Intake Form

Client Information
Full Legal Name (as shown on Social Security card)

First NameLast Name
Social Security Number
Numbers Only
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address

Mailing Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
This email will be used for tax-related communication and document delivery.
Filing Status
Select Your Filing Status
Head of Household Qualification
Did you pay more than 50% of the household expenses for the year?
Did a qualifying person live with you for more than half of the year?
Name of Qualifying Person
Relationship to You
Dependents
Do you have any dependents you are claiming this year?
How many dependents are you claiming?
Dependent 1 Information
Dependent 1 Full Name

First NameLast Name
Dependent 1 Social Security Number
Numbers Only
Dependent 1 Date of Birth

MonthDayYear
Date
Relationship to You (Dependent 1)
Did the dependent 1 live with you more than half of the year?
Did you provide more than 50% of the dependent’s 1 support?
Dependent 2 Information
Dependent 2 Full Name

First NameLast Name
Dependent 2 Social Security Number
Numbers Only
Dependent 2 Date of Birth

MonthDayYear
Date
Relationship to You (Dependent 2)
Did the dependent 2 live with you more than half of the year?
Did you provide more than 50% of the dependent’s 2 support?
Dependent 3 Information
Dependent 3 Full Name

First NameLast Name
Dependent 3 Social Security Number
Numbers Only
Dependent 3 Date of Birth

MonthDayYear
Date
Relationship to You (Dependent 3)
Did the dependent 3 live with you more than half of the year?
Did you provide more than 50% of the dependent’s 3 support?
Client Intake Disclaimer & Acknowledgment

This intake form is for information-gathering purposes only and does not constitute tax advice or the establishment of a tax preparer-client relationship. Tax preparation services begin only after review of required documentation and acceptance by Level Up Tax Services. The client certifies that all information provided is true, correct, and complete to the best of their knowledge and understands that the accuracy of the tax return depends on the information provided. The client acknowledges that additional questions or documentation may be required to comply with IRS due diligence requirements. No specific refund or tax outcome is guaranteed.
Client Acknowledgment
Client Signature
Should be Empty:

Client Information

Filing Status

Head of Household Qualification

Dependents

Dependent 1 Information

Dependent 2 Information

Dependent 3 Information