Client Intake Form

Select Your Tax Preparer

Date

Name

First NameLast Name

Date of Birth

Date

DOB

Social Security Number

XXX-XX-XXXX

Spouse Name

First NameLast Name

Spouse DOB

Spouse Social Security Number

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Dependent's First Name:   Dependent's Last Name: Social Security Number:

Dependent's Date of Birth :            Relationship to you:

Did Dependent live with you during the tax year? Yes   No   For how many months?

Dependent's First Name:   Dependent's Last Name: Social Security Number:

Dependent's Date of Birth :    Relationship to you:

Yes   No   For how many months?

Can someone else claim you or your spouse as a dependent on their tax return?

Do you pay the utility bill and rent?

Did you have Marketplace Insurance/ Obama Care?

Do you have any *known prior years debt?

Are you self employed?

Do you have any business receipts?

Business Name: Employee/Business Expenses Total: Product or Service: Advertising: Supplies: Income: Other Expenses: Utilities:

Please upload all Driver's License, Social Security Cards, Birth Certificates, W-2's and receipts here. *IMPORTANT NOTE* You MUST UPLOAD your License and the Social Security Cards of the tax payer and all dependents. They are *required* to process return*

How would you like receive your tax return?

Would you like to apply for a tax advance?

Bank Name

Type of Account

Bank Routing Number

Bank Account Number

I attest that all information provided on this form is true and correct.

Tax Payer Signature: