1040 Tax Preparation Client Intake Form

1040 Tax Preparation Client Intake Form

IF YOU ARE SELF-EMPLOYED, PLEASE CONTACT US BEFORE FILLING OUT INTAKE FORM. Complete everything that applies to you and submit all documents. Wait until you have all documents before submitting form.
Type of Client
Tax year needing prepared. You will need to submit a form for each year needing prepared.
Do you owe the IRS, your state, child support, student loans, government, etc.. that will offset your tax refund?
Do you receive any government assistance?

Name

First NameMiddle NameLast NameSuffix
SSN Number
Date of Birth

MonthDayYear
Date
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Carrier (ex. Verizon)
Work Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Present Employer
Occupation
Marital Status as of December 31st of tax year.
Employment Status
Are you a U.S. citizen?
Address

Street Address

Apt.

CityState / Province

Postal / Zip Code
Can anyone else claim you or are you listed as a dependent on someone else's tax return?

Name

First NameMiddle NameLast NameSuffix
SSN/ITIN
Date of Birth

MonthDayYear
Date
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Carrier (ex. Verizon)
Work Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Present Employer
Occupation
Employment Status
Are you a U.S. citizen?
Address

Street Address

Apt.

CityState / Province

Postal / Zip Code
Can anyone else claim you or are you listed as a dependent on someone else's return?

Do you have dependents?*

Enter your dependent information here. Do not enter spouse information.

Rows	First Name	Last Name	Date of Birth	SSN/ITIN	Relationship
1
2
3
4
5
6

How many months did dependent(s) live in your home?
Is dependent(s) a resident of U.S., Canada or Mexico?

If you had Marketplace insurance at anytime last year, you are required to provide a form 1095-A or your refund will be delayed.

Rows	Yes	No	Marketplace	Private/Other Healthcare Insurance	Medicaid	ALL Kids	Medicare
Taxpayer
Spouse
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5

0000How would you like to receive your tax refund? Refunds are applied to Prepaid cards 2-5 days faster.
Would you like to apply for the Fast Cash Advance Loan?
*Loan approval is based on the bank and IRS decision.
If you live out of state or out of town, would you like your Prepaid card or check sent overnight for an extra $50 deducted from your refund?
Would you like to receive tax updates via text and email?
Please provide the answer to the following security question:

What high school did you attend? Type a label*
Do you, your spouse or dependent(s) have an "IP PIN?" If so, submit your letter with your tax documents. If you are a confirmed victim of identity and have resolved your tax issues, the IRS will mail you a CP01A notice with your IP PIN every year. This is a six-digit number.
I hereby authorize 1040 Tax and Business Solutions to initiate automatic deposits to my account at the financial institution named below. I also authorize 1040 Tax and Business Solutions to make withdrawals from this account in the that a credit entry is made in error. Further, I agree not to hold 1040 Tax and Business Solutions responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial institution in depositing funds to my account. This agreement will remain in effect until 1040 Tax and Business Solutions receives a written notice of cancellation from me or my financial institution, or until I submit a new direct deposit form.
Bank Name
Routing Number Number
Account Number Number
Account Type

PLEASE BE ADVISED. ONCE YOU SIGN BELOW I AM HIRED AND YOUR TAX PREPARATION FEE WILL BE DUE WHETHER YOU RECEIVE A REFUND OR NOT.
Taxpayer Signature
Date Signed

MonthDayYear
Date
Spouse Signature
Date Signed

MonthDayYear
Date
Should be Empty: