2025 Tax Intake Form

Refund Information
Would you like a Refund Advance Loan?*

Yes, $250-$1000 and below (no interest)Yes, Above $1000 (interest added)No
Are you interested in AUDIT PROTECTION?*

YesNo
How would you like to receive your tax refund?*

Check (Only available for in office visits)Direct Deposit
Name of Bank*
Which type of account would you like your refund deposited into?*

Checking AccountSavings Account
Routing Number *
Bank Account Number *

Signatures
CLIENT NON PAYMENT/OFFSET CLAUSE

At Taxes by Chrysanthemum, we strive to assist all of our clients in their tax needs, however we understand that situations arise. If your refund is offset by the IRS, student loans, child support or your check is mailed, you are still obligated to pay our company the fees associated with filing your tax return.

By signing this agreement you acknowledge that if payment is not made in full with in 30 days legal actions will be sought to resolve payment.
Primary Taxpayer's Signature*

Clear
Date*

MonthDayYear
Date
I am giving Taxes by Chrysanthemum permission to prepare all forms related to my tax return; to apply for and secure Refund Advances and Refund Advance Loans on my behalf; and sign all necessary forms and file my taxes electronically. I take full responsibility for the accuracy of this form and understand that Taxes by Chrysanthemum and/or associated affiliates hold no responsibility for any misrepresentation or false claims.

I understand that the REFUND ADVANCE LOAN IS NOT GUARANTEED AND THAT THE DECISION AND AMOUNT OF THE ADVANCE IS BASED SOLELY ON THE BANK.
Taxpayer's Signature*

Clear
Spouse's Signature (If no spouse, leave blank)

Clear
Date*

MonthDayYear
Date

Upload Documents
Taxpayer's Driver's License*

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

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Taxpayer's W-2/ 1099'S

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Dependent(s) Birth Certificate(s)

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Dependent(s) Proof of Residency (Lease/Utility Bill)

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Healthcare Marketplace Insurance Docs(1095A)

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Business Income/Loss Records(Quickbooks data/receipts/Profit & Loss Sheet)

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Other Documents

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