Tax Preparation Client Intake Form

Tax Preparation Client Intake Form
Filing Status

SingleHead of HouseholdMarried Filing SeparateMarried Filing JointQualifying Widower

Enter your dependents here

Does you, your spouse, and your dependents have health insurance within 12 months last year? If yes, who covers for it?

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
Identity Verification Required

Government -Issued ID is required
State Issuing Driver's License *
Drivers License Number*
Driver's License Expiration Date*

MonthDayYear
Date
Spouse's Driver's License Number
State Issuing Driver's License
Driver's License Expiration Date

MonthDayYear
Date
Direct deposit/ Refund Deposit Information.Please provide your banking information below for direct deposit purposes. Information is encrypted and secure.
Bank Name
Routing Number*
Account Number*
Account Type*

Acknowledgment & Signature
- I confirmed that all information I entered here is accurate and true.
- I allow The Tax Doc to capture my sensitive data like personal id, government id, and other information.
- I have read the terms and conditions and privacy policy of The Tax Doc.
- By signing below, you acknowledge that you have read and understood your responsibilities and our responsibilities in doing this tax return.
- I authorize The Tax Doc to use banking information I have Provided for the purpose of processing my direct deposit.
Date Signed*

MonthDayYear
Date
Taxpayer Signature*

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Date Signed

MonthDayYear
Date
Spouse Signature

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Should be Empty:

Identity Verification Required