Tax Preparation Client Intake Form
Filing Status
Single
Head of Household
Married Filing Separate
Married Filing Joint
Qualifying Widower
Taxpayer Information
Name (a copy of social security card and driver's license will be required following initial intake)
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Occupation
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Spouse Information
Name (a copy of social security card and driver's license will be required following initial intake)
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Occupation
Dependents
Enter your dependents here (a copy of each social security card will be required after initial intake)
Rows
Name
Date of Birth
Relationship
1
2
3
4
5
6
Tax Related Questions
Employment Status (Taxpayer)
Employed
Unemployed
Self-employed
Employment Status (Spouse)
Employed
Unemployed
Self-employed
Did you have an employment change in the year?
Yes
No
Did your spouse have an employment change in the year?
Yes
No
Are any of your dependents required to file a tax return for last year?
Yes
No
I don't know
Are you, your spouse, or any of your dependents legally blind or disabled?
Yes
No
I don't know
Did you or your spouse contribute post-tax to an IRA last year?
Yes
No
Does you, your spouse, or your dependents have any tuition or continuing education expenses last year?
Yes
No
Did you have any expenses for child care last year? See below
Yes
No
Did you buy or sell a home last year?
Yes
No
Did you buy or sell any stock last tax year?
Yes
No
Did you take money from your retirement account last tax year?
Yes
No
Do you have mortgage interest or real property tax payments to report for last year? See below
Yes
No
Did you make any charitable donations last year? See below
Yes
No
Did you receive a 1095-A last year for health insurance purchased through the Marketplace last year? See below
Yes
No
Itemized Deductions- Amounts Paid, if applicable
Rows
Amount Paid
Additional Comments
Medical Expenses
Dental Expenses
Health Insurance Paid (will need for 1095-A if applciable)
LTC Premiums Paid
Prescription Expenses
Home Mortgage Paid
Real Estate Taxes Paid
Investment Interest Expenses
Cash Charitable Contributions
Non-Cash Charitable Contributions
Child Care Paid
Additional comments
Acknowledgment & Signature
I confirmed that all information I entered here is accurate and true.
I allow Jennifer OBrian Bookkeeping & Tax to capture my sensitive data like personal id, government id, and other information. I understand they will not buy, sell, or otherwise disclose my information unless otherwise directed by myself.
Date Signed
-
Month
-
Day
Year
Date
Taxpayer Signature
Date Signed
-
Month
-
Day
Year
Date
Spouse Signature
Print
Submit
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