TAX 2025 Tax Client Intake Form

Tax Client Intake Form
As a Personal Income Tax Client, we need to collect the following information from you in order to begin to prepare your income tax return. Please do not submit until you have everything received and ready.

If you have not already, please review our final tax checklist to ensure you have everything required.
Have you reviewed our final tax checklist to ensure you have everything you need to submit?*

YesNo

TAX INTAKE FORM

In order for us to file your federal and state return, we need the following information. The information you provide to us will remain confidential. We value you as our client and promise not to share your information with any third-party vendors.
Filing for Tax Year*
Type of Client*

NewExisting
Filing Status*

SingleMarried Filing SeparatelyWidowMarried Filing JointlyHead of Household
To be eligible for the Head of Household (HOH) credit, please provide either a lease agreement or a recent utility bill (water bill or PG&E bill). We require the Social Security card for each dependent and taxpayer, and/or birth certificate.
Upload a document that reflects your ability to claim head of household. An example would be a utility bill (water and PG&E), mortgage statement, rental payments, etc.*

Cancelof
For all taxpayers: Before signing, please ensure that you submit a copy of your Social Security card and birth certificate.

If you encounter any issues with your documents, please contact me!
If someone referred you, please type his or her name here.
Would you like to request a Refund Advance Loan?

YesNo

Taxpayer Information
Tax Payer's Name*

First NameLast Name
Tax Payer's Email Address*
example@example.com
Tax Payer's Phone Number*
Please enter a valid phone number.
Taxpayer's Date of Birth *
Example: 01/01/2001
Taxpayer's SSN *
Example: xxx-xx-xxxx
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation*

Spouse Information
Spouse's Full Name
Full Name
Spouse's SSN
Example: xxx-xx-xxxx
Spouse's Date of Birth
Example: 01/01/2001
Spouse's Phone Number
Example: xxx-xxx-xxxx
Spouse's Email Address
Example: example@example.com
Spouse's Job Title

Dependents
How many dependents are you claiming? *

Other dependents or people who lived with you

	Name	Social Security	IP Pin	Date of Birth	Relationship	Income
1
2
3
4
5

Please upload a rental agreement with your dependents listed on it, or school records with your address listed.

Cancelof
Does you, your spouse, and your dependents have health insurance within 12 months last year?*

YesNo
Are you claiming a niece, nephew, grandchild, or other relative instead of your own children, and you are providing 50% or more of their expenses?*

YesNo
Please write in details why the parents are unable to claim them. What is the status of the parents?*
If requested by the IRS, do you have documentation (i.e. receipts, records) to substantiate your eligibility for the Child Tax Credit, Earned Income Tax Credit and/or Head of Household Filing Status?*

YesNo

Business Information
BUSINESS INFORMATION
Name of Business
EIN Number
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you own any vehicle?*

YesNo

Anything else we should know to prepare your taxes?

	Answer
Name of Vehicle
Make/Model
Year of Manufacture
Purpose of Use
Total Miles Driven for Business Use
Total Miles Driven for the Year

Documents Upload
Taxpayer's ID and/or Driver's License/ Birth Certificate*

Cancelof
Taxpayer's and Dependent(s) Social Security Card(s)*

Cancelof
Taxpayer's W-2/ 1099*

Cancelof
If you have a 1098-T form, upload it here.

Cancelof
Dependent(s) Birth Certificate(s)

Cancelof
Dependent(s) Proof of Residency (Lease Agreement or/Utility Bill) if you would like to receive the HOH Credit (Head of Household)

Cancelof
Additional Documents

Cancelof
Self-Employment Expense Log, Summary of Income, Business License, Bank Statements, receipts, etc

Cancelof

Payment of Tax Refund Disbursement
Payment of Tax Refund Disbursement
How would you like to receive your tax refund?*

Check (Picked up in the office)Prepaid Visa Card (The Visa card will be provided to you with funds loaded onto it.)Pre-Advance/Cash Advance (If qualified) orDirect Deposit
Name of Bank*
Which type of account would you like your refund deposited into?*

Checking AccountSavings AccountOther
Routing Number*
Bank Account Number*
Consent for Payment

We value our relationship with our clients. We are in the business to provide you with the best service possible. We want to remind you that you are being provided a service and not a tax refund. You as a taxpayer have the option to pay your tax preparation fees by: cash, money order, credit card, electronic payment, or directly from your refund.

If you choose to have the tax preparation fees taken from your refund and your taxes are intercepted, YOU ARE STILL RESPONSIBLE FOR THE TAX PREPARATION FEES! By signing your return, you are agreeing to pay the tax preparation fees regardless of if your refund is released or not.

Upon our notification of your refund being intercepted, we will send you an invoice for payment. If payment is not received within 30 days of the invoice then we will proceed with ACH processing or collections if no bank account is held by the client.

NOTE: The Department of Treasury's Financial Management Services (FMS) can offset ANY UNPAID federal or government debt against your refund WITHOUT prior notice.

Most commonly, the offset is taken for: Past due child support, Debts owed to a federal/ state agency, Unemployment debts owed to state, and/or past due federal student loans.

ACH Authorization Form

I, hereby authorize Clearmind Solutions LLC to initiate electronic debits to my bank account for the purpose of collecting payment for the services related to the preparation of my tax return. I understand and agree to the following terms:

Payment for Tax Preparation Services: I acknowledge that I am engaging Clearmind Solutions LLC for the professional service of preparing my tax return. Payment is not contingent upon the approval or funding of my tax refund.

Billing Authorization: In the event that my tax refund is not approved and funded within 30 days through a bank product with a third-party bank, I authorize Clearmind Solutions LLC to electronically debit my bank account for the full amount of the tax preparation fees as agreed upon. This debit will be initiated as soon as practicable after the 30-day period has lapsed.

Bank Account Information: I have provided accurate and current information regarding my bank account for the purpose of this electronic debit authorization.

Right to Revoke: I understand that I may revoke this authorization at any time by providing written notice to Clearmind Solutions LLC. Such revocation will not affect any fees or charges that have already been incurred.

Record Keeping: Clearmind Solutions LLC will retain a copy of this authorization form, and I will receive written notice of any changes in the payment amount or schedule at least 10 days prior to the initiation of any debits.

Before signing, you can edit and add forms. Please check your email for the edit link after cliking save, then submit.

By signing below, I confirm that I have read and understand the terms of this ACH Authorization Form and agree to be bound by them.
Signature*

Clear

Acknowledgement and Signature
Letter of Engagement
Primary Taxpayer's Signature*

Clear
Date*

MonthDayYear
Date
Date

MonthDayYear
Date
Spouse's Signature

Clear
Should be Empty:

Tax Client Intake Form

TAX INTAKE FORM

INCOME

DEDUCTIONS

WORK RELATED EXPENSES

UNEMPLOYMENT BENEFITS

Payment of Tax Refund Disbursement