INSURANCE OPTIONS

TAX FILLING/INTAKE FORM

We will contact you within 24-72 hours
Disclosure:

I authorize Partners Multi Services,Corp Tax Office Representative to process my Tax Return based on the information that provided on this form. I also confirm that all information is true.

Submit ALL docs: ID, Social, W2, 1099, Statement etc to : makengsoninsurances@gmail.com
REFERRAL REP. / OFFICE /PARTNER

NAMEPhone
Applicant Name - Main Person*

First NameMiddle NameLast Name
Date Of Birth*
MonthDayXXXX
SSN *
XXX-XX-XXXX
Phone Number (Main) *

Area CodePhone Number
Name - (Spouse)

First NameMiddle NameLast Name
Date Of Birth (spouse)
MonthDayXXXX
SSN (Spouse)
XXXXXXXXX
Address (Main)

Street Address

APT #

City

Zip Code
Phone Number (Spouse)

Area CodePhone Number
Did you File Your Tax Last Year

YESNO
Any change of address since last year tax

YESNONot Applicable
Email
example@example.com
FILING STATUS (Please Check One)

DEPENDENT OF PARENTSINGLEMARRIED FILING JOINTLYMARRIED FILING SEPERATELYHEAD OF HOUSEHOLDQUALIFYING WIDOWER
REFUND TYPE

DIRECT DEPOSITREFUND CHECKMAIL
IF DIRECT DEPOSIT

Routing # OR Bank NameAccount #
Did you get OBAMACARE/ MARKETPLACE HEALTH PLAN ACA last year?:

yes ( If yes: Form 1095A required)NO
FORMS THAT YOU BRING OR SELF EMPLOYED:

W210981099GOther Form1099 (Ind. Contractor)CASH (self employed)
SELF-EMPLOYMENT

1099 MISC, NECCASH (Please attach profit and lost statement)
DO YOU OWE IRS ANY MONEY?

YESNO
Dependent You Claim # 1

FirstLastSocial Date of Birth
Dependent You Claim # 2

FirstLastSocial Date of Birth
Dependent You Claim # 3

FirstLastSocial Date of Birth
Dependent (s) Lived With you the whole Year.

YESNO
DAY CARE PROVIDER INFORMATION

FirstTAX ID:PAID $:ADDRESS:
YOUR SCHOOL/COLLEGE INFO OR CHILD SCHOOL/COLLEGE INFO

School Name: School Code:School Address:Did you recieved 1098: YES or NO
Did you received any Employment Benefits (Last Year)?

YesNo
Best Time to Contact as Needed

AnytimeMorning 9-12 AMAfternoon 1-7 PM
Do you own a Car/EV (Discuss Type of car with your preparer)

YesNo
Do You Own a House (Discuss any remodeling with your Preparer)

YESNO
Important Notes (For us to know)
Appointment
Signature

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TAX FILLING/INTAKE FORM