Loyalty Tax Prep Client Intake Form

Tax Preparation Client Intake Form
YesNo
Name of Person that referred you:
Prior year clients can skip this question.
SingleHead of HouseholdMarried Filing SeparateMarried Filing JointQualifying WidowerNot Sure
YesNoNot Sure

Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
SSN
YesNo
YesNo
YesNo
YesNo

Yes, I will be claiming dependent(s) on my returnNo, I will not be claiming any dependents on my returnNot sure at this time

Enter your dependents here

Rows	Name	SSN	Date of Birth	Relationship	A Student?
1
2
3
4

YesNoNot Sure
Social Security CardBirth CertificateMedical and/or School RecordsLeaseFood Stamps or Benefit StatementsPrior year tax returnOther
Please upload any documents you have in reference to your dependents:

Cancelof

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

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

Please fill-up the information within the current year only. Skip this section if you do not have this information or if this section does not apply to you

General Expenses

Rows	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
W2s/ Last Pay StubsSelf-Employment / Business IncomeSelf-Employment / Commission IncomeRental IncomeEmployment Expenses - Accompanied by T2200Trucking/Logging ExpensesMoving Expenses (Only if moved more than 40 km closer to work or school)Medical Expenses (more than 5 receipts)None of the above
Please upload all of your income and tax documentation (Ex: Last paystubs, W2 forms, 1099 forms, 1098 forms, Schedule C, 1095 forms, etc.)

Cancelof
Please upload your government issued identification card (Ex: driver's license, id card, passport, etc.)*

Cancelof
Direct Deposit (Please input your routing and account number below)Prepaid Card from our Tax Office (MUST BRING GOVERNMENT ISSUED ID TO PICK UP CARD FROM TAMPA TAX OFFICE. ONLY THE CARD HOLDER CAN PICK UP CARD)Paper Check
Bank Name*
Routing Number
Account Number
Routing Number
Confirm Routing Number
Account Number
Confirm Account Number
YesNoNot Sure
Refund Advance up tp $1,000 (No cost loan)Refund Advance up to $7,000 (There is a fee for this loan option
Additional information that you want your tax preparer to know:

Federal law requires this consent form to be provided to you (“you” refers to each taxpayer, if more thanone). Unless authorized by law, we cannot use or disclose your tax return information for purposes otherthan the preparation and filing of your tax return. You are not required to complete this form. Because our ability to disclose your tax return information to another institution affects the service(s) that we provide to you and its (their) cost, we may decline to provide you with the tax return preparation services or change the terms (including the cost) of the tax return preparation services that we provide to you. Your consent is valid for the amount of time that you specify. If you do not specify the duration of your consent, your consent is valid for one year.

For your convenience, we have entered into agreements with a bank to provide qualifying taxpayers with the opportunity to apply for a (bank product) Refund Transfer (RT) and/or Loan via Electronic Refund Check or Electronic Refund Deposit. In order to provide you with the opportunity to apply for one of these Products or Services, we must disclose all of your tax return information to our partnered financial institution.

By signing below, you (including each of you if there is more than one taxpayer) authorize us to disclose to financial institution we partnered with all your tax return information.

By signing below, you (including each of you if there is more than one taxpayer) authorize us to use the information you provided to us during the preparation of your tax return to determine whether to present you with the opportunity to apply for a bank product (described above) and services.

I confirmed that all information I entered here is accurate and true. I allow Loyalty Tax Prep LLC 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 Loyalty Tax Prep LLC. By signing below, you acknowledge that you have read and understood your responsibilities and our responsibilities in doing this tax return.
Date Signed

MonthDayYear
Date
Taxpayer Signature*

Clear
Date Signed

MonthDayYear
Date
Spouse Signature

Clear
Should be Empty:

Tax Preparation Client Intake Form