Taxfluence Financial
Client Intake Form
SECTION 1 - PERSONAL INFORMATION
Full Legal Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
*
Email
*
example@example.com
Preferred Contact Method
Phone
Text
Email
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
SECTION 2 - FILING STATUS
FILING STATUS
*
SINGLE
MARRIED FILLING JOINTLY
MARRIED FILLING SEPERATELY
HEAD OF HOUSEHOLD
QUALIFYING WIDOWER
SPOUSE INFORMATION
Spouse Full Name
Spouse SSN
Spouse Date of Birth
-
Month
-
Day
Year
Date
SECTION - 3 DEPENDENTS
Dependent 1 Full Name
Dependent 1 SSN
Dependent 1 Date of Birth
-
Month
-
Day
Year
Date
Relationship
Lived with you all year?
Yes
No
Full-time student?
Yes
No
Disabled?
Yes
No
Dependent 2 Full Name
Dependent 2 SSN
Dependent 2 Date of Birth
-
Month
-
Day
Year
Date
Relationship
Lived with you all year?
Yes
No
Full-time student?
Yes
No
Disabled?
Yes
No
Dependent 3 Full Name
Dependent 3 SSN
Dependent 3 Date of Birth
-
Month
-
Day
Year
Date
Relationship
Lived with you all this year?
Yes
No
Full-time student
Yes
No
Disabled
Yes
No
SECTION 4- INCOME SOURCES
Income Information
Select all income types received
W-2 Income
1099-NEC(Self-employed)
1099-MISC
1099-INT
1099-DIV
1099-R
1099-K (Cash App/PayPal/Stripe
Unemployment
Social Security
Rental Income
Cryptocurrency
Other Income
Other Income- Please Explain
SECTION-5 SELF-EMPLOYMENT
Are you self-employed or receive 1099 income?
*
Yes
No
Business Name
Type of Business
EIN (IF ANY)
Total Business Income (Approx.)
Total Business Expenses (Approx.)
Business Mileage
Additional Business Notes
SECTION 6- DEDUCTIONS & CREDITS
CHECK ALL THAT APPLY
Childcare Expenses
Education (1098-T)
Student Loan Interest (1098-E)
Retirement Contributions
Medical Expenses
Charitable Donations
Mortgage Interest (1098)
Property Taxes
Energy Credits
Earned Income Tax Credit (EITC)
Childcare Provided Name
Amount Paid
Provider EIN/SSN
SECTION 7- REFUND & BANKING
Refund Information
Refund Method
Direct Deposit
Paper Check
Bank Name
Routing Name
Account Number
Account Type (Checking/Savings)
Interested in Refund Advance
Yes
No
SECTION 8- ID VERIFICATION
ID TYPE
Please Select
DL
STATE ID
PASSPORT
ID Number
Issue Date
-
Month
-
Day
Year
Date
Expiration Date
-
Month
-
Day
Year
Date
State Issued
SECTION 9- PRIOR TAX INFO
Filed last year?
Yes
No
Prior Year AGI (if known)
Need us to retrieve transcripts?
Yes
No
SECTION 10 - ADDITIONAL QUESTIONS
RECEIVED IRS LETTERS?
YES
NO
Owe back taxes?
Yes
No
Victim of identity theft?
Yes
No
SECTION 11- DOCUMENT UPLOADS
Upload Photo ID
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload W-2s / 1099s
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload Prior Year Return
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload IRS Letters
Browse Files
Drag and drop files here
Choose a file
Cancel
of
SECTION 12- CONSENT & SIGNATURE
I certify that the information provided is accurate and authorize Taxfluence Financial to prepare and e-file my tax return.
*
I consent
Client Signature
*
Signature Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: