number) for your business? If so, please enter below.
What is your business name?
Did you or your spouse receive a 1099 form?*

YesNo
Did you or your spouse incur expenses for your business or self-employment?

YesNo
What forms of payments did your business accept from customers, clients, etc.?

Cash/ZelleElectronic Payments (credit/debit card)Merchant Account (Paypal, Square, etc.)CashappOther

FILING STATUS