Tax Preparation Client Intake Form

Tax Preparation Client Intake Form
Filing Status*

SingleHead of HouseholdMarried Filing SeparateMarried Filing JointQualifying WidowerIf Separated from Spouse has it been 6 months or more

Taxpayer Information
Name*

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
SSN
Are you a full-time student?

YesNo
Dynamic Dropdowns
Are you totally and permanently disabled?

YesNo
Are you legally blind?

YesNo
Is this individual dependent of other?

YesNo

Spouse Information
Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
SSN
Are you a full-time student?

YesNoIf you are a student do you have documentation to prove school status
Are you totally and permanently disabled?

YesNo
Are you legally blind?

YesNo
Is this individual dependent of other?

YesNo

Dependents

Enter your dependents here

	Name	SSN	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?

	Yes/No	Employer	Spouse Ins	Exchange/ Marketplace	Direct with Insurer	Medicare	Medicaid
Taxpayer
Spouse
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5

Expenses
Dependent Care/ Child care : Name , Tax ID # , Business address , Phone #
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
Dependent care

Total Expenses
Additional comments
Direct Deposit - Account Number
Direct Deposit - Routing Number

Acknowledgment & Signature
I confirm that all the information I have provided is accurate and true to the best of my knowledge. I give my explicit consent to Capital Maven Solutions to collect, store, and use my sensitive personal information, including but not limited to government-issued identification, Social Security Number (SSN), and other relevant details, solely for the purpose of preparing my tax return.

I have read, understood, and agree to the terms and conditions and privacy policy of Capital Maven Solutions. I acknowledge that my information will be handled in compliance with applicable data protection laws and industry standards to ensure its security and confidentiality.

Additionally, I acknowledge the following:

If my tax refund is garnished for any reason (e.g., outstanding debts or liens), I remain responsible for the agreed-upon tax preparation fee.

Any tax preparation fees and loan advances provided by the partnering bank will be auto-debited via ACH from the bank account I have provided. This will occur regardless of the status of my tax refund.

By signing below, I confirm that I have reviewed this acknowledgment and understand my rights and responsibilities, as well as those of Capital Maven Solutions, in preparing my tax return. I hereby authorize Capital Maven Solutions to prepare my tax return and submit it to the IRS and/or relevant state agencies. I understand that in the event of an IRS audit, I am responsible for providing the required substantial documentation to support my tax return.
Date Signed*

MonthDayYear
Date
Taxpayer Signature*

Clear
Date Signed

MonthDayYear
Date
Spouse Signature

Clear
File Upload/ Please upload your ID, children's Social Security Cards, W2's, 1099 NEC

Cancelof
Selfie *

Please take selfie to conform idenitification
Cancelof
Are you receiving government assistance ?
Section 8, Food stamps, Medicaid
Do you need any of the following services

LLC set upBusiness CreditLife InsuranceReal EstateBookkeepingCredit RestorationFuneral Plan AssitanceUnsecured LoansTax Debt Resolution
Email
example@example.com
Should be Empty: