Tax Preparation Client Intake Form

Tax Preparation Client Intake Form
Filing Status

SingleHead of HouseholdMarried Filing SeparateMarried Filing JointQualifying Widower

Enter your dependents here

Does you, your spouse, and your dependents have health insurance within 12 months last year? If yes, who covers for it?

General Expenses

	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

Acknowledgment & Signature
- I confirmed that all information I entered here is accurate and true.
- I allow ABC Financial 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 ABC Financial.
- 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

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Date Signed

MonthDayYear
Date
Spouse Signature

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