C & C TAX CLIENT INTAKE FORM

Thank you for allowing and trusting Claim & Conquer Tax to assist you with your taxes this year. Your confidence in us means so much, and we truly appreciate your business. We look forward to continuing to serve you with excellence and care.

✨ This tax season, we’re excited to offer AMAZING incentives: ✨
- Earn $25–$75 for every new client you refer to Claim & Conquer Tax!
- Take advantage of same‑day cash advances with high approval rates.
- Rest assured—we GUARANTEE you the maximum refund possible.
If you have any questions or would like to get started, feel free to text or call us directly at 859‑704‑0442.

Together, let’s Claim your refund & Conquer tax season!
Client Details:
Full Name*

FirstLast
Occupation/Job Title
Social Security Number *
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*
Phone Number*
E-mail*
example@example.com
Spouse
Full Name
Occupation/Job Title
Date of Birth
Social Security Number
E-mail
What is your filing status?*

SingleHead of HouseholdMarried Filing SeparateMarried Filing JointlyQualifying WidowUnsure
Would you like to designate funds to a political party?

Yes/RepublicanYes/DemocraticNO!
Do you have dependents?*

YesNo
Dependent 1
Full Name
Date of Birth
Social Security Number
What is the relationship?

SonDaughterNieceNephewSisterBrotherOther
Dependent 2
Full Name
Date of Birth
Social Security Number
What is the relationship?

SonDaughterNieceNephewSisterBrotherOther
Dependent 3
Full Name
Date of Birth
Social Security Number
What is the relationship?

SonDaughterNieceNephewSisterBrotherOther
Dependent 4
Full Name
Date of Birth
Social Security Number
What is the relationship?

SonDaughterNieceNephewSisterBrotherOther
Dependent 5
Full Name
Date of Birth
Social Security Number
What is the relationship?

SonDaughterNieceNephewSisterBrotherOther
What type of income do you have?

W21099 INDEPENDENT CONTRACTORSELF EMPLOYMENT/SIDE HUSTLERETIREMENT(1099R)UNEMPLOYMENTOTHER
Do you have an IP PIN?*

YesNo
Do you have a HSA?

YesNo
Did you pay for child care or a babysitter?

YesNo
Do you pay mortgage?

YesNo
What is your monthly rent/mortgage amount?
Were you enrolled in school in 2025?*

YesNo
Are you on disability?

YesNo
Will you be applying for a house in the next year or two?

YesNo
Do you currently owe the IRS for any previous tax year?

YesNo
Do you owe back child support?

YesNo
Would you like to take advantage of our audit protection for $79(comes out of refund)?

YesNo
Would you like a cash advance up to $1000 w/ NO finance charge or $7500 WITH finance charge?

Yes, up to $1000Yes, up to $7500NO!
How would you like to receive your refund?*

Direct Deposit (please enter acct info below)MONEY CARDCheck
BANK NAME
ACCOUNT #
ROUTING #
Did you receive your refund last year?

YesNo
What was your 2024 refund amount?
Please enter your AGI from your last year return
Upload All Required Identification Documents For You, Dependents (if any), & Spouse (if applicable)*

Driver's license, SS cards, etc
Cancelof
Upload Income Documentation (W2, 1099, 1099R, 1098T, 1098E)*

PLEASE make sure you have received ALL w2s from ALL employers before submitting.
Cancelof
If self-employed, what is your business description? (babysitter, hairdresser, barber, lash tech and etc.)
If self employed, How much income did you make in 2025?
Self Employed/Side Hustle

Please upload ALL expenses for your business for example: supplies, rent, utilities, advertisement, etc
Cancelof
Who referred you?
Would you be willing to refer me?

YesNo

Please give reference of at least one or two people whom you feel could use my services:

Rows	Full Name	Contact Number	Email
1
2
3
4
5

Claim & Conquer Tax also offers LLC Formation packages! Would you like more info sent to your email about this service?*

YESNOI'd rather set up an in-person meeting
Security Question
What was the name of your High School?
Signature
Should be Empty:

Client Details:

Spouse

Dependent 1

Dependent 2

Dependent 3

Dependent 4

Dependent 5