An Angel's Touch Financial Services LLC
Individual Tax Preparation Intake Form Pg 2
Tax Applicant Name
First Name
Last Name
Dependents - check which applies
Did your dependent(s) live in the home?
Y
N
How many months?
Student in School?
Will your dependent (s) be claimed by someone other than yourself?
Y
N
Did you pay more than half the cost of maintaining a home for this person?
Y
N
Did your dependent(s) have insurance all year or part of the year?
All year
Part of the Year
If part of the year, check the months of coverage below:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sept
Oct
Nov
Dec
Did your dependent(s) have Marketplace Insurance?
Y
N
Dependent #1
Name
DOB:
SSN:
Relationship
Is dependent #1 a student?
Y
N
What school attended:
Totally or Permanent Disabled?
Y
N
If parent, do they receive SSA, SSI, or Disability?
Can you provide a medical statement if needed for supporting documentation?
Y
N
Dependent #2
Name
DOB:
SSN:
Relationship
Is dependent #2 a student?
Y
N
What school attended:
Totally or Permanent Disabled?
Y
N
If parent, do they receive SSA, SSI, or Disability?
Can you provide a medical statement if needed for supporting documentation?
Y
N
Dependent #3
Name
DOB:
SSN:
Relationship
Is dependent #3 a student?
Y
N
What school attended:
Totally or Permanent Disabled?
Y
N
If parent, do they receive SSA, SSI, or Disability?
Can you provide a medical statement if needed for supporting documentation?
Y
N
Did your dependent(s) have any tuition expenses?
1098-T
1098-E
Do your dependent(s) have childcare expenses?
Y
N
How many dependents have childcare expenses?
Amount of Fees $
Childcare Facility
EIN #
Would you like An Angel's Touch Financial Service LLC to discuss your tax return with the IRS if needed?
Y
N
Are you an Educator? (teacher, teacher's aide, counselor, etc.)
Y
N
Did you receive the First Time Homebuyers Credit in 2008?
Y
N
How much is your payback amount?
Banking Information for Refund or Balance Due: (Optional)
Use Account for:
Refund
Balance Due
Date to withdraw from your account
Routing #:
Account #:
Account Type
Checking
Savings
This is the end of page 2 of 3. Make sure you submit all 3 pages of this intake form.
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