2023 INTAKE FORM

Client Intake Form

Phone: 682-243-5096

CHOOSE YOUR TAX PROFESSIONAL:

Were you referred to Obsidian Tax Services, please let us know who to thank. Referred by:

Today's Date:

Date

Client's Full Legal Name:

First NameLast Name

Client's Social Security Number:

Client's Date of Birth:

Date

Spouse's Full Name:

First NameLast Name

Spouse's Social Security Number:

Spouse's Date of Birth

Date

Current Address: (please include zip code)

Current Home Phone Number:

Please enter a valid phone number.

Current Cell Phone Number:

Please enter a valid phone number.

Spouse's Cell Phone Number

Spouse's Email Address

example@example.com

Email Address

example@example.com

Current Occupation

Your Spouse's Current Occupation

Have you been a victim of identity theft and been given an identity theft protection PIN by the IRS? If yes, enter the six digit identity protection PIN number.

Has the spouse been a victim of identity theft and been given an identity theft protection PIN by the IRS? If yes, enter the six digit identity protection PIN number.

Were you, your spouse, or any of your dependents Enrolled at least part time in an accredited College, Trade School or University in 2023?

Name of accredited College, Trade School or University?

How many years of school have been completed prior to December 31, 2023?

Were you, your spouse, or any of your dependents who were enrolled at least part time in an accredited College, Trade School or University issued a 1098T or1098E form?

What county did you live and work in as of December 31, 2023?

What SCHOOL DISTRICT did you live in as of December 31, 2023?

Did you file your 2022 Tax Return ?

Did you receive your expected refund ?

Have you ever had EARNED INCOME CREDIT DISALLOWED by the IRS?

Was your tax return completely offset last year?

Will you be filing more than one STATE return? If so, WHICH

Are you claiming any dependents that you provided MORE THAN HALF the support for? If so, fill out their information below:

Dependent #1

Full Legal Name

Relationship to Taxpayer

Social Security Number

Date of Birth

Date

Full Legal Name(s) of Biological Parent(s): How long did the dependent live in your home during the tax year?

Dependent #2

Full Legal Name

Relationship to Taxpayer

Social Security Number

Date of Birth

Date

Full Legal Name(s) of Biological Parent(s): How long did the dependent live in your home during the tax year?

Dependent #3

Full Legal Name

Relationship to Taxpayer

Social Security Number

Date of Birth

Date

Full Legal Name(s) of Biological Parent(s): How long did the dependent live in your home during the tax year?

Do you have joint custody of the above listed DEPENDENT(S)

Do you have a signed IRS Form 8332?

Per IRS new guidelines, please indicate where the dependent's Non- Custodial parent/parents are and why they will not be filing this dependent?

Will you claim the CHILD CARE DEDUCTION for this tax year? If so, full legal name, social security (tax ID), address and amount per child paid:

Do you receive ANY supplemental, nontaxable income such as child support, Food stamps, Medicaid/ Medicare, TANF, social security, or disability if so, how much? (Please list each type that applies along with the amount)

Have you traded, engaged in any stocks or any crypto currency (for example: Coinbase, Robinhood, Cashapp, etc?

Per IRS new guidelines, please indicate where the dependent's Non- Custodial parent/parents are and why they will not be filing this dependent?

Per IRS new guidelines, please indicate where the dependent’s Non-Custodial parent/parents are and why they will not be filing this dependent? Will you claim the CHILD CAREDEDUCTION for this tax year? If so, full legal name, social security (tax ID),address and amount per child paid

Do you receive ANY supplemental, nontaxable income such as child support, Food stamps, Medicaid/ Medicare, TANF, social security, or disability if so, how much? (Please list each type that applies along with the amount

Have you traded, engaged in any stocksor any crypto currency (for example:Coinbase, Robinhood, Cashapp, etc?

Did you pay Property Taxes for your home in 2023? Enter amount IF YES

Did you pay real estate taxes in 2023? IF YES enter AMOUNT

Are you a homeowner? Did you purchase your first home in 2023? Enter amount IF YES

Did you pay Mortgage Interest for your home in 2023? Enter amount IF YES

Did you make any ENERGYIMPROVEMENTS to your MAIN HOME in 2023? IF YES enter AMOUNT:

Did you make any ENERGY IMPROVEMENTS to your MAIN HOME in 2023? IF YES enter

Did you pay upkeep and repair expenses for your home in 2023? If Yes enter AMOUNT

Did you pay upkeep and repair expenses for your home in 2023? If Yes enter

Did you pay for Property Insurance for your home in 2023? IF YES enter AMOUNT

Did you pay for Property Insurance for your home in 2023? IF YES enter

Did you RENT? IF YES, how many months and the AMOUNT paid in 2023

Did you pay renters insurance? AMOUNT paid in 2023:

Did you pay renters insurance?

Did you purchase a NEW VEHICLE after February 16, 2023? IF YES enter

Did you purchase a NEW VEHICLE after February 16, 2023? IF YES enter AMOUNT

Amount of any significant MEDICAL/DENTAL expenses

Amount, IF any personal property taxes

Amount IF any rental income property in 2023?

Amount IF any cash noncash contributions to charity in 2023

Are you, your spouse, or any dependent listed on your tax return disabled?

What is the nature of the disability?

Has this dependent been declared disabled by a physician? If so, can you provide documentation?

Are you or your spouse listed as the Social Security Representative Payee for this dependent

Is this the dependent(s) expected to recover in the next year?

Will you claim the DEPENDENT CARE DEDUCTION for the disabled dependent If so, full legal name, social security (tax ID), address and amount per disabled dependent paid

Did you pay out of pocket for any uncovered Medical Expenses for the disabled dependent, if so, enter the amount for the year?

Taxpayer's Signature

Taxpayers Spouse's Signature

Name of Bank

Account Number:

Routing Number

WHO'S NAME IS ON THE BANK ACCOUNT?

First NameLast Name

WOULD YOU LIKE TO APPLY FOR THE TAX ADVANCE LOAN?

DID YOU RECEIVE THE CHRISTMAS HOLIDAY LOAN?

DRIVERS LICENSE NUMBER

ISSUING STATE

ISSUE DATE

EXPIRATION DATE

Signature of Taxpayer Date

We continue to grow our business through loyal customers like you. Please look in your cell phones and provide us with at least 3 names and phone numbers of people needing assistance in preparing their taxes and getting back the maximum amount of money they are legally entitled as such it is imperative to us that you leave at least 1 referral:

Referral #1

Name

Phone Number

Please enter a valid phone number.

Referral #2

Name

Phone Number

Please enter a valid phone number.

Referral #3

Name

Phone Number

Please enter a valid phone number.

DEPENDENT INFORMATION

REAL ESTATE AND VEHICLE

IF YOU WOULD LIKE DIRECT DEPOSIT: