Tax Filing Intake Form

Tax Filing Intake Form
Taxpayer Information
Marital Status*

SingleMarried Filing JointlyMarried Filing SeparatelyHead of HouseholdQualifying Widow(er) with Dependent Children
Taxpayer Name*

First NameLast Name
SSN # & Picture of Card*
Taxpayer Date of Birth*

MonthDayYear
Date
Taxpayer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Format: (000) 000-0000.
Email Address*
example@example.com
Taxpayer Occupation (if applicable)
Check all that apply:

Can you be claimed as a dependent on someone else's returnWere you over age 18 and a full-time student at an eligible educational institution.Taxpayer is blind.Taxpayer is deceased.Taxpayer has received, sold, sent, exchanged, or otherwise acquired financial interest in virtual currency during the current tax year.Taxpayer prefers to receive written communications from the IRS in a language other than English.Taxpayer prefers to receive written communications from the IRS in an accessible format.Taxpayer paid for childcare
Dependents Name #1 (leave blank if N/A)

First NameLast Name
SSN # + Photo of SS Card (Photo required if you are not parent)
Date of Birth

MonthDayYear
Date
Dependents Name #2 (leave blank if N/A) (Photo required if you are not parent)

First NameLast Name
SSN # + Photo of SS Card
Date of Birth

MonthDayYear
Date
Dependents Name #3 (leave blank if N/A) (Photo required if you are not parent)

First NameLast Name
SSN # + Photo of SS Card
Date of Birth

MonthDayYear
Date

DEPENDENTS INFORMATION

Rows	FULL DEPENDENT NAME	DATE OF BIRTH	# OF MONTHS DEPENDENT RESIDE WITH TAXPAYER
DEPENDENT 1
DEPENDENT 2
DEPENDENT 3
DEPENDENT 4
DEPENDENT 5

Do you have a "Special Needs" child?

YesNo
HEALTH INSURANCE COVERAGE:
DID YOU RECEIVED HEALTH COVERAGE (INSURANCE) THROUGH YOUR STATE MARKETPLACE OR HEALTHCARE.GOV? IF SO, PLEASE UPLOAD YOUR FORM 1095A
Please upload 1095A

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Wages and Salaries (Attach W-2's)

Interest Income (Attach 1099's) (List and identify as non-taxable Interest Income)

Unemployment Compensation Received (FORM 1099G) PLEASE UPLOAD FORM BELOW:
File Upload

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Were you, your spouse, or any dependent registered in college? Do you have a form 1098T?
File Upload

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If you would like your tax refund (if any) deposited directly into your bank

CheckingSavings
Bank Name
Your Account Number
Bank Routing Number
If Filing As A Businesss Owner

Business Income & Expenses (Sole Proprietorship, LLC)
Owner Name

First NameLast Name
Business name
Employer ID number
Business Type
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer ID number (EIN)
Do you use any part of your home regularly and exclusively for business?

YesNo
Estimated percentage of time spent in home office compared to total time spent in this business
Estimated of time in home office compared to total time in this business
Description of work done in home office
Description of work done outside of work office
Total area of home
Total area of home used regularly for business
Please upload any additional tax documents below:

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Does anyone listed on the Tax Return have an Identity Pin? If so, please list the name and Identity Pin below:
Signature*
Would You like a Tax Refund Advance? (yes or no)*
Todays Date*

MonthDayYear
Date
Should be Empty:

Tax Filing Intake Form

Taxpayer Information

HEALTH INSURANCE COVERAGE: