Clone of QTS Client intake form (2025 TS)

CLIENT IN-TAKE FORM

Name

First NameMiddle NameLast Name
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
SSN
YesNo
YesNo

Dependent 1
Name

First NameMiddle NameLast Name
SSN
Date of Birth

MonthDayYear
Date
Relationship
Why are the parents not claiming the dependent?*
YesNo
YesNo
YesNo
YesNo
YesNo
Child supportFood StampsMedicareMedicaid/ Hoosier HealthwiseWICWelfareHousing/Utility assistanceDay Care BenefitsHelp from FamilySocial Security Benefits $ __/ monthOther
Social Security Benefits $ _____________ / month (if dependent receives social security, how much?)
I paid more than 50% of dependent's supportDependent paid more for his/her support than I did
YesNo
YesNo
What is the higher income person’s relationship to the dependent?
Signature

Clear
Date

MonthDayYear
Date
YesNo
Dependent 2
Name

First NameMiddle NameLast Name
SSN
Date of Birth

MonthDayYear
Date
Relationship*
Why are the parents not claiming the dependent?*
YesNo
YesNo
YesNo
YesNo
YesNo
Child supportFood StampsMedicareMedicaid/ Hoosier HealthwiseWICWelfareHousing/Utility assistanceDay Care BenefitsHelp from FamilySocial Security Benefits $ __/ monthOther
Social Security Benefits $ _____________ / month (if dependent receives social security, how much?)
I paid more than 50% of dependent's supportDependent paid more for his/her support than I did
YesNo
YesNo
What is the higher income person’s relationship to the dependent?
Signature

Clear
Date

MonthDayYear
Date
YesNo
Dependent 3
Name

First NameMiddle NameLast Name
SSN
Date of Birth

MonthDayYear
Date
Relationship*
Why are the parents not claiming the dependent?*
YesNo
YesNo
YesNo
YesNo
YesNo
Child supportFood StampsMedicareMedicaid/ Hoosier HealthwiseWICWelfareHousing/Utility assistanceDay Care BenefitsHelp from FamilySocial Security Benefits $ __/ monthOther
Social Security Benefits $ _____________ / month (if dependent receives social security, how much?)
I paid more than 50% of dependent's supportDependent paid more for his/her support than I did
YesNo
YesNo
What is the higher income person’s relationship to the dependent?
Signature

Clear
Date

MonthDayYear
Date
YesNo
Dependent 4
Name

First NameMiddle NameLast Name
SSN
Date of Birth

MonthDayYear
Date
Relationship*
Why are the parents not claiming the dependent?*
YesNo
YesNo
YesNo
YesNo
YesNo
Child supportFood StampsMedicareMedicaid/ Hoosier HealthwiseWICWelfareHousing/Utility assistanceDay Care BenefitsHelp from FamilySocial Security Benefits $ __/ monthOther
Social Security Benefits $ _____________ / month (if dependent receives social security, how much?)
I paid more than 50% of dependent's supportDependent paid more for his/her support than I did
YesNo
YesNo
What is the higher income person’s relationship to the dependent?
Signature

Clear
Date

MonthDayYear
Date
YesNo
Dependent 5
Name

First NameMiddle NameLast Name
SSN
Date of Birth

MonthDayYear
Date
Relationship*
Why are the parents not claiming the dependent?*
YesNo
YesNo
YesNo
YesNo
YesNo
Child supportFood StampsMedicareMedicaid/ Hoosier HealthwiseWICWelfareHousing/Utility assistanceDay Care BenefitsHelp from FamilySocial Security Benefits $ __/ monthOther
Social Security Benefits $ _____________ / month (if dependent receives social security, how much?)
I paid more than 50% of dependent's supportDependent paid more for his/her support than I did
YesNo
YesNo
What is the higher income person’s relationship to the dependent?
Signature

Clear
Date

MonthDayYear
Date

Did you, your spouse, and your dependents have health insurance in 2025? If yes, who paid 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

File Upload*

Cancelof

I confirm that all information I entered here is accurate and true. I allow Quantity Tax Sevice to capture my sensitive data like personal id, government id, social security number (SSN), and other information. I have read the terms and conditions and privacy policy of Quantity Tax Service. By signing below, you acknowledge that you have read and understood your responsibilities and our responsibilities in doing this tax return.
Date Signed*

MonthDayYear
Date
Taxpayer Signature*

Clear
Date Signed

MonthDayYear
Date
Spouse Signature

Clear

Type a question

Should be Empty:

CLIENT IN-TAKE FORM

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