Tax Intake Form

Select Your Tax Professional

Did a friend send you?

Enter Name or Promo Code Here

Tax Payers Name*

First NameLast Name

Taxpayer's Email Address*

example@example.com

Taxpayer's Phone Number*

Example: xxx-xxx-xxxx

Taxpayer's Job Title*

Taxpayer's Date of Birth*

Example: 01/01/2001

Taxpayer's SSN*

Example: xxx-xx-xxxx

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Did you file a tax return last year?*

YesNoUnsureOther

Do you currently owe to Child Support or to the IRS?*

YesNoUnsureOther

Upload last year's Tax return

Tax Return

What is your marital status as of December*

Single (Not Married)Married Filing JointlyMarried Filing SeparatelySurviving Widow

Can someone else claim you as a dependent?*

YesNo

Are you and/or your spouse disabled?*

YesNo

Did you and your spouse live apart during the year?

YesNoNot Applicable

If yes, did you live together at any time after June 30th?

YesNoNot Applicable

Spouse's Full Name

Full Name

Spouse's SSN

Example: xxx-xx-xxxx

Spouse's Date of Birth

Example: 01/01/2001

Spouse's Phone Number

Example: xxx-xxx-xxxx

Spouse's Email Address

Example: example@example.com

Spouse's Job Title

Are you trying to buy a new home within the next year?*

YesNo

Did you pay over half the expenses of maintaining your residence for the entire year?*

YesNo

Are you on any Government Assistance*

YesNo

Did you support a child or family member for more than 6 months out of the year?*

YesNo

How many dependents are you claiming?*

Dependent #1

First NameLast Name

Dependent #1 Date of Birth

01/01/2001

Dependent #1 SSN

What is Dependent #1's Relationship to you ?

(son, daughter, mother, etc.)

How many months did Dependent #1 live with you last year? (If all year, enter 12)

Is this Dependent disabled?*

YesNo

Dependent #2

First NameLast Name

Dependent #2 Date of Birth

Example: 01/01/2001

Dependent #2s SSN

Example: xxx-xx-xxxx

What is Dependent #2's Relationship to you?

(son, daughter, etc.)

How many months did Dependent #2 live with you last year? (If all year, enter 12)

Is this Dependent disabled?*

YesNo

Dependent #3

First NameLast Name

Dependent #3's Date of Birth

01/01/2001

Dependent #3s SSN

Example: xxx-xx-xxxx

What is Dependent #3's Relationship to you?

(son, daughter, etc.)

How many months did Dependent #3 live with you last year? (If all year, enter 12)

Is this Dependent disabled?*

YesNo

Dependent #4

First NameLast Name

Dependent #4's Date of Birth

01/01/2001

Dependent #4's SSN

Example: xxx-xx-xxxx

What is Dependent #4's Relationship to you?

(son, daughter, mother, etc.)

How many months did Dependent #4 live with you last year? (If all year, enter 12)

Is this Dependent disabled?*

YesNo

Are there any dependents in daycare? If yes, please upload the form you received from your daycare provider.

YesNo

Upload a copy of your daycare form here.

If you do not have a daycare form, please provide Name, Address, and EIN/ SSN and amount paid for childcare:

If requested by the IRS, do you have documentation (i.e. receipts, records) to substantiate your eligibility for the Child Tax Credit, Earned Income Tax Credit and/or Head of Household Filing Status?*

YesNo

Are you self employed or do you own a business?*

YesNo

What is your business name?

What type of business do you have or what type of services do you provide?

Provide a copy of your Business EIN.

Upload a copy of your DBA or LLC Certificate.

Self-Employment Expense Log, Summary of Income, Business License, Bank Statements, receipts, etc

Did you own livestock?

YesNoOther

Did you have health insurance last year?*

YesNo

Was your insurance through:

Your EmployerMedicaidAffordable Care Act (the healthcare.gov marketplace)Other

Upload Taxpayer & Dependent(s)Insurance Document- 1095-A (if applicable)

Have you ever been denied or disallowed the Earned Tax Credit (EITC)?*

YesNo

Were you or any of your dependents in college last year?*

YesNo

Do you have a 1098-T Form from a college for either you or your dependents?

YesNo

Did you trade any Virtual Currency

YesNo

Did you own or rent your home last year

RentOwnNot Applicable

Anything else we should know to prepare your taxes?

Taxpayer's and Driver's License

Spouse's Driver's License

Taxpayer's and Dependent(s ) Social Security Card(s)

Taxpayer's W-2/ 1099'S/

If you have a 1098-T form, upload it here.

Dependent(s) Birth Certificate(s)

Dependent(s) Proof of Residency (Lease/Utility Bill)

Additional Documents

I do hereby state, the information list on this form with regards to my Personal and/or Business is true and accurate to the best of my ability. I further understand, the submitted information on this form will be submitted to VVI LLC, dba, Vital Investments Insurance & Multi-Services, to be used on my tax return. Should the IRS request documentation pertaining to the information listed on this form; I do hereby state, I will submit any and all receipts, invoices, bill etc; to the IRS upon request, as it relates to my Personal or Business listed for the Tax Year submitted.

I agree to hold VVI LLC, dba, Vital Investments Insurance & Multi-Services harmless, should an audit arise from the information pertaining to my Personal or Business. I am aware that I have the option to select audit protection from Protection Plus for my tax file. My signature at the end of this form shall serve as my agreement to the information listed on this tax return.

Primary Taxpayer Signature*

Spouse Signature

How would you like to receive your tax refund?*

CheckDirect Deposit

Name of Bank

Which type of account would you like your refund deposited into?

Checking AccountSavings AccountOther

Routing Number *

Bank Account Number *

Consent for Payment

Vital Investments Insurance & Multi-Services values our relationship with our clients. We are in the business to provide you with the best service possible. We want to remind you that you are being provided a service and not a tax refund. You as a taxpayer have the option to pay your tax preparation fees by: cash, credit or debit card, electronic payment, or directly from your refund.

If you choose to have the tax preparation fees taken from your refund and your taxes are intercepted, YOU ARE STILL RESPONSIBLE FOR THE TAX PREPARATION FEES! By signing your return, you are agreeing to pay the tax preparation fees regardless of if your refund is released or not.

Upon our notification of your refund being intercepted, we will send you an invoice for payment.

NOTE: The Department of Treasury's Financial Management Services (FMS) can offset ANY UNPAID federal or government debt against your refund WITHOUT prior notice.

Most commonly, the offset is taken for: Past due child support, Debts owed to a federal/ state agency, Unemployment debts owed to state, and/or past due federal student loans.

ACH Authorization Form

I, hereby authorize VVI LLC, dba, Vital Investments Insurance & Multi-Service, to initiate electronic debits to my bank account for the purpose of collecting payment for the services related to the preparation of my tax return. I understand and agree to the following terms:

Payment for Tax Preparation Services: I acknowledge that I am engaging VVI LLC, dba, Vital Investments Insurance & Multi-Service for the professional service of preparing my tax return. Payment is not contingent upon the approval or funding of my tax refund.

Billing Authorization: In the event that my tax refund is not approved and funded within 30 days through a bank product with a third-party bank, I authorize VVI LLC, dba, Vital Investments Insurance & Multi-Service, to electronically debit my bank account for the full amount of the tax preparation fees as agreed upon. This debit will be initiated as soon as practicable after the 30-day period has lapsed.

Bank Account Information: I have provided accurate and current information regarding my bank account for the purpose of this electronic debit authorization.

Right to Revoke: I understand that I may revoke this authorization at any time by providing written notice to VVI LLC, dba, Vital Investments Insurance & Multi-Service. Such revocation will not affect any fees or charges that have already been incurred.

Record Keeping: VVI LLC, dba, Vital Investments Insurance & Multi-Service, will retain a copy of this authorization form, and I will receive written notice of any changes in the payment amount or schedule at least 10 days prior to the initiation of any debits.

By signing below, I confirm that I have read and understand the terms of this ACH Authorization Form and agree to be bound by them.

Tax Prep Fees starting at $150+

Spouse's Signature

Primary Taxpayer's Signature*

Date*

Date

Date for Spouse

Date

ADDITIONAL SERVICES: At Vital Investments, we do more than just taxes. Please check below if you would be interested in any of the additional services we provide. Schedule a FREE consultation at: https://www.vitalinvestments.agency

1. Health, Dental & Vision Insurance

2. Life Insurance (Term & Whole Life)

3. Funeral/Final Expenses

4. Business Set-Up

5. Bookkeeping Services

6. Business Contract Preparation Services

7. Business Consulting Services

2023 CLIENT TAX INTAKE FORM