Tax Intake Form

How did you hear about us?

If someone referred you, please type his or her name here.

Name

First NameLast Name

Taxpayer's Date of Birth

Example: 01/01/2001

Taxpayer's SSN

Example: xxx-xx-xxxx

Taxpayer's Email Address

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Taxpayer's Job Title

Taxpayer's Phone Number

Example: xxx-xxx-xxxx

How would you like to receive your tax refund?

Do you have plans of purchasing a home within this next year?

Name of Bank

Routing Number

Bank Account Number

Spouse's Full Name

First Name

Spouse's Phone Number

Example: xxx-xxx-xxxx

Spouse's Date of Birth

Example: 01/01/2001

Spouse's SSN

Example: xxx-xx-xxxx

Spouse's Email Address

Example: example@example.com

Spouse's Job Title

Preferred Contact Method

Are you self employed?

How much Profit was made for your business?

Do you certify the profit made is true, accurate and is given to use as a source of income for my 2021 Federal and State Return?

Did incur expenses to materially operate your business?

What is your marital status as of December 2022

Did you pay over half the expenses of maintaining your residence for the entire year?

Did you support a child or family member for more than 6 months out of the year?

How many dependents are you claiming?

Dependent #1

First NameLast Name

Dependent #1 Date of Birth

01/01/2001

Dependent #1 SSN

What is Dependent #1's Relationship to you (son, daughter, etc.)?

How many months did Dependent #1 live with you in 2022? (If all year, enter 12)

Dependent #2

First NameLast Name

Dependent #2 Date of Birth

Example: 01/01/2001

Dependent #2 SSN

How many months did Dependent #2 live with you in 2022? (If all year, enter 12)

What is Dependent #2's Relationship to you (son, daughter, etc.)?

Dependent #3

First NameLast Name

Dependent #3's Date of Birth

01/01/2001

How many months did Dependent #3 live with you in 2022? (If all year, enter 12)

Dependent #3s SSN

Example: xxx-xx-xxxx

Dependent's #3 SSN

What is Dependent #3's Relationship to you (son, daughter, etc.)?

Dependent #4's First Name

First Name

Dependent #4's Last Name

Last Name

Dependent #4's Date of Birth

01/01/2001

Dependent #4's SSN

Example: xxx-xx-xxxx

What is Dependent #4's Relationship to you (son, daughter, etc.)?

How many months did Dependent #4 live with you in 2022? (If all year, enter 12)

Are there any dependents in daycare? If yes, please upload the form you received from your daycare provider.

Can someone claim you as a dependent?

Did you have insurance for the entire year?

Did your dependents have health insurance for the entire year?

If so, did you receive a 1095A? (Health Insurance Market Place) Please be sure, otherwise if you do not provide form, it will hold up your tax refund.

Have you ever been denied the Earned Tax Credit (EITC)?

Did you attend college?

Did your SPOUSE attend college?

Do you have a form 1098T (Tuition Statement) for either, you, your spouse and/or dependents?

Upload a copy of your daycare form here.

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Was your insurance through Medicaid?

Was your insurance through the Affordable Care Act (The Marketplace)?

Upload Taxpayer & Dependent(s)Insurance Documents

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Was YOUR DEPENDENTS' insurance through Medicaid?

Was YOUR DEPENDENTS' insurance through the Affordable Care Act (The Marketplace)?

If you have a 1098-T form, upload it here.

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CLIENT NON PAYMENT/OFFSET CLAUSE, we strive to assist all of our clients in their tax needs, howwever we understand that situations arise. If your refund is offset by the IRS, student loans, child support or your check is mailed, you are still obligated to pay our company the fees associated with filing your tax return. I By signing this agreement you acknowledge that if payment is not made in full with in 30 days legal actions will be sought to resolve payment. I am giving Nationwide Tax Pros Solutions and/or associated affiliates permission to prepare all forms related to my tax return and I have signed all necessary forms and file my income tax return electronically. I take full responsibility for the accuracy of this form and understand that Nationwide Tax Pros and/or associated affiliates hold no responsibility for any misrepresentation or false claims.

Taxpayer's Driver's License

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Taxpayer's W-2/ 1099'S

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Taxpayer's and Dependent(s ) Social Security Card(s)

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1098T

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Proof of HOH (Lease/Utility Bill)

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Taxpayer's Signature

CLIENT FORM