Tax Preparation Client Intake Form

Tax Preparation Client Intake Form
Filing Status

SingleHead of HouseholdMarried Filing SeparateMarried Filing JointQualifying Widower

Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
SSN
Are you a full-time student?

YesNo
Are you totally and permanently disabled?

YesNo
Are you legally blind?

YesNo
Is this individual dependent of other?

YesNo

Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
SSN
Are you a full-time student?

YesNo
Are you totally and permanently disabled?

YesNo
Are you legally blind?

YesNo
Is this individual dependent of other?

YesNo

Enter your dependents here

Rows	Name	SSN	Date of Birth	Relationship
1
2
3
4
5
6

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
Spouse
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5

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
Additional comments

Routing
Routing
Account
account

- I confirmed that all information I entered here is accurate and true.
- I allow ABC Financial to capture my sensitive data like personal id, government id, social security number (SSN), and other information.
- I have read the terms and conditions and privacy policy of ABC Financial.
- By signing below, you acknowledge that you have read and understood your responsibilities and our responsibilities in doing this tax return.
Date Signed

MonthDayYear
Date
Taxpayer Signature
Date Signed

MonthDayYear
Date
Spouse Signature

My Products

Tax Review/Consultation

This is a non-refundable 1 hour consultation charge for me to review your documents.

$75.00

DEPOSIT FOR TAX RETUNS

This is the base price for my tax returns, this amount will come off of the final price of your personal/business tax filing. If you are a client using Refund Transfer you are not required to place a deposit but understand there is a $60 fee associated with using the banking products.

$200.00

Total

$0.00

Payment Methods

Credit Card

Google Pay

Cash App Pay

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