Client Intake Form

Before you begin please ensure you have the following documentation handy:

Government Issued Photo ID
Social Security Card
Wage Statements (W2, 1099, etc.)
Healthcare Forms (1095A/B/C)*

*please note: this form is requireed for (1) any filing year prior to 2019 or (2) for any year after 2019 if it was issued by the government or an employer.

New Client Existing Client Returning Client

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Street Address

Street Address 2

State

Sole proprietorship Limited liability company (LLC) C corp S corp B corp Close corporation Nonprofit corporation Partnership Cooperative

Prefix First Name Middle Name Last Name Suffix

Street Address

Street Address 2

City State

Zip Code

Street Address

Street Address 2

City State

Zip Code

Street Address

County

City State

Zip Code

Social Security Number

Please input a different contact number

Morning Afternoon Evening

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Government Issued Photo ID, Social Security Card

Prefix First Name Middle Name Last Name Suffix

Street Address

County

City State

Zip Code

Social Security Number

Morning Afternoon Evening

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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
Number of months dependent resided with you
Childcare Expenses Paid
Education Expenses
Tuition/Fees Deduction

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Social(s), Birth Certificate(s)

Mutual Funds? Rental Income? Other?

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Wage Statements; W2, 1099, etc.

Street Address

Street Address Line 2

City State / 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
Being claimed (or eligible to be claimed) as a dependent on anyone else's tax return
Victim of identity theft (that included taxes)
Full-time student
Paid any tuition costs
Paid any 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)

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

Direct Deposit Check E1 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?

Purchase a home Start a business Get business credit Restore my credit Get a car Get insurance or switch carriers

*PLEASE NOTE: YOU MUST SCROLL THROUGH ALL TERMS BEFORE YOU ARE ABLE TO AGREE AND SUBMIT FORM.

COVID RELIEF

Taxpayer Information

Spouse's Information

Dependent Information

Financial Info

Income

Profit or Loss From Business

Itemized Deductions

Debts

Refund Options