New Customer Intake Form

New Customer Intake Form
Tax Payer's Intake Form:
Tax Payer's Full Name*

First NameLast Name
Tax Payer's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Tax Payer's Phone Number*
Tax Payer's E-mail*
example@example.com
Tax Payer's Date of birth*
Example: 12/30/1234
Tax Payer's SSN*
Example: 01-12-1234
Tax Payer's Job Title*
Example: Occupation
If someone referred you, please type their name here.*
Are you trying to buy a new home within the next 2 years?

YesNo
Are you interested in credit repair?

YesNo
Spouse's Full Name

First NameLast Name
Spouse's Phone Number
Spouse's E-mail
example@example.com
Spouse's SSN
01-12-1234
Spouse's Date of birth
Example: 12/30/1234
Spouse's Job Title
Example: Occupation
Are you self employed?

YesNo
Did you and your spouse live apart during the year?

YesNo
What is your marital status as of December?

Single (Not married)Married living with spouseMarried not living with spouse
Did you pay half of the expenses of maintaining your residence for the entire year?

YesNo
Did you support a child or family members for more than 6 months out of the year?*

YesNo
If yes, did you live together at any time after June 30, 2023?

YesNoNot applicable
Are you on government assistance of any kind?

YesNoNot applicable
How many dependents are you claiming?
Dependent #1

First NameLast Name
Dependent's Date of birth
Example: 12/30/1234
Dependent's SSN
Example: 01-12-1234
What is Dependent #1's relationship to you (son, daughter, etc.)?
Enter relation
How many months did Dependent #1 live with you in 2023? (If all year, enter 12)
Dependent #2

First NameLast Name
Dependent's Date of birth
Example: 12/30/1234
Dependent's SSN
Example: 01-12-1234
What is Dependent #2's relationship to you (son, daughter, etc.)?
Enter relation
How many months did Dependent #2 live with you in 2023? (If all year, enter 12)
Dependent #3

First NameLast Name
Dependent's Date of birth
Example: 12/30/1234
Dependent's SSN
Example: 01-12-1234
What is Dependent #3's relationship to you (son, daughter, etc.)?
Enter relation
How many months did Dependent #3 live with you in 2023? (If all year, enter 12)
Dependent #4

First NameLast Name
Dependent's Date of birth
Example: 12/30/1234
Dependent's SSN
Example: 01-12-1234
What is Dependent #4's relationship to you (son, daughter, etc.)?
Enter relation
How many months did Dependent #4 live with you in 2023? (If all year, enter 12)
Dependent #5

First NameLast Name
Dependent's Date of birth
Example: 12/30/1234
Dependent's SSN
Example: 01-12-1234
What is Dependent #5's relationship to you (son, daughter, etc.)?
Enter relation
How many months did Dependent #5 live with you in 2023? (If all year, enter 12)
Are there any dependents in daycare? If, so please upload the form you received from your daycare provider.

YesNo
Upload a copy of your daycare form here.

Cancelof
How would you like to receive your tax refund?

Check (Only available in office visits)Direct deposit
Name of Bank
Which type of account would you like your refund?

Checking AccountSavings AccountOther
Routing Number
Bank Account Number
Can someone else claim you as a dependent?

YesNo
Did you have health insurance in 2023?

YesNo
Did you have health insurance for the entire year?

YesNo
Who was your health insurance coverage through in 2023?
Was YOUR insurance through your employer?

YesNo
Was YOUR DEPENDENTS' insurance through your employer?

YesNoNot ApplicableOther
Who was your DEPENDENT(S) health insurance coverage through in 2023?
Upload Taxpayer & Dependent(s) Insurance Documents

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Have you ever been denied the Earned Tax Credit (EITC)?

YesNo
Did you trade any virtual currency?

YesNo
Were any of your dependents in college in 2023?

YesNo
Do you have a 1098-T form for either you or your dependents?

YesNo
If you have a 1098-T form, upload it here.

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Are you interested in AUDIT PROTECTION?

YesNo
CLIENT NON PAYMENT/OFFSET CLAUSE

LSB TAXES LLC, we strive to assist all of our clients in their tax needs, however we understand that situations arise. If your refund is offset by the IRS, student loans, child support or your check is mailed, you are still obligated to pay our company the fess associated with filing your tax return.

By signing this agreement you acknowledge that if payment is not made in full within 30 days legal actions will be sought to resolve payment.
Primary Taxpayer's Signature*

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ADDITIONAL SERVICES

At LSB Taxes LLC, we do more than just taxes. Please ask your specialized representative about our additional services.

By signing this document you agree to giving LSB Taxes LLC permission to prepare all forms related to my tax return; to apply for and secure RAC's and RAL's on my behalf; and sign all necessary forms and file my taxes electronically. I take full responsibility for the accuracy of this form and understand LSB Taxes LLC and/or associated affiliates hold no responsibility for any misrepresentation or false claims.
Date*

MonthDayYear
Date
Spouse's Signature (If no spouse leave blank)

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Taxpayer's Driver's License

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Taxpayer's & dependent(s) social security card(s)

Cancelof
Taxpayer's W-2/1099's

Cancelof
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Dependent(s) Proof of residency (Lease/Utility Bill)

Cancelof
Should be Empty: