Tax Preparation Client Intake Form
Filing Status
Single
Head of Household
Married Filing Separate
Married Filing Joint
Qualifying Widower
Taxpayer Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
SSN
*
Are you a full-time student?
*
Yes
No
Are you totally and permanently disabled?
*
Yes
No
Are you legally blind?
*
Yes
No
Spouse Information
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
SSN
Are they a full-time student?
Yes
No
Are they totally and permanently disabled?
Yes
No
Are they legally blind?
Yes
No
Are they your dependent?
Yes
No
Dependents
Enter your dependents here
Rows
Name
SSN
Date of Birth
Relationship
1
2
3
4
5
6
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
Yes
No
Spouse
Yes
No
Dependent 1
Yes
No
Dependent 2
Yes
No
Dependent 3
Yes
No
Dependent 4
Yes
No
Dependent 5
Yes
No
Tax Related Questions
Employment Status
*
Employed
Unemployed
Self-employed
Are you contributing to 401k or other pre-tax account?
Yes
No
Please select what state return are you requesting?
State return
School
Local
RITA
Country returns
Did your dependent have tuition expenses?
Yes
No
Do you have any expenses for child care?
Yes
No
Do you have energy star rated improvements to your home? (Enter amount in comment section)
Windows
Doors
Furnace
Solar Equipment
Air Conditioner Unit
Insulation
Other
Are you currently renting?
Yes
No
What is the monthly rental amount?
How long have you lived at the property?
# of months
Do you have your own home?
Yes
No
Do you have documents that shows you paid for property taxes?
Yes
No
Did you sell any stock?
*
Yes
No
Did you take money from your 401?
*
Yes
No
Did you pay your vehicle tax?
Yes
No
Do you have mortgage interest?
Yes
No
Do you have real estate tax?
Yes
No
Did you receive a federal tax refund last year?
*
Yes
No
Are you a victim of identity theft?
*
Yes
No
Expenses
Please fill-up the information within the current year only.
General Expenses
Rows
Amount
Medical Expenses-Copays including Hospital
Dental & Vision Expenses (including Insurance)
Medical Travel Expenses (Hotel Expenses)
Health Insurance Premiums paid
Medical Mileage Driven
Long Term Care Premiums
Prescription Drugs and Medications Expenses
Home Mortgage Interest Paid
Investment Interest
Cash Contributions(ex. Church, United Way)
Non-Cash Contributions (ex. Goodwill)
Unreimbursed Business Expenses
Union Dues
Tax Preparation Fees
Investment Expenses
Sales Taxes Paid
Tax Paid On Vehicle
Real Estate Taxes Paid
Mortgage Premium Insurance
Amount of Retirement Funds withdrawn for Medical Purposes
Total Expenses
Did you attend any educational courses, classes, college, university or school?
Yes
No
Additional comments
Acknowledgment & Signature
I confirmed that all information I entered here is accurate and true.
I allow Delta Accounting & Insurance Service Inc. 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 Delta Accounting & Insurance Service Inc.
By signing below, you acknowledge that you have read and understood your responsibilities and our responsibilities in doing this tax return.
Date Signed
-
Month
-
Day
Year
Date
Taxpayer Signature
Date Signed
-
Month
-
Day
Year
Date
Spouse Signature
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