2025-Individual and Small Business Client Intake Form

Individual and Small Business

Client Intake Form
Thank You for taking the time to complete your Client Intake Form.

For our new clients, this information is critical to ensure an accurate filing of your tax returns. For our existing clients, while we may have some of this information from past years filings, we kindly request you provide it again so we can make sure our records are 100% up to date.
This information is critical to ensure your tax return is filed accurately. Please take your time and review all information before you submit.

Please note that if documents are missing or information is incorrect this will result in a delay in processing your return.

This intake form will take 20- 30 minutes to complete.

Please complete this form in its ENTIRETY and click SUBMIT when finished.

Upload all documents at the end of the form.

Please wait until you have ALL of your documents before submitting this form.

Note: If you are claiming any dependents, be sure to upload their SS CARDS, BIRTH CERTIFICATES, and all items that show their address is the same as yours. (School records, Medical records, Doctor bills, Medicaid Statement, Social Services Records, or anything that shows your child's name and current address).

PLEASE READ THROUGH ITS ENTIREITY.

DO NOT SUBMIT THIS FORM UNTIL YOU HAVE ALL SUPPORTING DOCUMENTS.

BY NOT FOLLOWING DIRECTIONS YOUR INTAKE FORM WILL NOT BE PROCESSED.

BE SURE ALL SUPPORTING DOCUMENTS ARE VALID & CURRENT.

BE SURE LEASE AND OTHER SUPPORTING FORMS HAVE THE DEPENDENTS NAME ON THEM IF APPLICABLE.

YOU MUST FILL OUT EACH QUESTION WITH MARKED WITH A (*).
YOU MUST HIT THE SUBMIT AND GET THE COMPLETED MESSAGE OR THE FORM WILL NOT GO THROUGH!!

TAXPAYER INFORMATION
Taxpayer's Name*

First NameLast Name
Taxpayer's Job Title/ Occupation*
Taxpayer's Social Security Number*
Example: xxx-xx-xxxx
Taxpayer's Date of Birth*
Example: 01/01/2001
Taxpayer's Phone Number*
Example: (xxx)-xxx-xxxx
Taxpayer's Email Address*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (If Different from Home Address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your marital status as of December 31st?*

SingleMarriedDivorcedSeparatedSurviving Spouse
Taxpayer's Driver's License/ State ID (Stand directly over the item on a flat surface and zoom in for a clear shot)*

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Please upload a Selfie to Validate your Government Issued ID.*

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Taxpayer's Social Security Card (Stand directly over the item on a flat surface and zoom in for a clear shot)*

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Were you previously issues an Identity Protection Pin (IPPIN) by the IRS? *
IPPIN IDENTITY THEFT IF (APPLICABLE) (Stand directly over the item on a flat surface and zoom in for a clear shot.)*

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Can someone else claim you as a dependent?*
Who else can claim you as a dependent?*
Do you owe the IRS, Child Support or in default with student loans?*
Have you ever been disallowed for EITC/AOTC/CTC/ACTC? *
Did you buy or trade Crypto Currency? (Bitcoin)*
Do you have gambling winnings for the year?*
Upload W2-G Section*

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Did you make any charitable contributions during the year?*
Please provide details of the charitable contributions made.*
(Date of Donation, Name of the Organization and amount of the contribution.)
Did you withdraw from your 401K during the year ?*
How much did you withdraw?
How much Federal taxes were withheld?
Upload 1099-R 401k Distribution/Withdraw Form*

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SPOUSE INFORMATION
Spouse's Full Name*
First Name
Spouse's Social Security *
Example: xxx-xx-xxxx
Spouse's Date of Birth*
Example: 01/01/2001
Spouse's Phone Number*
Example: xxx-xxx-xxxx
Spouse's Email Address*
Example: example@example.com
Spouse's Driver's License/State ID (Stand directly over the item on a flat surface and zoom in for a clear shot)*

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Please upload a Selfie of your spouse to validate their Government Issued ID.*

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Spouse's Social Security Card (Stand directly over the item on a flat surface and zoom in for a clear shot)*

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Did you and your spouse live apart for more than 6 months in 2025?*
What months?*

INCOME
What is your primary source(s) of income?*

W2ContractSocial Security/DisabilityRetirement PensionOther
Did you receive unemployment during the year?*
1099G Unemployment Taxpayer/Spouse (Stand directly over the item on a flat surface and zoom in for a clear shot.)*

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Are you self employed?*
Please note that Blessed Services Mobile Notary & Tax Preparation requires all self-employed clients to complete a Schedule C Affidavit and a Business Income & Expense Certification. This is a firm policy of our office and not an IRS requirement. The purpose of this certification is to document that the income and expenses reported for your business are accurate and complete to the best of your knowledge and to protect both you and our firm during tax preparation.
Do you have supporting documentation to support your Business Income & Expenses?*
Do you need assistance with reconstruction of your Business Income & Expenses?*
Upload W2 statements (Stand directly over the item on a flat surface and zoom in for a clear shot.)

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Upload 1099 NEC (Stand directly over the item on a flat surface and zoom in for a clear shot.)

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Upload SSA-1099 Social Security/Disability Benefit Statement (Stand directly over the item on a flat surface and zoom in for a clear shot.)

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Upload 1099-R Retirement/Pension Distribution Form (Stand directly over the item on a flat surface and zoom in for a clear shot.)

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Upload other Misc. Income Documents such as 1099 INT, 1099 DIV, 1099 NEC, 1099K. (Stand directly over the item on a flat surface and zoom in for a clear shot.)

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CURRENT LIVING SITUATION
Do you receive Subsidized Housing or Section 8?*
Upload a copy of your Section 8 or Subsidized housing letter. (Stand directly over the item on a flat surface and zoom in for a clear shot.)*

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Do you receive any Government Assistance Programs such as Food stamps, TANF, Medicaid, or Medicare in during the year?*
How much do you receive monthly? *
Upload a copy of your Award Letter or a Screenshot from the online or mobile app. (Stand directly over the item on a flat surface and zoom in for a clear shot.)*

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Do you have a 1098 Mortgage Interest Statement?*
Upload your 1098 Mortgage Interest Statement Here. (Stand directly over the item on a flat surface and zoom in for a clear shot.)

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Was your insurance through the Affordable Care Act (The Marketplace)?*
PLEASE UPLOAD YOUR 1095A IF APPLICABLE (Stand directly over the item on a flat surface and zoom in for a clear shot.)

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Did anyone in your household attend college for the selected tax year? *
What was the Name of the person who attended college?*
What is the name of the educational institution?*
Did the Student receive a Form 1098-T from the educational institution? *
Was the student enrolled at least half-time for at least one academic period that began in 2025?*
Was the student enrolled in a program leading to a degree, certificate, or other recognized post-secondary credential?*
Has the American Opportunity Credit or Lifetime Learning Credit been claimed for this student for any 4 prior tax years? *
Did the student completed four years of post-secondary education before 2025?*
Before the end of 2025, was the student convicted of a felony involving possession or distribution of a controlled substance?*
Upload Form 1098-T (School Credit) *Stand directly over the item on a flat surface and zoom in for a clear shot.

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AUDIT PROTECTION
Audit Protection is required for all returns and is automatically added and included on all returns. The cost is already included in your preparation fee.

ADDITIONAL SERVICES
Are you interested in Credit Repair Services?*
Are you interested in Business Formation Services?*
Are you interested in Bookkeeping and/or Payroll Services?*
Are you interested in future Tax Planning Services?*
Are you interested in Audit Assistance or Tax Resolution Services?*

REFUND DISBURSEMENT OPTIONS
How would you like you refund disbursed if receiving on?*

Direct DepositCheckPrepaid CardBy MailN/A
Name of Bank
Routing Number
Bank Account Number

ACKNOWLEDGMENT & SIGNATURE

Client Engagement & Scope of Services

By engaging Blessed Services Mobile Notary & Tax Preparation, I understand and agree to the following: Blessed Services Mobile Notary & Tax Preparation will prepare my tax return(s) based solely on the information and documentation I provide. I am responsible for the accuracy, completeness, and truthfulness of all information submitted. Tax preparation services do not include legal representation before the IRS, state agencies, or the U.S. Department of the Treasury unless separately agreed to in writing. I understand that tax laws, credits, and refunds are subject to IRS review, verification, and adjustment.

Client Non-Payment/Offset Clause

At Blessed Services Mobile Notary & Tax Preparation, 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 within 30 days legal actions will be sought to resolve payment.

Refund Disclosure & Processing Acknowledgment

I acknowledge and understand the following regarding my tax refund: Refund amounts are estimates, not guarantees, and may change based on IRS or state review. The IRS and/or state agencies may: Delay processing,
Request additional documentation, Adjust credits or income,
Apply offsets to satisfy outstanding debts. Refund timing is controlled by the IRS and/or state agencies, not Blessed Services Mobile Notary & Tax Preparation.
Blessed Services Mobile Notary & Tax Preparation is not responsible for: IRS processing delays, Identity verification holds, PATH Act delays, Refund reductions or offsets.

Treasury Offset Program (TOP) Authorization
Consent to Contact Offset Line (1-800-304-3107)

I hereby voluntarily authorize Blessed Services Mobile Notary & Tax Preparation to contact the U.S. Department of the Treasury Offset Program (TOP) at 1-800-304-3107 to determine whether my federal tax refund may be subject to an offset and/or whether an outstanding debt exists. I understand and agree that: This authorization allows inquiry only and does not permit negotiation, dispute, release, or removal of any offset. Possible offsets may include, but are not limited to: Past-due federal or state taxes, Child support arrears, Student loan debt, Other qualifying government obligations. Information obtained reflects data available at the time of inquiry and does not guarantee that an offset will or will not occur.
Blessed Services Mobile Notary & Tax Preparation does not control, issue, or prevent offsets. I release and hold harmless Blessed Services Mobile Notary & Tax Preparation, its owners, staff, and representatives from any liability related to refund offsets or reliance on TOP information.

Client Certification & Attestation

I certify under penalty of perjury that: The information I have provided is true, correct, and complete to the best of my knowledge. I have read, understand, and agree to all sections of this engagement, refund disclosure, and authorization.
I understand that failure to disclose information or provide accurate documentation may result in delays, adjustments, or penalties.

Client Authorization & Responsibility Statement

I hereby grant Blessed Services Mobile Notary & Tax Preparation permission to prepare all federal and state tax forms related to my tax return(s). I authorize Blessed Services Mobile Notary & Tax Preparation to apply for and, if approved, secure Refund Anticipation Checks (RACs) and/or Refund Anticipation Loans (RALs) on my behalf, to sign all required documents as permitted by law, and to electronically file my tax return(s).

I acknowledge and agree that I am fully responsible for the accuracy, completeness, and truthfulness of all information provided. I understand that Blessed Services Mobile Notary & Tax Preparation and/or its associated affiliates are not responsible for any errors, omissions, misrepresentations, or false claims resulting from information I provide.

I further understand that any misrepresentation or false claim may result in delays, denial of credits, penalties, interest, audits, or other actions by the IRS or state taxing authorities, for which I am solely responsible.

Authorization Period

This authorization is valid for the current tax filing season and may be revoked at any time in writing.

Taxpayer's Signature

Clear
Date*

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

Clear
Date

MonthDayYear
Date
Form Status

Should be Empty:

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