Tax Issues Preparation Client Intake Form

Tax Issues Preparation Client Intake Form
Filing Status

SingleHead of HouseholdMarried Filing SeparateMarried Filing JointQualifying Widower

Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
SSN
Are you a full-time student?

YesNo
Are you totally and permanently disabled?

YesNo
Are you legally blind?

YesNo

Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
SSN
Are they a full-time student?

YesNo
Are they totally and permanently disabled?

YesNo
Are they legally blind?

YesNo
Are they your dependent?

YesNo
IF YOU ARE CLAIMING A DEPENDENT, PLEASE ANSWER THE QUESTIONS BELOW THAT PERTAINS TO YOUR DEPENDENT RELATIONSHIP. PER THE IRS REQUEST, WE MUST PROVE THAT NOBODY ELSE IS ELIGIBLE TO CLAIM YOUR DEPENDENT BUT YOURSELF.
If claiming son/daughter, where is the other parent of the dependent/dependents? Is the other parent providing any financial support?
If claiming niece, nephew, aunt, or uncle, how are you related to the dependent? Where are the parents to the dependent/dependents?
If claiming brother or sister, how are you related to the dependent? Why are the parents not claiming the dependent/dependents?

Enter your dependents here

Rows	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?

Rows	Yes/No	Employer	Spouse Ins	Exchange/ Marketplace	Direct with Insurer	Medicare	Medicaid
Taxpayer
Spouse
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5

Please fill-up the information within the current year only.

General Expenses

Rows	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
How would you like to receive your refund?**

Refund Transfer Direct DepositRefund Transfer Paper Check
Additional comments

I, hereby, state that all the information above is true to the best of my knowledge and that I am allowing Estate Harmonix to prepare my taxes based on that fact. I understand that I am financially responsible for any outstanding balance due to any false information given.

If there is a balance due, you must pay the tax preparation fee upfront. If for any reason you owe an entity and they take the entire refund, you are STILL responsible to pay the tax preparation fee for services rendered.

*For any reason an amendment has to be filed with no fault of the tax preparer, an upfront fee of $150.00 is required! Please view your tax return, which is emailed to you (it is sent prior to submission). Any copy after the first copy is a fee of $10.00.

ALL FEES (bank and service fees) are found in the return and are non-refundable nor negotiable! NO EXCEPTIONS TO THIS!!

Please utilize www.irs.gov for all federal refund tracking. Please utilze your state Department of Revenue site for any State Refund tracking. Do NOT add the amounts together. Federal taxes are federal, and state taxes are state when tracking your status. Please allow 8 weeks to surpass from the date of submission before calling the IRS, if you have any tracking questions.

For any direct assistance please email EstateHarmonix@gmail.com

IRS Contact 800-829-1040

Please click this link to check your federal refund status. You will need your filing status, social security number, and the total amount of the refund before fees

https://sa.www4.irs.gov/irfof/lang/en/irfofgetstatus.jsp
- I allow Estate Harmonix 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 Estate Harmonix.
- 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
Date Signed

MonthDayYear
Date
Spouse Signature
Should be Empty: