Tax Preparation Client Intake Form

Tax Preparation Client Intake Form
Filing Status (choose only one)*

SingleHead of HouseholdMarried Filing SeparateMarried Filing JointQualifying Widower

Spouse Information
Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Occupation
Are they a full-time student?

YesNo
Are they totally and permanently disabled?

YesNo
Are they legally blind?

YesNo
Are they your dependent?

YesNo

Dependents

Enter your dependents here

	Name	Date of Birth	Relationship	Social Security Number
1
2
3
4
5
6

Did you, your spouse, or your dependents have health insurance within 12 months last year? If yes, who covers for it?*

	Name	SSN	Date of Birth	Relationship	NO Insurance
Taxpayer
Spouse
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5

Expenses
Please fill-in the information within the current year only.
DID YOU HAVE MARKET PLACE INSURANCE (Government assisted, like Obama Care?) If YES, I WILL NEED A COPY OF YOUR 1095-A FORM THAT SHOULD HAVE BEEN MAILED TO YOU. WITHOUT THIS, YOUR RETURN WILL BE REJECTED.*

YesNo
1095-A Upload

Cancelof

General Expenses

	Amount
Medical Expenses
Dental Expenses
Insurance Premiums paid
Long Term Care Premiums
Prescription Drugs and Medications
Home Mortgage
Investment Interest
Cash Contributions
Non-Cash Contributions
Unreimbursed Business Expenses
Union Dues
Tax Preparation Fees
Investment Expenses

Total Expenses
Additional comments

Acknowledgment & Signature
- I confirmed that all information I entered here is accurate and true.
- I allow DC Tax Firm to capture my sensitive data like personal id, government id, and other information.
- I have read the terms and conditions and privacy policy of DC Tax Firm.
- By signing below, you acknowledge that you have read and understood your responsibilities and our responsibilities in doing this tax return.
DEPENDENT DUE DILIGENCE

Your child/dependent must pass all of the following criteria to be your qualifying child for ETIC:

RELATIONSHIP
- Your son, daughter, adopted child, step-child, foster child or a decendent of any of them such as your grandchild.
- Brother, sister, half-brother, half-sister, step-brother, step-sister or a decendent of any of them such as a niece or nephew.
AGE
- At the end of the filing year, your child was younger than you (or your spouse if filing a joint return) and younger than 19.
- At the end of the filing year, your child was younger than you (or your spouse if filing a joint return) younger than 24 and a full-time student.
- At the end of the filing year, your child was any age and permanently and totally disabled.
RESIDENCY
- Child must live with you ( or your spouse if you file a joint return) in The United States for more than half of the year.
JOINT RETURN
- The child can not file a joint return for the tax year unless the child and the child's spouse did not have a seperate filing requirement and filed the joint return only to claim a return.
By listing dependents, you agree that you have the legal right to claim each dependent due to The IRS.

By signing the form, I give DC Tax Firm permission to file my tax return.
Date Signed*

MonthDayYear
Date
Taxpayer Signature*

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Date Signed

MonthDayYear
Date
Spouse Signature

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