CBT FINANCIAL SOLUTIONS INTAKE FORM

CBT FINANCIAL SOLUTIONS INTAKE FORM

2024-2025 Tax Client Intake Form

Thank you for choosing to file with CBT Financial Solutions ! Please complete the intake form to the best of your ability. If you have any additional questions please don’t hesitate to reach out.
How Did You Hear About Us?
Referral Name ?
Filing Status

Name

First NameLast Name
Date of Birth

MonthDayYear
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

CityState / Province

Postal / Zip Code
Occupation
Select All That Apply

Name

First NameLast Name
Date of Birth

MonthDayYear
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

CityState / Province

Postal / Zip Code
Occupation
Select All That Apply

Please Type Dependent (1)

First NameLast Name
Dependent (1) Date of Birth

MonthDayYear
Date
Social Security Number
Dependent (1) Relationship to Taxpayer
Select All That Apply
Please Type Dependent (2)

First NameLast Name
Dependent (2) Date of Birth

MonthDayYear
Date
Social Security Number
Dependent (2) Relationship to Taxpayer
Select All That Apply
Please Type Dependent (3)

First NameLast Name
Dependent (3) Date of Birth

MonthDayYear
Date
Social Security Number
Dependent (3) Relationship to Taxpayer
Select All That Apply
Please Type Dependent (4)

First NameLast Name
Dependent (4) Date of Birth

MonthDayYear
Date
Social Security Number
Dependent (4) Relationship to Taxpayer
Select All That Apply

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
Spouse
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5

Did you receive any W2's?
Upload your Pay Stub for ESTIMATE!!!

Cancelof
Please Upload All W2's

Cancelof
Upload Any Additional Income Documents

Cancelof

Business Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Type
Total Business Wages
Upload Any 1099's and Other Business Income Documents

Cancelof

Business Expenses

Rows	Amount
Advertising
Car and Truck Expenses
Commissions and Fees
Contract Labor
Depletion
Depreciation
Employee Benefit Program
Insurance
Interest
Mortgage
Legal and Professional Services
Office Expense
Pension and Profit Sharing Plans
Rent or Lease
Vehicles
Machinery and Equipment
Other Business Property
Repairs and Maintenance
Supplies
Taxes and Licenses
Travel
Meals
Wages
Other Expenses

Total Business Expense
Upload Profit & Loss Statement

Cancelof

General Expenses for Itemizing Deductions

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
Charitable Donations

Total Itemized Deductions
Additional comments
Please Upload Any Additional Documents

Cancelof
Thank you for choosing CBT Financial Solutions !

Customer support: 945-310-4169

Monday-Friday 9am-5pm
Should be Empty: