Client Intake Form 2021

CLIENT INTAKE FORM

PLEASE FILL OUT ALL INFORMATION APPLICABLE
Taxpayer Name*

First NameLast NameSuffix
Social Security Number*
Date of Birth*

MonthDayYear
Occupation*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Spouse Information

First NameLast NameSuffix
Social Security Number
Date of Birth

MonthDayYear
Occupation
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address*

NO P O BOX/ PHYSICAL ADDRESS ONLY

Street Address Line 2

CityState / Province

Postal / Zip Code
Filing Status:*

SingleMarried Filing JointlyMarried Filing SeparatelyHead of HouseholdQualifying Widow
HEAD OF HOUSEHOLD FILERS MUST PRESENT ONE OF THE FOLLOWING TO FILE THIS STATUS. PICK ONE OF THE 3 OPTIONS THAT YOU WILL SUBMIT TO BE APPROVED TO FILE HEAD OF HOUSEHOLD.

LeaseUtility BillMortgage Statement
Dependent 1

First NameLast NameSuffix
Social Security Number
Date of Birth

MonthDayYear
Relationship
Dependent 2

First NameLast NameSuffix
Social Security Number
Date of Birth

MonthDayYear
Relationship
Dependent 3

First NameLast NameSuffix
Date of Birth

MonthDayYear
Social Security Number
Relationship
IF YOU ARE CLAIMING A DEPENDENT, PLEASE ANSWER THE QUESTIONS BELOW THAT PERTAINS TO YOUR DEPENDENT RELATIONSHIP. PER THE IRS REQUEST, WE MUST PROVE THAT NOBODY ELSE IS ELIGIBLE TO CLAIM YOUR DEPENDENT BUT YOURSELF.
If claiming son/daughter, where is the other parent of the dependent/dependents? Is the other parent providing any financial support?
If claiming niece, nephew, aunt, or uncle, how are you related to the dependent? Where are the parents to the dependent/dependents?
If claiming brother or sister, how are you related to the dependent? Why are the parents not claiming the dependent/dependents?
Did you pay someone to watch your child/children?

YESNO
Did you collect social security or retirement income?

YESNO
Did you purchase health insurance through healthcare.gov marketplace (Obama Care)?*

YesNo
If yes, did you receive a 1095-A Form from the marketplace?

YesNo
Were you ever disallowed the E.I.T.C prior to this year?*

YesNo
Did you receive unemployment compensation (1099-G) regular or PUA last year?*

YESNO
If yes, did you receive regular unemployment or PUA?

RegularPUA
Did you make college tuition payments and received a 1098-T Form last year?*

YESNO
Do you have any other income than your w-2(s)?*

YESNO
Do you owe any delinquent:*

Child SupportAlimonyStudent LoansBack TaxesState TaxesNone of the above
Did you receive the third Economic Impact Payment (Stimulus Payment) in 2021?*

YesNo
Enter the Amount of your Stimulus Payment Below*

2021 Stimulus Total

Amount Received

	2021 Stimulus Total
Amount Received

How would you like to receive your refund?*

Refund Transfer Direct DepositRefund Transfer Paper Check

Bank Information

	Name of Bank	Routing Number	Account Number
ENTER BANK DATA

I, hereby, state that all the information above is true to the best of my knowledge and that I am allowing Charlsey Sheppard to prepare my taxes based on that fact. I understand that I am financially responsible for any outstanding balance due to any false information given.

If there is a balance due, you must pay the tax preparation fee upfront. If for any reason you owe an entity and they take the entire refund, you are STILL responsible to pay the tax preparation fee for services rendered.

*For any reason an amendment has to be filed with no fault of the tax preparer, an upfront fee of $150.00 is required! Please view your tax return, which is emailed to you (it is sent prior to submission).

ALL FEES (bank and service fees) are found in the return and are non-refundable nor negotiable! NO EXCEPTIONS TO THIS!!

Please utilize www.irs.gov for all federal refund tracking. Please utilze your state Department of Revenue site for any State Refund tracking. Do NOT add the amounts together. Federal taxes are federal and state taxes are state when tracking your status. Please allow 8 weeks to surpass from the date of submission before calling the IRS, if you have any tracking questions.

For direct assistance, please email herexchange@yahoo.com or text 908-387-7189.

The link below can be used to track your federal refund status. You will need your filing status, social security number, and the total amount of the refund before fees.

https://sa.www4.irs.gov/irfof/lang/en/irfofgetstatus.jsp

IRS Contact 800-829-1040
Signature*

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CLIENT INTAKE FORM