Client Intake Form

Client Tax Registration Form

Please complete this form to register as a new client for tax services. Provide your details and payment information below.
Filing Status?
Full Name?*

First NameMiddle NameLast Name
Date of Birth (DOB)?

MonthDayYear
Date
Phone Number?
Please enter a valid phone number.
Spouse Name?

First NameMiddle NameLast Name
Spouse Date of Birth (DOB)?

MonthDayYear
Date
Spouse Phone Number?
Please enter a valid phone number.
Spouse Email Address?
example@example.com
Spouse Social Security Number (SSN)?
Spouse Occupation?
Do you have an IP PIN?

YesNo
Email Address?*
example@example.com
Mailing Address?

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
County?
IP PIN?
Social Security Number (SSN)?*
How did you earn income? W2, 1099 ETC..?
Do you receive government assistance?
Do you rent or own?

RentOwn
How much is the monthly payment?
Dependent Information
Number of Dependents?
Dependent Name

First NameMiddle NameLast Name
How long did dependent live with you?
Dependent Date of Birth

MonthDayYear
Date
Dependent Social Security Number (SSN)?
School District?
Dependent Disability Status

NonePhysical DisabilityMental DisabilityOtherOther
Child Care Payment Amount?
Child care Payment Frequency?
Add Dependents?
Received 1098-T Form?
1098-T Form Amount?
Do you have a 1098 mortgage form?

YesNo
Bank Information (Bank name, routing, and acct number.)?
How did you hear about us?
Last Year AGI
Would you like audit protection?

YesNo
Do you agree to pay bank fee of $102.00?

YesNo
Signature*

Clear
I agree all information provided is accurate and true to my knowledge
Should be Empty:

Client Tax Registration Form

Dependent Information