CLH Solutions LLC – Tax Preparation & IRS Debt Relief Intake

CLH Solutions LLC – Tax Preparation & IRS Debt Relief Intake

Virtual or In-Person • Secure • Confidential • Nationwide Service If you owe the IRS, are behind on taxes, or need help filing — you’re not alone. We’re here to help.
Taxpayer's Name*

First Name, Middle InitialLast Name
Taxpayer's Spouse

First Name, Middle InitialLast Name
Taxpayer's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What county do you live in?
County
I have stateside military addressCheck here if foreign address
Taxpayer's DOB*
01/01/2000
Taxpayer's Spouse DOB
01/01/2000
Taxpayer's SSN*
xxx-xx-xxxx
Taxpayer's Spouse's SSN
xxx-xx-xxxx
Upload Taxpayer's Identification and social security card (Spouse's also if applicable.) *

ID, Driver's License, Passport, SSC, Ect.
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Yes (Taxpayer)No (Taxpayer)Yes (Spouse)No (Spouse)
Taxpayer is blind.Taxpayer is deceased.Taxpayer wishes to contribute $3 to the Presidential Election Campaign Fund.Taxpayer or spouse served in a combat zone during the current tax year.Taxpayer was affected by a natural disaster during the current tax year.Taxpayer received, sold, or disposed of a digital asset (or financial interest in a digital asset) in 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.None of the above
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Alt. Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Occupation*
Title
Tax PreparationIRS Debt ReliefBack Taxes / Unfiled ReturnsAmended ReturnsIRS LettersPayment PlansWage GarnishmentTax Lien / LevyNot Sure - Need Guidance
TextCallEmailDM
GoogleFacebookInstagramTik TokPrevious Client
YesNoReturn Client
If someone referred you, who referred you?
SingleHead of HouseholdMarried Filing JointlyMarried Filing SeperateQualifying Widow(er)Not Sure / Need help choosing (we'll help you determine the best option)
W-2 (Employee)1099 / Independent ContractorSelf-Employed / Business OwnerGig Work (Uber,Doordash,Instacart,etc.)Rental IncomeUnemploymentSocial Security / DisabilityAny Crypto CurrencyNot Sure (we'll review it together)Other
Upload Income Documents*

Cancelof
yesno
YesNoNot SureOther
How many dependents do you have?
#1 Dependent
Full Name, B/O/D, SSN
What is you relationship to dependent #1
son, daughter, niece, nephew, etc.
This person was over age 18 and a full-time student at an eligible educational institution.Check if this person was DISABLED.Check if this qualifying child is NOT YOUR DEPENDENT.Check if you wish to NOT claim this dependent for Earned Income Credit purposes.Check if this dependent is married and filing a joint return.This individual made over $5,050 of incomeThis dependent qualifies for a Multiple Support Declaration.None of These
#2 Dependent
Full Name, B/O/D, SSN
What is you relationship to dependent #2
son, daughter, niece, nephew, etc.
This person was over age 18 and a full-time student at an eligible educational institution.Check if this person was DISABLED.Check if this qualifying child is NOT YOUR DEPENDENT.Check if you wish to NOT claim this dependent for Earned Income Credit purposes.Check if this dependent is married and filing a joint return.This individual made over $5,050 of incomeThis dependent qualifies for a Multiple Support Declaration.None of These
#3 Dependent
Full Name, B/O/D, SSN
What is you relationship to dependent #3
son, daughter, niece, nephew, etc.
This person was over age 18 and a full-time student at an eligible educational institution.Check if this person was DISABLED.Check if this qualifying child is NOT YOUR DEPENDENT.Check if you wish to NOT claim this dependent for Earned Income Credit purposes.Check if this dependent is married and filing a joint return.This individual made over $5,050 of incomeThis dependent qualifies for a Multiple Support Declaration.None of These
#4 Dependent
Full Name, B/O/D, SSN
What is you relationship to dependent #4
son, daughter, niece, nephew, etc.
This person was over age 18 and a full-time student at an eligible educational institution.Check if this person was DISABLED.Check if this qualifying child is NOT YOUR DEPENDENT.Check if you wish to NOT claim this dependent for Earned Income Credit purposes.Check if this dependent is married and filing a joint return.This individual made over $5,050 of incomeThis dependent qualifies for a Multiple Support Declaration.None of These
#5 Dependent
Full Name, B/O/D, SSN
What is you relationship to dependent #5
son, daughter, niece, nephew, etc.
This person was over age 18 and a full-time student at an eligible educational institution.Check if this person was DISABLED.Check if this qualifying child is NOT YOUR DEPENDENT.Check if you wish to NOT claim this dependent for Earned Income Credit purposes.Check if this dependent is married and filing a joint return.This individual made over $5,050 of incomeThis dependent qualifies for a Multiple Support Declaration.None of These
YesNoNo (religious purposes)
Are any dependents in College? (If so, which one(s)?
YesNoNot Sure
Upload Dependent(s) Documents

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YesNoNot Sure (We'll review it together)
YesNoNot Sure
YesNoNot Sure
YesNo
How much do you spend on daycare?
YesNoNot Sure
YesNoNot Sure
yesNoNot Sure
Who was your insurance coverage through?*
YesNoNot Sure
Who was your dependent(s) insurance coverage through?*
Upload Insurance Documents

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Please list any vehicles driven in 2025
Please list any vehicle expenses
Wage GarnishmentBank LevyFederal Tax LienIRS Notice of Intent to LevyUnfiled Tax returnsPenalties & interest adding upI'm behind but not being enforced yetBehind in child SupportNone of the aboveOther
YesNoNot Sure
Under $5,000$5,000-$15,000$15,000-$50,000Over $50,000
YesNo
Upload IRS Notice

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YesNo
YesNo
YesNo
In-PersonCallFacetimeTextGoogle MeetZoomSkypeOther
Briefly explain your situation(optional)
YesNo
Please Note: Eligibility and amounts are determined by the bank and IRS approvals.
CheckDirect Deposit
Name of Bank
checking accountsavings account
For your security, bank routing and account numbers will be collected securely during your appointment or entered directly into our tax preparation system.
Bank Routing number
Bank Account number
Appointment (Optional)
Date*

MonthDayYear
Date
Signature*

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Spouse's Signature

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Submitting this form does not grant Power of Attorney or authorize CLH Solutions LLC to contact the IRS without a separately signed Form 2848.
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