Tax Preparation Client Intake Form

Tax Preparation Client Intake Form

Submit your information to EmpowerMint Financial Group for professional tax preparation.
202520242023Multiple Years
Your Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Primary Taxpayer – 6-Digit IP PIN
Please ensure you have not been issued a IPPIN
SingleMarried Filing JointlyMarried Filing JointlyHead of HouseholdWidow(er)
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Spouse – 6-Digit IP PIN (if applicable)
Social Security Number:*
Email Address*
example@example.com
If more than one IP PIN was issued, each IP PIN must be assigned to the correct individual listed on the return.
Current Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Spouse Name (If Applicable)

First NameLast Name
Spouse SSN/ITIN
Spouse Identification Number
Driver License, State Identification
Dependents Information
YesNo
Dependent Information (Name, Relationship, Date of Birth) (Complete only if you have dependents)
Dependent IP PIN Assignment
Dependents Social/ITIN
Banking Information
Routing Number*
Account Number*
SingleMarried Filing JointlyMarried Filing SeparatelyHead of HouseholdQualifying Widow(er)Other
PRIOR IRS AUDIT HISTORY
YesNo
Audit Details
W-2 EmploymentSelf-Employment (1099)Unemployment BenefitsRetirement IncomeInvestment/Interest Income1095-A/1099-SAGamblingOther
MARKETPLACE HEALTH INSURANCE (ACA)
You may be required to provide Form 1095-A if Marketplace insurance was held.
YesNo
Not sure if you had Marketplace insurance? You can verify here: https://www.healthcare.gov/tax-form-1095/
Education CreditsChild Tax CreditEarned Income CreditRetirement ContributionsMedical ExpensesOther
YesNo
Upload last year's tax return (optional)

Cancelof
Upload Verifying Documents (Driver License or I.D., Birth Certificates, Social Security Cards)*

Cancelof
Upload Additional Forms (if available)

1099,1099-SA,1095-A etc.
Cancelof
REFUND ADVANCE / PRE-ADVANCE LOAN
YesNo
Refund advances are not guaranteed. Loan terms, amounts, and timing are determined by the participating financial institution. Please note not credit based.
After submitting this form, you will receive a confirmation email with client onboarding information. Key information you are responsible for any unpaid service fee. You'll be responsible for the preparer fee $250minimum if a service is provided and balance is not satisfied.
Should be Empty:

Tax Preparation Client Intake Form

Dependents Information

Banking Information

PRIOR IRS AUDIT HISTORY

MARKETPLACE HEALTH INSURANCE (ACA)

REFUND ADVANCE / PRE-ADVANCE LOAN