CLIENT INTAKE FORM

CLIENT INTAKE FORM
Taxpayer Information
Filing Status

SingleMarried Filing JointlyMarried Filing SeparatelyHead of HouseholdQualifying Widow(er) with Dependent Children
Taxpayer Name
Taxpayer SSN
Taxpayer Date of Birth
Taxpayer Occupation
Check all that apply:

Can you be claimed as a dependent on someone else's returnWere you over age 18 and a full-time student at an eligible educational institution.Taxpayer is blind.Taxpayer is deceased.Taxpayer or Spouse served in a combat zone during the current tax year.Taxpayer or Spouse was affected by a natural disaster during the current tax year.Taxpayer has received, sold, sent, exchanged, or otherwise acquired financial interest in virtual currency during the current tax year.Taxpayer prefers to receive written communications from the IRS in a language other than English.Taxpayer prefers to receive written communications from the IRS in an accessible format.
Spouse Name
Spouse SSN
Spouse Date of Birth
Spouse Occupation
Check all that apply:

Can you be claimed as a dependent on someone else's returnWere you over age 18 and a full-time student at an eligible educational institution.Taxpayer is blind.Taxpayer is deceased.Taxpayer or Spouse served in a combat zone during the current tax year.Taxpayer wishes to elect to use their 2019 earned income to figure their 2021 earned income credit and/or child tax credit.Taxpayer or Spouse was affected by a natural disaster during the current tax year.Taxpayer has received, sold, sent, exchanged, or otherwise acquired financial interest in virtual currency during the current tax year.Taxpayer prefers to receive written communications from the IRS in a language other than English.Taxpayer prefers to receive written communications from the IRS in an accessible format.
Taxpayer Address
Address (continued)
Taxpayer Phone Number
Spouse Address
Spouse Address (continued)
Spouse Phone Number
Taxpayer Email Address
example@example.com
Spouse Email Address
example@example.com

DEPENDENTS INFORMATION

	FULL DEPENDENT NAME	SOCIAL SECURITY NUMBER	DATE OF BIRTH	# OF MONTHS DEPENDENT RESIDE WITH TAXPAYER
DEPENDENT 1
DEPENDENT 2
DEPENDENT 3
DEPENDENT 4
DEPENDENT 5
DEPENDENT 6

Do you have a "Special Needs" child?

YesNo
HEALTH INSURANCE COVERAGE:
DID YOU RECEIVED HEALTH COVERAGE (INSURANCE) THROUGH YOUR STATE MARKETPLACE OR HEALTHCARE.GOV? IF SO, PLEASE UPLOAD YOUR FORM 1095A
Please upload 1095A

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Wages and Salaries (Attach W-2's)

Interest Income (Attach 1099's) (List and identify as non-taxable Interest Income)

Unemployment Compensation Received (FORM 1099G) PLEASE UPLOAD FORM BELOW:
File Upload

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Were you, your spouse, or any dependent registered in college? Do you have a form 1098T?
File Upload

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If you would like your tax refund (if any) deposited directly into your bank

CheckingSavings
Bank Name
Your Account Number
Bank Routing Number
Rental & Royalty Income and Expense (Rental Property)
Property Type

ResidentialCommercial
Number of days rented
Number of days used personally
Property is owned by

TaxpayerSpouseJoint
Percentage ownership of not 100%: Please indicate if income and expenses below are listed at 100% or your percentage

YesNo
Percentage ownership of not 100%
Did you live in part of the rental property?
If yes, what percentage did you occupy as a tenant?

Check if rented to a related party. Explain relation
If yes, what percentage did you occupy as a tenant?
Business Income & Expenses (Sole Proprietorship, LLC)
Owner Name
Business name
Employer ID number
Business Type
Address
City
State
Zip Code
Employer ID number (EIN)
Do you use any part of your home regularly and exclusively for business?

YesNo
Estimated percentage of time spent in home office compared to total time spent in this business
Estimated of time in home office compared to total time in this business
Description of work done in home office
Description of work done outside of work office
Total area of home
Total area of home used regularly for business
Please upload any additional tax documents below:

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Does anyone listed on the Tax Return have an Identity Pin? If so, please list the name and Identity Pin below:
Signature

Clear
Should be Empty:

CLIENT INTAKE FORM

Taxpayer Information

HEALTH INSURANCE COVERAGE: