Xcelent Taxes Client Intake Form

Assigned Tax Preparer

Disclaimer:
By completing this form, you acknowledge that Xcelent Taxes will use the information provided to prepare your tax return or perform other tax-related services. It is your responsibility to ensure that all information submitted is accurate and complete. Xcelent Taxes is not liable for errors or omissions resulting from inaccurate or incomplete information provided by the client.

Marital Status

Taxpayer Name

First NameLast Name

Taxpayer Date of Birth

Date

SOCIAL SECURITY NUMBER

Taxpayer Occupation

Check all that apply:

Spouse Name

First NameLast Name

Spouse Date of Birth

Date

Spouse Occupation

Check all that apply:

Taxpayer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Taxpayer Phone Number

Format: (000) 000-0000.

Spouse Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Spouse Phone Number

Format: (000) 000-0000.

Taxpayer Email Address

example@example.com

Spouse Email Address

example@example.com

Please upload valid IDs social security cards and any additional tax documents below:

DEPENDENTS INFORMATION

Rows	FULL DEPENDENT NAME	DATE OF BIRTH	# OF MONTHS DEPENDENT RESIDE WITH TAXPAYER
DEPENDENT 1
DEPENDENT 2
DEPENDENT 3
DEPENDENT 4
DEPENDENT 5

Do you have a "Special Needs" child?

Enter the aggregate amount of advance child tax credit payments you (and your spouse if filing jointly) received.

CHILD TAX CREDIT PAYMENT AMOUNT

Enter the amount from IRS Notice 1444-C, Your Economic Impact Payment.

ECONOMIC IMPACT PAYMENT (THIRD STIMULUS AMOUNT)

DID YOU RECEIVED HEALTH COVERAGE (INSURANCE) THROUGH YOUR STATE MARKETPLACE OR HEALTHCARE.GOV? IF SO, PLEASE UPLOAD YOUR FORM 1095A

Please upload 1095A

Wages and Salaries (Attach W-2's)

Interest Income (Attach 1099's) (List and identify as non-taxable Interest Income)

Unemployment Compensation Received (FORM 1099G) PLEASE UPLOAD FORM BELOW:

File Upload

Were you, your spouse, or any dependent registered in college? Do you have a form 1098T?

File Upload

If you would like your tax refund (if any) deposited directly into your bank

Bank Name

Your Account Number

Bank Routing Number

Rental & Royalty Income and Expense (Rental Property)

Property Type

Number of days rented

Number of days used personally

Property is owned by

Percentage ownership of not 100%: Please indicate if income and expenses below are listed at 100% or your percentage

Percentage ownership of not 100%

Did you live in part of the rental property?

If yes, what percentage did you occupy as a tenant?

Business Income & Expenses (Sole Proprietorship, LLC)

Owner Name

First NameLast Name

Business name

Employer ID number

Business Type

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employer ID number (EIN)

Do you use any part of your home regularly and exclusively for business?

Estimated percentage of time spent in home office compared to total time spent in this business

Estimated of time in home office compared to total time in this business

Description of work done in home office

Description of work done outside of work office

Total area of home

Total area of home used regularly for business

Does anyone listed on the Tax Return have an Identity Pin? If so, please list the name and Identity Pin below:

Assigned Tax Preparer

Acknowledgment StatementI hereby certify that the information provided in this form is true and accurate to the best of my knowledge. I understand that Xcelent Taxes is not liable for any errors or omissions resulting from inaccurate or incomplete information submitted by me.By submitting this form, I acknowledge that I have reviewed and agreed to Xcelent Taxes’ terms and conditions of service. I authorize Xcelent Taxes to use the information provided for the preparation of my tax return or other requested services. Signature

Taxpayer Information

ADVANCE CHILD TAX CREDIT PAYMENT:

HEALTH INSURANCE COVERAGE: