CLIENT INTAKE FORM
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Select an Appointment. You will receive a separate email confirmation from Google.
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Tax Year Being Filed (NOTE: For proper record keeping purposes, each tax return should be uploaded separately and a new submission must be entered. Non-Applicable for in-person services)
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2025
2024
2023
2022
2021
Unsure, Help Me Decide
Filing Status
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Single
Head Of Household
Married Filing Separately
Married Filing Jointly
Qualifying Widow(er)
Unsure, Help Me Decide
Name
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First Name
Last Name
Date Of Birth
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-
Month
-
Day
Year
Date
SSN
*
Spouse Name (if filing jointly)
First Name
Last Name
Spouse DOB
-
Month
-
Day
Year
Date
Spouse SSN
Do you (or your spouse) owe any delinquent:
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Child Support
Alimony
IRS Prior Year Taxes
State Prior Year Taxes
None of the Above
Other
If you could increase your credit score by 100 points, would you be interested?
*
Yes
No
What is your current credit score?
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
Email
*
example@example.com
Were you Self Employed? (1099-NEC recipient, Small Business Owner Uber, DoorDash, Only Fans, Meta, TikTok Shop, etc?)
*
YES, explain in next section.
NO, I had an employer (W-2)
Describe the roles you had in this category, or explain the goods/services you provided.
Describe the roles you had in this category, or explain the goods/services you provided.
How were you paid for the earnings you received?
CASH
Electronically (P2P apps like CashApp, Zelle, PayPal, etc.)
Both
Occupation
Were you or any of your qualified dependents a Full Time Student for this tax return?
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YES
NO
Did you pay for childcare?
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YES
NO
Did you have winnings from gambling, not limited to lottery, casinos, and/or online sports betting?
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YES
NO
Did you cash out any retirement plan funds? (401(k), IRA, 403(b), etc.)
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YES
NO
Number of Dependents
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Dependent 1 Name
First Name
Last Name
Dependent 1 SSN
Dependent 1 DOB
-
Month
-
Day
Year
Date
Relationship
Dependent 2 Name
First Name
Last Name
Dependent 2 SSN
Dependent 2 DOB
-
Month
-
Day
Year
Date
Relationship
Dependent 3 Name
First Name
Last Name
Dependent 3 SSN
Dependent 3 DOB
-
Month
-
Day
Year
Date
Relationship
Dependent 4 Name
First Name
Last Name
Dependent 4 SSN
Dependent 4 DOB
-
Month
-
Day
Year
Date
Relationship
List any additional dependents information here (Name, DOB, SSN, Relationship)
Leave blank if this does not apply.
Who were you referred by? (Referral MUST be noted here to receive credit for bonuses)
*
Please Select
ANQUINETTE YARBROUGH/BREAZIA STRONG CAMPAIGN
FOUND ON FACEBOOK/IG
GOOGLE/BING/SEARCH ENGINE SITES
OTHER (MUST LIST NAME FOR PERSON TO RECEIVE CREDIT)
WALK-IN
N/A (RETURNING CLIENT)
If "Other' selected above, please list that person's name here.
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DOCUMENT CENTER
Upload ALL documents requested here. NEED HELP?? Contact me.
Picture ID & Social Security Card(s)
Browse Files
Take a photo and upload here.
Cancel
of
Tax Documents (PDF preferred)
Browse Files
(W-2, 1099, 1098, IP PIN, etc.)
Cancel
of
EITC Due Diligence Required Documents
Browse Files
Ex: Lease, Utility Bill, Birth Certificates, etc.
Cancel
of
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BANKING INFORMATION
ACCOUNT LISTED WILL RECEIVE ALL REFUND DEPOSITS
How would you like to receive your refund?
*
Please Select
DIRECT DEPOSIT (ACCOUNT MUST BE IN YOUR NAME)
PAY CARD (PROVIDED BY RADIANT TAX PREP & PATHWARD BANK)
LIVE CHECK (PROVIDED BY RADIANT TAX PREP & PATHWARD BANK)
CHECK MAILED BY IRS (CONDITIONS APPLY*)
*Checks mailed by the IRS require pre-payment for all services rendered. This includes amended returns.
BANK NAME
Account MUST be in your name, or this could delay your refund. No Bank account, NO PROBLEM. Prepaid Debit Cards Available upon request. Type NA if
ROUTING NUMBER
MUST be 9 digits
ACCOUNT NUMBER
RE -ENTER ACCOUNT NUMBER
MUST MATCH INFO LISTED ABOVE TO PROCEED. ISSSUES WITH ACCOUNT NUMBERS COULD DELAY YOUR REFUND.
Are you interested in receiving a RAPID Refund Advance? You can receive up to $7,000 of your refund within 48 hours (fees apply).
*
Please Select
YES (INTEREST-FREE, UP TO $1000)
YES (MAXIMUM REFUND ALLOWED, FINANCE CHARGES APPLY)
NO
I'M NOT SURE. TELL ME MORE...
*No commitment is required if you select 'YES' . We can discuss details before the final submission.
Signature
*
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