Building Blocks Tax Preparation Client Intake Form

Tax Preparation Client Intake Form

Building Blocks Financial Solutions
Tax Year
Name*

First NameLast Name
Filing Status*

SingleHead of HouseholdMarried Filing SeparateMarried Filing JointQualifying Widower

Taxpayer Information
Age*
Date of Birth*

MonthDayYear
Date
Social Security Number*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation*

Are you a full-time student?

YesNo
Are you totally and permanently disabled?

YesNo
Are you legally blind?

YesNo
Is this individual dependent of any other person?

YesNo
Upload copy of State Issued ID*

Cancelof
Upload W2 and/or tax documents*

Cancelof

Spouse Information
Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
Number
Are you a full-time student?

YesNo
Are you totally and permanently disabled?

YesNo
Are you legally blind?

YesNo
Is this individual dependent of any other person?

YesNo
Upload copy of Spouse State Issued ID

Cancelof
Upload Spouse W2 and/or tax documents

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Dependents

Enter your dependents here

	Name	SSN	Date of Birth	Relationship
1
2
3
4
5
6

Did 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
Spouse
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5

Upload copy of Dependents' Social Security Card

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Tax Related Questions
Employment Status

EmployedUnemployedSelf-employed
Are you contributing to 401k or other pre-tax account?

YesNo
Is this your first time opening a pre-tax account?

YesNo
Does your dependents have tuition expenses? If yes, upload 1098T.

YesNo
Do you have any expenses for child care? If yes, upload tuition receipt.

YesNo
Do you have energy star rated improvements to your home?

WindowsDoorsFurnaceOther
Are you currently renting?

YesNo
What is the monthly rental amount?
How long have you been rented this property?
# of months
Do you have your own home?

YesNo
Do you have documents that shows you paid for property taxes?

YesNo

Did you buy or sell the following?

	Yes	No
Stocks
Cryptocurrency

Did you take money from your 401k?

YesNo
Did you pay for vehicle tax?

YesNo
Do you have mortgage interest?

YesNo
Do you have real estate tax?

YesNo
Did you receive a federal tax refund last year?

YesNo
Are you a victim of identity theft?

YesNo

Expenses
Please fill-up the information within the current year only.

General Expenses

	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
Upload tax form(s) not previously submitted. If filing as Head of Household, submit a copy of an utility bill with address listed above.

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Referrer Code:
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Additional comments

Acknowledgment & Signature
I understand the following: Building Blocks Financial Solutions will prepare my tax return based on the information that I provide. I am responsible for providing accurate and complete information to Building Blocks Financial Solutions. Building Blocks Financial Solutions is not responsible for any errors or omissions that are caused by inaccurate or incomplete information that I provide. Building Blocks Financial Solutions will keep my tax information confidential, except as required by law. I have the right to review my tax return before it is filed. I am responsible for paying any taxes, penalties, and interest that are due on my tax return.

I confirmed that all information I entered here is accurate and true. I allow Building Blocks Financial Solutions to capture my sensitive data like personal identification, government identification, social security number (SSN), and other information. By signing below, you acknowledge that you have read and understood your responsibilities and our responsibilities in doing this tax return.
By checking “I agree and signing below, I confirm my understanding and consent.

I agreeI do not agree
Date Signed*

MonthDayYear
Date
Taxpayer Signature*

Clear
Date Signed

MonthDayYear
Date
Spouse Signature

Clear
Should be Empty: