MRTC CLIENT INTAKE FORM

MRTC CLIENT INTAKE FORM
FILING STATUS:

MARRIEDMARRIED FILING SEPARATELYSINGLEHEAD OF HOUSEHOLD (NOT married w/ dependents)
Did you have health insurance for the entire 2022 year?

YesNo
Did you obtain your health insurance through the Marketplace?

EmployerSelf-paid Insured

	A	B	C
Do you have your 1095 Health Insurance Statement?

Taxpayer's Full Name*
As it appears on SS Card
Spouse's Full Name
As it appears on SS Card
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Spouse's Address (if different)

Street Address

Street Address Line 2

CityState

Zip Code
Taxpayer's Telephone Numbers:
Spouse's Telephone Numbers:
Do you have a IRS PIN? Please enter it here.
You can obtain one online https://www.irs.gov/identity-theft-fraud-scams/get-an-identity-protection-pin
Additional Notes:
Do you have any Dependents?*
IMPORTANT INFORMATION FOR YOUR TAX PREPARER

Please answer each question that applies to you. Additional space provided if needed

INCOME INFO

	Applies
Do you have W2s?
Did you receive Unemployment ?
Did you receive any bank interest?
Did you receive any Misc. 1099 INC?
Do you have rental property ?
Do you receive social security?
Did you take money from your 401
Do you have self employment income?
Did you sale any stock?
Does Not Apply

PAY OUT-OUT-POCKET

	Applies
Did you owe the state last year?
Did you pay the State?
Did you pay Alimony?
Did you file taxes last year?
Did you receive a Federal I last year?
Do you owe the IRS ? If so, note how much you owe
Have you received any letters from the IRS?
Does Not Apply

DEDUCTIONS

	Applies
Did you have Mortgage interest?
Did you pay Real Estate taxes?
Did you pay vehicle tax ?
Did you pay Tithes?
Does Not Apply

LOSSES

	Applies
Are you a victim of Identity Theft?
Did you suffer significant losses from being sued or by court order?
Does Not Apply

Did you pay or borrow funding for any
Amount paid for Self
College Tuition?
Amount paid for Child
Do you have any Child Care Expenses?
Are you an Armed Forces Reservist?
Business Partnership or Corporation?
Upload photocopies of Taxpayer and Spouse DL and SSN Card for each person named above. W2 and 1099 forms may be uploaded also.

OR Email to: TheTaxBoutique@gmx.com
Cancelof
Taxpayer's Signature*

Clear
Spouse's Signature

Clear
Should be Empty:

IMPORTANT INFORMATION FOR YOUR TAX PREPARER