Haven Tax Solutions Client Intake Form
Check Box For Your Tax Preparer:
*
Filing Status
*
Single
Head of Household
Married Filing Separate
Married Filing Joint
Qualifying Widower
Taxpayer Information
Name
*
First Name
Last Name
Age
Social Security Number
*
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Employment Status
*
Employed
Unemployed
Self-employed
Taxpayer DL & SS Card
*
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Are you a full-time student?
Yes
No
Are you totally and permanently disabled?
Yes
No
Are you legally blind?
Yes
No
Spouse Information
Name
First Name
Last Name
Age
Social Security Number
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Employment Status
Employed
Unemployed
Self-employed
Spouse DL & SS Card
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Are they a full-time student?
Yes
No
Are they totally and permanently disabled?
Yes
No
Are they legally blind?
Yes
No
Are they your dependent?
Yes
No
Dependents
Enter your dependents here
*
Name
Date of Birth
Relationship
Social Security Number
1
2
3
4
5
6
Dependents SS Cards
*
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of
Does you, your spouse, and your dependents have health insurance within 12 months last year? If yes, who covers for it?
*
Yes/No
Employer
Spouse Ins
Exchange/ Marketplace
Direct with Insurer
Medicare
Medicaid
Taxpayer
Yes
No
Spouse
Yes
No
Dependent 1
Yes
No
Dependent 2
Yes
No
Dependent 3
Yes
No
Dependent 4
Yes
No
Dependent 5
Yes
No
If you had Marketplace Insurance Upload your 1095-A Form?
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of
W2 Uploads
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Tax Related Questions
Are you contributing to 401k or other pre-tax account?
Yes
No
Is this your first time opening a pre-tax account?
Yes
No
Does your dependents have tuition expenses?
Yes
No
Do you have any expenses for child care?
Yes
No
Do you have your own home?
Yes
No
Do you have documents that shows you paid for property taxes?
Yes
No
Did you sell any stock?
Yes
No
Did you take money from your 401K?
Yes
No
Do you have mortgage interest?
Yes
No
Do you have real estate tax?
Yes
No
Did you receive a federal tax last year?
Yes
No
Are you a victim of identity theft?
Yes
No
Other
Expenses
Please fill-up the information within the current year only.
General Expenses( Optional)
Amount
Medical Expenses
Dental Expenses
Insurance Premiums paid
Home Mortgage
Investment Interest
Cash Contributions
Non-Cash Contributions
Total Expenses
Additional Documents
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Bank Information: (Make sure you state if Checking or Savings Account)
*
Acknowledgment & Signature
I confirmed that all information I entered here is accurate and true.
I allow Haven Tax Solutions LLC to capture my sensitive data like personal id, government id, and other information.
I have read the terms and conditions and privacy policy of Haven Tax Solutions LLC.
By signing below, you acknowledge that you have read and understood your responsibilities and our responsibilities in doing this tax return.
Date Signed
*
-
Month
-
Day
Year
Date
Taxpayer Signature
*
Date Signed
-
Month
-
Day
Year
Date
Spouse Signature
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