Tax Preparation Client Intake Form

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
If you have an IP-PIN please enter it below. Please Note: Intentional non-disclosure of an IP-Pin will cause rejections/delays with your refund and will cause our office to refrain from doing business with you in the future.
Please confirm that you do not owe the IRS in back taxes, child support or any other offsets. Please Note: If you owe IRS back payments, you are not qualified for our File Now Pay Later bank option and must pay your prep fees upfront before filing. Failure to disclose offsets will result in procedural action.
Are you a full-time student?
Are you totally and permanently disabled?
Are you legally blind?

Enter your dependents here

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

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

Please upload your W2, 1099, DL, SS card, Dependents SS Card and any other Tax documents.

Cancelof
Bank Routing Number blanks
Bank Account Number blank
I certify that the information provided is true, complete, and accurate to the best of my knowledge. I understand this information is used to prepare my tax return in compliance with IRS regulations.
Should be Empty: