JaxTax Intake Form

Personal Information
Name

First NameLast Name
Birthday

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

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Email
example@example.com
Social Security Number
PIN # (fill this out only if you were provided one by the IRS)
Drivers License Number
Issue Date

MonthDayYear
Date
Expiration Date

MonthDayYear
Date
STATE
By signing , I certify that the information I have provided on this page is accurate and complete to the best of my knowledge. I submit these documents securely on my own and on my own time and authorize my tax preparer to use them to prepare and file my tax return on my behalf. I understand and acknowledge that the preparation and submission of my tax return will be conducted by my designated tax preparer and that I have given explicit consent for the use of my information for this purpose.

Filing Status
What status are you filing with
If you have a 1095A form upload it here

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Check all that apply

Self Employed
(if you checked self employed please answer the following)
Job 1
Job Description
Months on the Job
Profit
Expenses
EIN Number
Check here if you do not have the EIN number
Self Employed Signature

House Hold Income
Income 1
Job Description
Name of Person You Did Work For
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Income
Household Income Signature

Banking
Bank Name
Routing Number
Account Number
Account Type
Documentation Upload
Use this section to upload ID Cards, W-2's, Social Security Cards, Birth Certificates, Pay Stubs, etc.
Document 1
Type Document Title Here
Upload Document

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DATA SECURITY DISCLAIMER

By submitting this form, you acknowledge and understand that:

This form is hosted by JotForm, a third-party service provider, and while they employ industry-standard security measures, no online platform can guarantee 100% protection against data breaches, hacking, or unauthorized access.
There is an inherent risk in transmitting sensitive personal and financial information (including Social Security Numbers, tax documents, banking information, and other confidential data) through any online form or digital platform.
In the event of a data breach, security incident, or unauthorized access to JotForm's systems that results in the exposure, theft, or misuse of your submitted information, JaxTax and its owners, employees, and affiliates shall not be held liable for any damages, losses, identity theft, or other consequences that may arise from such incidents.
You are submitting this information voluntarily and at your own risk, with full awareness of the potential security vulnerabilities inherent in online data transmission and storage.
ALTERNATIVE OPTIONS AVAILABLE:

If you prefer not to submit sensitive information through this online form, we offer alternative methods for securely providing your tax information:

Phone consultation: Call us at (806) 781-1583 to provide information verbally
Video meeting: Request a secure virtual meeting where you can share documents directly
In-person appointment: Schedule a face-to-face consultation
By clicking "Submit" below, you confirm that you have read, understood, and agree to the terms of this disclaimer, and you accept full responsibility for choosing to transmit your information through this online form.
Should be Empty:

Personal Information

Filing Status

Dependents

Education

Self Employed

House Hold Income

Banking

Documentation Upload