Client intake Tax Form

SingleHead of HouseholdMarried Filing SeparateMarried Filing JointQualifying WidowerIf Separated from Spouse has it been 6 months or more

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Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

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Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

YesNoIf you are a student do you have documentation to prove school status

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

	Yes/No	Employer	Spouse Ins	Exchange/ Marketplace	Direct with Insurer	Medicare	Medicaid
Taxpayer
Spouse
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5

EmployedUnemployedSelf-employedUnemployment income

WindowsDoorsFurnaceOther

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

	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
Dependent care

I confirmed that all information I have entered here is accurate and true. I give GLOBAL WEALTH TAX CO. ie ILICE JACKSON ENTERPRISES LLC consent 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 GLOBAL WEALTH TAX CO. . By signing below, you acknowledge that you have read and understood your responsibilities and our responsibilities in doing this tax return.This information will be used to prepare your taxes and will be sent to the IRS in case of an audit. In the event I am audited I have substaincial documentation to submit to the IRS. I do also understand that if my income tax return is offset by the IRS that I am obligated to still pay my tax preparartion fee to GLOBAL WEALTH TAX Co. within 30 Days from the date offset was listed or before. Failure to pay my tax preparer fee will result in removal as a client from database and collection activity on my account until entire balance of fee is retreived.

Please take selfie to conform idenitification

Section 8, Food stamps, Medicaid

Tax Preparation Client Intake Form