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.
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

W-2 IncomeSelf-Employment/1099Business IncomeRental IncomeInvestment Income
Business Name
Business Start Date

MonthDayYear
Date
Business Entity Type
Estimated Gross Receipts
Estimated Total Expenses
Deductions & Credits

Childcare or Education ExpensesHome OwnershipCharitable ContributionsHealth Insurance marketplace (1095-A)
Documents You May Need

Social Security CardsDriver's License/State IDPrior Year Tax ReturnW-2's1099sBusiness RecordsMortgage StatementsEducation FormsHealth Insurance FormsCharitable Receipts
Questions or Concerns
Certification Checkbox*

I certify that the information provided is accurate to the best of my knowledge.
Taxpayer Signature*

Clear
Date

MonthDayYear
Date
Spouse Signature

Clear
Should be Empty: