BHTaxandTalent Intake Form

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

Format: (000) 000-0000.

E-mail

example@example.com

Date of Birth

Are you filing with a spouse?

If Yes Please Enter Spouse's information

First NameLast Name

Spouse's Date of Birth

Will you be claiming any dependents this year?

If yes, please enter first and last name, ssn and dob for each dependent.

W-2 income10999-NEC/MISC (Contractor, Freelance, Side Hustles)Self=Employed/Sole Proprietor (Own a business with no W-2)Unearned Income (Interest, Dividends, Capital Gains)Government Benefits (Unemployment, Social Security)Retirement/Pension (1099-R)Other (Gambling winnings, Jury duty pay, etc)

Taxpayer paid Student Loan Interest or Tuition for Higher EducationTaxpayer owned a home or pay Mortgage Interest in 2025Taxpayer made significant Charitable Contributions in 2025Taxpayer is a teacher who spent personal funds on classroom supplies

Has Nikia, Owner of Blessed Hands provided tax assistance for you in previous years?Are you currently in need of community resource referrals? (e.g. housing assistance, utility assistance, educational support?)

Refund: Are you interested in having your Tax Preparation fees deducted directly from your refund?

Payment Option: Are you interested in applying for a Refund Advance Loan?

*These are subject to bank approval and are NOT guaranteed.

Use this section to provide additional information you would like Blessed Hands to know regarding preparing your taxes. (I.E., past audits, reviews, errors, new income for 2025, inquiries about tax processes or specific requested community resource referrals.

Consent and Accuracy: Blessed Hands Tax and Talent, LLC relies on the information provided by the taxpayer to prepare accurate returns. By checking the box below, you acknowledge that you are responsible for the validity of all income, dependents, and expenses reported. You certify that the information provided is true and accurate to the best of my knowledge.

Client Details: