Tax Preparation Client Intake Form
Filing Status
Single
Head of Household
Married Filing Separate
Married Filing Joint
Qualifying Widower
Taxpayer Information
Are you a new client?
Yes
No
If new, list who referred you or how you heard about us?
If new, upload the previous years tax return
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Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Social Security Number
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
Please upload the front of your ID
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Occupation
Are you a full-time student?
Yes
No
Are you totally and permanently disabled?
Yes
No
Are you legally blind?
Yes
No
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
Please upload the front of your ID
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Occupation
Are they a full-time student?
Yes
No
Are they totally and permanently disabled?
Yes
No
Are they legally blind?
Yes
No
Are they your dependent?
Yes
No
Dependents
Enter your dependents here
Rows
First Name
Last Name
Birthdate
Relationship
Social Security Number
1
2
3
4
5
6
Upload Dependents social and birth records (birth records are optional)
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File Upload
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File Upload
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Have all dependents lived with you for at least six months?
Yes
No
Are you the biological or custodial parent?
Yes
No
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 Ins
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
If you received Healthcare through the Marketplace please upload form 1095-A
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Did you, your spouse, or any dependents receive any tuition or fees paid for higher learning?
Yes
No
If so, have you received a 1098-T form?
Yes
No
Tax Questions/ Income (W2's. 1099's. 1098-T, etc)
Employment Status
Employed
Unemployed
Self-employed
Please upload any income documents 1099s, W2s, etc
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Are you contributing to 401k or other pre-tax account?
Yes
No
Is this your first time opening a pre-tax account?
Yes
No
Please select what state return are you requesting?
State return
School
Local
RITA
Country returns
Does your dependent/s have tuition expenses?
Yes
No
Do you have any expenses for child care?
Yes
No
Did you/dependents receive Social Security Benefits?
Yes
No
Do you have energy star rated improvements to your home?
Windows
Doors
Furnace
Other
Are you currently renting?
Yes
No
What is the monthly rental amount?
How long have you lived at the property?
# of months
Do you have your own home?
Yes
No
Do you have documents that shows you paid for property taxes?
Yes
No
Did you sell any stock?
Yes
No
Did you take money from your 401?
Yes
No
Did you pay your vehicle tax?
Yes
No
Do you have mortgage interest?
Yes
No
Do you have real estate tax?
Yes
No
Did you receive a federal tax refund last year?
Yes
No
Are you a victim of identity theft?
Yes
No
Do you or any dependents have an IP PIN?
Yes
No
If Yes, List name of taxpayer/dependent and IP PIN below
Name and IP PIN
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
Would you like to be contacted by one of our licensed agents for:
Life Insurance
Dental, Vision, or Hearing Coverage
Final Expense Coverage
Hospital Coverage
Cancer or Heart Attack & Stroke Coverage
Health Insurance
None
Would you like to apply for a Tax Refund Advance?
Yes
No
Advance Amount (Skip if not requesting a Tax Advance)
Rows
Advance Amount
$500 (15.78 finance charge)
$1,000 ($31.56)
$1,500 ($47.34)
$2,000 ($63.12)
$3,000 ($94.68)
$4.500 ($142.02)
$6,000 ($189.36)
Refund Type (The way you receive your Advance is the way your refund will come)
Direct Deposit
Check
NetSpend Card
Account Number (If Choosing Direct Deposit)
Re-enter Account Number
Routing Number
Acknowledgment & Signature
I confirmed that all information I entered here is accurate and true.
I allow ABC Financial to capture my sensitive data like personal id, government id, and other information.
I have read the terms and conditions and privacy policy of ABC Financial.
By signing below, you acknowledge that you have read and understood your responsibilities and our responsibilities in doing this tax return.
Date Signed
-
Month
-
Day
Year
Date
Taxpayer Signature
Date Signed
-
Month
-
Day
Year
Date
Spouse Signature
Print
Submit
Submit
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