tax_amendment_intake

TAX AMENDMENT INTAKE FORM
Taxpayer Information
Full Legal Name:
SSN:
DOB:

MonthDayYear
Date
Phone Number:
Format: (000) 000-0000.
Email:
example@example.com
Current Address:
Spouse Information (if applicable)
Full Legal Name:
SSN:
DOB:

MonthDayYear
Date
Phone Number:
Format: (000) 000-0000.
Email:
example@example.com
Original Tax Return Information
Tax Year to Amend:
Date Original Return Filed:

MonthDayYear
Date
Refund Received:

YesNo Amount:
Filing Status

Self-PreparedTax Professional (Name):
Reason for Amendment

Missed Income Form (W-2, 1099, etc.)Dependents ChangeCredits/Deductions MissedIncorrect Filing StatusBusiness Income CorrectionHealth Insurance CorrectionOther:
Income Changes

Additional W-2/1099 Forms Provided:
Dependent Name Changes / Additions / Removals:
Additional Notes
Additional Notes
Taxpayer Signature
Date (Taxpayer)

MonthDayYear
Date
Signature Authorization

I confirm that the above information is accurate and authorize amendment preparation. Taxpayer Signature: Date: Spouse Signature (if filing jointly): Date:
Spouse Signature (if filing jointly)
Date (Spouse)

MonthDayYear
Date
Should be Empty:

TAX AMENDMENT INTAKE FORM