Client Intake Form
Filing Status
Single
Head of Household
Married Filing Separate
Married Filing Joint
Qualifying Widower
Referral Information
Are you a new or existing customer of Door to Door Taxes?
New
Existing
How did you hear about us?
Social Media
Word of mouth/business card
We reward for referrals! If you were referred by someone, please provide their name!
Taxpayer Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Are you a full-time student?
Yes
No
Are you totally and permanently disabled?
Yes
No
Are you legally blind?
Yes
No
Please upload all relevant documents (W-2, 1099, Proof of Residence, etc)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Spouse Information
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Are they a full-time student?
Yes
No
Are they totally and permanently disabled?
Yes
No
Are they legally blind?
Yes
No
Dependents
Enter your dependents here
Rows
Name
Date of Birth
Relationship
1
2
3
4
5
6
Does you, your spouse, and your dependents have health insurance within 12 months last year? If yes, who covers for it?
Rows
Yes/No
Employer
Spouse Insurance
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
Please upload all relevant dependent information
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Tax Related Questions
Employment Status
Employed
Unemployed
Self-employed
Are you contributing to 401k or other pre-tax account?
Yes
No
Do your dependents have tuition expenses?
Yes
No
Do you have any expenses for child care?
Yes
No
Do you have your own home?
Yes
No
Do you have energy star rated improvements to your home?
Windows
Doors
Furnace
Other
Do you have documents that shows you paid for property taxes?
Yes
No
Did you sell any digital assets (bitcoin, etc)
Yes
No
Do you have mortgage interest?
Yes
No
Do you have real estate tax?
Yes
No
Did you receive a federal tax last year?
Yes
No
Are you a victim of identity theft?
Yes
No
Expenses
Please fill-up the information within the current year only.
General Expenses
Rows
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
Additional comments
Acknowledgment & Signature
I consent to Door to Door Taxes using my personal information, such as my identification details and any other necessary information, solely for the purpose of estimating and processing my tax return. This authorization is limited to the specific tasks related to the completion of my tax filing
By signing below, you affirm that all information provided is accurate and complete. We are not responsible for any delays resulting from inaccurate or incomplete information.
Date Signed
-
Month
-
Day
Year
Date
Taxpayer Signature
Date Signed
-
Month
-
Day
Year
Date
Spouse Signature
Print
Submit
Submit
Should be Empty: