Tax Preparation Client Intake Form

Tax Preparation Client Intake Form
How did you hear about us?
Who referred you?

First NameLast Name
If you were not referred by anyone just put NA in both boxes.
Filing Status

Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SSN
Employment Status
Occupation
Are you a full-time student?Were you a full-time student last year?
Are you totally and permanently disabled?
Are you legally blind?

Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
SSN
Are they a full-time student?
Are they totally and permanently disabled?
Are they legally blind?
Are they your dependent?

Enter your dependents here

Rows	Name	SSN	Date of Birth	Relationship
1
2
3
4
5

Does you, your spouse, and your dependents have health insurance within 12 months last year? If yes, who covers for it?

Rows	Yes/No	Employer	Spouse Ins	Exchange/ Marketplace	Direct with Insurer	Medicare	Medicaid
Taxpayer
Spouse
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5

Do you have any expenses for child care?
Does your dependents have tuition expenses?

Please fill-up the information within the current year only.

General Expenses

Rows	Amount
Medical Expenses
Dental Expenses
Insurance Premiums paid
Long Term Care Premiums
Prescription Drugs and Medications
Home Mortgage
Investment Interest
Cash Contributions
Non-Cash Contributions
Unreimbursed Business Expenses
Union Dues
Tax Preparation Fees
Investment Expenses

Total Expenses
EIN Number
Additional comments

If you have any reported income from any of the following please provide the amount and documentation. Please put NA if any of the questions below do to apply to you.
Interest and Dividends (Form 1099-INT or DIV)
IRA or Pension Distribution (Form 1099-R)
Unemployment Compensation (Form 1099-G)
Social Security/Social Security Disability (Form SSA-1099)

Taxpayer's VALID Drivers License

Cancelof
Taxpayer's Social Security Card

Cancelof
Spouse's VALID Drivers License

Cancelof
Spouse's Social Security Card

Cancelof
Dependents VALID Drivers License (if applicable)

Cancelof
Dependents Social Security Card

Cancelof
Dependents Social Security Card

Cancelof
Dependents Social Security Card

Cancelof
W2 Form

Cancelof
W2 Form

Cancelof
W2 Form

Cancelof
Utility Bill (Head of Household)

Cancelof
Form 1099

Cancelof
Form 1098T (for college students)

Normally this form is mailed to you from the school.
Cancelof

Routing Number
Please put NA if we have agreed to a check
Account Number
Please put NA if we have agreed to a check

- I certify that the information in this form is true and correct to the best of my knowledge. I also understand that this information will be used by T&C Tax to process and file my 2023 income tax return.
- I allow T&C Tax to capture my sensitive data like personal ID, government ID, social security number (SSN), and other information.
- I have read the terms and conditions and privacy policy of T&C Tax Group.
- By signing below, you acknowledge that you have read and understood your responsibilities and our responsibilities in doing this tax return.
- Refund Rejection: I understand that in the event of the IRS NOT releasing my scheduled income tax refund, I am liable for paying income tax rejection fees in the amount of $250.00 to T&C Tax.
- Reconstruction: I give T&C Tax authorization to deduct a record reconstruction service fee in the amount of $_____ from my 2023 tax return for record services rendered.
- Electronic Filing: I give T&C Tax authorization to file my 2023 tax return.
- I acknowledge that this is my responsibility to maintain and provide accurate records of expenses and do hereby hold T&C Tax harmless. I certify that the information in the affidavit is true and correct to the best of my knowledge. I also understand that this information will be used by T&C Tax to process and file my 2023 tax return.
- I understand that this information is needed to process my Money Market Dollars anticipation loan and to ensure that I do not have any previous debts with a federal or state agency that could reduce my 2023 income tax refund amount.
- I also understand that my information will not be used to access any other systems or without my knowledge.
Date Signed

MonthDayYear
Date
Taxpayer Signature
Date Signed

MonthDayYear
Date
Spouse Signature
Should be Empty: