Intake Form

Today's Date:*

Date

Name:*

FirstLast

Date of Birth:*

Date

Social Security Number:*

Phone Number:*

Format: (000) 000-0000.

Email:*

example@example.com

Physical Address:*

Identity Protection PIN

Spouse Name: (if applicable)

First NameLast Name

Date of Birth:

Date

Email

example@example.com

Social Security Number:

Phone Number:

Mailing Address (IF DIFFERENT)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What was your marital status on December 31? *

YesNo

Filing Status Last Year

YesNo

Number of dependents, if any.

Dependent Name 1:

First NameLast Name

Dependent Date of Birth:

Date

Dependent Social Security Number:

Relationship:

Identity Protection PIN

Dependent Name 2:

First NameLast Name

Dependent Date of Birth:

Date

Dependent Social Security Number:

Relationship:

Identity Protection PIN

Dependent Name 3:

First NameLast Name

Dependent Date of Birth:

Date

Dependent Social Security Number:

Relationship:

Identity Protection PIN

NoYes

YesNo

NoYes

YesNo

Business Name:

Type of Business:

Business EIN:

Business Email:

example@example.com

Business Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Business Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What Month/Year Did You Start Your Business?

Date

YesNo

How did you calculate your self employment income and expenses? (Receipts, bank statements, invoices, etc)

Total Income:

Total Expenses:

Paper CheckDirect DepositNetSpend CardDirect Mail Check From IRS

Direct Deposit Bank Name:

Direct Deposit Routing Number:

Direct Deposit Account Number:

CheckingSaving

Out of Pocket (Flat Rate)Pay By Refund (Additional banking fees applied)

Payment Plan 1 (Split Payment Into Two Payments)Payment Plan 2 (Split Payments Into Three Payments)

NoYes

YesNo

Tax Preparation Current Rates Starting at:

Individual Tax Return $300&#13;&#10;Individual Tax Return (more than 3 W2s) $350&#13;&#10;Joint Individual Tax Return	$400&#13;&#10;Joint Individual Tax Return (more than 3 W2s) $450&#13;&#10;Business Tax Return (Single) $400&#13;&#10;Business Tax Return (Complexity) $550&#13;&#10;Joint Business Tax Return $500&#13;&#10;Joint Business Tax Return (Complexity)  $650&#13;&#10;&#13;&#10;Additional Add-On Starting at: &#13;&#10;Additional Schedule Forms $150&#13;&#10;Previous Year Filing $300&#13;&#10;Amendment $550&#13;&#10;Audit Protection (optional) $74.95&#13;&#10;Identity Theft (optional) $69.99&#13;&#10;Itemized Deductions (with Receipts) $250&#13;&#10;Check Printing (Office-Issued Refund Check) $15&#13;&#10;Tax Return Print-Out Copy (Per Request) $15&#13;&#10;NetSpend Card Shipping $15&#13;&#10;Mailed Tax Return (via USPS) $15

I hereby affirm and declare under oath that the information I have provided on this intake form for KAJN Tax Services is accurate, complete, and true to the best of my knowledge.

I understand and acknowledge that:

Any false, misleading, or incomplete information may result in penalties, legal consequences, or rejection of my submission.

It is my responsibility to ensure that all information I submit to KAJN Tax Services is correct, complete, and current.

By signing below, I certify that I have read, understood, and agreed to the statements above.

Signature*