Empire Unlimited New Client Intake Form

Empire Unlimited Tax Services, LLC

New Client Intake Form
Your Income Taxes will by prepared by whom?*
What Is Your Filing Status *
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date Of Birth *
Social Security Number *
Driver License # & Issuing State *
DL Issue Date * DL EXP. Date *
Please Upload a Copy Of Your Drivers License *

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Occupation *
IP Pin (if applicable)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse Name & Information (If Applicable)

First NameLast Name
Social Security Number
Date Of Birth
Driver License # & Issuing State
DL Issue Date DL EXP. Date
Please Upload a Copy of Your Spouses Drivers License

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Occupation
Email
example@example.com
IP Pin (if applicable)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Bank Name *
Account Number* Routing Number*
Type Of Account*

CheckingSavingsFast Money CardCashier Check
DEPENDENTS (If Applicable)

First NameLast Name
Social Security Number
Date Of Birth
What is your relationship to the dependent?
DEPENDENTS (If Applicable)

First NameLast Name
Social Security Number
Date Of Birth
What is your relationship to the dependent?
If you are claiming a dependent, please answer the questions that pertain to your dependent relationship, per request of the IRS. The goal is to prove that nobody else is eligible to claim your dependent but yourself.
If your are claiming son/daughter where is the other parent?
Is the other parent providing financial support?

YesNoSometimes
If claiming niece, nephew, aunt or uncle; How are your related to related to the dependent?
If claiming brother or sister; How are you related to the dependent? Why are the parents not claiming the dependent/dependents?
Did you pay someone to watch your children?

YesNo
If yes we will need the contact information for the provider. Example: Name, Address, Phone Number, Payment Amounts
Did you purchase Health Insurance through healthcare.gov marketplace?*
If yes, did you receive a 1095-A form from marketplace? We will need a copy*

YesNoNot Applicable
If Available Please Upload Your Form 1095-A To The Link Below

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Were you disallowed the Earned Income Credit prior to this year?*

YesNoNot Applicable
Did you receive unemployment compensation (Form 1099-G) If yes we will need a copy of said form.*

YesNoNot Applicable
If Available Please Upload Your Form 1099-G To The Link Below

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Did you make college tuition payments and received a 1098-T from the previous year? If yes, we will need a copy of said form*

YesNoYes, I've received multiple
If Available Please Upload Your Form 1098-T To The Link Below

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Do you have any other income other than W-2 s (1099s, Schedule K1s, etc) If yes, we need supported documents and forms.*

YesNo
If Available Please Upload Your W2s, 1099s, 1098s and all other Miscellaneous Forms with Supporting Documentation To The Link Below

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Do you owe any delinquent taxes?*

Child SupportAlimonyStudent LoansBack TaxesState TaxesNone
Did you make any energy efficient improvements to your home?*

YesNo
Do you have solar energy or solar hot water heating?*

YesNo
If yes, expense amount
Thank you for choosing our tax services you have completed our intake form.
Signature*
Date*

MonthDayYear
Date
Should be Empty:

Empire Unlimited Tax Services, LLC