CIMA TAX SOLUTIONS INTAKE FORM

Name

First NameLast Name

Gender

FemaleMale

Birth Date*

Date

Social Security Number *

Phone Number*

please enter a valid phone number

Email*

example@example.com

Address

DRIVERS LICENSE, ID OR PASSPORT *

W-2, 1099-NEC 1099-MISC

Filing Status

HEAD OF HOUSEHOLD FILERS MUST PRESENT ONE OF THE FOLLOWING TO FILR THIS STATUS. PICK ONE OF THE 3 OPTIONS THAT YOU WILL SUBMIT TO BE APPROVED TO FILE HEAD OF HOUSEHOLD.

Documents to support Head of Household

LeaseUtility BillMortgage Statement

File Upload

Will you be filing a Tax return with your spouse?

YesNoN/A

IF YOURE CLAIMING A DEPENDENT, PLEASE ANSWER THE QUESTIONS BELOW THAT PERTAINS TO YOUR DEPENDENT(S) RELATIONSHIP. PER THE IRS REQUEST, WE MUST PROVE THAT NOBODY ELSE IS ELIGIBLE TO CLAIM YOUR DEPENDENT(S) BUT YOURSELF.

IF CLAIMING SON/DAUGHTER, WHERE IS THE OTHER PARENT OF THE DEPENDENT(s)? IS THE OTHER PARENT PROVIDING ANY FINACNCIAL SUPPORT?

IF CLAIMING NIECE, NEPHEW, AUNT, OR UNCLE, HOW ARE YOU RELATED TO THE DEPENDENT(S)? WHERE ARE THE PARENTS TO THE DEPENDENT(S)?

DID YOU PAY SOMEONE TO WATCH YOUR CHILD/CHILDEREN?

YESNO

DID YOU COLLECT SOCIAL SECURITY OR RETIREMENT INCOME?

YESNO

DID YOU PURCHASE HEALTH INSURANCE THROUGH HEALTHCARE.GOV MARKETPLACE (OBAMA CARE)?

YESNO

IF YES, DID YOU RECEIVE A 1095-A FORM FROM THE MARKETPLACE ?

YESNO

Dependent 1

First NameLast Name

Birth Date

Date

Social Security Number

Gender

FemaleMale

Dependent 2

First NameLast Name

Birth Date

Date

Social Security Number

Gender

FemaleMale

Dependent 3

First NameLast Name

Birth Date

Date

Social Security Number

Gender

FemaleMale

Dependent 4

First NameLast Name

Birth Date

Date

Social Security Number

Gender

FemaleMale

DO YOU OWE ANY DELINQUENT:

DO YOU HAVE ANY OTHER INCOME OTHER THAN YOUR W-2

YESNO

ARE YOU SELF EMPLOYED, OWN A FULL TIME OR SIDE BUSINESS OR 1099 CONTRACTOR

YESNO

IF YOU ARE SELF EMPLOYED, DOES YOUR BUSINESS HAVE A EIN ?

YESNO

BUSINESS FEDERAL TAX ID

BUSINESS NAME

BUSINESS DESCRIPTION

BUSINESS ADDRESS

DID YOU OR YOUR SPOUSE RECEIVE UNEMPLOYMENT BENEFITS IN 2024?

YESNO

DID YOU FILE 2023 TAXES:*

YESNON/A

DID YOU SUCCESSFULLY TAX RECEIVE YOUR 2023 TAX REFUND:*

YESNON/A

DID YOU SUCCESSFULLY RECEIVE YOUR 2023 TAX REFUND:*

YESNON/A

BUSINESS EIN LETTER

BUSINESS EXPENSES

UPLOAD VOID CHECK OR BANK STATEMENT

HOW WOULD YOU LIKE TO RECEIVE YOUR REFUND:*

Refund Transfer Direct DepositRefund Transfer Debit CardRefund Transfer Paper CheckRefund Direct Deposit

ENTER BANK NAME

UPLOAD VOID CHECK OR BANK STATEMENT

Date

Signature

I hereby, state that all the information above is true to the best of my knowledge and that I am allowing CIMA TAX SOLUTIONS to preparer my taxes based on the information I provided. I understand that I am financially responsible for any outstanding balance due to any false information given. If there is a balance due, I must pay the tax preparation fee upfront. If for any reason I owe an entity and they take the entire refund, I am STILL responsible to pay the tax preparation fee for services rendered. If for any reason an amendment has to be filed with no fault of the tax preparer, an upfront fee of $300 is required!

CIMA TAX SOLUTIONS is not responsible if you provide false information or do not provide all of my 2024 income documents. Please view your tax return, which is emailed to you. (it is sent AFTER submission). Any copy after the first copy is a fee of $40.00. ALL FEES (bank and service fees) are found in the return and are non-refundable nor negotiable! NO EXCEPTIONS TO THIS!! By signing this form you give CIMA TAX SOLUTIONS permission to transmit your 2024 tax return. Please utilize www.irs.gov for all federal refund tracking. Please utilize your state Department of Revenue site for any State Refund tracking. Do NOT add the amounts together. Federal taxes are federal, and state taxes are state when tracking your status.

Please allow 8 weeks to surpass from the date of submission before calling the IRS, if you have any tracking questions. For any direct assistance please email SUPPORT@CIMATAX.NET

or the IRS for all updates at 800-829-1040. IF YOU AGREE TO ALL STATED ABOVE, SIGN