• Tax Client Intake Form

  • Please complete all parts of this intake form. This information will be used to prepare your tax return. You are responsible for the information on your return. Please provide complete and accurate information. If you have questions, please contact our office.

  • Part 1 - Your Information

  • Format: (000) 000-0000.
  • Are you a US citizen?*
  • As of December 31, 2023, what was your marital status? (This includes registered domestic partnerships, civil unions, or other formal relationships under state law)*
  • Format: (000) 000-0000.
  • Is your Spouse a US Citizen?*
  • Your Date of Birth*
     - -
  • Last year, were you a Full-time student?*
  • Last year, were you totally and permanently disabled?*
  • Last year, were you legally blind*
  • Your Spouse's date of birth*
     / /
  • Last year, was your spouse a Full-time student?*
  • Last year, was your spouse totally and permanently disabled?*
  • Last year, was your spouse legally blind?*
  • Can anyone claim you or your spouse as a dependent?*
  • Have you, your spouse, or dependents been a victim of tax related identity theft or been issued an Identity Protection PIN?*

  • Part 2 - Martial Status and Household Information

  • Did you get married in 2022?*
  • Did you live with your spouse during any part of the last six months of 2022?*
  • Date of final decree.*
     - -
  • Date of separate maintenance decree.*
     - -
  • Date of spouse’s death.*
     - -

  • Part 3 - Income

  • Last Year, Did You (or Your Spouse) Receive Wages or Salary? (Form W-2)?*
  • Last Year, Did You (or Your Spouse) Receive Tip Income?*
  • Last Year, Did You (or Your Spouse) Receive Scholarships? (Forms W-2, 1098-T)*
  • Last Year, Did You (or Your Spouse) Receive Interest/Dividends from: checking/savings accounts, bonds, CDs, brokerage? (Forms 1099-INT, 1099-DIV)*
  • Last Year, Did You (or Your Spouse) Receive Refund of state/local income taxes? (Form 1099-G)*
  • Last Year, Did You (or Your Spouse) Receive Alimony income or separate maintenance payments?*
  • Last Year, Did You (or Your Spouse) Receive Self-Employment income? (Form 1099-MISC, 1099-NEC, cash, virtual currency, or other property or services)*
  • Last Year, Did You (or Your Spouse) Receive Cash/check/virtual currency payments, or other property or services for any work performed not reported on Forms W-2 or 1099?*
  • Last Year, Did You (or Your Spouse) Receive Income (or loss) from the sale or exchange of Stocks, Bonds, Virtual Currency or Real Estate? (including your home) (Forms 1099-S,1099-B)*
  • Last Year, Did You (or Your Spouse) Receive Disability income? (such as payments from insurance, or workers compensation) (Forms 1099-R, W-2)*
  • Last Year, Did You (or Your Spouse) Receive Retirement income or payments from Pensions. Annuities, and or IRA? (Form 1099-R)*
  • Last Year, Did You (or Your Spouse) Receive Unemployment Compensation? (Form 1099G)*
  • Last Year, Did You (or Your Spouse) Receive Social Security or Railroad Retirement Benefits? (Forms SSA-1099, RRB-1099)*
  • Last Year, Did You (or Your Spouse) Receive Income (or loss) from Rental Property?*
  • Last Year, Did You (or Your Spouse) Receive Other income? (gambling, lottery, prizes, awards, jury duty, virtual currency, Sch K-1, royalties, foreign income, etc.)*

  • Part 4 - Expenses

  • Last Year, Did You (or Your Spouse) Pay Alimony or separate maintenance payments?*
  • If yes, do you have the recipient’s SSN?*
  • Last Year, Did You (or Your Spouse) Pay Contributions or repayments to a retirement account?*
  • If "yes", select which type of retirement account.*
  • Last Year, Did You (or Your Spouse) Pay College or post secondary educational expenses for yourself, spouse or dependents? (Form 1098-T)*
  • Last Year, Did You (or Your Spouse) Pay Any of the following: Medical & Dental (including insurance premiums), Mortgage Interest (Form 1098), Taxes (State, Real Estate, Personal Property, Sales), Charitable Contributions?*
  • If "yes", please select which one:*
  • Last Year, Did You (or Your Spouse) Pay Child or dependent care expenses such as daycare?*
  • Last Year, Did You (or Your Spouse) Pay For supplies used as an eligible educator such as a teacher, teacher’s aide, counselor, etc.?*
  • Last Year, Did You (or Your Spouse) Pay Expenses related to self-employment income or any other income you received?*
  • Last Year, Did You (or Your Spouse) Pay Student loan interest? (Form 1098-E)*

  • Part 5 - Life Events

  • Last Year, Did You (or Your Spouse) Have a Health Savings Account? (Forms 5498-SA, 1099-SA, W-2 with code W in box 12)*
  • Last Year, Did You (or Your Spouse) Have credit card, student loan or mortgage debt cancelled/forgiven by a lender or have a home foreclosure? (Forms 1099-C, 1099-A)*
  • Last Year, Did You (or Your Spouse) Adopt a child?*
  • Last Year, Did You (or Your Spouse) Have Earned Income Credit, Child Tax Credit or American Opportunity Credit disallowed in a prior year?*
  • Last Year, Did You (or Your Spouse) Purchase and install energy-efficient home items? (such as windows, furnace, insulation, etc.)*
  • Did You (or Your Spouse) Receive the First Time Homebuyers Credit in 2008?*
  • Last Year, Did You (or Your Spouse) Make estimated tax payments or apply last year’s refund to this year’s tax?*
  • Last Year, Did You (or Your Spouse) File a federal return last year containing a “capital loss carryover” on Form 1040 Schedule D?*
  • Last Year, Did You (or Your Spouse) Have health coverage through the Marketplace (Exchange)? [Provide Form 1095-A]*
  • Last Year, Did You (or Your Spouse) Receive an Economic Impact Payment (stimulus)?*
  • Last Year, Did You (or Your Spouse) Receive Advanced Child Tax Credit payments?*

  • Consent to Disclose and Use

  • Federal Disclosure:
    Federal law requires this consent form be provided to you. Unless authorized by law, we cannot disclose your tax return information to third parties for purposes other than the preparation and filing of your tax return without your consent. If
    you consent to the disclosure of your tax return information, Federal law may not protect your tax return information from further use or distribution.
    You are not required to complete this form to engage our tax return preparation services. If we obtain your signature on this form by conditioning our tax return preparation services on your consent, your consent will not be valid. If you agree
    to the disclosure of your tax return information, your consent is valid for the amount of time that you specify. If you do not specify the duration of your consent, your consent is valid for one year from the date of signature.


    Terms:
    You have indicated that you are interested in receiving an Electronic Disbursement Service from a bank of our affiliation. In order to provide you with the opportunity to apply for one of these Products or Services, we must disclose all of your
    2022 tax return information necessary for evaluating the request to the affiliate bank. If you request a more limited disclosure of tax return information, you will not be eligible to submit an application request for these Products or Services. If you would like us to disclose your 2022 tax return information for this purpose, please sign and date your consent to the disclosure of your tax return information. By signing below, you authorize us to disclose to our affiliate bank(s) all of your 2022 tax return information necessary for the evaluation and processing of your request for a Product or Service. You understand that if you are unwilling to authorize the disclosure and sharing of your tax return information with our affiliate bank(s), you will not be able to obtain a Product or Service, but you may still choose to have your tax return prepared and filed by us for a fee.


    Consent:
    I/we, the taxpayer, have read the above information.
    I/we hereby consent to the disclosure of tax return information described in the terms above and allow the tax return preparer to enter a PIN in the tax preparation software on my behalf to verify that I/we consent to the terms of this
    disclosure.

  • Date*
     - -
  • Date*
     - -

  • Please upload the following documents:

    • All Tax related documents and forms such as Form W-2, 1099, 1098, 1095, etc.
    • Social Security Cards or ITIN letters for all persons on your tax return.
    • Unexpired Picture ID's for you and your spouse such as a valid driver's license.
    • Self Employment Income and Expense statements, if applicable.

    If you are unsure on what documents to upload, please contact our office. Failure to upload proper documentation can delay the preparation of your Tax Return.

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