Tax Preparation Client Intake Form
Welcome returning and new clients!
***Please note that we do not provide free estimates . If you are only seeking an estimate, please inform the preparer upfront. A $75 consultation fee applies***
Filing Status/ Informacion de declaracion
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Single/ Soltero
Head of Household/ Jefede familia
Married Filing Separate/ Casado declaracion separada
Married Filing Joint/ Casado Declaracion conunta
Qualifying Widower/ Viudo(a) calificado
Income/ Ingresos
*
W2
Unemployment/ Desempleo
1099 (self employment, contract, gig, etc.)/ Trabajo por cuenta propia, contrato, etc.)
Social Security/ Seguro Social, Pension
Other
Taxpayer Information
Name/ Nombre
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First Name/ Primer Nombre
Last Name/ Apellido
Date of Birth/ Fecha de Nacimiento
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-
Month
-
Day
Year
Phone Number/ Numero de telefono
*
Email/ Correoelectronico
*
example@example.com
Address/ Direccion
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation/ Occupacion
*
Spouse Information/ Informacion de conyuge
Spouse Name/ Nombre
First Name
Last Name
Date of Birth/ Fecha de Nacimiento
-
Month
-
Day
Year
Date
Phone Number/ Numero de telefono
Please enter a valid phone number.
Spouse Email/ Correo electronico
example@example.com
Address/ Direccion
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation/ Occupacion
Are they your dependent?/ Es tu dependiente?
Yes
No
Dependents/ Dependent
Enter your dependents here/ Ingrese sus dependientes
Name
Date of Birth
Relationship
1
2
3
4
5
6
Does you, your spouse, and your dependents have health insurance within 12 months last year? If yes, who covers for it?/ ¿Usted, su cónyuge y sus dependientes tienen seguro de salud dentro de los últimos 12 meses? Si es así, ¿quién lo cubre?
*
Yes/No
Employer
Spouse Ins
Exchange/ Marketplace
Direct with Insurer
Medicare
Medicaid
Taxpayer
Yes
No
Spouse
Yes
No
Dependent 1
Yes
No
Dependent 2
Yes
No
Dependent 3
Yes
No
Dependent 4
Yes
No
Dependent 5
Yes
No
Tax Related Questions/ Preguntas relacionadas con impuestos
Did you file a return last year? / ¿Presentaste una declaración el año pasado?
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Yes
No
If so, who prepared your taxes?
Yes
Did you owe a balance? / ¿Debías un saldo?
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Yes
No
Have you been audited in the past 3 years? /¿Ha sido auditado en los últimos 3 años?
*
Yes
No
Deductions & Credits/ Deduciones y Creditos
Childcare expenses/ Gastos de cuidado de nino
Mortgage interest/ Interes de hipoteca
Education Expenses/ Gastos de educacion
Medical Expenses/ Gastos Medicos
Charitable contributions/ Donaciones caritivas
Other
Business Expenses (If applies)/ Gastos de Negocio (si aplica)
General Expenses
Amount
Medical Expenses
Dental Expenses
Insurance Premiums paid
Long Term Care Premiums
Prescription Drugs and Medications
Home Mortgage
Investment Interest
Cash Contributions
Non-Cash Contributions
Unreimbursed Business Expenses
Union Dues
Tax Preparation Fees
Investment Expenses
Total Expenses
Document Upload/ Subida de Documentos
Income Forms (W2, 1099)/ Formas de Ingreso
Browse Files
Drag and drop files here
Choose a file
Cancel
of
SS Cards/ Seguro Social
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
IDs/ Identificaciones
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Any other documents
Browse Files
Drag and drop files here
Choose a file
Cancel
of
How did you hear about Tax Lounge? ** (IF AN INDIVIDUAL PLEASE LIST THEIR NAME**) ¿Cómo te enteraste de nosotras? SI ALGÚN INDIVIDUO, POR FAVOR ENUMERE SU NOMBRE
*
Acknowledgment & Signature/ Reconocimiento y Firma
I confirmed that all information I entered here is accurate and true.
I allow Tax Lounge to capture my sensitive data like personal id, government id, and other information.
I have read the terms and conditions and privacy policy of Tax Lounge.
By signing below, you acknowledge that you have read and understood your responsibilities and our responsibilities in doing this tax return.
I agree that this information is provided with the intent of filing a complete tax return with Tax Lounge. A Tax Lounge Rep must be notified upfront if in need of estimate/consultation only. There is a fee for consultation/estimate ONLY.
I understand that Tax Loungr does NOT offer free estimates.
Do you have an identity protection pin (IP PIN) needed to file your return electronically (if so, please enter below) ¿Tiene un número de identificación personal (IP PIN) necesario para presentar su declaración electrónicamente? (si es así, por favor ingréselo abajo)
*
Have you received assistance or insurance through health insurance marketplace or required to file a form 1095-A with return to reconcile Premium Tax Credits
*
Taxpayer Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Spouse Signature
Date Signed
-
Month
-
Day
Year
Date
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