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.
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?*

YesNo
Did a qualifying person live with you for more than half of the year?*

YesNo
Name of Qualifying Person*
Relationship to You*
Dependents
Do you have any dependents you are claiming this year?*

YesNo
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?*

YesNo
Did you provide more than 50% of the dependent’s 1 support?*

YesNo
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?*

YesNo
Did you provide more than 50% of the dependent’s 2 support?*

YesNo
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?*

YesNo
Did you provide more than 50% of the dependent’s 3 support?*

YesNo
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*

I have read and agree to the Client Intake Disclaimer & Acknowledgment.
Client Signature*

Clear
Should be Empty:

Client Information

Filing Status

Head of Household Qualification

Dependents

Dependent 1 Information

Dependent 2 Information

Dependent 3 Information