Tax Intake Form

CLIENT FORM
How did you hear about us?

FacebookInstagramSnapchatReferralReturning Client
Tax Preparer Name
If someone referred you, please type his or her name here.
Are you trying to buy a new home within the next 2 years?

YesNo
Are you interested in Credit Repair? Choose Personal or Business.

Yes, PersonalYes, BusinessNoOther
Email
example@example.com
Tax Payer's Name

First NameLast Name
Taxpayer's Phone Number*
Example: xxx-xxx-xxxx
Taxpayer's Job Title
Taxpayer's Date of Birth*
Example: 01/01/2001
Taxpayer's SSN
Example: xxx-xx-xxxx
Taxpayer's Email Address*
Spouse's Full Name
First Name
Spouse's SSN
Example: xxx-xx-xxxx
Name

First NameLast Name
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
Taxpayer's SSN
Example: xxx-xx-xxxx
Spouse's Job Title
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you self employed?*

YesNo
Did you and your spouse live apart during the year?*

YesNoNot Applicable
What is your marital status as of December*

Single (Not Married)Married living with SpouseMarried not living with spouse
Are you claiming Head of Household/(HOH)? Did you pay over half the expenses of maintaining your residence for the entire year?*

Yes, claiming HOHNo, Not claiming HOHYes, I paid over half the expenses of maintaining my residence for the entire year.No, I didn’t pay over half the expenses of maintaining my residence for the entire year.Other
Did you support a child or family member for more than 6 months out of the year?*

YesNo
If yes, did you live together at any time after June 30, 2024?*

YesNoNot Applicable
Are you on any Government Assistance*

YesNoNot Applicable
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 in 2024? (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 in 2024? (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 in 2024? (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 in 2024? (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 in 2024? (If all year, enter 12)
Are there any dependents in daycare? If yes, please upload the form you received from your daycare provider.

YesNoOther
Upload a copy of your daycare form here.

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How would you like to receive your tax refund?

Check (Only available for in office visits)Direct Deposit
Name of Bank
Which type of account would you like your refund deposited into?

Checking AccountSavings AccountOther
Routing Number
Bank Account Number
Can someone else claim you as a dependent?

YesNo
Did you have health insurance in 2024?

YesNo
Did you have health insurance for the entire year?

YesNo
Who was your insurance cover through in 2024?
Did your dependents have health insurance for the entire year?

YesNoNot Appliable
Was YOUR DEPENDENTS' insurance through your employer?

YesNoNot Applicable
Who was your Dependents insured with in 2024?
Was YOUR DEPENDENTS' insurance through Medicaid?

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

YesNoNot Applicable
Please Upload Form 1095-B/ Healthcare Tax Form (If Applicable)

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

YesNo
Were you or any of your dependents in college in 2024?

YesNo
Are you interested in applying for a tax advance loan up to $7,000?

Yes, up to $1,000 with NO finance chargeYes, up to $7,000 with BANK finance chargeNO, I don't want to apply for a tax advance loan.Yes, up to $1,000 with NO finance charge (Refund Advantage)Yes, up to $7,000 with BANK finance charge (Santa Barbara SBTPG)
Do you have a 1098-T Form for either you or your dependents?

YesNo
If you have a 1098-T form, upload it here.

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Are you interested in AUDIT PROTECTION?

YesNo
CLIENT NON PAYMENT/OFFSET CLAUSE

At The Tax Surgeon 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.
Primary Taxpayer's Signature

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ADDITIONAL SERVICES

At The Tax Surgeon LLC, we do more than just taxes. Please check below if you would be interested in any of the additional services we provide. We will schedule a time to speak with you ar a later time.
I am giving, The Tax Surgeon LLC permission to prepare all forms related to my tax return; to apply for and secure RAC's and Refund Advance Loans on my behalf; and sign all necessary forms and file my taxes electronically. I take full responsibility for the accuracy of this form and understand that The Tax Surgeon LLC and/or associated affiliates hold no responsibility for any misrepresentation or false claims.
Date

MonthDayYear
Date
Taxpayer's Signature (If no spouse, leave blank)

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

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Date

MonthDayYear
Date
Type a question
Date

MonthDayYear
Date
Taxpayer's Driver's License or Identification Card

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

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Taxpayer's W-2/ 1099'S (Receipts, Bank Statements, Profit & Loss Statements, If Filing Self-Employment)

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Dependent(s) Birth Certificate(s)

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Dependent(s) Proof of Residency (Lease/Utility Bill)

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Should be Empty:

CLIENT FORM