Tax Client Intake Form
Personal Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
SSN
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Job title or put N/A
Tax Filing Status
*
Single
Married filing jointly
Married filing separately
Head of household
Qualifying widow(er) with dependent child
Are you interested in getting a cash advance of up to $7,500?
*
Yes
No
Are you self employed?
*
Yes
No
Are you trying to become a homeowner within the next 2 years?
*
Yes
No
Did you receive health insurance through marketplace? 1095-A form
*
Yes
No
Did you owe debt any government agency, such as the IRS, student loans,child support etc?
*
Yes
No
Did any of your dependents attend college in 2025?
*
Yes
No
Do you or your dependents have a IRS PIN?
*
Yes
No
IRS PIN
Are you interested in credit repair ?
*
Yes
No
Income (Check all that apply)
W2
Self Employed
1099
Other
Bank Information
How would you like to receive your tax refund?
*
Direct Deposit
Cash Card
Check (Only available for in office visits)
Which type of account would you like your refund deposited into?
*
Checking Account
Savings Account
Other
Name Of Bank
*
Ex: Pnc,regions wtc.
Account number
*
Routing number
*
Dependents Information
Dependents
Upload Documents Here
Taxpayer's driver license/State ID
*
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Taxpayer's social security card
*
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Dependent(s) Social security card (s)
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Dependent (s) birth certificate(s)
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If you have a 1098-T, upload here
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Healthcare and insurance documents ( For 1095-A marketplace)
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of
Additional Information
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Please sign below to confirm that all information is correct and accurate and to authorize to file or prepare a free estimate.
*
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