Client Intake Sheet

Prior ClientNew Client

First NameLast NameSSN or ITINBirth DateOccupation

Email AddressPrimary Phone Secondary Phone

First NameLast NameSSN or ITINBirth DateOccupation

Email AddressPrimary Phone Secondary Phone

Street Address

Apartment Number

CityState / Province

Postal / Zip Code

Best time to reach you

NameBirth DateSSN or ITINRelationship to youUS Citizen or Resident

1095-A (Health Care through the marketplace)1095-B (State/Other Health Care)1095-C (Healthcare through employer)FTB 3895 (State of CA healthcare form)

DMV License TaxSales Taxes Paid on Purchase of vehicle, boat, motorcycle, etc.Real Estate Taxes / or Personal Propert TaxesState Income Taxes Paid in prior yearActual Sales Taxes Paid on purchase of food, clothing, medical supplies, etc.Other

Home Mortgage Interests (Form 1098)Time Share InterestOther

Charity/Organization NameDate of DonationAmount Donated or Fair Market ValueMethod of donation : Cash, Check, ClothingType of Proof you have?

Date of LossDescriptionValue before - and Value after LossInsurance ReimbursementDid you file a Police Report?

YesNoNot Applicable N/A

To submit this Client Intake Sheet you must sign below. By signing, you are certifying under penalty of perjury that you reviewed this form and the answers are true and correct to the best of your knowledge; that you can provide proof of everything you selected on this form if needed.

Client Intake Form

Part I. Personal Information

Part II. Dependent Information

Part III & IV: Income Information

Part V. Tax Credits & Deductions

Part VI. Determining Your Filing Status