Tax Preparation Client Intake Form
Filing Status
Single
Head of Household
Married Filing Separate
Married Filing Joint
Qualifying Widower
Taxpayer 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
What county do you live in?
Occupation
SSN
Are you a U.S. Citizen?
Yes
No
Do you have an identity protection pin issued from the IRS?
Are you an active member in the military?
Yes
No
Did you go to school full-time or at least half of the year? *additional documentation required prior to return submission
Yes
No
Did you owe any outstanding debts such as federal debts, child support, student loans, etc? *If you are unsure, please call 1-800-304-3107 to find out if your return will be offset
Yes
No
Are you filing self-employment or adding self-employment to your return?
Yes
No
Are you legally blind?
Yes
No
Are you totally and permanently disabled?
Yes
No
Are you adding a spouse to your return?
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
Occupation
SSN
Are you an active member in the military?
Yes
No
Did you go to school full-time or at least half of the year? *additional documentation required prior to return submission
Yes
No
Do you have an identity protection pin issued from the IRS?
Are you filing a self employment return or adding self-employment to your return?
Yes
No
Did you owe any outstanding debts such as federal debts, child support, student loans, etc? *If you are unsure, please call 1-800-304-3107 to find out if your return will be offset
Yes
No
Are you totally and permanently disabled?
Yes
No
Are you legally blind?
Yes
No
Can you be carried by someone else?
Yes
No
Dependents
Enter your dependents here
Rows
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?
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
Tax Related Questions
Employment Status
Employed
Unemployed
Self-employed
Are you contributing to 401k or other pre-tax account?
Yes
No
Does your dependents have tuition related expenses?
Yes
No
Do you have any expenses for child care?
Yes
No
Do you have energy star rated improvements to your home?
Windows
Doors
Furnace
Other
Are you currently renting?
Yes
No
Do you have your own home?
Yes
No
Do you have documents that show you paid property taxes?
Yes
No
Did you sell any stock?
Yes
No
Did you take money from your 401K?
Yes
No
Did you pay for 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 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
How would you like to receive your tax refund?
Check (printed by office)
Direct Deposit
Bank Name:
Account Number
Routing Number
Promo Code:
Please upload a copy of your W2, 1099 form(s), 1098T, 1099-G, and any other documentation to file your tax return.
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Please upload your identification documents: Driver's license, state-issued ID, social security card (s) for self and dependents, birth certificate for dependents, lease agreement or utility bill for filing Head of household
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Please upload the following signed documents: Consent to Use, Consent to Disclose These forms are on the website under attachments.
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Additional Comments
Acknowledgment & Signature
I confirmed that all information I entered here is accurate and true.
I allow Hierarchy Financial Consulting to capture my sensitive data like personal id, government id, social security number (SSN), and other information.
I have read the terms and conditions and privacy policy of Hierarchy Financial Consulting.
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
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Submit
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