2019 Compliance Doc: Tax Client Intake Form

2019 Client In-Take Form

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First Name Last Name

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Single Head of Household (unmarried with dependent(s)) Married Filing Joint Married Filing Separate Lived separate from spouse for last 6 months of year Divorced or Widowed this year Not Sure

First Name Last Name

Male Female Option 3

First Name Last Name

Male Female Option 3

First Name Last Name

Male Female Option 3

First Name Last Name

Male Female Option 3

First Name Last Name

Male Female Option 3

School Records Medical Records Landlord or property statement Child care provider records Placement agency statement Social service records/statement Other I don't have any records

Does this apply to you?: (select one option below)

If someone has custody of their child, but wants to release the right to claim the child's exemption to the non-custodial parent, this is perfectly legal. This is typcially done if you don't file a return OR if you reach an agreement with your child's noncustodial parent.

#1: This DOES NOT apply to me since I have no dependents #2: This DOES NOT apply to me because all my dependents lived with me for 12 months #3: Even though 1 or more of my dependents did not live with me for the full 12 months, I DO NOT have a "Custodial Parent Release Claim" (Form 8336 or similar document). I need one. I would like advisement on this. #4: This DOES apply to me and I DO have a "Custodial Parent Release Claim" (Form 8336 or similar document) because 1 or more of my dependents did not live with me for the full 12 months.

Had health insurance for all of 2017 through Medicaid/Medicare/VA Bought it on the ACA marketplace/exchange for all of 2017 (If so, preparer needs the form 1095-A) Had health insurance through an Employer for all of 2017 Did not have health insurance for more than 3 months in 2017 Had Health Insurance, but it was not for all of 2017, but I only went with out for less than 3 months Didn't have health insurance (ask how you can be exempt from the penalty) I am filing multiple years & need to answer this questions again (for a different tax year)

Yes No Not Sure I have been disallowed before, but not anymore

Mortgage Interest, and Investment Expenses Gifts to Charity Casualty Losses, Job Expenses, and Other Deductions Medical and Dental Expenses None of the Above

W-2 1099 Self-Employment Unemployment Compensation Social Security (You or dependents) IRA or Pension Distribution as reported on a 1099-R Interest and Dividends (reported on a 1099) A State Refund Received Last Year Gambling Winnings as reported on W-2G

(skip if you sent W2s/1099s to tax preparer)

List your expenses from your business (skip if you sent info to tax preparer)

Yes No Not Applicable Not Sure

- Area Code Phone Number

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

I will pay in check, cash or credit card at the time I get my taxes prepared I will pay using a bank product and have my fees deducted from my refund. Not sure. I will need my preparer to give me more info

Direct Deposit Check Walmart Direct2Cash Walmart Money Card

First Name Last Name