Client Intake form
Upload your info below you will be contacted in the order you receive it!
Tax Payers Name
*
First
Last Name
Email
*
example@example.com
Job Title
*
Social Security Number
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
EIN Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What tax years are you requesting to file?
*
2022
2023
2024
2025
What is your filing status?
*
Single
Married Filing jointly
Married filing separately
Head of household
Qualifying surviving spouse
Nonresident Alien
How did you hear about us
*
Facebook
Instagram
Tiktok
Flyer
Referral
Other
Are you self employed?
*
Yes
No
Name of the person who referred you! Enter their name and phone number if applicable
Who is your tax preparer?
*
Renata Johnson
Crachelle Lawson
LaToyia Douglas
Brandon McIntyre
Julian Shorter
Larry Randle
Robin Darnell
Ayanna Turl
Keioka Johnson
Chrishawn Keasley Jr
Any
Are you planning to buy a new home in the next 2 years?
*
Yes
No
Complete this section for spouse if you are married
If not you are unmarried you can skip this section
Spouse's Name
First Name
Last Name
Spouse's Email
example@example.com
Spouse's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Spouse's Social Security Number
Spouse's DOB
-
Month
-
Day
Year
Date
Spouse's job title
Spouse's EIN
Did you and your spouse live apart during the year?
*
YES
NO
N/A
What is your marital status as of December
*
Single (Not Married)
Married living with Spouse
Married not living with spouse
Did you pay over half the expenses of maintaining your residence for the entire year?
*
YES
NO
Did you support a child or family member for more than 6 months out of the year?
*
YES
NO
Are you on any Government Assistance
*
YES
NO
N/A
Are you disabled?
*
YES
NO
N/A
Is your dependent(s) disabled?
*
YES
NO
N/A
Are you applying for the Cash Advance?
*
YES
NO
N/A
How many dependents are you claiming?
Please Select
1
2
3
4
5
6+
Dependent 1 Name
First Name
Last Name
Dependent 1 Social Security Number
Dependent 1 DOB
-
Month
-
Day
Year
Date
Relationship
Please Select
Daughter
Son
Parent
Grandchild
Niece
Nephew
None
Aunt
Uncle
Sister
Brother
Other
Stepchild
Stepbrother
Stepsister
Half Brother
Foster Child (only if placed by agency)
Half Sister
Grandparent
Number of months lived with the tax payer?
Please Select
6
12
Dependent 2 Name
First Name
Last Name
Dependent 2 Social Security Number
Dependent 2 DOB
-
Month
-
Day
Year
Date
Relationship
Please Select
Daughter
Son
Parent
Grandchild
Niece
Nephew
None
Aunt
Uncle
Sister
Brother
Other
Stepchild
Stepbrother
Stepsister
Half Brother
Foster Child (only if placed by agency)
Half Sister
Grandparent
Number of months lived with the tax payer?
Please Select
6
12
Dependent 3 Name
First Name
Last Name
Dependent 3 Social Security Number
Dependent 3 DOB
-
Month
-
Day
Year
Date
Relationship
Please Select
Daughter
Son
Parent
Grandchild
Niece
Nephew
None
Aunt
Uncle
Sister
Brother
Other
Stepchild
Stepbrother
Stepsister
Half Brother
Foster Child (only if placed by agency)
Half Sister
Grandparent
Number of months lived with the tax payer?
Please Select
6
12
PLEASE LIST THE NAME DOB AND SSN OF ANY OTHER DEPENDENTS
Where is the other parent?
If you are not the biological parents, where are the biological parents, and do they have income?
If you are not the biological parent, do you have custody or mandate custody?
PLEASE UPLOAD dependents birth certificate and Social security cards.
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Are there any dependents in daycare? If yes, please upload the form you received from your daycare provider.
*
YES
NO
N/A
Upload a copy of the daycare form
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of
Can someone else claim you as a dependent?
*
YES
NO
Can someone else claim your dependents on their tax return?
*
YES
NO
PLEASE LIST YOUR IP PIN AND IP PIN OF YOUR DEPENDENTS (if applicable)
Taxpayer's and Dependent(s ) Social Security Card(s)
*
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of
Taxpayer's Driver's License
*
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of
Taxpayer's W-2/ 1099'S IF YOU haven't RECEIVED ALL YOUR W-2 PLEASE WAIT UNTIL YOU HAVE RECEIVED ALL YOUR W-2s. I do not file with your last check stub.
*
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of
Taxpayer's self employed income profit loss statement. if you do not have one will help you add your income and expenses and sign your P&L statement and ad it to your file
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of
Proof of Residency (Lease/Utility Bill)
*
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of
Last Year Tax Return if appiacplbe
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of
Did you have health insurance in 2025
*
YES
NO
Upload a your 1095-A form
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of
Was your insurance through your employer?
*
YES
NO
N/A
Have you ever been denied the Earned Tax Credit (EITC)?
*
YES
NO
Were you or any of your dependents in college in 2025?
*
YES
NO
Did you trade any Virtual Currency?
*
YES
NO
Were you enrolled in a Trade School or 4 year University?
*
YES
NO
Do you have a 1098-T Form for either you or your dependents?
*
YES
NO
How would you like to receive your refund?
Please Select
Direct Deposit
check (in office only)
Account type
Savings
Checking
Bank Name
Routing number
Account number
Would you like an advance Loan
*
YES
NO
Upload a your 1098-T form
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Drag and drop files here
Choose a file
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of
Are you interested in AUDIT PROTECTION?
*
YES
NO
Did You Receive The ERC
*
YES
NO
CLIENT NON PAYMENT/OFFSET CLAUSE
REBORN Financial & Business Services, strives to assist all of our clients in their tax needs, however I understand that situations arise. If your refund is offset by the IRS, student loans, child support or your check is mailed, you are still obligated to pay our company the fees associated with filing your tax return. By signing this agreement you acknowledge that if payment is not made in full with in 30 days legal actions will be sought to resolve payment.
Signature
ADDITIONAL SERVICES
While I specialize in tax preparation, our offerings go far beyond that! Below, you’ll find a list of additional services we provide.If any of these services catch your interest, let us know, and we’ll be happy to schedule a time to discuss them further..
ADDITIONAL SERVICES
Credit repair
Any additional Questions you would like to ask?
Electronic Filing Permission Disclosure
I am giving REBORN Financial & Business Services permission to prepare all forms related to my tax return; to apply for and secure RAC's and RAL's on my behalf; and sign all necessary forms and file my taxes electronically. I take full responsibility for the accuracy of this form and understand that REBORN Financial & Business Services and/or associated affiliates hold no responsibility for any misrepresentation or false claims.
Signature
*
Name
*
First Name
Last Name
Signing Date
*
-
Month
-
Day
Year
Date
Spouse's Signature
Spouse's Name
First Name
Last Name
Signing Date
*
-
Month
-
Day
Year
Date
*
Submit
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