A&S Tax Preparation Client Intake Form

1
Filing Status
Single
Head of Household
Married Filing Separate
Married Filing Joint
Qualifying Widower
2
Name
First Name
Last Name
3
Age
4
Date of Birth
Date
Month
Day
Year
5
Phone Number
Please enter a valid phone number.
6
Email
example@example.com
7
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
Occupation
9
SSN
10
Are you a full-time student?
Yes
No
11
Are you totally and permanently disabled?
Yes
No
12
Are you legally blind?
Yes
No
13
Is this individual dependent of other?
Yes
No
14
Name
First Name
Last Name
15
Age
16
Date of Birth
Date
Month
Day
Year
17
Phone Number
Please enter a valid phone number.
18
Email
example@example.com
19
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
20
Occupation
21
SSN
22
Are you a full-time student?
Yes
No
23
Are you totally and permanently disabled?
Yes
No
24
Are you legally blind?
Yes
No
25
Is this individual dependent of other?
Yes
No
26
Enter your dependents here
Name
SSN
Date of Birth
Relationship
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
6
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
1
2
3
4
5
6
Name
Row 0, Column 0
SSN
Row 0, Column 1
Date of Birth
Row 0, Column 2
Relationship
Row 0, Column 3
Name
Row 1, Column 0
SSN
Row 1, Column 1
Date of Birth
Row 1, Column 2
Relationship
Row 1, Column 3
Name
Row 2, Column 0
SSN
Row 2, Column 1
Date of Birth
Row 2, Column 2
Relationship
Row 2, Column 3
Name
Row 3, Column 0
SSN
Row 3, Column 1
Date of Birth
Row 3, Column 2
Relationship
Row 3, Column 3
Name
Row 4, Column 0
SSN
Row 4, Column 1
Date of Birth
Row 4, Column 2
Relationship
Row 4, Column 3
Name
Row 5, Column 0
SSN
Row 5, Column 1
Date of Birth
Row 5, Column 2
Relationship
Row 5, Column 3
1 of 6
27
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
Yes
No
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Spouse
Yes
No
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Row 1, Column 6
Dependent 1
Yes
No
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Row 2, Column 6
Dependent 2
Yes
No
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Row 3, Column 6
Dependent 3
Yes
No
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
Row 4, Column 6
Dependent 4
Yes
No
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Row 5, Column 5
Row 5, Column 6
Dependent 5
Yes
No
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Row 6, Column 5
Row 6, Column 6
Taxpayer
Spouse
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5
Yes/No
Yes
No
Row 0, Column 0
Employer
Row 0, Column 1
Spouse Ins
Row 0, Column 2
Exchange/ Marketplace
Row 0, Column 3
Direct with Insurer
Row 0, Column 4
Medicare
Row 0, Column 5
Medicaid
Row 0, Column 6
Yes/No
Yes
No
Row 1, Column 0
Employer
Row 1, Column 1
Spouse Ins
Row 1, Column 2
Exchange/ Marketplace
Row 1, Column 3
Direct with Insurer
Row 1, Column 4
Medicare
Row 1, Column 5
Medicaid
Row 1, Column 6
Yes/No
Yes
No
Row 2, Column 0
Employer
Row 2, Column 1
Spouse Ins
Row 2, Column 2
Exchange/ Marketplace
Row 2, Column 3
Direct with Insurer
Row 2, Column 4
Medicare
Row 2, Column 5
Medicaid
Row 2, Column 6
Yes/No
Yes
No
Row 3, Column 0
Employer
Row 3, Column 1
Spouse Ins
Row 3, Column 2
Exchange/ Marketplace
Row 3, Column 3
Direct with Insurer
Row 3, Column 4
Medicare
Row 3, Column 5
Medicaid
Row 3, Column 6
Yes/No
Yes
No
Row 4, Column 0
Employer
Row 4, Column 1
Spouse Ins
Row 4, Column 2
Exchange/ Marketplace
Row 4, Column 3
Direct with Insurer
Row 4, Column 4
Medicare
Row 4, Column 5
Medicaid
Row 4, Column 6
Yes/No
Yes
No
Row 5, Column 0
Employer
Row 5, Column 1
Spouse Ins
Row 5, Column 2
Exchange/ Marketplace
Row 5, Column 3
Direct with Insurer
Row 5, Column 4
Medicare
Row 5, Column 5
Medicaid
Row 5, Column 6
Yes/No
Yes
No
Row 6, Column 0
Employer
Row 6, Column 1
Spouse Ins
Row 6, Column 2
Exchange/ Marketplace
Row 6, Column 3
Direct with Insurer
Row 6, Column 4
Medicare
Row 6, Column 5
Medicaid
Row 6, Column 6
1 of 7
28
Employment Status
Employed
Unemployed
Self-employed
29
Are you contributing to 401k or other pre-tax account?
Yes
No
30
Is this your first time opening a pre-tax account?
Yes
No
31
Please select what state return are you requesting?
State return
School
Local
RITA
Country returns
32
Does your dependents have tuition expenses?
Yes
No
33
Do you have any expenses for child care?
Yes
No
34
Do you have energy star rated improvements to your home?
Windows
Doors
Furnace
Other
35
Are you currently renting?
Yes
No
36
What is the monthly rental amount?
37
How long have you been rented this property?
# of months
38
Do you have your own home?
Yes
No
39
Do you have documents that shows you paid for property taxes?
Yes
No
40
Did you sold any stock?
Yes
No
41
Did you take money from your 401?
Yes
No
42
Did you pay for vehicle tax?
Yes
No
43
Do you have mortgage interest?
Yes
No
44
Do you have real estate tax?
Yes
No
45
Did you receive a federal tax last year?
Yes
No
46
Are you a victim of identity theft?
Yes
No
47
Please fill-up the information within the current year only.
48
General Expenses
Amount
Medical Expenses
Row 0, Column 0
Dental Expenses
Row 1, Column 0
Insurance Premiums paid
Row 2, Column 0
Long Term Care Premiums
Row 3, Column 0
Prescription Drugs and Medications
Row 4, Column 0
Home Mortgage
Row 5, Column 0
Investment Interest
Row 6, Column 0
Cash Contributions
Row 7, Column 0
Non-Cash Contributions
Row 8, Column 0
Unreimbursed Business Expenses
Row 9, Column 0
Union Dues
Row 10, Column 0
Tax Preparation Fees
Row 11, Column 0
Investment Expenses
Row 12, Column 0
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
Amount
Row 0, Column 0
Amount
Row 1, Column 0
Amount
Row 2, Column 0
Amount
Row 3, Column 0
Amount
Row 4, Column 0
Amount
Row 5, Column 0
Amount
Row 6, Column 0
Amount
Row 7, Column 0
Amount
Row 8, Column 0
Amount
Row 9, Column 0
Amount
Row 10, Column 0
Amount
Row 11, Column 0
Amount
Row 12, Column 0
1 of 13
49
Total Expenses
50
Additional comments
51
I confirmed that all information I entered here is accurate and true. I allow A&S 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 A&S Financial. By signing below, you acknowledge that you have read and understood your responsibilities and our responsibilities in doing this tax return.
52
Date Signed
Date
Month
Day
Year
53
Taxpayer Signature
Clear
54
Date Signed
Date
Month
Day
Year
55
Spouse Signature
Clear
Should be Empty: