Client Intake Form

Client Intake Form
Client Data Form

Please complete this form in its ENTIRETY and click SUBMIT when finished. Upload all documents at the end of the form.

Please wait until you have ALL of your documents before submitting this form.

Note: If you are claiming any dependents, be sure to upload their SS CARDS, BIRTH CERTIFICATES, and all items that show their address is the same as yours. (e.g. school records, medical records, doctor bills, Medicaid Statement, Social Services Records, or anything that shows your child's name and current address).
How did you hear about us?
If someone referred you, please type his or her name here.
If you are filing multiple years you must complete a separate form for each year.
Which Tax Year(s) Are You Filing?
Did you receive the second round of the PPP 2*
Do you owe the IRS, Child Support or in default with student loans?*
Can someone else claim you as a dependent?*
Taxpayer's Name*

First NameLast Name
Taxpayer's Social Security Number*
Example: xxx-xx-xxxx
Taxpayer's Date of Birth*
Example: 01/01/2001
Taxpayer's Job Title*
Taxpayer's Phone Number*
Example: (xxx)-xxx-xxxx
Home Address*
Street Address
City
State/Province
Postal/Zip Code
Taxpayer's Email Address*
example@example.com
What is your filing status?*

Single (Not Married)Head of HouseholdMarried filing separately?Qualifying Widow(er)?Married filing jointly
Do you have dependents to claim on your tax return?*
UPLOAD THE SOCIAL SECURITY CARD(S) AND BIRTH CERTIFICATE(S) FOR ANY DEPENDENT(S) CLAIMED ON THIS TAX RETURN (Stand directly over the document(s) and on a flat surface take a clear picture with all four corners of the document(s) showing)

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JULY CTC Amount?
Note CTC payments were $300 per qualifying child 5 and under ; $250 per qualifying child 6 through 17.
August CTC Amount?
Note CTC payments were $300 per qualifying child 5 and under ; $250 per qualifying child 6 through 17.
September CTC Amount?
Note CTC payments were $300 per qualifying child 5 and under ; $250 per qualifying child 6 through 17.
October CTC Amount?
Note CTC payments were $300 per qualifying child 5 and under ; $250 per qualifying child 6 through 17.
November CTC Amount?
Note CTC payments were $300 per qualifying child 5 and under ; $250 per qualifying child 6 through 17.
December CTC Amount?
Note CTC payments were $300 per qualifying child 5 and under ; $250 per qualifying child 6 through 17.
Proof of Residency For Claiming HOH
Please upload supporting document(s) for Proof of Residency for claiming HOH (Stand directly over the document(s) and on a flat surface take a clear picture with all four corners of the document(s) showing)

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How many dependents are you claiming?*
Did anyone in your household attend college? *
Did they attend at least half time?*
Did any one else provide support for your dependents?*
ParentRelativeGovernment AgencyOther
Provide Proof Of Each Dependent’s Residency
Provide the following documents; Lease, Utility bill, Letter from Clergy, Rental Receipts, Housing Assistance document. (Stand directly over the document(s) and on a flat surface take a clear picture with all four corners of the document(s) showing)

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Please Upload IRS Forms 6419 Advanced Child Tax Credit Payment Received for Children (Stand directly over the document(s) and on a flat surface take a clear picture with all four corners of the document(s) showing)

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Did you or anyone on this tax return attend college last year?
Upload the 1098-T Education Form if received by anyone on this tax return (Stand directly over the document(s) and on a flat surface take a clear picture with all four corners of the document(s) showing)

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Did you or anyone else on this tax return receive an Identity Protection Pin (IP PIN) by the IRS for this tax season?
UPLOAD THE IP PIN IDENTITY THEFT LETTER(S) SENT BY THE IRS FOR ANYONE ON THIS TAX RETURN (Stand directly over the document(s) and on a flat surface take a clear picture with all four corners of the document(s) showing)

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Dependent #1

First NameLast Name
Dependent #1 Date of Birth
01/01/2001
Dependent #1 Social Security Number
###-##-####
What is Dependent #1's Relationship to you (son, daughter, etc.)?
How many months did Dependent #1 live with you in 2020? (If all year, enter 12)
Birth Certificate (Stand directly over the item on a flat surface and zoom in for a clear shot.)

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Dependent #2

First NameLast Name
Dependent #2 Date of Birth
Example: 01/01/2001
Dependent #2 Social Security Number
###-##-####
How many months did Dependent #2 live with you in 2020? (If all year, enter 12)
What is Dependent #2's Relationship to you (son, daughter, etc.)?
Birth Certificate (Stand directly over the document(s) and on a flat surface take a clear picture with all four corners of the document(s) showing)

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Dependent #3

First NameLast Name
Dependent #3's Date of Birth
01/01/2001
Dependent #3s Social Security
Example: xxx-xx-xxxx
What is Dependent #3's Relationship to you (son, daughter, etc.)?
How many months did Dependent #3 live with you in 2020? (If all year, enter 12)
Birth Certificate (Stand directly over the document(s) and on a flat surface take a clear picture with all four corners of the document(s) showing)*

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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 Social Security
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 2020? (If all year, enter 12)
Birth Certificate (Stand directly over the document(s) and on a flat surface take a clear picture with all four corners of the document(s) showing)*

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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 Social Security
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 2020? (If all year, enter 12)
Birth Certificate (Stand directly over the document(s) and on a flat surface take a clear picture with all four corners of the document(s) showing)*

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Did your dependents have health insurance for the entire year?
Was your dependents' insurance through Medicaid?
Was your dependents' insurance through the Affordable Care Act (The Marketplace)?
Are any of your dependents in daycare? If YES, please upload the form you received from your daycare provider below.
Daycare Form (Stand directly over the document(s) and on a flat surface take a clear picture with all four corners of the document(s) showing)*

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Spouse's Full Name
First Name
Spouse's Social Security
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
Did you and your spouse live apart for more than 6 months in 2023?
What months?
Have you received your 1st stimulus check?
How much was your 1st stimulus check
Have you received your 2nd stimulus check?
How much was your 2nd stimulus check?
Do you have gambling winnings for 2023?*
Upload W2-G Section (Stand directly over the document(s) and on a flat surface take a clear picture with all four corners of the document(s) showing)*

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Did you make any charitable contributions?
Have you ever been disallowed for EITC/AOTC/CTC/ACTC? *
Do you receive any Government Assistance Programs such as Food stamps, TANF, Medicaid, or Medicare?
Please list programs.
Please list the programs along with the supporting documents. (Stand directly over the document(s) and on a flat surface take a clear picture with all four corners of the document(s) showing)*

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Taxpayer's Driver's License/State ID (Stand directly over the document(s) and on a flat surface take a clear picture with all four corners of the document(s) showing)

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Upload W2 statements (Stand directly over the document(s) and on a flat surface take a clear picture with all four corners of the document(s) showing)

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Did you receive unemployment in 2023?
1099 Unemployment Taxpayer/Spouse (Stand directly over the document(s) and on a flat surface take a clear picture with all four corners of the document(s) showing)*

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Upload other Misc. Income Documents such as 1099 INT, 1099 DIV, 1099 NEC. (Stand directly over the document(s) and on a flat surface take a clear picture with all four corners of the document(s) showing)

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Do you have a 1098 Mortgage Interest Statement?
Upload your 1098 Mortgage Interest Statement Here. (Stand directly over the document(s) and on a flat surface take a clear picture with all four corners of the document(s) showing)

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Was your insurance through the Affordable Care Act (The Marketplace)?
PLEASE UPLOAD YOUR 1095A IF APPLICABLE (Stand directly over the document(s) and on a flat surface take a clear picture with all four corners of the document(s) showing)

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Are you self employed?
If you are self employed 2023 were you exposed to, had to quarantine or provide for anyone who had COVID?
If you answered yes please enter all dates individually.
Please upload supporting business documents. (ex P&L, 1099 NEC, Summary of Income, Spread sheet with expenses). (Stand directly over the document(s) and on a flat surface take a clear picture with all four corners of the document(s) showing)

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What is the name of your business?
What is your business entity?

Sole PropriotorLLC- Single MemberLLC- SCorpLLC- Multi-MemberC-CorpS-CorpNonprofit
Enter EIN- Employer Identification Number
What Was Your Gross Income For 2023?

Detailed Summary of Expenses (Stand directly over the document(s) and on a flat surface take a clear picture with all four corners of the document(s) showing)

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How long have you owned your business?
What services do you perform?
Do you travel for business?
How do you track of mileage?
Please provide documentation to support proof of your business? (Stand directly over the document(s) and on a flat surface take a clear picture with all four corners of the document(s) showing)*

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Who maintains the business records?
Do you maintain separate banking accounts for personal and business transactions?
What form of records were provided?
How do you differentiate between personal and business transactions and monetary assets?
Legal Address of Business

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your business email address?
example@example.com
What is your business phone number?
Are you interested in Audit Protection? (Mandatory For ALL Schedule C'S)
Are you interested in Credit Repair?
STOP!

Did you finish uploading your documents?

IF YOU DID NOT UPLOAD ALL NECESSARY DOCUMENTS YOUR INTAKE FORM WILL BE VOIDED.
CLIENT NON-PAYMENT/OFFSET CLAUSE

At Deluxe Consultants and Accounting LLC, we strive to assist all of our clients in 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 actions will be sought to resolve payment.
How would you like your refund disbursed?
Name of Bank
Routing Number
Bank Account Number
Primary Taxpayer's Signature*

Clear
Primary Taxpayer's Spouse Signature*

Clear
* Read Carefully and Sign Before Submitting This Form*

* I understand that the information given in this report may impact my benefits.

* I declare under penalty of perjury that the information given in this report is true and correct to the best of my knowledge. (Both husband and wife must sign if living together).
Taxpayer's Signature

Clear
Date*

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

Clear
Date

MonthDayYear
Date
Should be Empty: