Max Refund Client Intake Form
Please fill out the following information to help us estimate your tax refund.
Full Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
SSN
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Filing Status
Single
Married Filing Jointly
Married Filing Separately
Head of Household
Qualifying Widow(er)
What is your job description?
W2 or Self Employed?
Total Income for the Year ($)
Federal Withholdings if any?
Are you a full time/part time student?
Do you have any dependents? If so how many?
Were you assigned an IP Pin (Identity Protection Pin) from the IRS?
If Yes, what is your IP Pin?
Have you received a 1095-A Form?
Please Select
Yes
No
Dependent 1
First Name
Last Name
DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
SSN
Dependent 2
First Name
Last Name
DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
SSN
Dependent 3
First Name
Last Name
DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
SSN
Who referred you?
Routing
Account number
Name of Institution
Other Income Sources (if any)
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