CLIENT INTAKE FORM

First Name

Last Name

Email *

Date of birth

Phone *

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Address

Street Address

City

State

Country

Postal code

Filing Status

Occupation(Taypayer#1)

SSN/ITIN

Driver License#

DL Issue Date (TaxPayer 1)

DL Expiration Date (TaxPayer 1)

Identity Protection PIN-Identity Theft Victim

First Name (Taxpayer 2)

Middle Name (Taxpayer 2)

Last Name (Taxpayer 2)

Occupation (Taxpayer 2)

SSN/ITIN (Taxpayer 2)

Birth Date (Taxpayer 2)

Drivers License # (Taxpayer 2)

DL Issue Date (Taxpayer 2)

DL Expiration Date (Taxpayer 2)

Phone Number (Taxpayer 2)

Email (Taxpayer 2)

Identity Protection PIN-Identity Theft Victim (Taxpayer 2)

Choose All That Applies To You

Types of Income(choose all that apply)

Are you self-employed?

Yes

No

Do you receive a 1099?

Yes

No

Do you have a EIN?

Yes

No

Is your business registered with State Corporations Division?

Yes

No

Dependent 1

Dependent First Name#1

Dependent Middle Name#1

Dependent Last Name#1

Dependent DOB#1

Dependent SSN#1

Dependent Relationship#1

Number of months Dependant#1 lived with you in the US?

Did you pay for Dependent 1 daycare?

Yes

No

Do You Have Another Dependent

Yes

No

Dependent 2

Dependent First Name#2

Dependent Middle Name#2

Dependent Last Name#2

Dependent DOB#2

Dependent SSN#2

Dependent Relationship#2

Number of months Dependant#2 lived with you in the US?

Did you pay for Dependent 2 daycare?

Yes

No

Do You Have Another Dependent?

Yes

No

Dependent 3

Dependent First Name#3

Dependent Middle Name#3

Dependent Last Name#3

Dependent DOB#3

Dependent SSN#3

Dependent Relationship#3

Number of months Dependant#3 lived with you in the US?

Did you pay for Dependent 3 daycare?

Yes

No

How would you like to receive your Federal refund?

How would you like to receive your State refund?

Bank Name(Direct Deposit ONLY)

Bank Routing#

Bank Account#

ID, Birth Certificate, Social, Medical Card or Lease Agreement

Please Upload All Pertinent Data

Signature

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