Tax Professional
Please Select
Tamara
Arlinda
Kesha
Sh'Timara
AMENDED TAX RETURN INTAKE FORM
1. CLIENT INFORMATION
Full Name:
Date of Birth:
-
Month
-
Day
Year
Date
SSN (Last 4 digits):
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Current Address:
Filing Status:
Single
HOH
MFJ
MFS
QW
2. ORIGINAL RETURN DETAILS
Tax Year Being Amended:
Date Original Return Filed:
-
Month
-
Day
Year
Date
Prepared By:
Self
Tax Professional
Other
Filed:
Electronically
Paper
Refund or Balance Due:
Original Refund Received?
Yes
No
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3. REASON FOR AMENDMENT
Reason for Amendment
Forgot income
Incorrect income
Add/Remove dependent
Filing status correction
Missed credits
Incorrect deductions
1095-A corrections
IRS/State notice
Other
Explanation:
4. INCOME CHANGES
W-2: Original $
Correct $
1099: Original $
Correct $
Self-Employment: Original $
Correct $
Other: Original $
Correct $
5. DEPENDENT CHANGES
Dependent Change Type
Add
Remove
Name:
SSN:
DOB:
Relationship:
6. DEDUCTIONS & CREDITS
Child Tax Credit
EITC
Education
Energy
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Medical
Charitable
Business
Other
Explanation:
7. HEALTH INSURANCE
Received 1095-A?
Yes
No
Included originally?
Yes
No
Corrections needed?
Yes
No
8. IRS / STATE NOTICES
Received notices?
Yes
No
Explanation:
9. DOCUMENT CHECKLIST
Original tax return
New/corrected documents
Notices
ID
SS cards (dependents)
Supporting documents
10. BANKING INFO
Bank Name:
Routing Number:
Account Number:
Back
Next
Checking Savings
Checking
Savings
11. CERTIFICATION
I certify all information is true and complete.
Signature:
Date:
-
Month
-
Day
Year
Date
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12. PREPARER NOTES
Risk Level:
Low
Moderate
High
Notes:
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