Tax Preparation Client Intake Form
Taxpayer Information
Name
*
First
Middle
*
Last
Last four of SSN
*
Date of Birth
*
-
Month
-
Day
Year
Date
Occupation
*
Are you totally and permanently disabled?
*
Yes
No
Did you receive healthcare insurance from the Health Insurance Marketplace during any time of the tax year and received a 1095A (Health Insurance Market Statement)?
*
Yes
No
Not Applicable
Filing Status
*
Married Filing Separate
Single
Head of Household
Married Filing Joint
Qualifying Widower
Please select what state return are you requesting?
Federal
School
State
Local
City
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Do you live in any another state during the tax year?
*
Yes
No
Did you make any money in any other state during the tax year
*
Yes
No
Not applicable
Do you own a Business?
*
Yes
No
Are you a Full-Time Student?
*
Yes
No
Spouse Information
Name
First
Middle
Last
Last four of SSN
Date of Birth
-
Month
-
Day
Year
Date
Occupation
Are they totally and permanently disabled?
Yes
No
Did they receive healthcare insurance from the Health Insurance Marketplace during any time of the tax year and received a 1095A (Health Insurance Market Statement)?
Yes
No
Not Applicable
Phone Number
Please enter a valid phone number.
Email
example@example.com
Did they live in any another state during the tax year?
Yes
No
Did they make any money in any other state during the tax year
Yes
No
Not applicable
Do they own a Business?
Yes
No
Are they a full-time student?
Yes
No
Dependents
Do you have any dependants?
*
Please Select
Yes
No
If so how many?
Does your dependent(s) have tuition expenses?
*
Yes
No
Not applicable
Tax Related Questions
Employment Status
*
Employed
Unemployed
Self-employed
Retired
Do you have any expenses for child care?
*
Yes
No
Not applicable
Do you have energy star rated improvements to your home?
*
Windows
Doors
Furnace
Not Applicable
Other
Do you own a home?
*
Yes
No
Do you have documentation of the property taxes you paid ?
*
Yes
No
Not applicable
Did you sell any stock, crypto, bonds and received documents stating so (ex. Form 1099-B)?
*
Yes
No
Not applicable
Did you take money from your 401k or Retirement?
*
Yes
No
Not applicable
Did you pay mortgage interest and recieved documentation? (ex. Form 1098)?
Yes
No
Not applicable
Do you have real estate tax (ex. investment properties)?
*
Yes
No
Not applicable
Did you receive a federal tax refund last year?
*
Yes
No
Are you a victim of identity theft?
*
Yes
No
Expenses
Please complete the information for the current tax 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
Business income/Expenses (*only complete if filing in person)
Amount
Gross Sales
Office Expenses
Legal and Professional Services
Advertising
Car and truck Expenses
Commissions and Fees
Contract Labor
Depletion
Depreciation and section 179 Deduction
Employee Benefits Program
Insurance
Office Expenses
Pension
Rent
Repairs and Maintenance
supplies
Taxes
Travel
Utilities
Vehicle Expenses
Wadges
Total Expense
Additional comments
Acknowledgment & Signature
I confirmed that all information I entered here is accurate and true.
I allow Nexxt Level Tax Services to capture my sensitive data like personal id, government id, social security number (SSN), and other information.
I have read the terms and conditions and privacy policy of Nexxt Level Tax Services
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
Taxpayer Signature
*
Date Signed
-
Month
-
Day
Year
Date
Spouse Signature
Print
Submit
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