Taxpayer Intake Form
Filing Status
Single
Head of Household
Married Filing Separate
Married Filing Joint
Qualifying Widower
Taxpayer Information
Name
*
First Name
Last Name
Age
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
*
SSN
*
Are you a full-time student?
Yes
No
Are you totally and permanently disabled?
Yes
No
Are you legally blind?
Yes
No
Is this individual dependent of other?
Yes
No
Upload IP Pin / Letter
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Upload State ID / Driver License
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Spouse Information
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
SSN
Are you a full-time student?
Yes
No
Are you totally and permanently disabled?
Yes
No
Are you legally blind?
Yes
No
Is this individual dependent of other?
Yes
No
Upload State ID / Driver License
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Dependents
Enter your dependents here
Rows
Name
SSN
Date of Birth
Relationship
1
2
3
4
5
6
Your child/ children are one of the following: your son, daughter, stepchild, foster child, brother, sister, stepbrother, stepsister, or grandchild and you cared for him/ her as your child.
Yes
No
Upload All Dependents SS Cards
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Does you, your spouse, and your dependents have health insurance within 12 months last year? If yes, who covers for it?
Rows
Yes/No
Employer
Spouse Ins
Exchange/ Marketplace
Direct with Insurer
Medicare
Medicaid
Taxpayer
Yes
No
Spouse
Yes
No
Dependent 1
Yes
No
Dependent 2
Yes
No
Dependent 3
Yes
No
Dependent 4
Yes
No
Dependent 5
Yes
No
Tax Related Questions
Employment Status
*
Employed
Unemployed
Self-employed
Are you contributing to 401k or other pre-tax account?
Yes
No
Is this your first time opening a pre-tax account?
Yes
No
Please select what state return are you requesting?
State return
School
Local
RITA
Country returns
Does your dependents have tuition expenses?
Yes
No
Do you have any expenses for child care?
Yes
No
Do you owe student loans?
Yes
No
Do you owe child support?
Yes
No
Do you have your own home?
Yes
No
Do you have documents that shows you paid for property taxes?
Yes
No
Are you applying for the Refund Advance?
Yes
No
Refund Option:
Check
Direct Deposit
Do you owe state taxes?
Yes
No
Have you received any notices from IRS?
Yes
No
Do you have real estate tax?
Yes
No
Did you receive a federal tax last year?
Yes
No
Are you a victim of identity theft?
Yes
No
Expenses
Please fill-up the information within the current year only.
General Expenses
Rows
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
Bank Name:
*
Bank routing number (Please check)
*
Bank account number (Please check)
*
Upload W2
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Upload any additional TAX DOCUMENTS
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Additional comments
Acknowledgment & Signature
I confirmed that all information I entered here is accurate and true and will be used to prepare my tax return.
I allow Financial Reliable Services to capture my sensitive data like personal id, government id, social security number (SSN),W2, and other information.
I have read the terms and conditions and privacy policy of Financial Reliable Services.
By signing below, you acknowledge that you have read and understood your responsibilities and our responsibilities in doing this tax return. I understand that failure to pay tax preparation fees will result in legal action and I will be responsible for court and tax preparation fee.
Date Signed
*
-
Month
-
Day
Year
Date
Taxpayer Signature
*
Date Signed
-
Month
-
Day
Year
Date
Spouse Signature
Configurable list
*
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