Tax Preparation Client Intake Form

Tax Preparation Client Intake Form
Did you receive a federal tax last year?

YesNo
Fast Cash Advance

****This loan is not credit based. You will get approved or denied based on your tax refund. The minimum is $500 and the maximum is $7000 ****
Would you like to apply for the loan?

YesNo
Filing Status*

SingleHead of HouseholdMarried Filing SeparateMarried Filing JointQualifying Widower

Taxpayer 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
SSN*
Are you a full-time student?*

YesNo
Are you totally and permanently disabled?*

YesNo
Are you legally blind?*

YesNo
Is this individual dependent of other?*

YesNo
SS Card *
Driver's License/State ID*

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
SSN
Are you a full-time student?

YesNo
Are you totally and permanently disabled?

YesNo
Are you legally blind?

YesNo
Is this individual dependent of other?

YesNo

Dependents

Enter your dependents here

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

Does you, your spouse, and/or your dependents have health insurance ? 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

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
Additional comments

Tax Preparation Checklist
Personal Information
Please "Upload" or take a "Clear Photo" all relevant tax documents and/or expense evidence here*

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