Client Intake Form Please enable JavaScript in your browser to complete this form.New Client *New ClientReturning ClientPERSONAL INFORMATIONFiling Status (copy) *Head of Household SingleMarried/Jointly Married/SeparatelyWidowerTaxpayerSocial Security *Name *Birthdate *Occupation *Phone *Work Phone *Email *FacebookInstagramAddress *SpouseSocial SecurityNameBirthdateOccupationPhoneWork PhoneEmailFacebookInstagramAddressDEPENDENT INFORMATION (First Kid)Dependent Name (First, Last)Date of BirthSocial SecurityDependent’s Relationship to youMonths dependent lived in your home in 2020College Student / Disabled/DaycareYesNoDEPENDENT INFORMATION (Second Kid)Dependent Name (First, Last)Date of BirthSocial SecurityDependent’s Relationship to youMonths dependent lived in your home in 2020College Student / Disabled/DaycareYesNoDEPENDENT INFORMATION (Third Kid)Dependent Name (First, Last)Date of BirthSocial SecurityDependent’s Relationship to youMonths dependent lived in your home in 2020College Student / Disabled/DaycareYesNoDEPENDENT INFORMATION (Fourth Kid)Dependent Name (First, Last)Date of BirthSocial SecurityDependent’s Relationship to youMonths dependent lived in your home in 2020College Student / Disabled/DaycareYesNoQUESTIONNAIRECan you provide any records that show the dependents lived with you? (medical/school records, daycare letter) *YesNoDid you have Medicaid or health insurance through your job every month last year? *YesNoIf no, did you purchase health insurance from the marketplace (Obamacare)? (Form 1095-A is needed if yes). *YesNoDid you receive a refund last year? *YesNoRefund Amount *If no, why? *Did you receive the stimulus? *YesNoAmount *If no, why? (copy) *Was anyone listed on this form a college student during the last year? (If yes, form 1098T from the college is needed). *YesNoDid you pay for daycare or afterschool care fr any of your dependents that are under 12? (If so, please provide a daycare letter). *YesNoTotal number of:W21099MISCUnemployment form (1099G)1098tOtherSELF EMPLOYED/1099MISC/BUSINESS INFORMATION(Must complete business questionnaire form)Were you self employed and/or had business income/expenses last year? (If so, please complete the business questionaire provided by your tax advisor) *YesNoATTESTATION STATEMENTUnder the penalties of perjury, I/We attest that all information supplied and contained on this form is true, correct, to the best of my/our knowledge.How did you hear about us?Yard Sign Business Card/FlyerFacebook/IGReferralLicense Click or drag files to this area to upload. You can upload up to 2 files. Socials Click or drag files to this area to upload. You can upload up to 5 files. Birth certificates Click or drag files to this area to upload. You can upload up to 3 files. Utility bill from last year Click or drag files to this area to upload. You can upload up to 2 files. Tax Forms Click or drag files to this area to upload. You can upload up to 5 files. EmailSubmit
