Tax Preparation Client Intake Form

Tax Preparation Client Intake Form

Please complete EVERYTHING that applies to you and submit all your documents. Please wait until you have ALL your documents before submitting your intake form.
Type of Client*
Tax Year needing prepared. You will need to submit a form for each year needing prepared.*

202520242023Other
Do you owe the IRS, your state, child support, student loans, government, etc?*
Do you receive any government assistance?*

Name*

First NameMiddle NameLast NameSuffix
SSN/ITIN*
Date of Birth*

MonthDayYear
Date
Cell Number*
Please enter a valid phone number.Format: (000) 000-0000.
Cell Carrier (ex. Verizon)*
Work Number
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Present Employer*
Occupation*
Marital Status as of December 31, 2022*
Employment Status*
Are you a U.S. citizen?*
Address*

Street Address

Apt.

CityState / Province

Postal / Zip Code
Can anyone else claim you or are you listed as a dependent on someone else's tax return?*

Name

First NameMiddle NameLast NameSuffix
SSN/ITIN
Date of Birth

MonthDayYear
Date
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Carrier (ex.Verizon)
Work Number
Email
example@example.com
Present Employer
Occupation
Employment Status
Are you a U.S. citizen?
Address

Street Address

Apt.

CityState / Province

Postal / Zip Code
Can anyone else claim you or are you listed as a dependent on someone else's return?

Enter your dependent information here. Do not enter spouse information.

If you had Marketplace insurance at anytime last year, you are REQUIRED to provide a form 1095-A or your refund will be delayed!

Rows	Yes/No	Marketplace	Private/Other Healthcare Insurance	Medicaid	ALL Kids	Medicare
Taxpayer
Spouse
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5

If you were an employee, contractor, received unemployment or received any other income of any kind not listed, you can take photos and/or upload documents below.
TAKE PHOTO of documents here.
UPLOAD documents here.

Cancelof

How would you like to receive your tax refund?*

Prepaid CardCheckDirect Deposit (Availability of funds depends on your bank.)N/A
If your tax preparation fees will be deducted from your refund, please provide the answer to the following security question:
What high school did you attend? Type a label
I hereby authorize Disja Tax Services to initiate automatic deposits to my account at the financial institution named below. I also authorize Disja Tax Services to make withdrawals from this account in the that a credit entry is made in error.
Further, I agree not to hold Disja Tax Services responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial institution in depositing funds to my account.
This agreement will remain in effect until Disja Tax Services receives a written notice of cancellation from me or my financial institution, or until I submit a new direct deposit form.
Bank Name   Type a label
Routing Number
Account Number