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Laquerian Moses
Michael Chatman
Latonya Brooks
Jasmine Johnson
Tameika Holmes
Aleyni Brown
Jackie Johnson
Jacki Rasco
Taylor Cotton
Sallie Saulsberry
Markita Qualls
Toney Foster
JQ Johnson
Damion Bethea
Linda Wright
Elizabeth Seamans
Keetron Rasco
Shirley Henderson
Brittany White
Aariance Marles
Jimmie Marbley
John Meneweather
Josette Johnson
Johnathan Ashley
Tiffonie Johnson
1017 Client Intake Form
Thank you for choosing us!
Filing Status
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Single
Head of Household
Married Filing Together
Married Filing Separately
Name
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First Name
Last Name
DOB
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-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Were you previously issued an Identity Protection PIN (IP PIN) by the IRS?
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Yes
No
Was the taxpayer affected by a natural disaster in 2025?
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Yes
No
Can another taxpayer claim you as a dependent on their tax return?
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Yes
No
Will you be filing a tax return with your Spouse?
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Yes
No
Do you need to file Previous years Taxes ?
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Yes
No
Did the taxpayer work in 2025?
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Yes
No
Do you have any dependents you will claim on your 2025 tax return?
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Yes
No
Did you, your spouse or any dependents attend college in 2025?
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Yes
No
Did you, your spouse or dependents receive health insurance through the Marketplace in 2025 and receive Form 1095-A?
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Yes
No
Did you or your spouse receive unemployment benefits in 2025?
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Yes
No
Do you rent or own your current residence?
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Yes
No
Did you or your spouse make payments on your student loans in 2025?
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Yes
No
Did you or your spouse pay any medical or dental expenses in 2025? (this does not include insurance premiums)
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Yes
No
Do you or your spouse own a rental property?
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Yes
No
Did you or your spouse have any gambling winnings in 2025?
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Yes
No
Did you or your spouse sell, acquire, send, receive or exchange any virtual currency?
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Yes
No
Did you or your spouse receive social secuirty benefits in 2025?
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Yes
No
Did you or your spouse make any charitable contributions in 2025? (Goodwill, Salvation Army, Church etc.)?
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Yes
No
Did you or your spouse make any charitable cash contributions of $300 or more in 2025?
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Yes
No
Did you or your spouse purchase an electric vehicle in 2025?
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Yes
No
Did you or your spouse purchase a vehicle in 2025?
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Yes
No
Did you or your spouse withdraw money from their 401k in 2025?
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Yes
No
Did you or your spouse receive any earnings from interest or dividends in 2025?
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Yes
No
Are you self-employed, own a full time or side business or 1099 contractor?
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Yes
No
Do you or your spouse owe debt to any Government Agency; such as IRS, Student Loans, Child Support etc?
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Yes
No
Do you plan to purchase a home within the next one or two years?
*
Please Select
Yes
No
Would you like the fees deducted from your refund?
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Please Select
Yes
No
Are you interested in securing your family with a Life Insurance Policy ?
*
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Yes
No
Would you like your tax refund direct deposited into your bank account? If so, please complete bank information below:
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Yes
No
Would you like to receive a text message when your refund is funded?
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Yes
No
Do you and your spouse understand and agree to the fees for 1017 Tax Consulants preparing your Federal/ State Income tax return?
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Yes
No
Taxpayer Signature
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