Client Intake Form
Theresa Harper in partnership with J.Well & Company Tax Preparation Services.
How did you hear about us?
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
Birthdate:
-
Month
-
Day
Year
Date
Social Security Number:
Occupation Title:
Spouse Full Name:
First Name
Last Name
Spouse Email:
example@example.com
Spouse Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Spouse Occupation:
Dependent 1 Name, Dependent 1 Social Security #, Dependent 1 Date of Birth, Dependent 1 Relationship:
Dependent 2 Name, Dependent 2 Social Security #, Dependent 2 Date of Birth, Dependent 2 Relationship:
Dependent 3 Name, Dependent 3 Social Security #, Dependent 3 Date of Birth, Dependent 3 Relationship:
Dependent 4 Name, Dependent 4 Social Security #, Dependent 4 Date of Birth, Dependent 4 Relationship:
If any of your dependents are disabled list them here:
Are you disabled?
Yes
No
Select your filing status
Single
Head of household
Married Filing Seperate
Married Filing Joint
Widowed
Were you audited by the IRS last year?
Yes
No
Did you receive marketplace health insurance??
Yes
No
Do you have an IP PIN?
Yes
No
Do you have any credits that were disallowed or reduced?
Yes
No
If you have any credits that were disallowed or reduced, please enter here.
2024 Identity Protection Pin & who it was issued to.
Please upload proof of residency for each dependency.
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If you are filing head of Houshold, what documents will you provide for proof of head of household?
utility bill
rental lease
rent receipts
mortgage interest payments
Property tax payments
Other
Please upload proof of head of household, if applicable.
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Please upload your drivers license/ID for you & your spouse (if applicable)
*
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Social Security Cards for Each Individual on Return
*
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Please answers only if it applies to you.
If your address is different than the one thats on your government ID or drivers license, please indicate the reason why
If applicable, please indicate why you are claiming a dependent that is not related to you. What are the circumstances that you have supported this dependent for at least 6 months of 2023. Please outline the support you have provided to this dependent.
Are all of the dependents being claimed related to the taxpayer by birth or bloodline? If not, please identify which child is not related to you?
Please answer if applicable, if your last name is different than your dependent's last names, that you are filing, what is the reason why? Please indicate the reason why there is a difference in the last names between you and your dependents.
Please answer, only if applicable: If your income is at or below $13,000.00 & you have 2 or more children, how are you able to maintain the household. For example, did you receive government assistance, as such as: section 8, public housing, SNAP benefits, or other.
If you are the father of the child and claiming the child. Please indicate the reason why the child is living with you and not the mother. Please outline the support you have provided to the child.
Federal Financial Documents
Financial Tax Documents (W2,1099,Unemployment,ect)
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If you received a 1099G form for unemployment, please upload it here.
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If you received a 1098T form for school, please upload here.
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Do you need assistance with organizing your/side hustle business income & expenses?
Yes
No
Did you have a business in 2024? Includes 1099s, or side business. Ex. hair braiding, hair stylist, baby sitting, uber, lyft, door dashing, & etc. If so, what is the name & nature of your business or side business. If you don't have a name, you can bypass the name.
Did you purchase a vehicle recently?
Yes
No
If yes, please list the year make and model of the vehicle.
Other Documents
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Do you want to apply for cash advance up to $7k. No credit check. You will be notified if you are approved within 24 hours.
Yes
No
How do you want to receive your refund?
Printed Check
Direct Deposit
Go2Bank Prepaid Debit Card
If you selected direct deposit, please enter your information below
Bank Name
Account Number
Confirm Account Number
Routing Number
Confirm Routing Number
JWells & Company Business Consulting, LLC
will prepare your 2024 individual tax return from the information you furnished to us. You, the taxpayer, are ultimately responsible for the preparation and filing of your tax return. I, the Taxpayer named above, have provided to JWells & Company Business Consulting, LLC the attached tax information and to the best of my knowledge this information is true, correct, and complete.
Tax Form Abandonment/Ach Agreement
Here at JWells & Co. Unfulfilled Tax Quotes will result in a $150 Service Fee - If the client decides to file their tax return elsewhere. This fee will be processed through our payment merchant until fulfilled. If the client files their taxes with us, they will be charged the regular tax filing fees processed from the tax return per usual. No upfront fees - all fees will be cured from the tax return unless otherwise agreed due to intricate tax situations. Thank you - JWells & Co.
Tax Payer Signature ( Must be legible)
Spouse Signature
Notes (anything you think we need to know :)
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