A Unique Experience LLC- 2023 Tax Intake Form
"The Best Is Yet to Come!"
Who is Your Tax Professional?
Please Select
Unique Rose (Owner)
Mi-Kala Hutcherson
Jessica Foster
Maurice Carter
Do you currently have an offset with the IRS (delinquent student loans, delinquent child support, tax liens etc)? Call (800)304-3107 to confirm. You may be required to pay a deposit up front, if you answered yes to this question.
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Yes
No
-WE DO NOT PROVIDE FREE SERVICES OR ESTIMATES. Once your intake form is received and we begin working on your tax return...TAX PREPERATION FEES ARE STILL REQUIRED whether you file with us or NOT! -In the event that your refund is INTERCEPTED due to child support, student loans, unemployment overpayment, & wage garnishments, YOUR TAX PREPARATION FEE IS STILL REQUIRED to be PAID! -By signing this disclosure, you are agreeing to pay the preparation fees even if you DO OR DONT RECEIVE YOUR REFUND. -After 48 hours from the date the refund was scheduled to arrive, if no payment or payment arrangement is made, I will be forced to put your account into collections. Please stay in communication with me, so that I can work with you if you need a arrangement. I have read the terms and conditions and privacy policy of A Unique Experience, LLC. By signing below, you acknowledge that you have read and understood your responsibilities and our responsibilities in doing this tax return.
Are You Filing a Federal or State Tax Return?
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Federal
State
Tax Year
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2023
2022
2021
Other
First Name
*
Middle Name
Last Name
*
Suffix
Jr, Sr, II, III
Do you have an Identity Protection Pin issued by the IRS?
*
Yes
No
If yes, please upload your IP Pin from the IRS here.
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Are you, the taxpayer, over the age of 65 or legally blind?
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Yes
No
Social Security Number
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Date of Birth
*
 /
Month
 /
Day
Year
Date
Occupation
*
Photo of Driver's License and Social Security Card
*
Choose File
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Identification
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Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Did you receive Section 8, government assistance, food stamps or child support during 2023? If so, please provide the amount below.
Phone Number
*
 -
Area Code
Phone Number
Email
*
example@example.com
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What is your filing status?
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Choose One
Single
Head Of Household
(Single with dependents) income under 19K
Married Filing Joint
Married Filing Separate
Qualified Surviving Spouse
Can someone else claim you as a dependent?
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Yes
No
Are you filing an eligible spouse on your tax return?
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Yes
No
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Spouse Name
*
First Name
Middle Name
Last Name
Suffix
Social Security Number
*
Occupation
*
Date of Birth
*
 -
Month
 -
Day
Year
Date
Phone Number
*
 -
Area Code
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Driver's License #
*
State Driver's License Was Issued
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Date Driver's License Was Issued
*
MM/DD/YYYY
Driver's License Expiration Date
*
MM/DD/YYYY
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$$$How would you like your REFUND$$$
Select below the method that you prefer to receive your refund
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Direct Deposit
Check
PrePaid Debit Card Issued by A Unique Experience
Bank Name:
Bank Account Number:
Bank Routing Number
Account Type
Checking
Savings
Are you interested in applying for a cash advance? Up to 6K?
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Yes (bank fees do apply)
No
Is this year your first year filing taxes with us?
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Yes
No
Did your marital status change during the year?
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Yes
No
Did you or your dependents attend a College or university or took post secondary education classes last year?
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Yes
No
Upload form 1098T or post secondary class information
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Has the student already claimed the AOTC (school credit) on 4 prior tax returns?
Yes
No
Was the student convicted of a felony for possession or distribution of a controlled substance this tax year?
Yes
No
Do you have any children or dependents to file?
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Yes
No
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Dependents
MUST SHOW PROOF! Birth certificate, social security card, leasing agreement, report card & shot records!
Are any of your children disabled?
*
Yes
No
Image of All Dependent's S.S.Card
*
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Upload ALL here
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1. Dependent Information
*
Gender
First Name
Middle Name
Last Name
Suffix
Date Of Birth
*
 -
Month
 -
Day
Year
Date
Social Security Number
*
Relationship
*
Total Months Lived with you during the tax season??
*
Do you want to enter another dependent?
*
Yes
No, all dependents are entered
2. Dependent Information
Gender
First Name
Middle Name
Last Name
Suffix
Date Of Birth
 -
Month
 -
Day
Year
Date
Social Security Number
Relationship
Total Months Lived with you during the tax season?
Do you want to enter another dependent?
Yes
No, all dependents are entered
3. Dependent Information
Gender
First Name
Middle Name
Last Name
Suffix
Date Of Birth
 -
Month
 -
Day
Year
Date
Social Security Number
Relationship
Total Months Lived with you during the tax season?
4. Dependent Information
Gender
First Name
Middle Name
Last Name
Suffix
Date Of Birth
 -
Month
 -
Day
Year
Date
Relationship
Social Security Number
Total Months Lived with you?
Do you want to enter another dependent?
Yes
No, all dependents are entered
Did you pay any child care expenses throughout the year ?
*
Yes
No
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Child and Dependent Daycare Expenses
If the provider is a person, enter the care provider's SSN
Child Name Amount Paid
*
First Name
Amount Paid
Provider Phone Number
*
 -
Area Code
Phone Number
Provider
*
Name
Tax ID #/ SSN
Provider Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Do you want to enter another child care provider?
*
Yes
No
Child Name Amount Paid
*
First Name
Amount Paid
Provider
*
Name
Tax ID #/ SSN
Provider Phone Number
*
 -
Area Code
Phone Number
Provider Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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Upload photos of your W-2,1099, and ALL Income documents
Attach an image of all documents that can be used to assist your tax preparer with the preparation of your tax return.
Upload All Income Documents Here
*
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Enter any additional information or comments that you would like the include for your tax preparer
If you did not file your tax return with us last year, please upload a copy of your previous year's tax return
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HIGHLY RECOMMENED!
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Do you owe from previous years?
*
Yes
No
I have not filed previous years
Upload your 1098E or closing paperwork if you are a new homeowner.
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Do you have a business that you would like to be included on your return?
*
Yes
No
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BU$INE$$ OWNER$
Schedule C
Name of Business
*
Employer ID Number (Leave blank if using your ssn)
EIN
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is the legal structure of your business?
*
Choose One
Sole Proprietor
Partnership
Corporation
LLC
Non-Profit
Haven't Filed It
What is your NAICS code or business industry code? If you do not know, please tell us what type of business this is.
*
Amount of business taxes paid throughout the year?
$
What month, day, and year did you start using this vehicle for business use?
What is the make and model of your vehicle used for business purposes?
$Business OWNER$
PLEASE INCLUDE EIN, ARTICLES FROM YOUR STATE!
Total Income
Business Expenses
Complete to the best of your ability. In each field enter the approximate amount you spent in each category.
Advertising
Commericials, busisiness cards, flyers, photoshoot etc?
Contract Labor
Someone Paid to work with you or for you!
Insurance
(Other than health)
Interest
Mortgage, Loans, Credit Cards, etc.
Legal & Professional Services
Training, Conferences, Mentors, Lawyers, etc
Office Expenses
Software, postage, email, internet, and any operating expenses
Did you pay any commercial rent? If so, how much for the year?
*
Rent and Lease
Vehicles, Machinery, Equipment, Electronics, Accessories, etc.
Repairs and Maintenance
Supplies
Taxes and Licenses
Travel, Meals, and Entertainment
Utilities
Other Expenses
Is there any other information, questions, or concerns that you want to include to your tax preparer pertaining to your business?
Attach any photos or documents that you want us to have on file.
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Expenses
Check the expenses you paid for during the tax year and have documentation.
Types of Expenses
IRA's
Property Tax
Mortgage Interest (Form1098-INT)
Tax Prep Expenses
Union Dues
Education Expense (1098-T)
Significant Loss or Theft
Additional Types of Expenses
Charity Contributions
Mortgage Investment
Moving Expenses
Medical Expense
Alimony Paid
Buy or Sell Home
Job Related Expenses
Other
Please upload any Expenses listed above (1098-T, 1098-INT, etc..)
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Health Insurance
Please make sure you answer this question to the best of your knowledge to avoid your refund being DELAYED!
What type of coverage did you have?
Employer/Job Health Plan
Medicaid/State/Healthy Kids Plan
Medicare
Healthcare.gov Marketplace/ObamaCare
Other
Did you receive a Health Insurance Coverage Form (1095-A, 1095-B, or 1095-C)?
*
Yes
No
Other
Do you and/or your dependents have any medical bills? (this includes prescriptions, co-pays, vision and dental, etc...)
*
Yes
No
If so, how much for the year?
Do you pay for medical insurance out of pocket? If so, how much monthly?
*
Did you and all household have health care coverage during the tax year?
*
Yes
No
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Additional Questions
Do you pay tithes to your church or make monetary donations to charity or non profit?
*
Yes
No
If so, how much for the year?
Do you pay for your parents living expenses including rent, mortgage, utilities, or medical bills?
*
Yes
No
If so, how much for the year?
Have you ever been disallowed certain credits or had them reduced in previous years such as EIC or education credits?
*
Yes
No
E- Signature Below
*
By filling out this form, you are giving us permission to prepare your tax return and you are confirming that ALL information entered is accurate. If you have any questions do not hesitate to call 615-633-6300 or 615-987-2005 or email us info@auniqueexperience.org
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