Tax Intake Form

Filing Status

If someone referred you, please type his or her name here.

Email

example@example.com

Tax Payers 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?

Did you and your spouse live apart during the year?

What is your marital status as of December

Did you pay over half the expenses of maintaining your residence for the entire year?

Did you support a child or family member for more than 6 months out of the year?

If yes, did you live together at any time after June 30, 2023?

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 2023? (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 2023? (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 2023? (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 2023? (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 2023? (If all year, enter 12)

Are there any dependents in daycare? If yes, please upload the form you received from your daycare provider.

Upload a copy of your daycare form here.

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How would you like to receive your tax refund?

Name of Bank

Which type of account would you like your refund deposited into?

Other

Routing Number

Bank Account Number

Can someone else claim you as a dependent?

Did you have health insurance in 2023?

Did you have health insurance for the entire year?

Was your insurance through your employer?

Was your insurance through Medicaid?

Was your insurance through the Affordable Care Act (The Marketplace)?

Did your dependents have health insurance for the entire year?

Was YOUR DEPENDENTS' insurance through your employer?

Who was your Dependents insured with in 2023?

Upload Taxpayer & Dependent(s)Insurance Documents

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Was YOUR DEPENDENTS' insurance through Medicaid?

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

Were you or any of your dependents in college in 2023?

Do you have a 1098-T Form for either you or your dependents?

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

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Are you interested in AUDIT PROTECTION?

CLIENT NON PAYMENT/OFFSET CLAUSE

At Supreme Tax Solutions, 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. I

By signing this agreement you acknowledge that if payment is not made in full with in 30 days legal actions will be taken to resolve payment.

I am giving Supreme Tax Solutions permission to prepare all forms related to my tax return; to apply for and secure RAC's and RAL's 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 Supreme Tax Solutions and/or associated affiliates hold no responsibility for any misrepresentation or false claims.

Date

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

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

Date

Taxpayer's Driver's License

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

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Taxpayer's W-2/ 1099'S

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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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CLIENT INTAKE FORM