Blatch Brand Financial Group Tax Preparation Intake
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Filing Status
*
Single
Head of Household
Married Filing Separate
Married Filing Joint
Qualifying Widower
Taxpayer Information
Name
*
First Name
Last Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
*
SSN
*
Are you a full-time student?
*
Yes
No
Are you totally and permanently disabled?
*
Yes
No
Are you legally blind?
*
Yes
No
Spouse Information
Name
*
First Name
Last Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
*
SSN
*
Are they a full-time student?
*
Yes
No
Are they totally and permanently disabled?
*
Yes
No
Are they legally blind?
*
Yes
No
Are they your dependent?
*
Yes
No
Dependents
Enter your dependents here
*
Name
SSN
Date of Birth
Relationship
1
2
3
4
5
6
Enter your dependents here
*
Name
SSN
Date of Birth
Relationship
1
2
3
4
5
6
Does you, your spouse, and your dependents have health insurance within 12 months last year? If yes, who covers for it?
*
Yes/No
Employer
Spouse Ins
Exchange/ Marketplace
Direct with Insurer
Medicare
Medicaid
Taxpayer
Yes
No
Spouse
Yes
No
Dependent 1
Yes
No
Dependent 2
Yes
No
Dependent 3
Yes
No
Dependent 4
Yes
No
Dependent 5
Yes
No
Tax Related Questions
Employment Status
*
Employed
Unemployed
Self-employed
Are you contributing to 401k or other pre-tax account?
*
Yes
No
Is this your first time opening a pre-tax account?
*
Yes
No
Please select what state return are you requesting?
*
State return
School
Local
RITA
Country returns
Does your dependents have tuition expenses?
*
Yes
No
Do you have any expenses for child care?
*
Yes
No
Do you have energy star rated improvements to your home?
*
Windows
Doors
Furnace
Other
Are you currently renting?
*
Yes
No
What is the monthly rental amount?
*
How long have you lived at the property?
# of months
Do you have your own home?
*
Yes
No
Do you have documents that shows you paid for property taxes?
*
Yes
No
Did you sell any stock?
*
Yes
No
Did you take money from your 401?
*
Yes
No
Did you pay your vehicle tax?
*
Yes
No
Do you have mortgage interest?
*
Yes
No
Do you have real estate tax?
*
Yes
No
Did you receive a federal tax last year?
*
Yes
No
Are you a victim of identity theft?
*
Yes
No
Expenses
Please fill-up the information within the current year only.
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
Total Expenses
Additional comments
Acknowledgment & Signature
I confirmed that all information I entered here is accurate and true.
I allow
Blatch Brand Tax & Financial Group
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
Blatch Brand Tax & Financial Group.
By signing below, you acknowledge that you have read and understood your responsibilities and our responsibilities in doing this tax return.
Date Signed
*
-
Month
-
Day
Year
Date
Taxpayer Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Spouse Signature
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