Tax Preparation Client Intake Form

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If you were not referred by anyone just put NA in both boxes.

Please enter a valid phone number.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

EmployedUnemployedSelf-employed

Please enter a valid phone number.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

	Name	SSN	Date of Birth	Relationship
1
2
3
4
5

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

If you do not know you can find out by calling the IRS offset number 1 800-304-3107. Please enter NA if you do not owe.

Put NA if you do not have any insurance

Put NA if this does not apply to you.

If yes, please provide the required 1098-T form. You can upload it in the document upload section of this form.

WindowsDoorsFurnaceOther

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

	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

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.

Normally this form is mailed to you from the school.

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.