Tax Client Intake Form
Please fill out this form to provide your tax information.
Filing Status
Single
Married Filing Jointly
Married Filing Separately
Head of Household
Qualifying Widow(er) with Dependent Child
Taxpayer Information
First Name
Middle Name
Last Name
Suffix
Date of Birth
*
-
Month
-
Day
Year
Date
SSN/ITIN
*
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Opt-In
*
By checking this box, I consent to receive transactional messages from Legacy Finance regarding your tax and financial services at the phone number provided. Message frequency varies. Message & Data rates may apply. Reply STOP to opt out, HELP for help
Young Adult Taxpayer (Ages 18-24)
*
Yes
No
Occupation
*
Spouse Information
First Name
Middle Name
Last Name
Suffix
Spouse's Date of Birth
-
Month
-
Day
Year
Date
SSN/ITIN
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Dependent(s)
Income Sources
(Check all that apply)
W-2
W-2G
1099-R
1099-INT
1099-G
1099-MISC
1099-DIV
1099-NEC/Self-Employment
1099-SSA
Unemployment
Other
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Deductions & Credits
If Applicable
Mortgage Interest $
Property Taxes
Medical Expenses
Education Expenses (1098-T)
Retirement Contributions (401K, 403B, IRA, HSA..)
State/Local Tax Payments
Health Insurance Coverage
(Check all that apply)
Marketplace Insurance (1095-A)
Employer Coverage
Medicaid/Medicare
Not Insured
Life Changes
(Check all that apply)
New Child
Bought or Sold home
New Job
Marriage or Divorce
Started a Business or Side Gig
Other
Refund Preferences
Please indicate how you would like your refund
Direct Deposit (Fastest)
Tax Advance Loan (upon approval)
Faster Money Visa Prepaid Card (up to 4 days)
Paper Check ($20 print fee)
Bank Name
*
Checking/Savings
*
Please Select
Checking
Savings
Routing Number
*
Double-check routing numbers to avoid refund delays
Account Number
*
Double-check account numbers to avoid refund delays
Attestation & Payment Acknowledgement
I CONSENT to electronic filing.
I CONSENT to IRS disclosure (if applicable).
I ATTEST that all information provided is true and accurate to the best of my knowledge.
I UNDERSTAND that I am responsible for payment of tax preparation services regardless of whether I receive a refund or owe taxes.
Taxpayer Declaration & Responsibility Statement
I certify that during this tax season I provided more than half of my own financial support, paid my own living expenses, including: housing, food, transportation, and personal expenses, from my own income. To the best of my knowledge, no other individual provided more than half of my financial support during the year, and I am filing my tax return as an independent taxpayer. I declare this statement is true and correct to the best of my knowledge.
Dependency Status
No one can claim me as a dependent for this tax year. OR
I may be claimed as a dependent by another taxpayer.
Signature
*
Date
.
Month
.
Day
Year
Date
Submit
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