Client Intake Form

Form

Well Living, LLC – Client Intake & Tax Consultation Form
Full Legal Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Contact Method
Occupation
Filing Status
Major Life Changes This Year (Marriage, Divorce, New Baby, Job Change, Business Start, Relocation, Etc.)
Social Security Number
Date of Birth

MonthDayYear
Date
Spouse Full Name

First NameLast Name
Spouse Email
example@example.com
Spouse SSN
Spouse Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have dependents?
Dependent Full Name

First NameLast Name
Dependent Date of Birth

MonthDayYear
Date
Dependent SSN
Dependent Full Name

First NameLast Name
Dependent Date of Birth

MonthDayYear
Date
Dependent SSN
Dependent Full Name

First NameLast Name
Dependent Date of Birth

MonthDayYear
Date
Dependent SSN
Dependent Full Name

First NameLast Name
Dependent Date of Birth

MonthDayYear
Date
Dependent SSN
Dependent Full Name

First NameLast Name
Dependent Date of Birth

MonthDayYear
Date
Dependent SSN
Income Sources
Business Name
Business Start Date

MonthDayYear
Date
Business Entity Type
Estimated Gross Receipts
Estimated Total Expenses
Deductions & Credits
Documents You May Need
Questions or Concerns
Certification Checkbox
Taxpayer Signature
Date

MonthDayYear
Date
Spouse Signature
Should be Empty: