Tax Client Intake Form

Tax Client Intake Form
(Publication 4687 & IRC §6695(g) Compliant)
IMPORTANT NOTICE TO CLIENT

Federal law requires paid tax preparers to ask detailed questions and verify eligibility before claiming certain credits or filing statuses. Incomplete, inaccurate, or inconsistent answers may result in denial of credits or refusal to prepare your return.
Outstanding Federal or Financial Obligations
1. Do you currently have any outstanding balance or financial obligation with the Internal Revenue Service (IRS) or any other government or financial agency (including, but not limited to, IRS tax balances, student loans, or past-due child support)?

YesNoUnsure
If yes, please list the type of obligation and the agency or creditor to whom it is owed (e.g., IRS, Department of Education, State Child Support Agency):
Acknowledgment: I understand that if I have outstanding balances or financial obligations, all tax preparation fees must be paid in full prior to filing my tax return.

Acknowledged
If unsure, please stop here and contact the IRS directly at (800) 304-3107 to confirm your account status before proceeding.
Health Insurance Marketplace Coverage (Form 1095-A)
2. At any time during the 2025 tax year, did you or anyone listed on your tax return receive health insurance coverage through the Health Insurance Marketplace (Affordable Care Act / ACA)?

YesNoUnsure
If yes, do you have Form 1095-A available for upload?

YesNo
Please note: Form 1095-A is available in your IRS.gov account under Tax Records → Information Returns.

Your tax return cannot be electronically filed without this form and will reject if it is missing or incorrect.

If unsure, please contact the Health Insurance Marketplace at (800) 318-2596. They can provide the required figures over the phone.
Identity Protection PIN (IP PIN)
3. Has the IRS issued you an Identity Protection Personal Identification Number (IP PIN) for the 2025 tax year?

YesNoUnsure
If yes, please enter your 6-digit IP PIN below (numbers only):
Prior IRS Credit Disallowance (Due Diligence Requirement)
4. Have any tax credits (including, but not limited to, the Earned Income Tax Credit (EITC), Child Tax Credit (CTC/ACTC/ODC), American Opportunity Tax Credit (AOTC), or Head of Household filing status) ever been disallowed, reduced, or denied by the IRS on a prior tax return?

YesNoUnsure
A: If yes, please identify: The tax year(s) in which the credit was disallowed:
B: The specific credit(s) affected (check all that apply):

EITCChild Tax Credit / ACTC / ODCAmerican Opportunity Tax CrediHead of HouseholdOther
If selected other, please list it here.
C: The reason provided by the IRS for the disallowance (e.g., dependency/residency issues, income mismatch, missing documentation, identity verification, audit or examination findings):
If unsure, please indicate whether you received any IRS notices (CP, Letter, or audit correspondence) related to credits or filing status:

YesNoUnsure
If available, please upload copies of any related IRS notices or correspondence

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SECTION 1 — TAXPAYER IDENTIFICATION (ALL CLIENTS)

SECTION 2 — HOUSEHOLD COMPOSITION (REQUIRED FOR DEPENDENTS, EITC, HOH)
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
SSN
Relationship to you
Dates lived with you (MM/DD–MM/DD)
Follow-up (mandatory):
Who are this child’s biological or legal parents?
Where did the child live when not with you?
Did anyone else provide financial support for this person?
Did this person file a joint return with anyone?
(Required under “Know the Facts” standard — Pub 4687, pgs. 4, 8–11)

SECTION 4 — EARNED INCOME (EITC / CTC / ACTC)
W-2 Income
List all employers you worked for during the year:
Did you receive any cash income, side income, or informal pay?

YesNo
If yes, explain source and amount:
Self-Employment (Schedule C)
Name

First NameLast Name
Describe your business activity:
Describe your business activity.
Did you operate with the intent to make a profit? ☐

YesNo
Total gross income received:
List all business expenses (even small ones):
Do you have records for income and expenses?

YesNo
(IRS flags “no expenses” as inconsistent — Pub 4687, pg. 9)

SECTION 6 — CHILD TAX CREDIT / ACTC / ODC
For each child claimed:
Child’s age on December 31:
Relationship
Did the child live with you more than half the year?

YesNo
Does the child have a valid SSN (CTC/ACTC) or ITIN (ODC)?

YesNo
Is the child claimed as a dependent on this return?

YesNo
Did the child live outside the U.S. at any point?

YesNo
If yes, list dates and country:
(Residency & ID rules enforced — Pub 4687, pgs. 10, 13–14)

SECTION 8 — AMERICAN OPPORTUNITY TAX CREDIT (AOTC)
Student’s name and SSN:
School attended (must be eligible institution):
Was the student enrolled at least half-time?

YesNo
Is the student pursuing a degree or credential?

YesNo
How many years has AOTC been claimed for this student?
Did you pay qualified education expenses?

YesNo

SECTION 9 — DUE DILIGENCE CERTIFICATION (CLIENT)
Due Diligence

I certify that all information provided is true, correct, and complete to the best of my knowledge.I understand that false or incomplete information may result in denial of credits or IRS penalties.
Signature

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Date

MonthDayYear
Date

SECTION 10 — Direct Deposit Information
Bank Name
Routing Number
Account Number

SECTION 11 - Upload Important Documents
Photo Identification

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Taxpayer Social Security Card

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Dependent Social Security Card

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Dependent Social Security Card

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Dependent Social Security Card

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Dependent Social Security Card

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W2(s)

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1099(s)

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Acknowledgment & Signature
- I confirmed that all information I entered here is accurate and true.
- I allow THOMFLIP FINANCIAL SERVICES to capture my sensitive data like personal id, government id, and other information.
- I have read the terms and conditions and privacy policy of ABC Financial.
- By signing below, you acknowledge that you have read and understood your responsibilities and our responsibilities in doing this tax return.
Date Signed*

MonthDayYear
Date
Taxpayer Signature*

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Date Signed

MonthDayYear
Date
Spouse Signature

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Should be Empty:

Tax Client Intake Form

(Publication 4687 & IRC §6695(g) Compliant)

Outstanding Federal or Financial Obligations

Health Insurance Marketplace Coverage (Form 1095-A)

Identity Protection PIN (IP PIN)

Prior IRS Credit Disallowance (Due Diligence Requirement)

SECTION 1 — TAXPAYER IDENTIFICATION (ALL CLIENTS)

(Required under “Know the Facts” standard — Pub 4687, pgs. 4, 8–11)

W-2 Income

Self-Employment (Schedule C)

(IRS flags “no expenses” as inconsistent — Pub 4687, pg. 9)

For each child claimed:

(Residency & ID rules enforced — Pub 4687, pgs. 10, 13–14)