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CLIENT INTAKE FORM
Taxpayer Information
Tax Payers Name
*
First Name
Last Name
Taxpayer's Phone Number
*
Example: xxx-xxx-xxxx
Taxpayer's Job Title
Taxpayer's Date of Birth
*
Example: 01/01/2001
Taxpayer's SSN
*
Example: xxx-xx-xxxx
Taxpayer's Email Address
*
Spouse's Full Name
First Name
Spouse's SSN
Example: xxx-xx-xxxx
Name
First Name
Last Name
Spouse's Date of Birth
Example: 01/01/2001
Spouse's Phone Number
Example: xxx-xxx-xxxx
Spouse's Email Address
Example: example@example.com
Taxpayer's SSN
Example: xxx-xx-xxxx
Spouse's Job Title
Address
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you self employed?
*
Yes
No
Dependent Information
How many dependents are you claiming?
*
Please Select
0
1
2
3
4
5
Dependent #1
First Name
Last Name
Dependent #1 Date of Birth
01/01/2001
Dependent #1 SSN
What is Dependent #1's Relationship to you (son, daughter, etc.)?
How many months did Dependent #1 live with you in 2020? (If all year, enter 12)
Dependent #2
First Name
Last Name
Dependent #2 Date of Birth
Example: 01/01/2001
Dependent #2 SSN
Dependent #2s SSN
Example: xxx-xx-xxxx
How many months did Dependent #2 live with you in 2020? (If all year, enter 12)
What is Dependent #2's Relationship to you (son, daughter, etc.)?
Dependent #3
First Name
Last Name
Dependent #3's Date of Birth
01/01/2001
How many months did Dependent #3 live with you in 2020? (If all year, enter 12)
Dependent #3s SSN
Example: xxx-xx-xxxx
Dependent's #3 SSN
What is Dependent #3's Relationship to you (son, daughter, etc.)?
Banking Information
How would you like to receive your tax refund?
Check (Only available for in office visits)
Direct Deposit
Green Dot Card
Name of Bank
Which type of account would you like your refund deposited into?
Checking Account
Savings Account
Routing Number
Bank Account Number
Health Insurance Information
Did you have health insurance in 2024?
Yes
No
Was your insurance through Medicaid?
Yes
No
Did your dependents have health insurance for the entire year?
Yes
No
Not Appliable
Upload Taxpayer & Dependent(s)Insurance Documents
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Cash Advance
Are you interested in a Cash Advance up to $7,000?
Yes
No
IRS Identity PIN Information
Were you issued an Identity Pin from the IRS
Yes
No
Identity Pin if Applicable
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If you have questions, please type them here.
Documents to be Uploaded-Please upload ALL requested info
Taxpayer's Driver's License
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Taxpayer's and Dependent(s ) Social Security Card(s)
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Taxpayer's W-2/ 1099'S/
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Only as it applies: Self-Employment Expense Log, Summary if Income, Business License, Bank Statements, receipts, etc
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Dependent(s) Birth Certificate(s) (LONG FORM)
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Dependent(s) Proof of Residency (Lease/Report Card/ School Demographic)
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Healthcare Card for Taxpayer(s) and Dependent (s)
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