Eminent Tax Solutions Khyla Mingo Client Intake Form

Eminent Tax Solutions

Client Intake Form
Please choose your tax professional*

Khyla Mingo
How did you hear about us?*

FacebookInstagramReferralI'm A Returning Client
If someone referred, you please list the name.*
if no one referred you, type no one.

What is the best time to reach you?
What Tax Year Are you Filing?*

2024 (Current Tax Year)20232022202120202019
Did you file your previous year tax return?

YESNO
** IF YOU'RE LOOKING TO FILE MORE THAN 1 YEAR YOU HAVE TO DO SEPARATE INTAKE FORMS FOR EACH INDIVIDUAL TAX YEAR **

Taxpayer Information
Filing Status*

SingleHead Of HouseholdMarried Filing SeparateMarried Filing Joint
Taxpayer Name*

First NameLast Name
Taxpayer SSN*
example:000-00-0000
Taxpayer Date OF Birth*
example:12/31/2000
Taxpayer Phone Number*
Example: 222/326/4444
Taxpayer Email*
Example: yourname@yahoo.com
Taxpayer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Taxpayer Occupation*
Example: job title
Spouse Name
Spouse SSN
Spouse Date of Birth
Spouse Email
Spouse Occupation

Income Information
Which tax document(s) you received (if any) in 2024?*

W2Unemployment IncomeHousehold EmployeeSelf-EmployedAny 1099 formsUnemployment (1099-G)Other
Business income received.
Example:$15,000.00
Please list all your business expenses here along with amounts
Example: Advertisement $25.00

Dependent Information
Dependent #1 Name

First NameLast Name
Dependent #1 Date of Birth
Dependent #1 SSN#
Relationship to the dependent
Dependent #2 Name

First NameLast Name
Dependent #2 SSN#
Dependent #2 Date of Birth
Relationship to the dependent
Dependent #3 Name

First NameLast Name
Dependent #3 SSN#
Dependent #3 Date of Birth
Relationship to the dependent
Dependent #4 Name

First NameLast Name
Dependent #4 SSN#
Dependent #4 Date of Birth
Relationship to the dependent
If you have additional dependents, please list them here. Name, Date of Birth, SSNs and Relationship.
Do you have any disabled dependents ? If so please list them here along with their Name, Date of Birth, SSNS, and relationship.
Proof Dependent its Disabled

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How many months did the dependent(s) live in the same home as you? The child must have lived with you for more than half of the year.
Example: 12 Months
Will any of the dependents listed be carried or is intended to be carried on another taxpayers return?

YESNO
Did any of your dependents work?

YESNO
If yes, did they earn more than $4,300 ?

YESNO
Are any dependent(s) in daycare? If yes, please upload the form that was provided to you from the daycare provider.

YesNo
Please upload a copy of your daycare form here.

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Health Insurance Questionnaire
Did you have health insurance?*

YesNo
Did you or your dependent receive Medicaid?*

YesNo
Did you, your spouse or your dependent(s) receive health insurance through the Affordable Care Act/Marketplace(Obama Care)?*

YesNo
Please upload your marketplace insurance 1095-A form.

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Banking Information
Which type of account would you like your refund deposited into?*

CheckingSavings
Name Of Bank?*
Routing Number*
Account Number*
Are you interested in the cash advance loan up to $7,500.00 upon bank approval?*

YesNo
Upload Direct Deposit Form

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IRS Identity Pin Information
Were you issued an Identity Pin from the IRS*

YesNo
Please list your pin here.
Were any of your dependents issued an Identity Pin ? If so list their name and their Pin # here.

Documents to be uploaded. Please upload all the documents.
Taxpayer’s Drivers License/State ID/Passport *

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Taxpayer and dependent(s) Social Security card(s)*

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Taxpayer/Spouse/Dependent(s) Birth Certificates

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Proof of Residency: (Example): Leases,School Records,Vaccination Cards, Award Letters from Gov Assistance, etc. If filing Head of Household Lease Agreement/Utility Bill in your name is needed. *

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Taxpayer’s W-2s /1099’s/Unemployment(1099G)

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Self-Employment only! Expenses log,Summary of income etc

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Provide 1098-T, Child Care Forms, any other Government Documents, Alimony, Proof of Charitable Contributions, Taxes Paid, Medical/Dental Expenses

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Additional Documents

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Additional Documents

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Taxpayer’s Signature
By signing below, I hereby certify the information provided above is true and accurate to the best of my knowledge. As the taxpayer, I have been informed that claiming a dependent for EITC/CTC/AOTC/HOH can result in audit, fines, and other consequences if the information provided is incorrect. Eminent Tax Co. will prepare your individual tax return from the information you furnished to us. You, the taxpayer, are ultimately responsible for the preparation and filing of your tax return. I, the Taxpayer named above, have provided to Eminent Tax Co. the attached tax information and to the best of my knowledge this information is true, correct, and complete.
Date*

MonthDayYear
Date
Primary Taxpayers Signature *

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Taxpayers Spouse Signature if applicable

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Date

MonthDayYear
Date