Client Tax Intake Form

Client Intake Form
Marital Status
Taxpayer Name

First NameLast Name
Taxpayer Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Taxpayer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Taxpayer Phone Number
Format: (000) 000-0000.
Taxpayer SSN
XXX-XX-XXXX
Taxpayer Email Address
example@example.com
Taxpayer Occupation
Taxpayer's Driver's License

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Taxpayer's Social Security Card(s)

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Spouse Name

First NameLast Name
Spouse Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Spouse SSN
XXX-XX-XXXX
Spouse Email Address
Spouse Occupation
Spouse Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse Phone Number
Format: (000) 000-0000.
Spouse Email Address
example@example.com
Taxpayer's W-2/1099s

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Are you self employed?
Name of your business?
Example: ASG Essential Services
How much did you make for the year with self employment?
Example: $10,000
How much was your expenses for the year with self employment?
Example: $5,000
Self-employment records/ receipts

Example: Cash app transactions/bank statements/receipts
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Did you support a child or family member for more than 6 months out of the year?

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

Dependent(s) Social Security Card(s)

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Dependent(s) Birth Certificate(s)

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Are there any dependents in daycare? If yes, please upload the form you recieved from your daycare provider.
Upload a copy of your daycare form here.

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

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CLIENT NON PAYMENT/OFFSET CLAUSE

At ASG Essential Services, I strive to assist all of my clients with their tax needs; however, I understand that unexpected situations may arise. If your refund is offset by the IRS, student loans, child support, or if your check is mailed, you are still obligated to pay the fees associated with filing your tax return.
I give ASG Essential Services permission to prepare all forms related to my tax return, to file on my behalf, and to submit my taxes electronically. I take full responsibility for the accuracy of the information provided and understand that ASG Essential Services is not responsible for any misrepresentation or false claims.
ADDITIONAL SERVICES

At ASG Essential Services, I provide more than just tax preparation. Please comment below if you are interested in any of the additional services I offer. I can schedule a time to speak with you at your convenience.
Type a question
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty:

Client Intake Form

HEALTH INSURANCE COVERAGE: