2025 Tax Intake Form

Are you a new or returning client?*

NewReturningReferral
Who Referred You?
- What is your marital status as of December 2024?*
  
  Single (Not Married)Married living with SpouseMarried not living with Spouse
- First and Last Name
  
  First NameLast Name
- Phone Number*
  Format: (000) 000-0000.
- Email Address*
- Taxpayer's Date of Birth*
  Example: 01/01/2001
- Taxpayer's SSN*
  Example: xxx-xx-xxxx
- Taxpayer's Job Title*
- Street Address*
- City*
- State*
- Zip Code*
- Spouse's Full Name*
  First Name
- Spouse's SSN*
  Example: xxx-xx-xxxx
- Spouse's Date of Birth*
  Example: 01/01/2001
- Spouse's Job Title
- Spouse's Phone Number
  Example: xxx-xxx-xxxx
- Spouse's Email Address
  Example: example@example.com
- Are you self employed?*
  
  YesNo
- Did you pay over half the expenses of maintaining your residence for the entire year?*
  
  YesNo
- Are you on any Government Assistance*
  
  YesNoNot Applicable
- Did you support a child or family member for more than 6 months out of the year?*
  
  YesNo
- How many dependents are you claiming?*
- Dependent #1*
  
  First NameLast Name
- Dependent #1 Date of Birth*
  01/01/2001
- Dependent #1 SSN*
- What is Dependent #1's Relationship to you (son, daughter, etc.)?*
- How many months did Dependent #1 live with you in 2025? (If all year, enter 12)*
- Dependent #2 *
  
  First NameLast Name
- Dependent #2 Date of Birth*
  Example: 01/01/2001
- Dependent #2 SSN*
- How many months did Dependent #2 live with you in 2024? (If all year, enter 12)*
- What is Dependent #2's Relationship to you (son, daughter, etc.)?*
- Dependent #3*
  
  First NameLast Name
- Dependent #3's Date of Birth *
  01/01/2001
- How many months did Dependent #3 live with you in 2024? (If all year, enter 12)*
- Dependent #3s SSN*
  Example: xxx-xx-xxxx
- Dependent's #3 SSN*
- What is Dependent #3's Relationship to you (son, daughter, etc.)?*
- Dependent #4's First Name*
  First Name
- Dependent #4's Last Name*
  Last Name
- Dependent #4's Date of Birth *
  01/01/2001
- Dependent #4's SSN*
  Example: xxx-xx-xxxx
- What is Dependent #4's Relationship to you (son, daughter, etc.)?*
- How many months did Dependent #4 live with you in 2024? (If all year, enter 12)*
- Upload a copy of your daycare form here.
  
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- Are you interested in Credit Repair?*
  
  YesNo
- Would you like to pay upfront or from your refund?*
  
  Pay from refundPay upfront
- Credit Repair Contract
  
  Provide 3 months of professional advice and counseling on how to repair and maintain good credit.
  
  Assist in disputing inaccurate items on your credit report.
  
  Complete a 90-day review with clients to go over the updated credit report.
  
  All paperwork shall be held confidential as stated in the Privacy and Consumer Credit Protection Act.
  
  The fees for our services are $600 per person. You must maintain the $40 plan during the credit repair process.
  
  NO REFUNDS ONCE SERVICE HAS BEEN RENDERED.
  
  By signing below I agree that I have read and understand the above agreement.
- Signature
- 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 *
- Can someone else claim you as a dependent?*
  
  YesNo
- Did you have health insurance in 2025?*
  
  YesNo
- Who was your insurance cover through in 2025?*
- Who was your Dependents insured with in 2025?*
- Did you trade any Virtual Currency?*
  
  YesNo
- Have you ever been denied the Earned Tax Credit (EITC)?*
  
  YesNo
- Were you or any of your dependents in college in 2025?*
  
  YesNo
- Do you have a 1098-T Form for either you or your dependents?*
  
  YesNo
- If you have a 1098-T form, upload it here.
  
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- 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*
- 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*
- Spouse's Signature (If no spouse, leave blank)
- Date*
  
  MonthDayYear
  Date
- 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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- IP Pin
  
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- Other Documents
  
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- Should be Empty: