Source Financial Solutions SFS Tax Pros
Client Intake Form
Tax Year 2022
Filing Status
*
Single
Head of House Hold
Married Filing Single
Married Filing Joint
Widow(er)
Name
*
First Name
Middle Name
Last Name
Social Security Number
*
Format 123-45-6789
Date of Birth
*
/
Month
/
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Occupation
*
Spouse Name
*
First Name
Middle Name
Last Name
Social Security Number
*
Format 123-45-6789
Date of Birth
*
/
Month
/
Day
Year
Date
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Occupation
*
Did you have any Dependents?
*
YES
NO
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Dependents
Please complete each entry below
Number of Dependents
Please Select
1
2
3
4
5
6
Dependents Name
*
First Name
Middle Name
Last Name
Social Security Number
*
Format 123-45-6789
Date of Birth
*
/
Month
/
Day
Year
Date
Relationship
*
Please Select
SON
DAUGHTER
NIECE
NEPHEW
GRANDCHILD
STEP-SON
STEP-DAUGHTER
PARENT
OTHER
Dependents Name
*
First Name
Middle Name
Last Name
Social Security Number
*
Format 123-45-6789
Date of Birth
*
/
Month
/
Day
Year
Date
Relationship
*
Please Select
SON
DAUGHTER
NIECE
NEPHEW
GRANDCHILD
STEP-SON
STEP-DAUGHTER
PARENT
OTHER
Dependents Name
*
First Name
Middle Name
Last Name
Social Security Number
*
Format 123-45-6789
Date of Birth
*
/
Month
/
Day
Year
Relationship
*
Please Select
SON
DAUGHTER
NIECE
NEPHEW
GRANDCHILD
STEP-SON
STEP-DAUGHTER
PARENT
OTHER
Dependents Name
*
First Name
Middle Name
Last Name
Social Security Number
*
Format 123-45-6789
Date of Birth
*
/
Month
/
Day
Year
Date
Relationship
*
Please Select
SON
DAUGHTER
NIECE
NEPHEW
GRANDCHILD
STEP-SON
STEP-DAUGHTER
PARENT
OTHER
Dependents Name
*
First Name
Middle Name
Last Name
Social Security Number
*
Format 123-45-6789
Date of Birth
*
/
Month
/
Day
Year
Date
Relationship
*
Please Select
SON
DAUGHTER
NIECE
NEPHEW
GRANDCHILD
STEP-SON
STEP-DAUGHTER
PARENT
OTHER
Dependents Name
*
First Name
Middle Name
Last Name
Social Security Number
*
Format 123-45-6789
Date of Birth
*
/
Month
/
Day
Year
Date
Relationship
*
Please Select
SON
DAUGHTER
NIECE
NEPHEW
GRANDCHILD
STEP-SON
STEP-DAUGHTER
PARENT
OTHER
Questionnaire
Please complete each question
Did you have self-employed income to report for this tax year? (Please provide income and expense worksheet) If yes, Please complete Business Income and Expense Worksheet attached below.
*
YES
NO
Did you, your Spouse, or your Dependents attend college or pursue a secondary education this tax year? If Yes, Please provide form 1098T from school
*
YES
NO
Did you, your Spouse, or your Dependent receive an Identify Protection Pin (IP PIN) from the IRS?(Please Provide)
*
YES
NO
PIN NUMBER
Did you have healthcare for yourself/your family? (Please provide 1095 A if through the market place)
*
YES
NO
Do you own a home?
*
YES
NO
Do you plan to purchase or refinance a home within the next 24 months?
*
YES
NO
Did you incur any medical expenses this tax year?
*
YES
NO
Did you receive dividends from stocks, bonds or Cryptocurrency (Bit Coin)?
*
YES
NO
Have you filed for bankruptcy in the last 12 months?
*
YES
NO
Bankruptcy Type
*
Please Select
Chapter 7
Chapter 13
Did you have any past-due tax debt? (Student loans/ child support/ Underpayment)
*
YES
NO
Tax Debt Type
*
Please Select
Student Loans
Child Support
Previous Years Balance
Did you have a child in daycare? (Please provide statement including EIN#)
*
YES
NO
DayCare Provider Name Business or Individual
EIN# or Social Security Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Did you currently have a financial plan for retirement?
*
YES
NO
Would you like a Financial Plan?
Please Select
Yes
No
Did you currently have life insurance?
*
YES
NO
Type of Life Insurance
Please Select
Employer Provided
Self Provided
Would you like a quote?
Please Select
Yes
No
Would you like information regarding lowering your auto or home insurance ?
*
YES
NO
Insurance Type
Please Select
Home
Auto
Home and Auto
Renters Insurance
Business Insurance
Would you like information regarding Credit Repair ?
*
YES
NO
Requested Tax Preparer
*
Please Select
James Chenevert
Ericka Chenevert
Karen Scott
Angel Cleary
Daniel Cornelius
Jennifer Bristol
Kyles Petties
John Moultrie
How did you hear about us?
*
Please Select
Google
Facebook
Instagram
Friend or Family Member
Friend or Family Member
*
First Name
Last Name
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Bank Information
Name of Bank
*
Account Type
*
Please Select
Checking
Savings
CASHAPP
Accounting Number
*
Routing Number
*
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Items Needed Checklist
Please provide all that is applicable
*
Drivers License or State ID
Social Security Cards / Tax ID number (small business)
Social Security Cards for dependents (Date of birth)
W2 Forms (All if worked multiple jobs
1099 Income (unemployment...Ets..) Self-employment income totals
Investment interest statement / Mortgage 1098 statement
Donation Receipts
Previous years last pay stub
Summary of business expenses (if any)
Education form 1098-E / Education expenses (if any)
Previous years tax return (For new clients only)
Advance child tax credit form 6419 ( if any)
Other supportive documentation
Upload Documents
*
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Please note:*All items must be enclosed for the tax return to be completed.*By signing below you agree all documents listed on this form were provided at the time of document submission to the tax preparer. Unless requested all documents needed are enclosed.To the best of my knowledge and belief, the information provided in this questionnaire is true, correct, and complete.
*
Comments
Business Income and Expense Worksheet
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