Tax Preparation Client Intake Form

Tax Preparation Client Intake Form

Submit your information to EmpowerMint Financial Group for professional tax preparation.
Select the filing tax year (Check all that apply)
Your Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Primary Taxpayer – 6-Digit IP PIN
Please ensure you have not been issued a IPPIN
Filing Status (Will Be Verified)
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Spouse – 6-Digit IP PIN (if applicable)
Social Security Number:
Email Address
example@example.com
If more than one IP PIN was issued, each IP PIN must be assigned to the correct individual listed on the return.
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Spouse Name (If Applicable)

First NameLast Name
Spouse SSN/ITIN
Spouse Identification Number
Driver License, State Identification
Dependents Information
Do you have any dependents to claim?
Dependent Information (Name, Relationship, Date of Birth) (Complete only if you have dependents)
Dependent IP PIN Assignment
Dependents Social/ITIN
Banking Information
Routing Number
Account Number
What is your tax filing status?

Other
PRIOR IRS AUDIT HISTORY
Have you or anyone listed on this tax return been audited by the IRS in a prior tax year?
Audit Details
What types of income did you have in the past year? (Select all that apply)

Other
MARKETPLACE HEALTH INSURANCE (ACA)
You may be required to provide Form 1095-A if Marketplace insurance was held.
Did you or anyone on this tax return have Marketplace (Affordable Care Act) health insurance during the tax year?
Not sure if you had Marketplace insurance? You can verify here: https://www.healthcare.gov/tax-form-1095/
Which deductions or credits may apply to you? (Select all that apply)

Other
Did you file a tax return last year?
Upload last year's tax return (optional)

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Upload Verifying Documents (Driver License or I.D., Birth Certificates, Social Security Cards)

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Upload Additional Forms (if available)

1099,1099-SA,1095-A etc.
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REFUND ADVANCE / PRE-ADVANCE LOAN
Are you interested in a Refund Advance (Pre-Advance Loan), if eligible?
Refund advances are not guaranteed. Loan terms, amounts, and timing are determined by the participating financial institution. Please note not credit based.
After submitting this form, you will receive a confirmation email with client onboarding information. Key information you are responsible for any unpaid service fee. You'll be responsible for the preparer fee $250minimum if a service is provided and balance is not satisfied.
Should be Empty:

Tax Preparation Client Intake Form

Dependents Information

Banking Information

PRIOR IRS AUDIT HISTORY

MARKETPLACE HEALTH INSURANCE (ACA)

REFUND ADVANCE / PRE-ADVANCE LOAN