Tax Return Questionnaire 2022

Tax Intake Form
Taxpayer Information
Marital Status*

SingleMarried Filing JointlyMarried Filing SeparatelyHead of HouseholdQualifying Widow(er) with Dependent Children
Taxpayer Name*

First NameLast Name
Taxpayer Date of Birth*

MonthDayYear
Date
Taxpayer Occupation
Check all that apply:

Can you be claimed as a dependent on someone else's returnWere you over age 18 and a full-time student at an eligible educational institution.Taxpayer is blind.Taxpayer is deceased.Taxpayer or Spouse served in a combat zone during the current tax year.Taxpayer wishes to elect to use their 2019 earned income to figure their 2021 earned income credit and/or child tax credit.Taxpayer or Spouse was affected by a natural disaster during the current tax year.Taxpayer has received, sold, sent, exchanged, or otherwise acquired financial interest in virtual currency during the current tax year.Taxpayer prefers to receive written communications from the IRS in a language other than English.Taxpayer prefers to receive written communications from the IRS in an accessible format.
Spouse Name

First NameLast Name
Spouse Date of Birth

MonthDayYear
Date
Spouse Occupation
Check all that apply:

Can you be claimed as a dependent on someone else's returnWere you over age 18 and a full-time student at an eligible educational institution.Taxpayer is blind.Taxpayer is deceased.Taxpayer or Spouse served in a combat zone during the current tax year.Taxpayer wishes to elect to use their 2019 earned income to figure their 2021 earned income credit and/or child tax credit.Taxpayer or Spouse was affected by a natural disaster during the current tax year.Taxpayer has received, sold, sent, exchanged, or otherwise acquired financial interest in virtual currency during the current tax year.Taxpayer prefers to receive written communications from the IRS in a language other than English.Taxpayer prefers to receive written communications from the IRS in an accessible format.
Taxpayer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Taxpayer Phone Number*
Spouse Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse Phone Number
Taxpayer Email Address
example@example.com
Spouse Email Address
example@example.com

DEPENDENTS INFORMATION

	FULL DEPENDENT NAME	DATE OF BIRTH	# OF MONTHS DEPENDENT RESIDE WITH TAXPAYER
DEPENDENT 1
DEPENDENT 2
DEPENDENT 3
DEPENDENT 4
DEPENDENT 5

Do you have a "Special Needs" child?

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

Cancelof
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

Cancelof
Wages and Salaries (Attach W-2's)

Interest Income (Attach 1099's) (List and identify as non-taxable Interest Income)

Unemployment Compensation Received (FORM 1099G) PLEASE UPLOAD FORM BELOW:
File Upload

Cancelof
STOP!
Did you finish uploading your documents?
IF YOU DID NOT UPLOAD ALL NECESSARY DOCUMENTS YOUR INTAKE FORM WILL BE VOIDED.
If your refund is offset by the IRS, student loans, child support or your check is mailed, you are still obligated to pay our company the fees associated with filing your tax return.

By signing this agreement you acknowledge that if payment is not made in full within 30 days legal actions will be sought to resolve payment.
If you would like your tax refund (if any) deposited directly into your bank*

CheckingSavingsPaper Check
Bank Name
Your Account Number
Bank Routing Number
Rental & Royalty Income and Expense (Rental Property)

(COMPLETE IF YOU OWN A PROPERTY)
Property Type

ResidentialCommercial
Number of days rented
Number of days used personally
Property is owned by

TaxpayerSpouseJoint
Percentage ownership of not 100%: Please indicate if income and expenses below are listed at 100% or your percentage

YesNo
Percentage ownership of not 100%
Did you live in part of the rental property?
If yes, what percentage did you occupy as a tenant?

Check if rented to a related party. Explain relation
If yes, what percentage did you occupy as a tenant?
Business Income & Expenses (Sole Proprietorship, LLC)
Owner Name

First NameLast Name
Business name
Employer ID number
Business Type
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer ID number (EIN)
Do you use any part of your home regularly and exclusively for business?

YesNo
Description of work done in home office
Total area of home used regularly for business
Please upload any additional tax documents below: Prior Year Tax Returns, ETC.

Cancelof
Does anyone listed on the Tax Return have an Identity Pin? If so, please list the name and Identity Pin below:
Client Responsibility & Service Disclosure

By continuing, you acknowledge and agree to the following:

Qualitas Choice Service Group will prepare and electronically file your federal and applicable state income tax returns based solely on the information you provide.
You are responsible for providing complete and accurate information and for keeping your tax records and supporting documents.
You agree to review your tax return for accuracy before authorizing electronic filing (IRS Form 8879).
If you choose a refund advance or refund transfer, you authorize us to:
- Use your tax information to apply for the bank product
- Deduct approved tax preparation fees from your refund
- Share required information with the participating financial institution
- Approval, funding, and processing of bank products are determined by the financial institution and tax authorities, and additional fees may apply.
  Qualitas Choice Service Group is not responsible for penalties, interest, delays, or refund changes resulting from incomplete, incorrect, or omitted information.
  By signing you “Agree,” you confirm that you understand and accept these terms.
Please upload a current picture of taxpayer*

Cancelof
BEFORE YOU SUBMIT GO BACK AND REVIEW

Make sure you have uploaded current and valid documents. If we find that you are missing documents or documents are not valid, we will place your return on hold and WILL NOT EFILE until we receive the proper documents.
Signature

Powered by Jotform SignClear
Should be Empty:

Tax Intake Form

Taxpayer Information

HEALTH INSURANCE COVERAGE: