NEW CLIENT INTAKE FORM CRUTCHFIELD TAXES AND FINANCIAL SOLUTIONS

Please provide the name of the person who referred you or provide the place where you saw our business.
Do you or your kids have an IP PIN?
Did you have any overtime pay?
Would you like to appy for the tax advance loan?: PLEASE CHECK ONE
Do you have marketplace insurance?
Did you get a refund last year? If so upload transcript or copy of tax return at the bottom of this form? (NEW CLIENTS ONLY)
Are you in the home buying process?
Your Full Name

PrefixFirst NameLast Name
Your Phone Number

Area CodePhone Number
Your E-mail
example@example.com
Tax Payers Social Security Number
Tax Payers Date of Birth

YearMonthDay
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Did you receive health insurance through the Market Place?
Your Occupation
Have you ever been audited by the IRS?
If so, Please provide the year/s of audit and what were the outcomes of the audits
Primary Taxpayer - Please Check Any That Apply
Spouse Information

If no spouse, please skip.
Spouse's Name

First NameLast Name
Spouse's Date of Birth

YearMonthDay
Date
Spouse's Social Security Number
Spouse's Occupation
Spouse's Email Address
example@example.com
Spouse - Please Check Any That Apply
Dependent Information

The Earned Income Credit (EIC) increases with the first 3 Children you claim. The maximum number of dependents you can claim for Earned Income Purposes is Three. You MUST also meet other requirements related to your Adjusted Gross Income (AGI) to qualify for EIC. If you are MARRIED and FILING SEPARATE you CAN'T claim the credit.
BEFORE ADDING YOUR DEPENDENTS INFO YOU ARE AGREEING THAT THEY LIVED WITH YOU FOR 6MONTHS OR LONGER AND THEY ARE ON YOUR LEASE, AND YOU ARE ON THE SCHOOL DOCUMENTS? IF AT ANY TIME IF YOU ARE TO GET AUDIT WITH THESE DEPENDENTS AND WE FIND OUT DURING THE AUDIT YOU DID NOT PROVIDE CARE OR NEVER LIVED IN THE HOME WE AT OPTIMA FINANCIAL TAX SOLUTIONS WILL NOT BE RESPONSIBLE FOR COMPLETING YOUR AUDUT SINCE TAX RETURN WAS DONE IN DISHONESTY. IF YOU AGREE TO THESE TERMS SIGN BELOW THAT YOU UNDERSTAND
PLEASE SIGN HERE

Dependent Information

Rows	Name	Date of Birth	Social Security Number	Full Time Student? Yes or No	Disabled? Yes or No?	How Many Months Did The Child Live In Your Home?	Relationship To The Dependent
1st Dependent
2nd Dependent
3rd Dependent
4th Dependent
5th Dependent
6th Dependent

TAXPAYER IP PIN (issued from IRS yearly) EVERYONE DOESNT HAVE THIS. IF IT DOESNT APPLY SKIP
SPOUSE IP PIN (issued from IRS yearly) EVERYONE DOESNT HAVE THIS. IF IT DOESNT APPLY SKIP
Business Information

Please complete if you are self employed.
Are you self employed or a business owner?
If so what kind of business do you have?
Please provide your business EIN Number If Any
How long have you been in business?
Business Adress

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please upload your profit/expense records.

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Did you have a vehicle you used for your business?
If so, list the year make and model of the vehicle.
Do you have a separate personal vehicle?
College Student Information

Please complete if anyone in your household went to college.
Did Anyone Listed On This Return Attend College this Tax Season
If so - please upload form 1098-T and other college related documents below.

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Name(s) of the person who attended college
Did all students attend at least half time?
Were they seeking a degree?
How much money was spent on other books or materials in relation to college?
How many tax years have you claimed the American Opportunity Tax Credit?
Was the student ever charged with drug related felonies?
Are You Currently Paying Student Loans?
If so please upload your Form 1098-E - Student loan Interest

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Upload Requested Documents

PLEASE NOTE: YOU CAN UPLOAD MULTIPLE DOCUMENTS
Upload ID/DL (for anyone over 18 years old on this filing)

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Please take a selfie
Upload Social Security Card (for all listed on this filing) IF PREVIOUS CLIENT NOT NEEDED ITS ON FILE

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Please upload all W2's HERE - You can upload multiple files

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Please upload your last check stub if you had Overtime pay ONLY

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If you received Unemployment Please Provide 1099-G form

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Withdrawal out of 401K? Please attach documentation if available.

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Please provide Mortgage / Property Tax form(s) if paid taxes / insurance

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Please Upload any Additional Tax Forms that you have Received.

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Please upload Birth Certificates for all dependents. IF PREVIOUS CLIENT NOT NEEDED ITS ON FILE

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Banking Information
Do you owe or have you owed the IRS?
Will you want any of the following Bank Products? (Choose All That Apply ) ** Please note all bank products must go through an approval process and will require a written authorization Form 7216 Bank Consent to Disclosure of Tax Return Information
Signature Consenting to Form 7216 Bank Consent to Disclosure of Tax Return Information
How would you like your refund to be deposited when ready?
Bank Name
Is this a Checking or Savings account?
Routing Number
Confirm Routing Number
Account Number
Confirm Account Number
Due Diligence Questions
Have you ever been disallowed the Earned Income tax Credit, The additional child Tax credit, or the Child tax credit?
If you are divorced or separated, when did you last live in the same home?
Do you have joint custody of your child? (If so which child/children)
How long did your child/children live in the other parent's home during the tax year? (in months)
Do you have a signed form 8332 granting the right to claim this child/children?
Did anyone else live in the home that provides financial support for your child/dependents?
Can or could anyone else be eligible to claim this dependent on their tax return?
Did you pay someone to watch your child/children?
If so please upload any childcare statements.

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Did you receive any type of supplemental, non taxable income such as child support, Welfare benefits, Social security, etc?
In the case of a random IRS audit, can you provide for the children: SKIP IF CLAIMING NO DEPENDENTS
Signatures

Please Review & Sign Consent Forms
Signature Consenting to Client Engagement Letter
Signature Consenting to Consent To Use Of Tax Return Information
Signature Consenting to Consent To File Tax Return Electronically
By Typing Your Name, Signature & Date you agree that everything entered on this form is true and correct.

- I have confirmed that all the information I entered here is accurate and true.
- I allow Optima Financial & Tax Solutions LLC to capture my sensitive data like personal id, government id, social security number (SSN), and other information.
- By typing your name below and signing your signature, you acknowledge that you have read and understood your responsibilities and our responsibilities in doing this tax return.

-I understand that once tax return is sent to IRS, IRS have full control over the time frame the tax retrun is sent to the Taxpayer.

-Please be advised that if your tax refund is offset for any reason (e.g., federal or state debt), you are still fully responsible for payment of tax preparation fees. AND AUTO COLLECT WILL BE SET IN PLACE TO COLLECT FEES

If payment has not been received within 45 days of filing, Optima Financial Tax Solutions LLC reserves the right to initiate automatic collection procedures for the unpaid balance.

Thank you for your understanding and cooperation.

— Optima Financial Tax Solutions LLC
Type Your Name

First NameLast Name
Signature
Today's Date:

YearMonthDay
Date
OFTS LIKE TO BE OPEN AND TRASPARENT WHEN IT COMES TO FEES IF YOU DO NOT AGREE TO FEES PLEASE DO NOT CONTINUE WITH THIS INTAKE FORM THE FEES ARE BASED ON THE TAX PREPARATION FEES ONLY THIS IS NOT INCLUDING THE BANK FEE OF REFUND ADVANTAGE AND OR SBTPG

HIGHSCHOOL STUDENTS FREE

SINGLE FILERS 10% OF REFUND

HOH WITH DEPENDANTS $450

MARRIED JOINT $750

SELF EMPLOYED $950 UP VARIES ON LENGTH OF TIME TO PREPARE SCH C

MARRIED SINGLE 10% OF REFUND

IF YOU AGREE TO ALL TERMS AND FEES PLEASE SIGN BELOW
Signature
Should be Empty:

Spouse Information

Dependent Information

Business Information

College Student Information

Upload Requested Documents

Banking Information

Due Diligence Questions

Signatures