CLIENT INTAKE FORM

CLIENT INTAKE FORM

Please Complete the Form Below
Part I - Your Personal Information (If you are filing a joint return, enter your names in the same order as last year's return)
What is your filing status for the current tax year? Please select one of the following options:*

SingleHead of HouseholdMarried Filing JointlyMarried Filing SeparatelyQualifying Widow/Widower with Dependent Child
1. Your First Name*
M.I.*
Last Name*
Social Security Number*
Daytime telephone number*
Are you a US citizen?*

YesNo
2. Your Spouse's First Name*
M.I.*
Last Name*
You spouse's Social Security Number*
Daytime telephone number*
Is your spouse a US citizen?*

YesNo
3. Mailing Address*

Apt #

Street Address Line 2

CityState

ZIP Code
4. Your Date of Birth*

MonthDayYear
Date
5. Your job title *

6. Last year, were you:*

	Yes	No
a. Full-time student
b. Totally and permanently disabled
c. Legally blind

7. Your spouse's Date of Birth*

MonthDayYear
Date
8. Your spouse's job title *

9. Last year, was your spouse:*

	Yes	No
a. Full-time student
b. Totally and permanently disabled
c. Legally blind

10. Can anyone claim you or your spouse as a dependent?*

YesNoUnsure
11. Have you, your spouse, or dependents been a victim of tax related identity theft or been issued an Identity Protection PIN?*

YesNo
Part II - Marital Status and Household Information
1. As of December 31, 2023 what was your marital status?*

Single (This includes registered domestic partnerships, civil unions, or other formal relationships under state law)Married (If yes, did you get married in 2023?)
If yes, did you get married in 2023?*

YesNo
DivorcedLegally SeparatedWidowed
Date of final decree*

MonthDayYear
Date
Date of separate maintenance decree*

MonthDayYear
Date
Year of spouse's death*

MonthDayYear
Date

2. List of the names below of: • everyone who lived with you last year (other than your spouse) • anyone you supported but did not live with you last year *

	First Name (Do not enter your name or your spouse's name)	Last Name (Do not enter your name or your spouse's name)	Date of Birth	Number of months lived in your home last year	Relationship to you	US Citizen	Single or Married as of 12/31/20	Full-time Student last year	Totally and permanently disabled
1
2
3
4

If you have additional dependents, let your Tax Preparer know.
Check approprite box for each question in each section.
Part III - Income - Last Year, Did You (or Your Spouse) Receive

Part III - Income - Last Year, Did You (or Your Spouse) Received*

	Yes	No	Unsure	Remarks
1. Wages or Salary? (Form W-2) If yes, how many jobs did you have last year?
2. Tip income?
3. Scholarships? Choose: a. Forms W-2 b. 1098-T
4. Interest/Dividends from: checking/savings account, bonds, CDs, brokerage? (Forms 1099-INT or 1099-DIV) Choose: a. Forms 1099-INT b. 1099-DIV
5. Refund of state/local income taxes? (Form 1099-G)
6. Alimony income or separate maintenance payments?
7. Self-employment income? (Form 1099-MISC, 1099-NEC, cash, virtual currency, or other property or services) Choose: a. Form 1099-MISC b. 1099-NEC
8. Cash/check/virtual currency payments, or other property or services for any work performed not reported on Forms W-2 or 1099? Choose: a. Cash b. Check
9. Income (or loss) from the sale or exchange of Stocks, Bonds, Virtual Currency or Real Estate? (including your home) (Forms 1099-S, 1099-B) Choose: a. Forms 1099-S b. 1099-B
10. Disability income? (such as payments from insurance, or workers compensation) (Forms 1099-R, W-2) Choose: a. Forms 1099-R b. W-2
11. Retirement income or payments from Pensions, Annuities, and or IRA? (Form 1099-R)
12. Unemployment Compensation? (Form 1099G)
13. Social Security or Railroad Retirement Benefits? (Forms SSA-1099, RRB-1099) Choose: a. Forms SSA-1099 b. RRB-1099
14. Income (or loss) from Rental Property?
15. Other income? (gambling, lottery, prizes, awards, jury duty, virtual currency, Sch K-1, royalties, foreign income, other property or services, etc.) Specify.

Part IV - Expenses - Last Year Did you (or Your Spouse) Pay

Part IV - Expenses - Last Year Did you (or Your Spouse) Pay*

	Yes	No	Unsure	Remarks
1. Alimony or separate maintenance payments? If yes, do you have the recipient's SSN?
2. Contributions to a retirement account? Choose: a. IRA b. 401K c. Roth IRA d. Other
3. College or post secondary educational expenses for yourself, spouse, or dependents? (Form 1098-T)
4. Any of the following? a. Medical and Dental (including insurance premiums) b. Taxes (State, Real Estate, Personal Property, Sales) c. Mortgage Interest (Form 1098) d. Charitable Contributions
5. Child or dependent care expenses such as daycare?
6. For supplies used as an eligible educator such as a teacher, teacher's aide, counselor, etc.?
7. Expenses related to self-employment income or any other income you received?
8. Student loan interest (Form 1098-E)

Part V - Life Events - Last Year Did you (or Your Spouse)

Part V - Life Events - Last Year Did you (or Your Spouse)*

	Yes	No	Unsure	Remarks
1. Have a Health Savings Account? (Forms 5498-SA, 1099-SA, W-2 with code W in box 12) Choose: a. Forms 5498-SA b. 1099-SA c. W-2
2. Have credit card or mortgage debt cancelled/forgiven by a lender or have a home foreclosure? (Forms 1099-C, 1099-A) Choose: a. Forms 1099-C b. 1099-A
3. Adopt a child?
4. Have Earned Income Credit, Child Tax Credit or American Opportunity Credit disallowed in a prior year? If yes, for which tax year?
5. Purchase and install energy-efficient home items? (such as windows, furnace, insulation, etc.)
6. Receive the First Time Homebuyers Credit in 2008?
7. Make estimated tax payments or apply last year's refund to this year's tax? If so, how much?
8. File a federal return last year containing "capital loss carryover" on Form 1040 Schedule D?
9. Have health coverage through the Marketplace (Exchange)? [Provide Form 1095-A]
10. Receive an Economic Impact Payment (stimulus) in 2023?

Additional Information

Additional Information and Questions Related to the Preparation of Your Return
1. Provide an email address (optional) (this email address will not be used for contacts from the Internal Revenue Service)*
2. Presidential Election Campaign Fund (If you check a box, your tax or refund will not change) Check here if you, or your spouse if filing jointly, want $3 to go to this fund*

YouSpouse

3. If you are due a refund, would you like:*

	Yes	No
a. Direct deposit
b. To purchase U.S. Savings Bonds
c. To split your refund between different accounts

4. If you have a balance due, would you like to make a payment directly from your bank account?*

YesNo

5. Did you live in an area that was declared a Federal disaster area? *

	Yes	No	Remarks
Did you live in an area that was declared a Federal disaster area? If yes, where?

6. Did you, or your spouse, if filing jointly, received a letter from the IRS?*

YesNo
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Consent:
I/we, the taxpayer, have read the above information.

I/we hereby consent to the disclosure of tax return information described in the Global Carry Forward terms above and allow the tax return preparer to enter a PIN in the tax preparation software on my behalf to verify that I/we consent to the terms of this disclosure.
Primary taxpayer printed name*
I authorize my Tax Preparer to enter the five number PIN I have chosen below.*
Date:*

MonthDayYear
DateDate
Secondary taxpayer printed name*
I authorize my Tax Preparer to enter the five number PIN I have chosen below.*
Date:*

MonthDayYear
Date
Should be Empty:

CLIENT INTAKE FORM

Part I - Your Personal Information (If you are filing a joint return, enter your names in the same order as last year's return)

Part II - Marital Status and Household Information

Part III - Income - Last Year, Did You (or Your Spouse) Receive

Part IV - Expenses - Last Year Did you (or Your Spouse) Pay

Part V - Life Events - Last Year Did you (or Your Spouse)

Additional Information

Consent: