Client Intake & Consent Form

Client Intake & Consent Form

Richman Elite Financial & Realty Services (REFRS) “Where Purpose Fuels Prosperity and Legacy Lasts Forever.” 📞 (407) 587-6476 | 🌐 WWW.REFRS.NET 📧 RichmanEliteFinancialRealtyServices@outlook.com
Filing Status*

SingleMarried Filing JointlyMarried Filing SeparatelyHead of HouseholdQualifying Widow(er)
Primary Taxpayer Full Name*

First NameLast Name
Primary Taxpayer Date of Birth*

MonthDayYear
Date
Primary Taxpayer Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Primary Taxpayer Phone Number*
Please enter a valid phone number.
Primary Taxpayer Email Address*
example@example.com
Primary Taxpayer Occupation*
Primary Taxpayer Preferred Contact Method*

PhoneTextEmail
Spouse Information
Spouse Full Name *

First NameLast Name
Spouse Date of Birth*

MonthDayYear
Date
Spouse Phone Number*
Please enter a valid phone number.
Spouse Email*
example@example.com
Preferred Spouse Contact Method*

EmailTextCall
Spouse Occupation*
Same address as your spouse?*

YesNo
Months Lived with Spouse(Months separated, if applicable)
Spouse Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Dependent Full Name

First NameLast Name
Relationship to Client
Months Lived with Client
Dependent Date of Birth

MonthDayYear
Date
Dependent Full Name

First NameLast Name
Relationship to Client
Months Lived with Client
Dependent Date of Birth

MonthDayYear
Date
Dependent Full Name

First NameLast Name
Relationship to Client
Dependent Date of Birth

MonthDayYear
Date
Months Lived with Client
Tax Documents Provided

W-2s1099s1098 (Mortgage/School)Childcare ExpensesSelf-Employment IncomeBusiness DocumentsHealth Insurance Form 1095-AIdentificationSocial Security Card(s)Child Birth CertificateDriver LicenseOther
File Upload*

Cancelof
Other Documents Description
File Upload

Cancelof
Health Insurance Marketplace.(Form 1095-A) Acknowledgment.

If you or anyone in your household had health insurance through the Health Insurance Marketplace (also known as Obamacare or Healthcare.gov), you are required by law to provide Form 1095-A before your tax return can be filed. If you choose not to upload this form or indicate that you do not have it, I/We cannot legally file your tax return. The IRS will not accept the return without accurate information from your Form 1095-A. If you cannot locate your Form 1095-A, please contact the Health Insurance Marketplace at 1-800-318-2596 to request a copy or download it from your Healthcare.gov account.
Did you or anyone in your household have Marketplace health insurance (Healthcare.gov) in 2025?”*

YesNo
File Upload

Cancelof
Do you and your spouse have the same bank account?*

YesNo
Primary Taxpayer Bank Name
Primary Taxpayer Name on Account
Primary Taxpayer Account Type

CheckingSavings
Primary Taxpayer Account Routing Number
Primary Taxpayer Account Number
Spouse Bank Name
Spouse Name on Account
Account Type

CheckingSavings
Spouse Account Number
Spouse Routing Number
Representation and Audit Support*

NO. If I decline, I understand that I am responsible for handling all IRS or state correspondence directly.Yes. If I purchase Audit Protection, REFRS will provide representation support in the event of an IRS or state audit.
Authorization to Prepare and File*
Responsibility for Accuracy*
Communication Consent*
Data Privacy and Confidentiality*
Refund and Payment Acknowledgment*
Consent for Record Retention*
Date of Primary Taxpayer Signature*

MonthDayYear
Date
Primary Taxpayer Signature*

Powered by Jotform SignClear
By signing below, I acknowledge that I have read, understood, and agree to all policies, authorizations, and consents outlined in this form. I certify that the information provided is true and that I have the legal right to file under the taxpayer name(s) listed above.
Date of Spouse Taxpayer Signature*

MonthDayYear
Date
Spouse Signature (if applicable)*

Powered by Jotform SignClear
By signing below, I acknowledge that I have read, understood, and agree to all policies, authorizations, and consents outlined in this form. I certify that the information provided is true and that I have the legal right to file under the taxpayer name(s) listed above.
Should be Empty:

Client Intake & Consent Form

Spouse Information

Health Insurance Marketplace.(Form 1095-A) Acknowledgment.