Client Intake Form

Client Intake Form
Mayberry Professional Group
3379 Peachtree Rd, NE
Atlanta, GA 30326
info@mayberryprofessionalgroup.com
www.mayberryprofessionalgroup.com
(800) 571-0065
Tax Year Filing
What Tax Year Are You Needing Assistance With?
Are You Behind On Any Tax Filings? If So, Which Year(s)?
Personal Information
Taxpayer's Information

First NameLast Name
Birth Date

MonthDayYear
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Taxpayer's ID

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Taxpayer's SSN

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Spouse's Information

First NameLast Name
Birth Date

MonthDayYear
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Spouse's ID

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Spouse's SSN

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Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dependent Information
Dependent's Information (1)

First NameLast Name
Birth Date

MonthDayYear
Dependent's SSN

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Dependent's Birth Certificate

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Dependent's Information (2)

First NameLast Name
Birth Date

MonthDayYear
Dependent's SSN

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Dependent's Birth Certificate

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Dependent's Information (3)

First NameLast Name
Birth Date

MonthDayYear
Dependent's SSN

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Dependent's Birth Certificate

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Filing Status
Filing Status
Income
Do you have a W2?
Are you a contractor? (1099 or self-employed?)
Upload Income Documents (W2, 1099-NEC, 1099-INT, 1099-C)

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Did you receive unemployment?
Upload 1099-G

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Did you receive any retirement, dividend, or gambling income?
Did you receive social security income?
Upload 1099-SSA

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Business Information
Do you own a business or a pay side hustle?
What is the name of your business?
What business activity do you perform?
Do you have a EIN?
Do you have business income?
Do you have business expenses?
Gross Income
Rent
Advertising
Repair
Insurance
Supplies
Legal Fees
Licenses
Utilities
Wages
Post High School Education
Did you, your spouse, or any of your dependents attend school?
What college or university did you, your spouse, or dependent(s) attend?
Upload 1098-T

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Insurance
Did you receive insurance from the HealthPlace market?
Upload your 1095-A

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Tax Liability
Do you owe a governmental tax liability such as student loans, IRS, state, city, county, child support, food stamps, unemployment, USDA, or the SBA?
If yes, which agency do you owe? And how much do you owe?
Have you ever received a letter from the IRS about claiming ineligible credits for things such as fuel, household employees, unemployment, Covid 19, or reporting the IRS owes you money from a previous year?
If yes, which agency do you owe? And how much do you owe?
Tax Advance
Do you want to apply for a tax advance, that has to be repaid?
Advances are up to $7000, are you ok with this?
The tax advance is NOT free. There is a finance charge associated with the advance. It MUST be paid back via your tax refund. If you understand and agree, type "I Agree."
How do you want your advanced and refund disbursed ?
Banking Information
Bank Name
Routing Number
Account Number
Referrals
Did anyone refer you?
If yes, who referred you?

First NameLast Name
Choose Your Professional
Which agent would you like to work with?
Type any additional information you would like to your tax professional to concerning your tax return.
Consent To File
Filling out this form and submitting it is also giving the company consent to file your tax return. If you DO NOT want to file, please DO NOT submit this form. If you understand and agree, please type I consent to filing my tax return with Mayberry Professional Group.
Signature
Schedule Your Appointment
Appointment
Should be Empty:

Client Intake Form

Tax Year Filing

Personal Information

Dependent Information

Filing Status

Income

Business Information

Post High School Education

Insurance

Tax Liability

Tax Advance

Banking Information

Referrals

Choose Your Professional

Consent To File

Schedule Your Appointment