Empower Accounting & Tax Service
Tax Client Intake Form
Please choose your tax professional
Shelisha
Ebony
Yasmeen
Toreaka
Mikayla
How did you hear about us?
Facebook
Instagram
Referral
Returning Client
If someone referred, you please list the name.
What is the best time to reach you?
Did you file a tax return?
Yes
No
Taxpayer Information
Filing Status
Single
Head Of Household
Married Filing Separate
Married Filing Joint
Taxpayer Name
First Name
Last Name
Taxpayer SSN
example:000-00-0000
Taxpayer Date OF Birth
example:12/31/2000
Taxpayer Phone Number
Example: 222/326/4444
SMS consent
By checking this box, I consent to receive text messages related to Tax Preparation Updates from Empower Accounting And Tax Service .You can reply "STOP" at any time to opt-out. Message and data rates may apply. Message frequency may vary, text HELP to 678-661-2142 for assistance. For more information please refer to our privacy policy, and SMS Terms and Conditions on our website at https://empower-ats.com.com.
Taxpayer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Taxpayer Occupation
Example: job title
Taxpayer Email
Example: yourname@yahoo.com
Spouse Name
Spouse SSN
Spouse Date of Birth
Spouse Email
Spouse Occupation
Income Information
Which tax document you received this tax year?
W2
Unemployment Income
Household Employee
Self-Employed
Any 1099 forms
Business income received.
Example:$15,000.00
Please list all your business expenses here.
Example: Advertisement $25.00
Due Diligence Questionnaire
Did you and your spouse live apart this year?
Yes
No
Did you pay over half the expenses to maintain your home for the entire year?
Yes
No
Did you support a child(ren)or family member at least 6 months out the year?
Yes
No
If yes, did y'all live together at any time after June 30,2025?
Yes
No
Have you ever been denied the Earn Income Tax Credit or Child Tax Credit?
Yes
No
Did you receive any government assistance?
Section 8
Rental Assistance
Can someone else claim you as a dependent?
Yes
No
Dependent Information
Dependent #1 Name
First Name
Last Name
Dependent #1 Date of Birth
Dependent #1 SSN#
Relationship to the dependent
Dependent #2 Name
First Name
Last Name
Dependent #2 SSN#
Dependent #2 Date of Birth
Relationship to the dependent
Dependent #3 Name
First Name
Last Name
Dependent #3 SSN#
Dependent #3 Date of Birth
Relationship to the dependent
Dependent #4 Name
First Name
Last Name
Dependent #4 SSN#
Dependent #4 Date of Birth
Relationship to the dependent
If you have additional dependents, please list them here. Name, Date of Birth, Social Security Numbers and Relationship.
How many months did the dependent(s) live in the same home as you?
Example: 12 Months
Are any dependent(s) in daycare? If yes, please upload the form that was provided to you from the daycare provider.
Yes
No
Please upload a copy of your daycare form here.
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Health Insurance Questionnaire
Did you have health insurance in 2025?
Yes
No
Did you or your dependent receive Medicaid?
Yes
No
Did you or your dependent receive health insurance through the Affordable Care Act (Marketplace)?
Yes
No
Please upload your marketplace insurance 1095-A form.
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College Questionnaire
Were you or any of your dependents enrolled in college in 2025?
Yes
No
Do you have the 1098-T form for either you or your dependent(s)?
Yes
No
If you have your 1098-T form, please upload here.
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Banking Information
How would you like to receive your refund?
*
Direct Deposit
Check
Prepaid Crad
Which type of account would you like to your refund deposited into?
*
Checking
Savings
Name Of Bank?
Routing Number
Account Number
Other Services Offered
Are you interested in Audit Protection for $93.00?
Yes
No
Are you interested in Credit Repair Services for 4 months for $399
Yes
No
Are you interested in Identity Theft Protection $39.95?
Yes
No
Are you interested in Bookkeeping Services? prepares invoices, expense reports, 1099s, receipts etc. for all small business owner for $350.00.
Yes
No
Tell me more about the service
Are you interested in the cash advance loan up to $7000.00 upon bank approval?
Yes
No
IRS Identity Pin Information
Were you issued an Identity Pin from the IRS
Yes
No
Please list your pin here.
Taxpayer’s Signature
Date
*
-
Month
-
Day
Year
Date
Primary Taxpayers Signature
*
Taxpayers Spouse Signature if applicable
Date
-
Month
-
Day
Year
Date
Need to ask a question?
Do you have any questions? If so type here.
Documents to be uploaded. Please upload all the documents.
Taxpayer’s Drivers License
*
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Taxpayer and dependent(s) Social Security card(s)
*
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Taxpayer’s W-2 /1099’s
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Self-Employment only! Expenses log,Summary of income etc
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Dependent(s) Birth Certificate
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Proof of Residency.
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Save
Submit
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