Client Intake Form

Client Intake Form

Thank you for choosing U.P.A. to handle your taxes with precision. Please complete this secure form so we can get started.
SingleMarried Filing JointlyMarried Filing SeparatelyHead of HouseholdQualifying Widow(er)
- Full Name*
  
  First NameMiddle NameLast Name
- Date of Birth*
  
  MonthDayYear
  Date
- Social Security Number*
- Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Email Address
  example@example.com
- IP PIN (If applicable)
- Mailing Address*
  
  Street Address
  
  Street Address Line 2
  CityState / ProvincePostal / Zip Code
- If “MFJ or MFS” was selected in the filing status, please add Spouse information
- Spouse Full Name
  
  First NameMiddle NameLast Name
- Spouse Date of Birth
  
  MonthDayYear
  Date
- Spouse Social Security Number
- Spouse Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Spouse Email Address
  example@example.com
- Spouse IP PIN (If applicable)
- Please upload your Drivers License or Identification Card (upload spouse DL/ID if applicable)*
  
  Cancelof
- Please upload your social security card (upload spouse SSN if applicable)
  
  Cancelof
- YesNo
- Number of Dependents
- Dependent 1 Full Name
  
  First NameMiddle NameLast Name
- Dependent 1 Date of Birth
  
  MonthDayYear
  Date
- Dependent 1 Social Security Number
- MaleFemale
- Dependent 2 Full Name
  
  First NameMiddle NameLast Name
- Dependent 2 Date of Birth
  
  MonthDayYear
  Date
- Dependent 2 Social Security Number
- MaleFemale
- Dependent 3 Full Name
  
  First NameMiddle NameLast Name
- Dependent 3 Date of Birth
  
  MonthDayYear
  Date
- Dependent 3 Social Security Number
- MaleFemale
- What are your relationship to the Dependent(s)?
- YesNo
- Upload the Dependent(s) Social Security Card (if applicable)
  
  Cancelof
- Upload the Dependent(s) Birth Certificate (if applicable)
  
  Cancelof
- Upload the Dependent(s) School/Medical Records (if applicable)
  
  Cancelof
- W-21099-NEC/MISC/INT/K (Contact, Freelance, Gig Work)Self-Employment (Income & Expense Summary)Rental Income (Supporting Docs)Investments/Dividends (1099-DIV, 1099-B)Retirement/Social Security (SSA-1099, 1099-R, etc)Unemployment (1099-G)
- Please upload all the income sources you checked above
  
  Cancelof
- Childcare PaymentsRetirement ContributionsHome Ownership (Mortgage Interest Statement)Medical Expenses over 7.5% of IncomeSolar Panels or Energy-efficient UpgradesCollege Attendance (1098-T)Affordable Care Act Insurance (1095-A)
- Please upload all the deductions & credits you checked above
  
  Cancelof
- YesNo
- If no, please upload the necessary documents for us to assist (Income wages, Dependents, deductions, etc)
  
  Cancelof
- YesNo
- If Yes, please specify amount/type
- Direct DepositPaper Check
- Bank Name (if Direct Deposit)
- CheckingSavings
- Routing Number: (if Direct Deposit)
- Account Number: (if Direct Deposit)
- Referrals: (First & Last Name, phone Number)
- Any Other Additional Comments:
- •U.P.A. provides free estimates before filing.
  
  •Once your return is accepted by the IRS, it cannot be changed or withdrawn.
  
  •If your refund is offset (student loans, child support, or other obligations), you are still responsible for U.P.A.’s filing fees. Failure to pay may result in legal action.
  
  • You authorize U.P.A. to securely capture and store sensitive personal information as required to complete your tax return (SSN, ID, Tax Docs, etc.)
  
  •By signing below, you acknowledge that you have read and agree to U.P.A.’s Terms & Conditions and Privacy Policy.
  
  •By submitting the client intake form, you confirm that all information provided is accurate and true to the best of your knowledge.
- Date*
  
  MonthDayYear
  Date
- Signature
  
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- Should be Empty: