Tax Intake Form

CLIENT INTAKE FORM
How did you hear about us?

FacebookInstagramReferralPrevious Client
Tax Preparer Name
If someone referred you, please type his or her name here.
Are you trying to buy a new home within the next 2 years?

YesNo
Are you interested in Credit Repair

YesNo
Email
example@example.com
Tax Payers Name

First NameLast Name
Taxpayer's Phone Number*
Example: xxx-xxx-xxxx
Taxpayer's Job Title
Taxpayer's Date of Birth*
Example: 01/01/2001
Taxpayer's SSN
Example: xxx-xx-xxxx
Taxpayer's Email Address*
Spouse's Full Name
First Name
Spouse's SSN
Example: xxx-xx-xxxx
Name

First NameLast Name
Spouse's Date of Birth
Example: 01/01/2001
Spouse's Phone Number
Example: xxx-xxx-xxxx
Spouse's Email Address
Example: example@example.com
Taxpayer's SSN
Example: xxx-xx-xxxx
Spouse's Job Title
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you self employed?*

YesNo
Did you and your spouse live apart during the year?*

YesNoNot Applicable
What is your marital status as of December*

Single (Not Married)Married living with SpouseMarried not living with spouse
Did you pay over half the expenses of maintaining your residence for the entire year?*

YesNo
Did you support a child or family member for more than 6 months out of the year?*

YesNo
If yes, did you live together at any time after June 30, 2024?*

YesNoNot Applicable
Are you on any Government Assistance*

YesNoNot Applicable
How many dependents are you claiming?*
Dependent #1

First NameLast Name
Dependent #1 Date of Birth
01/01/2001
Dependent #1 SSN
What is Dependent #1's Relationship to you (son, daughter, etc.)?
How many months did Dependent #1 live with you in 2024? (If all year, enter 12)
Dependent #2

First NameLast Name
Dependent #2 Date of Birth
Example: 01/01/2001
Dependent #2 SSN
What is Dependent #2 Relationship to you (son, daughter,etc)?
How many months did Dependent #2 live with you in 2024? (If all year, enter 12)
Dependent #3

First NameLast Name
Dependent #3's Date of Birth
01/01/2001
How many months did Dependent #3 live with you in 2024? (If all year, enter 12)
Dependent #3 SSN
Example: xxx-xx-xxxx
What is Dependent #3's Relationship to you (son, daughter, etc.)?
Dependent #4's First Name
First Name
Dependent #4's Last Name
Last Name
Dependent #4's Date of Birth
01/01/2001
Dependent #4's SSN
Example: xxx-xx-xxxx
What is Dependent #4's Relationship to you (son, daughter, etc.)?
How many months did Dependent #4 live with you in 2024? (If all year, enter 12)
Dependent #5's First Name
First Name
Dependent #5's Last Name
Last Name
Dependent #5's Date of Birth
01/01/2001
Dependent #5's SSN
Example: xxx-xx-xxxx
What is Dependent #5's Relationship to you (son, daughter, etc.)?
How many months did Dependent #5 live with you in 2024? (If all year, enter 12)
Are there any dependents in daycare? If yes, please upload the form you received from your daycare provider.

YesNo
Upload a copy of your daycare form here.

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How would you like to receive your tax refund?

Check (Only available for in office visits)Direct Deposit
Name of Bank
Which type of account would you like your refund deposited into?

Checking AccountSavings AccountOther
Routing Number
Bank Account Number
Can someone else claim you as a dependent?

YesNo
Did you have health insurance in 2024?

YesNo
Did you have health insurance for the entire year?

YesNo
Who was your insurance cover through in 2024?
Was your insurance through your employer?

YesNo
Was your insurance through Medicaid?

YesNo
Was your insurance through the Affordable Care Act (The Marketplace)?

YesNo
Did your dependents have health insurance for the entire year?

YesNoNot Appliable
Was YOUR DEPENDENTS' insurance through your employer?

YesNoNot Applicable
Who was your Dependents insured with in 2024?
Upload Taxpayer & Dependent(s)Insurance Documents

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Was YOUR DEPENDENTS' insurance through Medicaid?

YesNoNot Applicable
Was YOUR DEPENDENTS' insurance through the Affordable Care Act (The Marketplace)?

YesNoNot Applicable
Have you ever been denied the Earned Tax Credit (EITC)?

YesNo
Did you trade any Virtual Currency

YesNo
Were you or any of your dependents in college in 2024?

YesNo
Do you have a 1098-T Form for either you or your dependents?

YesNo
If you have a 1098-T form, upload it here.

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Are you interested in AUDIT PROTECTION?

YesNo
CLIENT NON PAYMENT/OFFSET CLAUSE

PB&J Financial Services LLC, we strive to assist all of our clients in their tax needs, howwever we understand that situations arise. If your refund is offset by the IRS, student loans, child support or your check is mailed, you are still obligated to pay our company the fees associated with filing your tax return. I

By signing this agreement you acknowledge that if payment is not made in full with in 30 days legal actions will be sought to resolve payment.
Primary Taxpayer's Signature

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ADDITIONAL SERVICES

At PB&J Financial Services LLC, we do more than just taxes. Please check below if you would be interested in any of the additional services we provide. We will schedule a time to speak with you ar a later time.
I am giving PB&J Financial Services LLC permission to prepare all forms related to my tax return; to apply for and secure RAC's and RAL's on my behalf; and sign all necessary forms and file my taxes electronically. I take full responsibility for the accuracy of this form and understand that PB&J Financial Services LLC and/or associated affiliates hold no responsibility for any misrepresentation or false claims.
Date

MonthDayYear
Date
Taxpayer's Signature (If no spouse, leave blank)

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Spouse's Signature (If no spouse, leave blank)

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Date

MonthDayYear
Date
Type a question
Date

MonthDayYear
Date
Taxpayer's Driver's License

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Taxpayer's and Dependent(s ) Social Security Card(s)

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Taxpayer's W-2/ 1099'S

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Dependent(s) Birth Certificate(s)

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Dependent(s) Proof of Residency (Lease/Utility Bill)

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CLIENT INTAKE FORM