Tax Intake Form

CLIENT INTAKE FORM

Thank you for taking the time to complete your 2023 Client Intake Form For new clients, this information is critical to ensuring we accurately file your tax return. For existing clients, we kindly request that you provide this information again to ensure our records are 100% accurate and up-to-date. ALL FORMS ARE REQUIRED. If you submit this entry with no income statements, social security cards, or state-issued ID, your submission will be removed from our system. Please keep in mind that, in order to comply with federal and state identity theft prevention initiatives, our firm will require a valid state-issued picture identification card during your engagement. The page is highly secure. We use industry-leading technology, Secured Socket Layer (SSL), to keep your information safe. All sensitive information is securely transmitted and cannot be compromised. This questionnaire may take you up to 20 minutes to complete. Please be sure to organize all of your tax documents prior to completing the form. IMPORTANT: ONCE ALL APPLICABLE PARTS OF THIS FORM HAVE BEEN COMPLETED, YOU MUST CLICK THE "SUBMIT" BUTTON AT THE BOTTOM OF THE FORM TO SEND THIS INFORMATION TO OUR OFFICE. Closing your browser before clicking the "SUBMIT" button will remove all data without sending it to us.
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
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
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Taxpayer's Email Address*
example@example.com
Spouse's Name

First NameLast Name
Spouse's SSN
Example: xxx-xx-xxxx
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
Spouse's Job Title
example@example.com
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, 2023?*

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 2023? (If all year, enter 12)
Dependent #2

First NameLast Name
Dependent #2 Date of Birth
Example: 01/01/2001
Dependent #2 SSN
How many months did Dependent #2 live with you in 2023? (If all year, enter 12)
What is Dependent #2's Relationship to you (son, daughter, etc.)?
Dependent #3

First NameLast Name
Dependent #3's Date of Birth
01/01/2001
Dependent's #3 SSN
How many months did Dependent #3 live with you in 2023? (If all year, enter 12)
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 2023? (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 2023? (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.

Cancelof
How would you like to receive your tax refund?

Check (Only available for in office visits)Direct DepositDebit Card
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 2023?*

YesNo
Did you have health insurance for the entire year?*

YesNo
Who was your insurance cover through in 2023?*
Was your insurance through the Affordable Care Act (The Marketplace)?*

YesNo
Upload Taxpayer & Dependent(s)1095A Insurance Documents

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

YesNo
Were you or any of your dependents in college in 2023?

YesNo
Did you trade any Virtual Currency

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.

Cancelof
Are you interested in AUDIT PROTECTION?

YesNo
CLIENT NON-PAYMENT/OFFSET CLAUSE

At SHE iMpAcTz Solutions LLC, we strive to assist all of our clients with their tax needs; however, 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.

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

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ADDITIONAL SERVICES

At SHE iMpAcTz Solutions 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.
Type a question

Business FormationBusiness CreditPersonal CreditNotary
I am giving SHE iMpAcTz Solutions 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 SHE iMpAcTz Solutions 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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Date

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

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Type a question
Taxpayer's Driver's License

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

Cancelof
Taxpayer's W-2/ 1099'S/Self-Employed Docs

Cancelof
Dependent(s) Birth Certificate(s)

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

Cancelof
Should be Empty: