An Angel's Touch Financial Services LLC
Individual Tax Preparation Intake Form Pg 1
How did you hear about us?
Referred By:
Filing Status:
Single
Married Filing Jointly
Married Filing Single
Qualifying Widow
Head of Household
Is this an Amended Return?
Yes
No
Name:
First Name
Last Name
DOB:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Occupation:
Claimed on someone else return?
Yes
No
US Citizen:
Yes
No
Social Security Number:
Phone:
Format: (000) 000-0000.
E-Mail:
example@example.com
Do you have an IRS PIN number?
Yes or No. If yes, include PIN number.
Address
Street Address
Street Address Line 2
City
State
Zip Code
County
School District
City
Do you have an HSA?
Yes
No
If yes, was it for yourself or your family?
Family
Self
Value of HSA on Dec 31st
How much was in your HSA account at the end of the year?
Do you have a 1099-SA?
Yes
No
Did you have health insurance last year?
All year
Part of the year
If for only part of the year, select the months of coverage below:
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Did you acquire Health Ins. through MarketPlace?
Yes
No
Did you receive a 1095-A?
Yes
No
Required To Help Prevent Identity Theft:
Driver's License Number
Issuing State
Issue Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Expiration Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Does Not Expire (State ID Only)
Spouse's Name:
First Name
Last Name
DOB:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Occupation:
Are you claiming yourself?
Claimed by someone else?
US Citizen:
Yes
No
Social Security Number:
Phone:
Format: (000) 000-0000.
E-Mail:
example@example.com
Do you have an IRS PIN number? If yes, provide it.
If yes, provide it here.
Do you have an HSA?
Yes
No
If yes, was it for yourself or your family?
Family
Self
Value of HSA on Dec 31st
How much was in your HSA account at the end of the year?
Do you have a 1099-SA?
Yes
No
Did you have health insurance last year?
All year
Part of the year
If for only part of the year, select the months of coverage below:
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Did you acquire Health Ins. through the Market Place?
Yes
No
Did you receive a 1095-A?
Yes
No
Required To Help Prevent Identity Theft:
Driver's License Number
Issuing State
Issue Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Expiration Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Does Not Expire (State ID Only)
This is the end of page 1 of 3. Make sure you submit all 3 pages of this intake form.
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