Tax Intake Form

How did you hear about us?

FacebookInstagramReferralPrevious Client

Tax Preparer Name

If someone referred you, please type his or her name here.

Are you trying to buy a new home within the next 2 years?

YesNo

Are you interested in Life Insurance?

YesNo

Email

example@example.com

Tax Payers Name*

First NameLast Name

Taxpayer's Phone Number*

Example: xxx-xxx-xxxx

Taxpayer's Job Title*

Taxpayer's Date of Birth*

Example: 01/01/2001

Taxpayer's SSN*

Example: xxx-xx-xxxx

Taxpayer's Email Address*

example@example.com

Spouse's Full Name

First Name

Spouse's SSN

Example: xxx-xx-xxxx

Name

First NameLast Name

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

Taxpayer's SSN

Example: xxx-xx-xxxx

Spouse's Job Title

example@example.com

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are you self employed?*

YesNo

Did you and your spouse live apart during the year?*

YesNoNot Applicable

What is your marital status as of December*

Single (Not Married)Married living with SpouseMarried not living with spouse

Did you pay over half the expenses of maintaining your residence for the entire year?*

YesNo

Did you support a child or family member for more than 6 months out of the year?*

YesNo

Are you on any Government Assistance*

YesNoNot Applicable

How many dependents are you claiming?*

Dependent #1

First NameLast Name

Dependent #1 Date of Birth

01/01/2001

Dependent #1 SSN

What is Dependent #1's Relationship to you (son, daughter, etc.)?

How many months did Dependent #1 live with you in 2023? (If all year, enter 12)

Dependent #2

First NameLast Name

Dependent #2 Date of Birth

Example: 01/01/2001

Dependent #2 SSN

How many months did Dependent #2 live with you in 2023? (If all year, enter 12)

What is Dependent #2's Relationship to you (son, daughter, etc.)?

Dependent #3

First NameLast Name

Dependent #3's Date of Birth

01/01/2001

How many months did Dependent #3 live with you in 2023? (If all year, enter 12)

Dependent #3s SSN

Example: xxx-xx-xxxx

Dependent's #3 SSN

What is Dependent #3's Relationship to you (son, daughter, etc.)?

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 SSN

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 2023? (If all year, enter 12)

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 SSN

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 2023? (If all year, enter 12)

Are there any dependents in daycare? If yes, please upload the form you received from your daycare provider.

YesNo

Upload a copy of your daycare form here.

How would you like to receive your tax refund?

Check (Only available for in office visits)Direct Deposit

Name of Bank

Which type of account would you like your refund deposited into?

Checking AccountSavings AccountOther

Routing Number

Bank Account Number

Can someone else claim you as a dependent?

YesNo

Did you have health insurance in 2023?

YesNo

Did you have health insurance for the entire year?

YesNo

Who was your insurance cover through in 2023?

Was your insurance through your employer?

YesNo

Was your insurance through Medicaid?

YesNo

Was your insurance through the Affordable Care Act (The Marketplace)?

YesNo

Did your dependents have health insurance for the entire year?

YesNoNot Appliable

Was YOUR DEPENDENTS' insurance through your employer?

YesNoNot Applicable

Who was your Dependents insured with in 2023?

Upload Taxpayer & Dependent(s)Insurance Documents

Was YOUR DEPENDENTS' insurance through Medicaid?

YesNoNot Applicable

Was YOUR DEPENDENTS' insurance through the Affordable Care Act (The Marketplace)?

YesNoNot Applicable

Have you ever been denied the Earned Tax Credit (EITC)?

YesNo

Were you or any of your dependents in college in 2019?

YesNo

Did you trade any Virtual Currency ( Crypto)

YesNo

Do you have a 1098-T Form for either you or your dependents?

YesNo

If you have a 1098-T form, upload it here.

Are you interested in AUDIT PROTECTION?

YesNo

Type a question

Taxpayer's Driver's License*

Taxpayer's and Dependent(s ) Social Security Card(s)

Taxpayer's W-2/ 1099'S

Dependent(s) Birth Certificate(s)

Proof of Residency (Lease/Utility Bill) for Head of Household Filing

I am giving Superior Mindz Consulting permission to prepare all forms related to my tax return; to apply for and secure RAC's and RAL's on my behalf; and sign all necessary forms and file my taxes electronically. I take full responsibility for the accuracy of this form and understand that Superior Mindz Consulting and/or associated affiliates hold no responsibility for any misrepresentation or false claims.

CLIENT NON PAYMENT/OFFSET CLAUSE

At Superior Mindz Consulting 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 with in 30 days legal actions will be sought to resolve payment.

Taxpayer's Signature *

Date*

Date

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

Date

ADDITIONAL SERVICES

At All Superior Mindz Consulting we do more than just taxes. Please check below if you would be interested in any of the additional services we provide. We will schedule a time to speak with you ar a later time.

Appointment*

CLIENT INTAKE FORM