Client Intake Form 2021

1
Taxpayer Name* This field is required.
First Name
Last Name
Suffix
2
Social Security Number* This field is required.
3
Date of Birth* This field is required.
Date
Month
Day
Year
4
Occupation* This field is required.
5
Email* This field is required.
example@example.com
6
Phone Number* This field is required.
Please enter a valid phone number.
7
Address* This field is required.
NO P O BOX/ PHYSICAL ADDRESS ONLY
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
Has your address changed since filing your last most current return?* This field is required.
Yes
No
9
Are you married or have you ever been married?* This field is required.
Single
Married
Legally Separated
Divorced
Widowed
10
Filing Status:
Single
Married Filing Jointly
Married Filing Separately
Head of Household
Qualifying Widow
11
HEAD OF HOUSEHOLD FILERS MUST PRESENT ONE OF THE FOLLOWING TO FILE THIS STATUS. PICK ONE OF THE 3 OPTIONS THAT YOU WILL SUBMIT TO BE APPROVED TO FILE HEAD OF HOUSEHOLD.
Lease
Utility Bill
Mortgage Statement
12
Income Source?* This field is required.Melva is a W2 preparer only. If you own a business please ask for a referral
W2
13
Income Information
Employer
Wages in box 1 W2
Tax Withheld Box 2 W2
14
Income InformationPlease complete only if you have an additional W2
Employer
Wages in box 1 W2
Tax Withheld Box 2 W2
15
Spouse Information
First Name
Last Name
Suffix
16
Social Security Number
17
Date of Birth
date
Month
Day
Year
18
Occupation
19
Email
example@example.com
20
Phone Number
Please enter a valid phone number.
21
Dependent 1
First Name
Last Name
Suffix
22
Social Security Number
23
Date of Birth
Date
Month
Day
Year
24
Relationship
Choose One
Choose One
Son
Daughter
Parent
Aunt
Uncle
Niece
Nephew
Stepchild
Brother
Sister
Stepbrother
Stepsister
Half Brother
Half Sister
Adopted Child
Grandchild
25
Dependent 2
First Name
Last Name
Suffix
26
Social Security Number
27
Date of Birth
Date
Month
Day
Year
28
Relationship
Choose One
Choose One
Son
Daughter
Parent
Aunt
Uncle
Niece
Nephew
Stepchild
Brother
Sister
Stepbrother
Stepsister
Half Brother
Half Sister
Adopted Child
Grandchild
29
Dependent 3
First Name
Last Name
Suffix
30
Date of Birth
Date
Month
Day
Year
31
Social Security Number
32
Relationship
Choose One
Choose One
Son
Daughter
Parent
Aunt
Uncle
Niece
Nephew
Stepchild
Brother
Sister
Stepbrother
Stepsister
Half Brother
Half Sister
Adopted Child
Grandchild
33
If you have more than 3 dependents, please provide info for other dependents by email to taxprep@melvadukes.com
34
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.
35
If claiming son/daughter, is the other parent providing any financial support? Is there an agreement in place as to who files child/children each year?
36
If claiming brother, sister, niece, nephew, aunt, or uncle, etc- Where are the parents to the dependent/dependents? Are you providing more than half of the care these dependents?
37
Were you ever disallowed the E.I.T.C prior to this year?* This field is required.
Yes
No
38
Did you pay childcare expenses for your child/children?
Yes
No
39
Did you collect social security or retirement income?
Yes
No
40
Did you purchase health insurance through healthcare.gov marketplace (Obama Care) and receive a 1095-A?* This field is required.
Yes
No
41
Did you receive unemployment compensation (1099-G) regular or PUA last year?* This field is required.
Yes
No
42
Did you make college tuition payments and received a 1098-T Form last year?
Yes
No
43
Do you have any other income outside of your w-2(s)?* This field is required.
Yes
No
44
Do you owe any delinquent:* This field is required.
Child Support
Alimony
Student Loans
Federal Taxes
State Taxes
None of the above
45
I, hereby, state that all the information above is true to the best of my knowledge and that I am allowing Melva Dukes 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.

This form only initiates the tax prep process. No return will be filed on your behalf without agreement by signature on your Tax Return documentation.

Upon receiving this information along with your tax document submission, an estimate will be emailed to you. An estimate does not replace an official filing of your Tax Return.

All official tax documentation should be submitted in person or on melvadukes.com
46
Signature* This field is required.
47
Date
Date
Month
Day
Year
Should be Empty: