Income Tax Intake Form

Income Tax Intake Form
Basic Information

Please make sure ALL information provided below is accurate. We appreciate your business and look forward to servicing all of your financial service needs.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Filing Status*
Are you self-employed?*
Are you married?*
Referral Agent*
Referral Agent, Tax preparer or 1st Available
Dependent Information

If dependent(s) are disabled, letter documentation will be required by IRS.
Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Social Security Number
Relationship to Taxpayer
How many months did the dependent stay with you in the current filing year?
Can anyone else claim dependent(s)?
Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Social Security Number
Relationship to Taxpayer
How many months did the dependent stay with you in the current filing year?
Can anyone else claim dependent(s)?

Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Social Security Number
Relationship to Taxpayer
How many months did the dependent stay with you in the current filing year?
Can anyone else claim dependent(s)?
Income Information

Please provide any and all related personal and business earned income documentation to support you filing status, such as W2s, 1099s, business expense sheets, K1s, Photo ID, etc.
File Upload

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ALL information provided is true and accurate to the best of my knowledge. I also give permission to have this Income reported for tax purposes only by Millz Financial Group on my behalf, and hold them harmless if any information and/or documents, provided by the taxpayer, is found to be false.
Signature*

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This is a fill in the blanks field. Please add appropriate blank fields and text.
Last Name Please enter any 5 number of your choice except "00000" this 5 digit PIN acts as your electronic signature for your tax return. If you filed last year you may use the same pin or enter a new Pin. You are Authorizing your tax preparer to enter this pin into the E-file system on your behalf.
Should be Empty:

Basic Information