MLA Tax & Financial Services Intake Form

Tax Organizer Form
Heading

Organizer
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Do you give us permission to call and/or text you via the mobile number listed above concerning your tax information or products and service that we may offer?*

YesNo
Check all that apply*

Do you have Health care coverage?Did you have health care coverage the entire year? (January 1st- December 31st)Can someone else claim you as a dependent?You and your spouse lived apart during the year.You and your spouse were a resident of another state or earned income inanother state during last year.Your child did not live with you, but is claimed as your dependent.You paid esitmated Federal (Form 1040 ES) or State taxes last year.You sold a business, real estate, business equipment, a vehicle or have rental property.You purchased a home.You were a student, had education expenses or made student loan payments
Are you self-employed?

YesNo
How would you like to receive your refund?

MailDirect DepositBank Products-Refund Advantage
If you would like your refund deposited into your bank account? Select Checking Savings
Routing # Account#

Dependents

Child Care Provider Information blanks .
Provider's SSN/EINblank . Provider's address Street Address Address Line 2 City State Zip
I blanks* have reviewed all information recorded in this document and under penalty of perjury, declare all information is true, correct and accurate. Signature
Should be Empty:

Tax Organizer Form