LQFG - TAX CLIENT INTAKE FORM 2023 - DO NOT DELETE THIS!!!

2023 TAX CLIENT INTAKE FORM
* PLEASE ENTER ALL INFORMATION ACCURATELY SO THAT WE MAY COMPLETE AN ACCURATE TAX QUOTE FOR YOU.
HOW DID YOU HEAR ABOUT US?*
REFERRING CLIENTS NAME*
LQ FINANCIAL GROUP TAX SPECIALIST YOU HAVE PREVIOUSLY SPOKE WITH?*
Please select from the dropdown list
ARE YOU A PREVIOUS CLIENT OF LQ FINANCIAL GROUP?*
Please select from the dropdown list
TAXPAYER INFORMATION
TAXPAYER NAME*

First NameLast Name
EMAIL ADDRESS*
example@example.com
MOTHERS MAIDEN LAST NAME
For Security
TAXPAYER ADDRESS*

Street Address

Street Address Line 2

CityState

Zip Code
PLEASE UPLOAD PROOF OF RESIDENCY (LEASE, MORTGAGE, BILL, ETC)

If not available please skip and you will have the opportunity to submit later.
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TAXPAYER SOCIAL SECURITY #*
PLEASE UPLOAD A COPY OF YOUR SOCIAL SECURITY CARD

If not available please skip and you will have the opportunity to submit later.
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TAXPAYER PHONE NUMBER*
Please enter a valid phone number.
CELL PHONE COMPANY*
Please select from the dropdown list
TAXPAYER BIRTHDATE*

MonthDayYear
Date
TAXPAYER DRIVERS LICENSE OR ID #*
ISSUING STATE OF LICENSE OR ID*
DATE LICENSE OR ID ISSUED *

MonthDayYear
Date
LICENSE OR ID EXPIRATION DATE*

MonthDayYear
Date
PLEASE UPLOAD A COPY OF YOUR DRIVER LICENSE OR ID*

This must be submitted.
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TAXPAYER OCCUPATION *
WHAT IS YOUR FILING STATUS? *
(If unknown, select unknown)
DID YOU RECEIVE UNEMPLOYMENT PAYMENTS DURING 2022?*
PLEASE UPLOAD A COPY OF YOUR UNEMPLOYMENT 1099-G

If not available please skip and you will have the opportunity to submit later.
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DID YOU RECIEVE A W2 OR 1099 FROM A JOB(s)?*
PLEASE UPLOAD A COPY OF YOUR W2s and/or 1099s*

If not available please skip and you will have the opportunity to submit later.
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IF YOU HAVE AN IRS ISSUED PERSONAL IDENTITY PROTECTION PIN (IP PIN) LIST IT HERE (LEAVE BLANK IF NOT)
PINS for other Spouses or Dependents may be listed later in this form. Please leave blank if there is no PIN.
ARE YOU OR YOUR SPOUSE A BUSINESS OWNER?*
DID YOU OR YOUR SPOUSE PURCHASE HEALTH INSURANCE THROUGH THE HEALTHCARE MARKETPLACE (OBAMACARE)?*
DO YOU OR YOUR SPOUSE HAVE LIFE INSURANCE?*
WOULD YOU LIKE TO FIND OUT HOW TO GROW YOUR WEALTH WITH LIFE INSURANCE?*
ARE YOU MARRIED OR FILING WITH A SPOUSE?*
SPOUSE INFORMATION

Please enter your spouses information
SPOUSE INFORMATION (leave blank if no Spouse)*

First NameLast Name
SPOUSE EMAIL*
example@example.com
DO YOU AND YOUR SPOUSE LIVE AT THE SAME ADDRESS?*
SPOUSE ADDRESS (ONLY IF DIFFERENT THAN PRIMARY TAXPAYER)*

Street Address

Street Address Line 2

CityState

Zip Code
SPOUSE SOCIAL SECURITY #*
PLEASE UPLOAD A COPY OF YOUR SPOUSES SOCIAL SECURITY CARD

If not available please skip and you will have the opportunity to submit later.
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SPOUSE PHONE NUMBER*
Please enter a valid phone number.
SPOUSE CELL PHONE COMPANY*
Please select from the dropdown list
SPOUSE BIRTHDATE*

MonthDayYear
Date
SPOUSE DRIVERS LICENSE OR ID #*
ISSUING STATE OF LICENSE OR ID*
DATE LICENSE OR ID ISSUED *

MonthDayYear
Date
LICENSE OR ID EXPIRATION DATE*

MonthDayYear
Date
PLEASE UPLOAD A COPY OF YOUR SPOUSES DRIVER LICENSE OR ID*

This must be submitted.
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SPOUSE OCCUPATION *
DID YOUR SPOUSE RECEIVE UNEMPLOYMENT PAYMENTS DURING 2022?*
PLEASE UPLOAD A COPY OF YOUR SPOUSES UNEMPLOYMENT 1099-G

If not available please skip and you will have the opportunity to submit later.
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DID YOUR SPOUSE RECIEVE A W2 OR 1099 FROM A JOB(s)?*
PLEASE UPLOAD A COPY OF YOUR SPOUSES W2s and/or 1099s*

If not available please skip and you will have the opportunity to submit later.
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IF SPOUSE HAS AN IRS ISSUED IDENTITY PROTECTION PIN (IP PIN) LIST IT HERE (LEAVE BLANK IF NOT)
If not available please skip and you will have the opportunity to submit later. Please leave blank if there is no PIN.
DEPENDENT INFORMATION
HOW MANY DEPENDENTS DO YOU HAVE?*
ARE YOU BANNED FROM CLAIMING EARNED INCOME CREDIT?*
WERE ANY CREDITS DISALLOWED OR REDUCED IN A PREVIOUS TAX YEAR?*
ARE ANY OF THE DEPENDENTS DISABLED?*
IF YES, WHAT IS THE NATURE OF THE DISABILITY?*
DISABLED DEPENDANTS NAME(S)*
DO YOU HAVE SUPPORTING DOCUMENTS TO PROVE YOUR RELATIONSHIP TO ALL DEPENDENTS? (BIRTH CERTIFICATE, SOCIAL SECURITY CARD, SCHOOL DOC, ETC)*
IN CASE OF AN AUDIT CAN YOU PROVE RESIDENCY AND RESPONSIBILITY FOR THE DEPENDENTS BEING CLAIMED?*
DID YOU PAY FOR CHILD OR DEPENDENT CARE TO ATTEND WORK OR WHILE LOOKING FOR WORK?*
DEPENDENT 1 DETAILS
DEPENDENT #1*

First NameLast Name
DEPENDENT #1 BIRTHDATE*

MonthDayYear
Date
DEPENDENT #1 SOCIAL SECURITY #*
Social Security
RELATIONSHIP TO TAXPAYER*
Can DEPENDENT #1 be claimed by anyone else?*
Did the dependent live in your home for 6 months or more in the past year?*
DEPENDENT #1 IDENTITY PROTECTION PIN (leave blank if none)
Enter Identity Protection PIN if dependent has one
PLEASE UPLOAD A COPY OF DEPENDENT #1 SOCIAL SECURITY CARD

If not available please skip and you will have the opportunity to submit later.
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PLEASE UPLOAD A COPY OF DEPENDENT #1 BIRTH CERTIFICATE

If not available please skip and you will have the opportunity to submit later.
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DEPENDENT 2 DETAILS
DEPENDENT #2*

First NameLast Name
DEPENDENT #2 BIRTHDATE*

MonthDayYear
Date
DEPENDENT #2 SOCIAL SECURITY #*
Social Security
RELATIONSHIP TO TAXPAYER*
Can DEPENDENT #2 be claimed by anyone else?*
Did the dependent live in your home for 6 months or more in the past year?*
DEPENDENT #2 IDENTITY PROTECTION PIN (leave blank if none)
Enter Identity Protection PIN if dependent has one
PLEASE UPLOAD A COPY OF DEPENDENT #2 SOCIAL SECURITY CARD

If not available please skip and you will have the opportunity to submit later.
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PLEASE UPLOAD A COPY OF DEPENDENT #2 BIRTH CERTIFICATE

If not available please skip and you will have the opportunity to submit later.
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DEPENDENT 3 DETAILS
DEPENDENT #3*

First NameLast Name
DEPENDENT #3 BIRTHDATE*

MonthDayYear
Date
DEPENDENT #3 SOCIAL SECURITY #*
Social Security
RELATIONSHIP TO TAXPAYER*
Can DEPENDENT #3 be claimed by anyone else?*
Did the dependent live in your home for 6 months or more in the past year?*
DEPENDENT #3 IDENTITY PROTECTION PIN (leave blank if none)
Enter Identity Protection PIN if dependent has one
PLEASE UPLOAD A COPY OF DEPENDENT #3 SOCIAL SECURITY CARD

If not available please skip and you will have the opportunity to submit later.
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PLEASE UPLOAD A COPY OF DEPENDENT #3 BIRTH CERTIFICATE

If not available please skip and you will have the opportunity to submit later.
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DEPENDENT 4 DETAILS
DEPENDENT #4*

First NameLast Name
DEPENDENT #4 BIRTHDATE*

MonthDayYear
Date
DEPENDENT #4 SOCIAL SECURITY #*
Social Security
RELATIONSHIP TO TAXPAYER*
Can DEPENDENT #4 be claimed by anyone else?*
Did the dependent live in your home for 6 months or more in the past year?*
DEPENDENT #4 IDENTITY PROTECTION PIN (leave blank if none)
Enter Identity Protection PIN if dependent has one
PLEASE UPLOAD A COPY OF DEPENDENT #4 SOCIAL SECURITY CARD

If not available please skip and you will have the opportunity to submit later.
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PLEASE UPLOAD A COPY OF DEPENDENT #4 BIRTH CERTIFICATE

If not available please skip and you will have the opportunity to submit later.
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DEPENDENT 5 DETAILS
DEPENDENT #5*

First NameLast Name
DEPENDENT #5 BIRTHDATE*

MonthDayYear
Date
DEPENDENT #5 SOCIAL SECURITY #*
Social Security
RELATIONSHIP TO TAXPAYER*
Can DEPENDENT #5 be claimed by anyone else?*
Did the dependent live in your home for 6 months or more in the past year?*
DEPENDENT #5 IDENTITY PROTECTION PIN (leave blank if none)
Enter Identity Protection PIN if dependent has one
PLEASE UPLOAD A COPY OF DEPENDENT #5 SOCIAL SECURITY CARD

If not available please skip and you will have the opportunity to submit later.
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PLEASE UPLOAD A COPY OF DEPENDENT #5 BIRTH CERTIFICATE

If not available please skip and you will have the opportunity to submit later.
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BANKING INFORMATION
Would You Like to Apply for a Refund Advance Loan?*
Refund Advances are subject to bank approval.
How Would You Like to Receive Your Refund?*
Bank Name*
Type of Account*
Account Number*
Routing Number*
Taxpayer Agrees That if He/She Owes Any Taxes, Prior Obligations, or Back Taxes (Offsets), All Fees Will Have to Be Paid Upfront Before the Return Is Filed*
PRIOR TAX YEARS
DO YOU NEED TO FILE TAXES FOR PREVIOUS MISSING YEARS*
PLEASE CHECK ALL PRIOR TAX YEARS THAT YOU HAVE NOT FILED YET.

2022202120202019201820172016 OR PRIOR
THE AMERICAN CARES ACT
DID YOU OR YOUR SPOUSE RECEIVE THE 3RD ECONOMIC IMPACT PAYMENT?(STIMULUS)*
How much was your 3rd ECONOMIC IMPACT PAYMENT? (STIMULUS)*
This references ONLY the 3rd payment. If exact amount is unknown please enter best estimate
DID YOU OR YOUR SPOUSE RECEIVE UNEMPLOYMENT DURING 2020 OR 2021?*
DID YOU OR YOUR SPOUSE RECEIVE AN ADVANCED CHILD TAX CREDIT PAYMENT (CTC) DURING 2021?*
DID YOU OR YOUR SPOUSE RECEIVE A LOAN FROM THE PAYCHECK PROTECTION PROGRAM (PPP)?*
BUSINESS INFORMATION
WOULD YOU LIKE TO GROW YOUR BUSINESSES REVENUE THIS YEAR?*
DOES YOUR BUSINESS NEED TO BECOME MORE FINANCIALLY ORGANIZED?*
ARE YOU INTERESTED IN RECEIVING MORE MONEY FOR YOUR BUSINESS THIS YEAR? (Loans, Grants, Business Credit Cards, etc)*
WHAT IS THE NAME OF YOUR BUSINESS?*
WHAT DOES YOUR BUSINESS DO?*
Explain what your company does in 60 words or less
ARE YOU INTERESTED IN STARTING YOUR OWN BUSINESS THIS YEAR?*
ARE YOU INTERESTED IN STARTING A NEW BUSINESS THIS YEAR?*
BUSINESS INCOME DOCUMENTS
DID YOU MAKE OR LOSE ANY INCOME FROM A BUSINESS YOU OWN THIS YEAR?*
PLEASE UPLOAD ANY BUSINESS OR ADDITIONAL INCOME DOCUMENTS YOU HAVE (Business Revenue, Rental Income, Stock or Other Securities Sales, Business Profit and Loss Statement, etc )

If not available please skip and you will have the opportunity to submit later.
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PLEASE UPLOAD ANY BUSINESS EXPENSE DOCUMENTS YOU HAVE (Business Revenue, Rental Income, Stock or Other Securities Sales, Business Profit and Loss Statement, etc )

If not available please skip and you will have the opportunity to submit later.
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STUDENT INFORMATION
DID YOU, YOUR SPOUSE, OR ANY DEPENDENT ATTEND ANY POST-SECONDARY EDUCATION? (College, Trade School, etc)*
PLEASE UPLOAD YOUR SCHOOL EXPENSES 1098-T FORM (IF AVAILABLE)

If not available please skip and you will have the opportunity to submit later.
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SUPPORTING DOCUMENTS UPLOAD
ADDITIONAL INCOME DOCUMENTS
PLEASE UPLOAD ANY ADDITIONAL INCOME DOCUMENTS YOU HAVE (Rental Income, Stock or Other Securities Sales, etc)

If not available please skip and you will have the opportunity to submit later.
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DID YOU, YOUR SPOUSE, OR ANY DEPENDENT RECEIVE GOVERNMENT ASSISTANCE IN 2023? (Food Stamps, Housing, TANF, Medicaid, Star, Job Training, etc)*
PLEASE UPLOAD ALL GOVERNMENT ASSISTANCE SUPPORT DOCUMENTS YOU HAVE (Food Stamps, Housing, TANF, Medicaid, Star, Job Training, etc)

If not available please skip and you will have the opportunity to submit later.
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PERSONAL EXPENSE DOCUMENTS
PLEASE UPLOAD ALL OF YOUR EXPENSE DOCUMENTS (Health Care Expenses, Charity Donations, Tax Bills, etc)

If not available please skip and you will have the opportunity to submit later.
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ADDITIONAL DEPENDENT DOCUMENTS
PLEASE UPLOAD YOUR DEPENDENT CARE EXPENSE DOCUMENTS (Dependent Care, Day Care, Medical Cost, etc)

If not available please skip and you will have the opportunity to submit later.
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PLEASE UPLOAD YOUR DEPENDENT RESIDENCY PROOF (School Records, Vaccination Cards, Govt Assistance Award Letters, Guardianship Letter, Adoption Letter, Foster Care, Medical Power of Attorney, etc)

If not available please skip and you will have the opportunity to submit later.
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PLEASE UPLOAD PROOF OF DEPENDENTS DISABILITY (Social Security Award Letter, Disability Determination or Award, Medical Record, etc)

If not available please skip and you will have the opportunity to submit later.
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By signing below, I hereby certify that the information I have provided above is fully true and accurate to the best of my knowledge. As the taxpayer, I have been informed that providing any form of fradulently information can result in audit, fines, criminal charges, and other consequences.

I also acknowledge that i have been informed via this statement that providing false or fradulent information in order to claim a dependent, credit, deduction, reduction, filing status or other tax position can result in audit, fines, criminal charges, and other consequences.
Signature*
TODAYS DATE

MonthDayYear
***Thank you for your submission. Our office will be in contact with you as soon as possible but no later than 24hrs. Thank you for the opportunity to earn your business it is greatly appreciated.
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2023 TAX CLIENT INTAKE FORM

TAXPAYER INFORMATION

SPOUSE INFORMATION

DEPENDENT INFORMATION

DEPENDENT 1 DETAILS

DEPENDENT 2 DETAILS

DEPENDENT 3 DETAILS

DEPENDENT 4 DETAILS

DEPENDENT 5 DETAILS

BANKING INFORMATION

PRIOR TAX YEARS

THE AMERICAN CARES ACT

BUSINESS INFORMATION

BUSINESS INCOME DOCUMENTS

STUDENT INFORMATION

SUPPORTING DOCUMENTS UPLOAD

ADDITIONAL INCOME DOCUMENTS

PERSONAL EXPENSE DOCUMENTS

ADDITIONAL DEPENDENT DOCUMENTS