CLIENT INTAKE FORM

CLIENT INTAKE FORM
First Name, MI
Last Name
Social Security Number
Date of Birth

MonthDayYear
Date
Date of DeathType a question

MonthDayYear
Date
Work Phone
Format: (000) 000-0000.
Cell/Other Phone
Format: (000) 000-0000.
Occupation
Email
example@example.com
SPOUSE
First Name
MI
Last Name
Social Security Number
Date of Birth

MonthDayYear
Date
Date of Death

MonthDayYear
Date
Work Phone
Format: (000) 000-0000.
Cell/Other Phone
Format: (000) 000-0000.
Occupation
Email
example@example.com
Legally Blind
FILING STATUS
Filing Status
Street & Apt. No.
City
State
Zip
County
DEPENDENTS FIRST, MI LAST NAME DATE OF BIRTH, RELATIONSHIP

DUE DILIGENCE QUESTIONS
How many people live with you ?
HOW MANY ADULTS AND CHILDREN
Did anyone help support you during the year? If yes, who?
How Much?
In the case of audit can you prove financial responsibility and residency for any of the Dependents being claimed? Which document(s) can you provide? (i.e. copy of lease, medical records, school records, food stamps or benefit statements)
If Yes, why are the parents not claiming the child? (Please explain and list the child's name(s) if more than one listed on the return)
Are any of the dependents being claimed NOT your Son or Daughter? If Yes, why are the parents not claiming the child? (Please explain and list the child's name(s) if more than one listed on the return)

Were any of the credits disallowed or reduced in a previous year? YesNo If yes, please explain:
If yes, please explain
Did you have any other income during the year? (Child support, alimony) If yes, please specify

Are any of the dependents that you are claiming disabled? YesNo If Yes, what is the nature of the disability (permanently and totally disabled, temporarily disabled)?
If Yes, what is the nature of the disability (permanently and totally disabled, temporarily disabled)?
Does the dependent received social security/disability benefits ? If yes what type?
If yes what type?
Taxpayer Signature
Date

MonthDayYear
Date
Spouse Signature
Date

MonthDayYear
Date

How do you want your refund? (Check one of the following)
Cash Advance option (Check one of the following) * The loan of fered in amounts 25%, 50% or 75% of your expected tax refund to up to $6000. Some loans are interest bearing loan, and will have an annual APR. Please confirm the interest rates with your preparer. Cash Advance (RT Refund Transfer)
The Following products require fees paid at thetime of the service.
By signing below, I understand that I have received an explanation of all refund methods and cash advance options available to me and I have selected the option that I feel is the best delivery method for me.
Taxpayer Signature:
Date

MonthDayYear
Date

Schedule C Income & Expense Form
Taxpayer
Name of Business (If any)
Address of Business
Business EIN (If any): Date Business Started:
Date Business Started

MonthDayYear
Date
Did you materially participate in the business?
Income Questions: (Required if no P&L or Trial Balance Available)
Total Income $
1099 Income:
Enter Amount $
Total Sales Services:
Enter Amount $
ADVERTISING:
Auto Expense
Enter an Amount $
Commissions
Enter an Amount $
Depletion
Enter an Amount $
Depletion
Enter an Amount $
Insurance (Other than Health)
Enter an Amount $
Interest
Mortgage
Legal & Professional:
Pension & Profit Sharing
Rent or Lease
a) Vehicles: b) Machinery: C) Other:
Repair/ Maintenance
Enter an Amount $
Supplies
Enter an Amount $
Taxes/Licenses
Enter an Amount $
Travel
Enter an Amount $
Meals (Total):
Enter an Amount $
Utilities
Enter an Amount $
Other
Enter an Amount $
Total Expenses
Enter an Amount $
Net Income
Total Income - Total Expenses = $ (Please attach any other supporting document(s) if available)
Total Income - Total Expenses = $ (Please attach any other supporting document(s) if available)
If you do not have any business expenses, please explain why?
Client Signature
Date

MonthDayYear
Date
By signing above, I hereby certify the information given above is true and accurate.

Non-Standard Dependent Questionnaire
Taxpayer Name
SSN
Spouse Name
SSN
DEPENDENT 1:
Name
SSN
Date of Birth

MonthDayYear
Date
What is your relationship to the dependent?
Why aren't the parent's not claiming this child?
Did the dependent live in your home for more than 6 months?
Do you have custody of the child?
Do you have document proving relationship to the child?
DEPENDENT 2:
Name
SSN
Date of Birth

MonthDayYear
Date
What is your relationship to the dependent?
Why aren't the parent's not claiming this child?
Do you have document proving relationship to the child?
Did the dependent live in your home for more than 6 months?
Do you have custody of the child?
Do you have document proving relationship to the child?
DEPENDENT 3:
Name
SSN
Date of Birth

MonthDayYear
Date
What is your relationship to the dependent?
Why aren't the parent's not claiming this child?
Did the dependent live in your home for more than 6 months?
Do you have custody of the child?
Do you have document proving relationship to the child?
By signing below, I hereby certify the information given above is true and correct to the best of my knowledge. Taxpayer has been informed that claiming a dependent for EITC/CTC/AOTC/HOH or other can result in audit, fines, and if information provided is incorrect.
Client Signature
Date

MonthDayYear
Date

AOTC Student Acknowledgement Form
Full name of the student

First NameLast Name
Name of school attended
What year did you attend college?
I certify that all the information found on this form is true and to the best of my knowledge. I understand that it is my responsibility to have all valid documents and or receipts, as required to claim any credit for attending a college or university. Below is a recap of all information, status, and expenses I have encountered
Room & Boarding $
Books $
Tuition $
Supplies (On campus) $
Supplies (Off campus)
Other expenses $
Total
By signing below I certify all information is true, valid, and to the best of my knowledge. I accept full responsibility of the statements mentioned above. Any and all disputes regarding this matter shall be forwarded to me with the information found on my tax returns forms.
Student Signature
Date

MonthDayYear
Date

Head of Household Due Diligence
Taxpayer Name
SSN
Monthly Income: (wages, child support, other income)
Property Taxes
Rent
Mortgage Interest Expense
Utility Charges
Upkeep/Repair
Property/ Renters Insurance
Food Consumed on premises
TOTALS COST (GOVERNMENT ASSISTANCE)
Please do not count any money received under any governmental/public assistance/welfare/snap (Food Stamps) in the amounts that you paid. Include cost paid with the publuc assistance in the total cost

Taxpayer has provided all answers to the above questions to be true and correct to the best of the taxpayer's knowledge. Taxpayer has been informed that claiming a dependent for HOH or other can result in an audit, fines, and penalties if information provided to a prepare is incorrect.
Taxpayer Signature
Date

MonthDayYear
Date

CHILD DEPENDENT CARE

You may be able to claim the credit if you pay someone to care for your dependent who is under age 13 or for your spouse or dependent who is not able to care for himself or herself. The credit can be up to 35% of your expenses. To qualify, you must pay these expenses SO you can work or look for work.

Name of Person Being Cared For

Daycare/ Childcare Provider (s)
Name of Provider
FEIN
Address

Address

Street Address Line 2

CityState

Postal / Zip Code
Zip
Phone Number
Format: (000) 000-0000.
Amount Paid
Name of Provider
FEIN
Address

Address

Street Address Line 2

CityState

Postal / Zip Code
Zip
Amount Paid
Format: (000) 000-0000.
Amount Paid
By signing below I certify all information is true, valid, and to the best of my knowledge. I accept full responsibility of the statements mentioned above. Any and all disputes regarding this matter shall be forwarded to me with the information found on my tax returns forms.
Taxpayer Signature
Date

MonthDayYear
Date

Schedule A Deductions
Medical Expenses
Medical & DentalType a question Expenses
Medical Insurance Premiums Paid (Other than Social Security Medicare Payments)
Long Term care Premiums
Type a questionState & Local Income Taxes Paid (Other than those on W-2's, 1099's, etc Prior year Income Taxes paid in current year Real Estate Taxes
Prescription Drugs & Medications
January 1 to June 30
July 1 to December 31
Prior year Income Taxes paid in current year
Real Estate Taxes
Home Mortgage Interest reported on Form 1098 Home Mortgage Interest paid to others Refinancing Points Paid Investment Interest (other than K-1)
Personal Property Taxes
Other taxes:
Qualified New Vehicle Taxes Additional State/ Local Taxes
Qualified New Vehicle Taxes
Additional State/ Local Taxes
Home Mortgage Interest reported on Form 1098
Home Mortgage Interest paid to others
Refinancing Points Paid
Investment Interest (other than K 1)
CONTRIBUTIONS
Cash Contributions (If over $500 please provide detailed list) Non Cash Contributions (If over $500 please provide detailed list) Volunteer Mileage Driven
Cash Contributions (If over $500 please provide detailed list)
Non Cash Contributions (If over $500 please provide detailed list)
Volunteer Mileage Driven
Unreimbursed Business Expenses Union Dues
Unreimbursed Business Expenses
Union Dues
Tax Prep Fees (Paid for Previous Return) Safe Deposit Rental Investment Expenses (Other than K-1) Gambling Losses (Due to extent of winnings) Other Expenses:
Tax Prep Fees (Paid for Previous Return)
Safe Deposit Rental
Investment Expenses (Other than K 1)
Gambling Losses (Due to extent of winnings)
Other Expenses
CASUALTY & THEFT LOSSES
If you had any casualty or theft losses during the year, please provide detail below, including date, description, amount of casualty or loss, any insurance reimbursement & basis in the property.
Client Signature
Date

MonthDayYear
Date

Should be Empty:

CLIENT INTAKE FORM

SPOUSE

FILING STATUS

DUE DILIGENCE QUESTIONS

Schedule C Income & Expense Form

Schedule C Due Diligence Questions

Non-Standard Dependent Questionnaire

DEPENDENT 1:

DEPENDENT 2:

DEPENDENT 3:

CONTRIBUTIONS

CASUALTY & THEFT LOSSES