Client Intake Form

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New ClientExisting ClientReturning Client

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Street Address

Street Address 2

State

PrefixFirst NameMiddle NameLast NameSuffix

Street Address

City

CountyState

Zip Code

Street Address

City

CountyState

Zip Code

Street Address

City

CountyState

Zip Code

Social Security Number

Please input a different contact number

MorningAfternoonEvening

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Government Issued Photo ID, Social Security Card

PrefixFirst NameMiddle NameLast NameSuffix

Street Address

City

CountyState

Zip Code

Social Security Number

MorningAfternoonEvening

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Government Issued Photo ID, Social Security Card

	Dependent 1	Dependent 2	Dependent 3	Dependent 4	Dependent 5
First Name
Middle Name
Last Name
Date of Birth
Social Security
Relationship
How many months did dependent live with you in filling year? (If all year, enter 12)
Childcare Expenses Paid
Education Expenses
Tuition

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Social Security Card(s), Birth Certificate(s)

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Documents from daycare provider

	Yes	Amount
Rental income
Investment earnings
Unemployment
Other

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Wage Statements; W2, 1099, etc.

Street Address

City

CountyState / Province

Postal / Zip Code

Check here if you started or acquired this business during the current tax filing year

	Taxpayer	Spouse	Dependent(s)	Unsure
Started a new business or purchased any rental property during the past year
Purchased any business assets or converted any assets to business use?
Disposed of any business assets
Ceased operating any business or rental property

	Amount
Advertising
Car & truck expenses
Car & truck mileage
Commissions & fees
Contract labor
Depletion
Depreciation & section - 179 expense deduction
Employee benefit programs
Insurance
Interest
Mortgage (paid to banks, etc.)
Other
Legal and professional services
Office expense
Pension and profit-sharing plans
Rent or lease
Vehicles, machinery, & equipment
Other business property
Repairs & maintenance
Supplies
Taxes & licenses
Travel & meals
Travel
Deductible meals
Utilities
Wages
Other expenses

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Profit & Loss Statement (P&L)

	Taxpayer	Spouse	Dependent(s)	Unsure
Victim of identity theft (that included taxes)
Full-time student
Paid tuition costs
Paid student loan interest
Changed marital status
Were there any changes in your dependents last year
Childcare expenses
Adopted a child
Changed jobs
Unreimbursed employee or work-related expenses
Withdrew retirement funds
Had healthcare
Had healthcare marketplace
Health/Dental/Other insurance premiums
Prescription medications
Medical mileage
Long term insurance premiums
Totally or permanently disabled
Legally blind
Moved/relocated
Purchased or sold principal home
Mortgage interest statement
Real estate and personal property taxes paid
Make any federal or state estimated tax payments
Incurred loss due to damaged or stolen property
Made any cash donations
Gambling losses (up to amount of winnings)

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	Federal Amount Paid	Federal Date Paid	State Amount Paid	State Date Paid
1st Qtr.
2nd Qtr.
3rd Qtr.
4th Qtr.

Direct DepositCheckE1 Card

Example: Wells Fargo

Up to $1,000 (NO finance charge)Up to $6,000 (WITH bank finance charge)

What is your Mother's Maiden Name?What is the name of your first pet?What high school did you attend?What is the name of your oldest child?What is your Father's middle name?

What is the answer to the security question you selected?

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Client Details

COVID RELIEF

Taxpayer Information

Spouse's Information

Dependent Information

Income

Profit or Loss From Business

Itemized Deductions

Debts

Refund Options