2023 Tax Preparation Client Intake Form

2023 Tax Preparation Client Intake Form

2023 Tax Preparation Client Intake Form
Are You a Returning Client?
If You Were Referred, Please Type The Name of The Person That Referred You
Pick your Tax Preparer
Filing Status

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
Are you a full-time student?
Are you totally and permanently disabled?
Are you legally blind?

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
Is your spouse a full-time student?
Is your spouse totally and permanently disabled?
Are they legally blind?

Enter your dependents here

Rows	Name	SSN	Date of Birth	Relationship
1
2
3
4
5
6

Employment Status

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
Spouse
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5

Are you contributing to 401k or other pre-tax account?
Is this your first time opening a pre-tax account?
Did you have any of the following income last year?

Other
Does your dependents have tuition expenses?
Do you have any expenses for child care?
Did you purchase or install energy-efficient home items?

Other
Do you have your own home?
Do you have mortgage interest?
Do you have documents that shows you paid for property taxes?
Did you sell any stock?
Did you take money from your 401?
Did you pay your vehicle tax?
Do you have real estate tax?
Did you receive a federal tax last year?
Are you a victim of identity theft?
Please list if you have a IRS Pin number
Itemizing Expenses

ONLY COMPLETE IF YOU ARE NOT USING STANDARD DEDUTION

General Expenses (ONLY COMPLETE IF YOU ARE ITIMIZING)

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
Investment Expenses
Supplies used as an eligible educator

Total Expenses

Please fill-up the information within the current year only.
Photo ID

Cancelof
SS Cards

Cancelof
W2 and 1099s

Cancelof

Routing number blanks Checking number blank
Additional comments

- I confirmed that all information I entered here is accurate and true.
- I allow The Dependable Group LLC 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 The Dependable Group LLC.
- By signing below, you acknowledge that you have read and understood your responsibilities and our responsibilities in doing this tax return.
Date Signed

MonthDayYear
Date
Taxpayer Signature
Date Signed

MonthDayYear
Date
Spouse Signature
Should be Empty: