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?

Can you be claimed as a dependent on someone else take return?

Did you and your spouse live together all year?

Did you pay more than 50% of household expenses? (rent, mortgage, utilities, food, insurance, repairs, etc.)

Filing Status Last Year

Did you have marketplace health insurance? If Yes; Please include form 1095 A. If No, what insurance did you have? (Employer, Private, Medicaid/Medicare)

No

Type of Income

Did you report any and ALL income earned during 2025 tax year?

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

Did your dependent live with you all year? If Yes, how many months?

Yes

Is your dependent under age 17 at end of tax year 2025?

Did the child receive SSI or disability?

Are you the custodial/guardian parent?

Can any of your dependents be claimed by someone else?

Are you and/or your dependent a college student? If yes, what's the name of the school?

Yes

If yes to question above; Does college student have a 1098T form?

Are you self-employed?

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

Do you have proof of self-employment income/expenses in the event of an audit?

Do you make quarterly payments on your self employment income?

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

Total Income:

Total Expenses:

Refund Method:

Direct Deposit Bank Name:

Direct Deposit Routing Number:

Direct Deposit Account Number:

Direct Deposit Account Type

Payment Type:

Payment Plan Option: 50% OF THE BALANCE IS DUE UPFRONT, AND THE NEXT PAYMENT IS DUE TWO WEEKS FOLLOWING! Your return will NOT be submitted until the balance is paid in full!!!!!

Has the IRS ever taken or offset your refund? (If yes, what year?)

Yes

Do you owe child support?

Did you move during the year?

Did you receive any IRS letters?

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