Client Intake Form
Personal Information
Name
First Name
Middle Initial
Last Name
SSN
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Format: (000) 000-0000.
Mobile phone
Format: (000) 000-0000.
Occupation
Email:
example@example.com
Legally Blind?
YES
NO
Dependent of another?
YES
NO
Spouse
Name
First Name
Middle Initial
Last Name
SSN
Date of Birth
-
Month
-
Day
Year
Date
Occupation
Email:
example@example.com
Legally Blind?
YES
NO
Mobile phone
Format: (000) 000-0000.
Dependent of another?
YES
NO
Filing Status
Single:
Do you have outstanding student loan?
YES
NO
Married Filing Joint:
Do you owe back child support?
YES
NO
Married Filing Separately:
Are you current with your tax obligations?
YES
NO
Head of Household:
Any other information we need to know:
Qualifying Widower:
Dependents
Rows
First
MI
Last
D.O.B.
SSN
Relationship
1
2
3
4
5
Affordable Care Act
Did everyone on this tax return have health insurance all 12 months last year?
YES
NO
If no, were you exempt?
YES
NO
If yes, coverage through (check one)
Employer
Spouse Insurance
Direct with Insurer
Exchange Marketplace
If not covered for 12 months, please provide 1095-A
Refund Information
Are you interested in getting a advance on your refund today?
YES
NO
Would you like your refund deposited into your bank account?
YES
NO
Routing #
Account#
Are you interested in credit repair with no upfront cost?
YES
NO
All the information on this form is true and correct to the best of my knowledge
Signature:
Date
-
Month
-
Day
Year
Date
Upload ID and all other tax documents below
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