Tax Preparation Client Intake Form

Tax Preparation Client Intake Form

Tax Preparer: Roell Moreles
Filing Status

Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState

Zip Code
Occupation
Are you a full-time student?
Are you totally and permanently disabled?
Are you legally blind?
License or ID

Cancelof
W-2, 1099, 1095-A, 1098-T K1 etc.

Cancelof

Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
The address is the same as the taxpayer
Address

Street Address

Street Address Line 2

CityState

Zip Code
Occupation
Are they a full-time student?
Are they totally and permanently disabled?
Are they legally blind?
Are they your dependent?
License or ID

Cancelof
W-2, 1099, 1095-A, 1098-T, K1 etc.

Cancelof

Enter your dependents here

Rows	Name	Date of Birth	Relationship	Social Security
1
2
3
4
5
6

Does you, your spouse, and your dependents have health insurance within 12 months last year? If yes, who covers for it?

Rows	Yes/No	Employer	Spouse Ins	Exchange/ Marketplace	Direct with Insurer	Medicare	Medicaid
Taxpayer
Spouse
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5

Please fill-up the information within the current year only.

General Expenses

Rows	Amount
Medical Expenses
Dental Expenses
Insurance Premiums paid
Long Term Care Premiums
Prescription Drugs and Medications
Home Mortgage
Investment Interest
Cash Contributions
Non-Cash Contributions
Unreimbursed Business Expenses
Union Dues
Tax Preparation Fees
Investment Expenses

Total Expenses
Additional comments

Name of the Bank
Routing Number
Account Number

Accuracy / Exactitud: I confirm that all information I entered here is accurate and true. / Confirmo que toda la información que he ingresado aquí es exacta y verdadera.

Data Authorization / Autorización de Datos: By providing my personal information, I hereby authorize MB Insurance & More Services to collect and utilize this information solely for the purpose of tax reporting. / Al proporcionar mi información personal, autorizo a MB Insurance & More Services a recopilar y utilizar esta información únicamente para fines de reporte de impuestos.

Upfront Payment & No Refunds / Pago por Adelantado y No Reembolsos: I acknowledge that a 50% upfront payment is required to begin my tax preparation. This deposit is non-refundable, as it covers the professional analysis of my documentation. / Acepto que se requiere un pago por adelantado del 50% para iniciar la preparación de mis impuestos. Este depósito no es reembolsable, ya que cubre el análisis profesional de mi documentación.

No Estimates Policy / Política de No Estimados: I understand that this office does not provide "estimates." All calculations are based on official documentation as part of the formal tax preparation. / Entiendo que esta oficina no realiza "estimados". Todos los cálculos se basan en la documentación oficial como parte de la preparación formal de impuestos.

Responsibilities / Responsabilidades: By signing below, you acknowledge that you have read and understood your responsibilities and our responsibilities in doing this tax return. / Al firmar a continuación, reconoce que ha leído y comprendido sus responsabilidades y nuestras responsabilidades al realizar esta declaración de impuestos.
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Taxpayer Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Spouse Signature
Código de solicitud MB
Should be Empty: