Clone of Tax Client Intake Form

Tax Client Intake Form
What Preparer are you filing your 2025 Tax Return with
Filing Status
- Social Security Number
- Name
  
  First NameLast Name
- Date of Birth
  
  MonthDayYear
  Date
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email
  example@example.com
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Occupation
- Are you a full-time student?
- Are you totally and permanently disabled?
- Name
  
  First NameLast Name
- Social Security Number
- Age
- Date of Birth
  
  MonthDayYear
  Date
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email
  example@example.com
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Occupation
- Are they a full-time student?
- Are they legally blind?
- Are they your dependent?
- Dependent #1
- Name
  
  First NameLast Name
- Social Security Number
- Date of Birth
  
  MonthDayYear
  Date
- Relationship
- Dependent #2
- Name
  
  First NameLast Name
- Social Security Number
- Date of Birth
  
  MonthDayYear
  Date
- Relationship
- Dependent #3
- Name
  
  First NameLast Name
- Social Security Number
- Date of Birth
  
  MonthDayYear
  Date
- Relationship
- Dependent #4
- Name
  
  First NameLast Name
- Social Security Number
- Date of Birth
  
  MonthDayYear
  Date
- Relationship
- Employment Status
- Do you have an IP PIN number?
  if yes, include 6 digit number
- Did you pay someone to watch your children?
- Did you collect social security or retirement income?
- Did you purchase health insurance through healthcare.gov marketplace (Obama Care)?
- If yes, did you receive a 1095-A Form from the Marketplace?
- Were you ever disallowed the E.T.I.C prior to this year?
- Did you take money from your 401K?
- Did you make a college tuition payment and received a 1098-T Form?
- Do you have any other income other than your W2?
- Did you successfully receive your federal taxes last year?
- Are you a victim of identity theft?
- Are you delinquent in any of the following?
  
  Other
- Are you interested in a cash advance?
- Bank Name
- Routing Number
- Account Number
- Valid Photo Identification
  
  Cancelof
- Taxpayer Social Security Card
  
  Cancelof
- Dependent Social Security Card
  
  Cancelof
- Dependent Social Security Card
  
  Cancelof
- Dependent Social Security Card
  
  Cancelof
- Dependent Social Security Card
  
  Cancelof
- W2(s)
  
  Cancelof
- 1099(s)
  
  Cancelof
- Appointment
- I, hereby, state that all the information above is true to the best of my knowledge and that I am allowing Medellin Tax Services LLC to prepare my taxes based on the information I provided. I understand that I am financially responsible for any outstanding balance due to any false information given. If you opt out of providing personal information via form you do have the option of uploading to tax software app. Taxestogo
  
  Please utilize your state Department of Revenue site for any State Refund tracking. Do NOT add the amounts together. Federal taxes are federal, and state taxes are state when tracking your status. Please allow 8 weeks to surpass from the date of submission before calling the IRS, if you have any tracking questions. For any direct questions email us at angela@medellintaxservices.com or the IRS for all updates at 800-829-1040.
- Date Signed
  
  MonthDayYear
  Date
- Taxpayer Signature
- Date Signed
  
  MonthDayYear
  Date
- Spouse Signature
- File Upload
  
  Cancelof
- Should be Empty:

Tax Client Intake Form

Dependent #1

Dependent #2

Dependent #3

Dependent #4