Client Intake Form
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What is the best day & time to contact you?
Did you file a 2023 tax return?
Yes
No
Unsure
Taxpayer Information
Tax Payers Name
*
First Name
Last Name
Taxpayer's Phone Number
*
Please enter a valid phone number.
Taxpayer's Job Title
Taxpayer's Date of Birth
*
/
Month
/
Day
Year
Date
Taxpayer's SSN
*
Taxpayer's Email Address
*
example@example.com
Spouse's Full Name
First Name
Last Name
Spouse's SSN
Spouse's Date of Birth
-
Month
-
Day
Year
Date
Spouse's Phone Number
Please enter a valid phone number.
Spouse's Email Address
example@example.com
Spouse's Job Title
Address
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Due Diligence Questions
Are you self employed?
*
Yes
No
Did you and your spouse live apart during the year?
*
Yes
No
Not Applicable
If you own your home, have you received form 1098 from your mortgage lender?
Yes
No
What is your marital status as of December?
*
Single (Not Married)
Married living with Spouse
Married not living with spouse
Did you pay over half the expenses of maintaining your residence for the entire year?
*
Yes
No
If yes, did you live together at any time after June 30, 2024
*
Yes
No
Not Applicable
Have you ever been denied the Earned Tax Credit (EITC)?
Yes
No
Are you on any Government Assistance?
*
Yes
No
Not Applicable
Can someone else claim you as a dependent?
*
Yes
No
Dependent Information
How many dependents are you claiming?
*
Enter your dependents here
Name
Date of Birth
Relationship
1
2
3
4
5
6
Dependent #1
First Name
Last Name
Dependent #1 Date of Birth
-
Month
-
Day
Year
Date
Dependent #1 SSN
How many months did Dependent #1 live with you in 2024 ? ( If all year, enter 12)
ex:12
What is Dependent #1's Relationship to you (son, daughter, etc.)?
Dependent #2
First Name
Last Name
Dependent #2 Date of Birth
-
Month
-
Day
Year
Date
Dependent #2 SSN
How many months did Dependent #2 live with you in 2024 ? ( If all year, enter 12)
ex:12
What is Dependent #2's Relationship to you (son, daughter, etc.)?
Dependent #3
First Name
Last Name
Dependent #3 Date of Birth
-
Month
-
Day
Year
Date
Dependent #3 SSN
How many months did Dependent #3 live with you in 2024 ? ( If all year, enter 12)
ex:12
What is Dependent #3's Relationship to you (son, daughter, etc.)?
Are there any dependents in daycare? If yes, please upload the form you received from your daycare provider.
Yes
No
Upload a copy of your daycare form here.
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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
Does you, your spouse, and your dependents have health insurance within 12 months last year? If yes, who covers for it?
Yes/No
Employer
Spouse Ins
Exchange/ Marketplace
Direct with Insurer
Medicare
Medicaid
Taxpayer
Yes
No
Spouse
Yes
No
Dependent 1
Yes
No
Dependent 2
Yes
No
Dependent 3
Yes
No
Dependent 4
Yes
No
Dependent 5
Yes
No
Upload Taxpayer & Dependent(s)Insurance Documents
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College Credit
Were you or any of your dependents in college in 2024 ?
Yes
No
Did you or your spouse make payments on your student loans in 2024?
Yes
No
Do you have a 1098-T Form for either you or your dependents?
Yes
No
If you have a 1098-T form, upload it here.
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Virtual Currency
Did you trade any Virtual Currency
Yes
No
Misc Services
Do you currently owe any debt to any federal agencies such as student loans, city tickets, child support, food stamps etc ?
Yes
No
Not Sure
Has the irs ever denied you from claiming a tax credit before ?
Yes
No
Child tax credit
Earned income credit
American opportunity (school credit)
Did you receive any unemployment benefits in 2024?
Yes
No
Have you ever been audited by the irs before ?
Yes
No
IRS Identity PIN Information
Were you issued an Identity Pin from the IRS
Yes
No
Identity Pin if Applicable
Expenses
Please fill-up the information within the current year only.
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
Need to ask a Question??
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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Healthcare Card for Taxpayer(s) and Dependent (s)
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Dependent(s) Proof of Residency (Lease/Report Card/ School Demographic)
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Acknowledgment & Signature
I confirmed that all information I entered here is accurate and true.
I allow Yemaya's Tax and Financial Services LLC to capture my sensitive data like personal id, government id, and other information.
I have read the terms and conditions and privacy policy of Yemaya's Tax and Financial Services LLC.
By signing below, you acknowledge that you have read and understood your responsibilities and our responsibilities in doing this tax return.
Date Signed
-
Month
-
Day
Year
Date
Primary Taxpayer's Signature
Date Signed
-
Month
-
Day
Year
Date
Taxpayer's Spouse Signature (If no spouse, leave blank)
Submit
Submit
Should be Empty: