Client Intake Form

Client Intake Form

Thank you for choosing Certitude Financials. We kindly request specific information to initiate the preparation of your income tax return. Please ensure you have all the necessary documents ready before submitting your information.Important: We require a separate form for each individual whose taxes we prepare for the respective tax year. The taxpayer must submit their information, as certain sections require their digital signature.
Filing Status
How were you referred to us?

Name

First NameLast Name
Filing Status
Age
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
Please upload the taxpayer's Photo Identification.

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Please upload the Taxpayer's Social Security Card.

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Please upload your proof of residency. (ex. ex. mortgage statement, utility bill, lease or rental agreement, bank statement, property tax bill, homeowner’s or renter’s policy, government mail (IRS, SSA, DMV)

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Were you issued an Identity Protection PIN (IP PIN) by the IRS?
If yes, please upload your IRS document that includes your IP PIN.

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Were you employed at any time last year and received or expect to receive a W-2 statement?
Please upload your W-2 forms received.

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Are you a full-time student?
If yes, please upload your 1098-T form.

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Are you totally and permanently disabled?
Are you legally blind?
Do you have any dependents that you will claim on your current tax return?
Did you receive health insurance through the Marketplace in the current filing year?
If yes, please upload your 1095-A Tax Statement.

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Did you pay any medical or dental expenses in the current tax year? (this does not include insurance premiums)
If yes, please update your documents.

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Did you receive unemployment benefits?
If yes, please upload tax form 1099G.

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Do you have any gambling winnings in the current tax year?
Did you sell, acquire, send, receive or exchange any virtual currency?
Did you receive social security benefits in the previous year?
Did you receive any payments for goods or services for transactions of $600 or more through any third-party merchants?
If yes, please upload your 1099-K form.

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Household workers

Individuals who hire household employees (e.g., nannies, babysitter, housekeepers, caregivers, yard workers paid directly.)

If yes, please provide the following information:

Rows	Name	Type of household employee(s) Nanny, babysitter, caregiver, housekeeper, other	Amount Paid
Employee 1
Employee 2
Employee 3
Employee 4
Employee 4
Employee 5
Employee 6
Employee 7
Employee 8
Employee 9
Employee 10

Please upload proof of payments paid to household workers.

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If you receive a tax refund, how do you want to be paid?
Would you like to see if you pre-qualify for same day advances?
Would you like your tax refund direct deposited into your bank account?
Please provide your bank account information if you choose to be paid by direct deposit.
Name of Bank
Please provide your bank routing number.
Please provide your bank account number.
Please upload confirmation of your routing and account number.

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Enter your dependents here

Rows	Name	Date of Birth	Relationship
1
2
3
4
5
6

Does you, your spouse, and your dependents have health insurance within 12 months last year? If yes, who covers for it?

Rows	Yes/No	Employer	Spouse Ins	Exchange/ Marketplace	Direct with Insurer	Medicare	Medicaid
Taxpayer
Spouse
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5

Please upload the social security card for the dependent(s).

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Please upload the birth certificate for the dependent(s).

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Please upload proof of qualifying dependents (ex. school records (report card, enrollment letter, attendance record), daycare or head start records, medical records (doctor, clinic, hospital).

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Tax Year
I affirm under penalty of perjury that the information below is true and correct.
Date of Birth

MonthDayYear
Date
SSN (Last 4 digits)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dependent Information
Please include the name, date of birth, and the relationship to taxpayer for each dependent.
Residency Statement
The dependent resided with me:
From blank to blank
Supporting Documentation Provided (check all that apply)
Certification

I hereby declare under penalty of perjury that the information provided above is true, accurate, and complete to the best of my knowledge.
Signature
Date

MonthDayYear
Date

Tax Year
Taxpayer Information
Name

First NameLast Name
SSN (Last 4 digits)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dependent Information
Please include the name, date of birth, and the relationship to taxpayer for each dependent.
I certify that I have conducted reasonable due diligence to verify that the above-named dependents) qualify under IRS rules for the applicable tax benefits, including but not limited to Child Tax Credit, Earned Income Credit, Additional Child Tax Credit, and Head of Household filing status.

I acknowledge that providing false or misleading information may result in:
- Denial of tax benefits
- Repayment of refunds
- Penalties, interest, and potential IRS examination
Supporting Documentation Provided (check all that apply)
Certification

I hereby declare under penalty of perjury that the information provided above is true, accurate, and complete to the best of my knowledge.
Signature
Date

MonthDayYear
Date

Are you a small business owner or an independent contractor?
Please provide your business name.
Please upload your business documents.

LLC, EIN document, business statements, etc.
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Please upload receits and documents for the following business expenses:
- Advertising,
- Supplies
- Insurance
- Repairs and Maintenance
- Legal and Professional services
- Commission
- Taxes and License
- Misc. Items
- Office Equipment
- Any Expenses That Are Used to Operate Your Business
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Please provide proof of the folowing personal expenses:
- Real-estate Taxes
- Mortgage Interest
- Employee Business Expenses
- Moving Expenses
- Tithes and offering
- Charitable Donations
- Student Loan Interest
- Private Mortgage Insurance
Did you make any charitable contributions in 2024? (Goodwill, Salvation Army, Church, etc.)?

General Expenses

Rows	Amount
Medical Expenses
Dental Expenses
Insurance Premiums paid
Long Term Care Premiums
Prescription Drugs and Medications
Home Mortgage
Investment Interest
Cash Contributions
Non-Cash Contributions
Unreimbursed Business Expenses
Union Dues
Tax Preparation Fees
Investment Expenses

Total Expenses
Please upload supporting documents and/or proof of expenses.

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Additional comments

Client Engagement Agreement

Certitude Financials

Dear Taxpayer,

Thank you for choosing Certitude Financials to assist with preparing your income tax returns. To ensure a clear understanding of our professional relationship and services, please carefully review the terms outlined below.

Scope of Services

We will prepare your income tax returns based exclusively on the information you provide. Upon completion, your original tax documents will be returned to you. While we may retain scanned copies of your records for our files, it is your responsibility to keep all relevant documentation that supports the income, deductions, and credits claimed on your tax returns.

These documents may include but are not limited to:
    •    Records of expenses for meals, travel, entertainment, and business gifts.
    •    Receipts for charitable contributions.
    •    Logs or records for vehicle use (if applicable).
    •    Bank and credit card statements.

It is critical to retain these documents to validate the accuracy of your tax returns, particularly if they are selected for examination by taxing authorities. We recommend retaining all records and copies of your tax returns for at least five years after filing or the due date, whichever is later.

Limitations of Services

Our work in preparing your income tax returns does not include:
    •    Detecting or addressing errors, irregularities, or illegal acts such as fraud.
    •    Audit or examination representation (unless separately agreed upon).
    •    Compliance services related to payroll taxes, sales taxes, excise taxes, property taxes, or licensing.

We will use our professional judgment to resolve any unclear tax laws or conflicting positions. When possible, we will adopt tax positions in your favor, provided they are reasonable and supportable. However, we cannot guarantee that these positions will not be challenged by taxing authorities or predict the outcome of such challenges.

Fee Structure and Payment Policy

Our fees are determined based on a “per form” basis, along with time spent by our staff and costs incurred during tax preparation (e.g., copying, long-distance calls, and computer processing).

Payment Terms:
    •    Fees are due upon completion of your tax returns.
    •    Tax returns and related documents will not be released until payment is made in full.
    •    If legal action is required to collect unpaid fees, you may be held responsible for any legal costs incurred.

Estimates:
We strive to provide fee estimates before completing your returns. However, unforeseen circumstances may affect the final cost. If adjustments are required, we will inform you promptly.

Tax Return Completion and Filing

Once your returns are completed and fees are paid, we will provide you with:
    •    A copy of your tax returns.
    •    E-file signature authorizations (if applicable).
    •    Payment vouchers, if needed, to complete your filing.

You are responsible for reviewing the completed returns for accuracy. If corrections are needed, notify us immediately, and we will make the necessary adjustments.

Important Notes:
    •    Taxing authorities require signed authorization before we can e-file your returns.
    •    For paper filings, we will provide you with signed copies to submit directly.

Termination and Additional Services

Should you terminate this engagement before we complete your tax returns, you may be invoiced for:
    •    Time incurred at our hourly rate.
    •    Out-of-pocket expenses.

Audit or examination representation is not included in our standard tax preparation fee and requires a separate agreement. If desired, you may opt into our Audit Maintenance Protection, which covers basic representation services in the event of an audit.

Confidentiality and Privacy

Your privacy is a top priority at Certitude Financials. We will safeguard your personal information and never sell or disclose it to third parties. However, we may use your information for limited internal purposes, such as sending newsletters, holiday greetings, or birthday messages. By signing this agreement, you consent to these uses.

Acknowledgment and Agreement

By signing this agreement and providing us with your tax information, you confirm your understanding and acceptance of the terms outlined herein.

We appreciate your trust in Certitude Financials and look forward to serving you.
Signature
Date

MonthDayYear
Date

Acknowledgment and Agreement

I acknowledge that all information provided to Ceritude Financials is true and accurate to the best of my knowledge. I understand that I am responsible for maintaining supporting documentation to validate the information provided. Furthermore, I understand that knowingly providing false information on my tax return and submitting it to the IRS constitutes a potentially criminal offense punishable by law. This may include court proceedings, restitution, and possible imprisonment.

I waive Ceritude Financials and its preparers of any liability for errors caused by incorrect information I have provided. I authorize Ceritude Financials by signing below to file my tax return.

Additionally, I understand that if I and/or my spouse owe a federal or government debt (e.g., IRS, child support, student loans), we remain responsible for paying the tax preparation fees to 5 Shades of Harmony Tax Services at the time of service. If the federal refund is issued via mail or otherwise withheld, I/we are still obligated to pay the tax preparation fees as indicated on the invoice.

If tax preparation fees are not paid, I acknowledge that Ceritude Financials reserves the right to pursue legal action to collect any unpaid fees.
Signature
Date

MonthDayYear
Date
Should be Empty:

Client Intake Form

Household workers

Residency Statement

Certification

Taxpayer Information

Certification

Personal Information `

Coverage Details

Health & Medical

Lifestyle & Background