CLIENT INTAKE FORM

Golden Roots Tax Solutions Client Intake Form

PLEASE DO NOT FORGET TO UPLOAD A DRIVERS LICENSE OR ID FOR THE TAXPAYER AND TWO FORMS OF ID FOR EACH DEPENDENT.
Full Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Birth Date

MonthDayYear
Social Security Number
Occupation/Title
Who referred you?
Filing Statues
Check All That Applies
Are you a recipient of Obama Care or did you purchase Medical Insurance from the federal marketplace? If so, please provide form 1095A in the upload section at the bottom of this application:
Has the dependent lived with you at least half of the year?

Dependent Information

Do you receive Social security benefits? If you do, we want to ensure that you stay within the income guidelines to continue receiving your benefits.
Approximately how much was your tax refund last year after fees?
ACCEPTABLE FORMS OF ID ARE SOCIAL SECURITY CARD, BIRTH CERTIFICATE, MEDICAL RECORD, SCHOOL RECORD, WRITTEN LEDGER, RECEIPTS, W2 ETC

Cancelof
Date

MonthDayYear
Date
Signature

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
Should be Empty:

Golden Roots Tax Solutions Client Intake Form