Client Tax Intake Form

How did you hear about us?

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Tax Specialist Name

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

Tax Payers Name*

First NameMiddle NameLast Name

Taxpayer's SSN*

Example: xxx-xx-xxxx

Taxpayer's Job Title

Taxpayer's Date of Birth*

Example: 01/01/2001

Taxpayer's Phone Number*

Example: xxx-xxx-xxxx

Taxpayer's Email Address*

example@example.com

What is your marital status as of December*

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

Spouse's Name

First NameMiddle NameLast Name

Spouse's SSN

Example: xxx-xx-xxxx

Spouse's Job Title

Example: Teacher

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

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you operate your own Business or Do you have a Home Based Business?*

YesNo

Do you have an EIN Number?

Summary of Business Expenses. What is the Name of Your Business? What did you spend big money on related to your business? Did you buy computer, phone, car repairs, business trips, supplies, maintenance or construction around the house, insurance other than health, etc.

Did you support a child or family member and did they LIVE with YOU for more than 6 months out of the year?*

YesNo

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? (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? (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? (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? (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? (If all year, enter 12)

Are you buying your Home? If so, do you have the Mortgage Interest Statement?*

YesNo

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

YesNo

Can someone else claim you as a dependent?

YesNo

Was your insurance through your employer?

YesNo

Did you have health insurance thru Obama Care Marketplace?

YesNo

If YES, please upload the 1095-A if you have Obama Care.

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 Medicaid?

YesNoNot Applicable

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

YesNoNot Applicable

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

YesNo

Were YOU or any of your DEPENDENTS in college last year?

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? PROTECTS YOU IN CASE OF AN AUDIT

YesNo

CLIENT NON PAYMENT/OFFSET CLAUSE

At Tator Tax Service LLC, 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 Driver's License*

Taxpayer's Spouse Driver's License

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

Taxpayer's W-2/ 1099'S*

How would you like to receive your tax refund?*

Direct Deposit

Name of Bank*

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

Checking AccountSavings AccountFast Money Card

Routing Number *

Bank Account Number *

CONSENT TO USE OF TAX RETURN INFORMATION
For the purposes of this consent form, “we,” “us,” and “our” mean
TATOR TAX SERVICE LLC
(Printed Name of Tax Preparer)

Federal law requires this consent form be provided to you. Unless authorized by law, we cannot use your tax return information for purposes other than the preparation and filing of your tax return without your consent.

You are not required to complete this form to engage in our tax return preparation services. If we obtain your signature on this form by conditioning our tax preparation services on your consent, your consent will not be valid. 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.
If you do not consent, you may still have your tax return prepared and electronically filed by us for a fee.

For your convenience, we have entered into an arrangement with third parties to provide qualifying taxpayers with the opportunity to apply for an Electronic Refund Disbursement Service and/or Loan product. To determine whether these products may be available to you, we will need to use your tax return information in order to calculate the amount of your anticipated refund.

If you would like us to use your tax return information to determine whether these products may be available to you while we are preparing your return, please sign and date this consent to the use of your tax return information.

By signing below, you authorize us to use the information you provide to us during the preparation of your 2023 tax return to determine whether to present you with the opportunity to apply for these products and services.

If you believe your tax return information has been disclosed or used improperly in a manner unauthorized by law or without your permission, you may contact the Treasury Inspector General for Tax Administration (TIGTA) by telephone at 1-800-366-4484, or by e-mail at complaints@tigta.treas.gov.

CONSENT TO DISCLOSURE OF TAX RETURN INFORMATION
For the purposes of this consent form, “we,” “us,” and “our” mean
TATOR TAX SERVICE LLC
(Printed Name of Tax Preparer)

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 in our tax preparation services. If we obtain your signature on this form by conditioning our 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.

You have indicated that you are interested in receiving an Electronic Disbursement Serviceand/or Loan (or collectively, “Products or Services”) from Pathward, National Association. In order to provide you with the opportunity to apply for one of these Products or Services, we must disclose all of your 2023 tax return information necessary for evaluating the request to Pathward.

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 2023 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 Pathward all of your 2023 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 Pathward, 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.

If you believe your tax return information has been disclosed or used improperly in a manner unauthorized by law or without your permission, you may contact the Treasury Inspector General for Tax Administration (TIGTA) by telephone at 1-800-366-4484, or by e-mail at complaints@tigta.treas.gov.

Printed Name of Taxpayer:*

Primary Taxpayer's Signature*

Printed Name of Spouse:

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

Date*

Date

CLIENT FORM

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CLIENT FORM

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