Clone of Client Intake form

Taxpayer Name*

First NameLast NameSuffix

Social Security Number*

Date of Birth*

MonthDayYear

Occupation*

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Spouse Information

First NameLast NameSuffix

Social Security Number

Date of Birth

MonthDayYear

Occupation

Email

example@example.com

Phone Number

Please enter a valid phone number.

Address*

NO P O BOX/ PHYSICAL ADDRESS ONLY

Street Address Line 2

CityState / Province

Postal / Zip Code

Filing Status:*

HEAD OF HOUSEHOLD FILERS:To qualify for this filing status, you must provide one of the following documents for verification.

LeaseUtility BillMortgage Statement

Dependent 1

First NameLast NameSuffix

Social Security Number

Date of Birth

MonthDayYear

Relationship

Dependent 2

First NameLast NameSuffix

Social Security Number

Date of Birth

MonthDayYear

Relationship

Dependent 3

First NameLast NameSuffix

Date of Birth

MonthDayYear

Social Security Number

Relationship

IF YOU ARE CLAIMING A DEPENDENT: Please answer the questions below that apply to your relationship with the dependent. As required by the IRS, we must verify that no one else is eligible to claim your dependent other than you.

If you are claiming a niece, nephew, aunt, or uncle: What is your relationship to the dependent? Where are the parents of the dependent (or dependents)?

If you are claiming a brother or sister: What is your relationship to the dependent? Why are the parents not claiming the dependent (or dependents)?

If you are claiming a son or daughter: Where is the other parent of the dependent (or dependents)? Does the other parent provide any financial support?

If low income status. How are you able to provide for the dependents?

Did you pay someone to watch your child/children?

YESNO

Are you married?*

YESNO

Have you been married before?*

YESNO

Can you provide separation/divorce paperwork?*

YESNO

Did you collect social security or retirement income?

YESNO

Did you purchase health insurance through healthcare.gov marketplace (Obama Care)?*

YesNo

If yes, did you receive a 1095-A Form from the marketplace?

YesNo

Were you ever disallowed the E.I.T.C prior to this year?*

YesNo

Did you receive unemployment compensation (1099-G) regular or PUA last year?*

YESNO

If yes, did you receive regular unemployment or PUA?

RegularPUA

Did you make college tuition payments and received a 1098-T Form last year?*

YESNO

Do you have any other income than your w-2(s)?*

YESNO

Do you have an IP Pin?*

YESNO

Choose your trusted tax preparer

IP Pin

Do you owe any delinquent:*

How would you like to receive your refund?*

Refund Transfer Direct DepositRefund Transfer Debit CardRefund Transfer Paper Check

Bank Information

	Name of Bank	Routing Number	Account Number
ENTER BANK DATA

Client Acknowledgment and Agreement:

I hereby state that all information provided above is true and accurate to the best of my knowledge. I authorize PEBA Solutions LLC to prepare my tax return(s) based on the information I have supplied. I understand that I am financially responsible for any balance due resulting from false or incomplete information provided by me.

If there is a balance due, the tax preparation fee must be paid upfront. In the event that my refund is intercepted or applied to an outstanding debt owed to any entity, I understand that I am still responsible for paying the full tax preparation fee for services rendered.

If an amendment must be filed for any reason not caused by an error of the tax preparer, an upfront fee of $150.00 will be required. Please review your tax return carefully — it will be emailed to you prior to submission. Any additional copy requested after the initial one will incur a $10.00 reprint fee.

All bank and service fees are disclosed within your return and are non-refundable and non-negotiable. No exceptions.

To track your refund:

Visit www.irs.gov for federal refunds.
Visit your state Department of Revenue website for state refunds.
Please do not combine federal and state refund amounts when tracking. Allow up to 8 weeks from the submission date before contacting the IRS regarding refund status.

IRS Contact: 1-800-829-1040

To check your federal refund status online, you will need your filing status, Social Security number, and the total refund amount before fees.

https://sa.www4.irs.gov/irfof/lang/en/irfofgetstatus.jsp

Identification*

Social Security Card*

Head Of Household

Dependent Birth Certificate or Certificates

Dependent Social Security Card or Cards

W2 Forms

Self Employment

College Forms

Healthcare Forms

IP Pin (paper from the IRS)

Direct Deposit

Misc. Forms

Previous Year Tax Return (2024 Tax Return If Possible)

Were you referred?*

YesNo

Who referred you?

Signature*

Date

MonthDayYear

Take Photo

Type a question

TAX CLIENT INTAKE