2024 Client Intake Form

2024 Client Intake Form
Filing Status*

SingleHead of HouseholdMarried Filing SeparateMarried Filing JointQualifying WidowerUnsure
Were you referred by anyone? If so, please provide their name below.
Has the taxpayer been issued an Identity Protection PIN by the IRS?

YesNo
If the taxpayer selected yes to having an Identity Protection PIN, enter it below:
Are you behind on your taxes or child support payments, or have you not filed your 2022 or previous years' tax returns yet?*

YesNo

Spouse Information
Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
SSN
Spouse's State ID or Driver's License (Please Upload)

Cancelof
Spouse's Social Security Card(Please Upload)

Cancelof
Have you or anyone in your household obtained health insurance through the Affordable Care Act (ACA) marketplace also known as Obamacare in 2023?

YesNo
If you selected yes to the previous question, please upload existing 1095-A form or download from HealthCare.gov

Cancelof
Did you or your spouse have a Health Savings Account (HSA) or other Medical Savings Account (Form 1099-SA & Form 5498-SA) in 2023?

YesNo
If you selected yes to the previous question, please upload existing Form 1099-SA & Form 5498-SA

Cancelof

Please upload copies of all dependents' Social Security or birth certificate documents

Cancelof
If you've indicated that you or a member of your household had marketplace insurance, please proceed to upload your 1095-A form.

Cancelof

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

Business Expenses
Does your Business have an EIN

YesNo
If you selected yes to the previous question, please enter your EIN below
What is the nature of your business or what industry does your business operate in?

General Business Expenses (2023)

	Amount
Office Supplies and Expenses
Rent or Lease Payments
utilities
Travel Expenses
Advertising and Marketing Costs
Insurance Premiums
Professional Services Fees (Fees paid for services such as accounting, legal advice, and consulting.)
Software and Subscriptions
Depreciation
Repairs and Maintenance
Home Office Expenses
Tax Preparation Fees
Contractor Expenses
Wages
Other Expenses

Acknowledgment & Signature
1. Thank you for choosing Be Rich Financial and giving us the opportunity to serve you. We appreciate your business and trust. By confirming below, you assert that all information provided by you is accurate and truthful.
  
  You authorize Be Rich Financial to securely store sensitive information such as your personal ID, government ID, Social Security Number (SSN), and other relevant data.
  
  You confirm that you have thoroughly reviewed and agree to the terms and conditions and the privacy policy of Be Rich Financial.
  
  By signing this document, you acknowledge and understand both your responsibilities and ours in the preparation of this tax return.
Your Voice Matters: We value your insights and queries. If there's anything else you'd like to share about your financial situation, any specific concerns you have, or questions about our services, please use the space below.
Date Signed

MonthDayYear
Date
Taxpayer Signature

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Date Signed

MonthDayYear
Date
Spouse Signature

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