This is a “CLIENT INTAKE FORM” and the information provided will help to get you an accurate quote.¬†Provide as much information as you can in the form. At the end of the form please remember to upload an image of your last check stub, W2, ID, and any other information that can help to MAXIMIZE your return.

How did you hear about us?:

Word of mouthInternetFlyer / CardAdvertisement / bannerRadioTvOther

Referred by name:

Referred by email:

Promo Code:

Taxpayer Information:

Name:

SSN:--

Date of Birth://

Day Phone #:()-

Evening #: ()-

Please check one of the above phone numbers for us to contact if we have any questions.

Address: Street # Street Name

City: State: Zip:


Spouse Information:

Name:

SSN:--

Date of Birth://

Day Phone #: ()-Evening #: ()-


Child/Dependent # 1

(Additional dependents enter on page 2)

Name:

SSN:--

DOB://

Check One:

SonSisterDaughterNieceParentNephewGrandparentAuntGrandchildUncle
Child/Dependent # 2

(Additional dependents enter on page 2)

Name:

SSN:--

DOB://

Check One:

SonSisterDaughterNieceParentNephewGrandparentAuntGrandchildUncle
Child/Dependent # 3

(Additional dependents enter on page 2)

Name:

SSN:--

DOB://

Check One:

SonSisterDaughterNieceParentNephewGrandparentAuntGrandchildUncle
Child/Dependent # 4

(Additional dependents enter on page 2)

Name:

SSN:--

DOB://

Check One:

SonSisterDaughterNieceParentNephewGrandparentAuntGrandchildUncle
Child/Dependent # 5

(Additional dependents enter on page 2)

Name:

SSN:--

DOB://

Check One:

SonSisterDaughterNieceParentNephewGrandparentAuntGrandchildUncle
Child/Dependent # 6

(Additional dependents enter on page 2)

Name:

SSN:--

DOB://

Check One:

SonSisterDaughterNieceParentNephewGrandparentAuntGrandchildUncle

Do you have dependant care expenses? (Daycare)YesNo

Child Care Provider info: Name:

Address: City: State: Zip:

EIN or SSN: Amount Paid: $


General Questions

Can anyone else claim you or your dependents on their taxes?YesNoN/A

Are you or your spouse legally blind?YesNo

Are you, spouse, or any of your dependents disabled?YesNo

Are you, spouse, and dependents able to legally work in US?YesNo

Have you ever been denied EIC (earned income credit)?YesNo

Are any of your dependents married?YesNoN/A

Are any of your dependents over 18 and NOT in school?YesNoN/A


How would you like your Refund? Check one of the following for Federal Refund.
BANK PRODUCT *All bank and prep fees will be withheld from refund check.

Refund payment options:
Direct deposit- Personal accountDebit cardPaper check (Office pickup)Paper Check mailed


Please list any additional information below, such as additional dependents, if anyone is disabled, who, charitable contributions, college or trade school tuition paid, medical and dental expenses, uniforms or other work expenses, etc.

Email Address: Date:

Taxpayer Signature: Date:

Spouse Signature: Date:

__________________________________________________

State Issued ID / Drivers License
tabmembers_photoID

Social Security Card
tabmembers_SS_Card

W2 / Last Paycheck Stub
tabmembers_W2










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