Himadri Das Client Intake Form

CLIENT INTAKE FORM
How did you hear about us?

FacebookInstagramReferralPrevious Client
Are you interested in Bookkeeping?

YesNo
If someone referred you, please type his or her name here.
TaxPayer's Name*

First NameLast Name
Taxpayer's Phone Number*
Example: xxx-xxx-xxxx
Taxpayer's Job Title
Taxpayer's Date of Birth*
Example: mm/dd/yyyy
Taxpayer's SSN*
Example: xxx-xx-xxxx
Taxpayer's Email Address
example@example.com
Spouse's Full Name*
First Name
Spouse's SSN*
Example: xxx-xx-xxxx
Spouce's Date of Birth*
Example: mm/dd/yyyy
Spouse's Phone Number
Example: xxx-xxx-xxxx
Spouse's Job Title
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you self employed?

YesNo
Did you and your spouse live together during the whole year?*

YesNoNot Applicable
What is your marital status as of December*

Single (Not Married)Married living with SpouseMarried not living with spouse
Did you pay over half the expenses maintaining your residence for the entire year?*

YesNo
Did you support a child or family member for more than 6 months out of the year?

YesNo
Are you on any Government Assistance

YesNoNot Applicable
How many dependents are you claiming?
Dependent #1

First NameLast Name
Dependent #1 Date of Birth
mm/dd/yyyy
Dependent #1 SSN
What is Dependent #1's Relationship to you (son, daughter, etc.)?
How many months did Dependent #1 live with you this year? (If all year, enter 12)
Are there any dependents in daycare? If Daycare, Then upload the form you received from your daycare provider.

YesNo
Upload a copy of your daycare form here.

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How would you like to receive your tax refund?*

Check (Only available for in office visits)Direct DepositDebit cardOther
Which type of account would you like your refund deposited into?*

Checking AccountSavings AccountOther
Name of Bank*
Routing Number *
Bank Account Number *
Can someone else claim you as a dependent?*

YesNo
Did you have health insurance during the whole year?*

YesNo
Did you have health insurance for the entire year?*

YesNo
Who was your insurance cover through this year??
Was YOUR DEPENDENTS' insurance through your employer?

YesNoNot Applicable
Who was your Dependents insured with this year??
Was your insurance through your employer?

YesNo
Have you ever been denied the Earned Tax Credit (EITC)?*

YesNo
Were you or any of your dependents in college this year??

YesNo
Did you trade any Virtual Currency

YesNo
Are you interested in AUDIT PROTECTION?

YesNo
Do you have a 1098-T Form for either you or your dependents?

YesNo
Upload Taxpayer & Dependent(s) Insurance Documents

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If you have a 1098-T form, upload it here.

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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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Spouse's W-2/ 1099'S

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Attention Business Owners
I have attached or included with this form all W2s, 1099s, a copy of my identification and social security card if available as well as all other documents that are relevant to preparing my taxes.

I understand and agree that I will receive an email, call or text notification within 24 hours notifying me of my expected Federal & State Tax Outcome or an update if not completed.
Primary Taxpayer's Signature*

Clear
Date*

MonthDayYear
Spouse's Signature (If no spouse, leave blank)

Clear
Date

MonthDayYear
Should be Empty:

CLIENT INTAKE FORM

Attention Business Owners