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CLIENT INTAKE

Client Intake Form

Please complete the information below so we can prepare your return accurately. All fields are confidential and used solely for tax preparation purposes.

Estimated time: 10–15 minutes

Preferred Tax Preparer *

Choose your preferred tax preparer

Referral Affiliate Name

First Name *

Last Name *

Social Security Number *

Date of birth *

Occupation *

Email *

Phone

Address

Street Address *

Country *

Enter your country

State *

City *

Postal Code *

First name (Spouse)

Last Name (Spouse)

Suffix

Social Security Number

Date of Birth (Spouse)

Occupation

Email (Spouse)

Phone Number

Filing Status *

HEAD OF HOUSEHOLD FILERS MUST PRESENT ONE OF THE FOLLOWING TO FILE THIS STATUS. PICK ONE OF THE OPTIONS THAT YOU WILL SUBMIT TO BE APPROVED TO FILE HEAD OF HOUSEHOLD.

First Name (Dependent 1)

Last Name (Dependent 1)

Suffix (Dependent 1)

Social Security Number (Dependent 1)

Date of Birth (Dependent 1)

Relationship (Dependent 1)

First Name (Dependent 2)

Last Name (Dependent 2)

Suffix (Dependent 2)

Social Security Number (Dependent 2)

Date of Birth (Dependent 2)

Relationship (Dependent 2)

First Name (Dependent 3)

Last Name (Dependent 3)

Suffix (Dependent 3)

Social Security Number (Dependent 3)

Date of Birth (Dependent 3)

Relationship (Dependent 3)

First Name (Dependent 4)

Last Name (Dependent 4)

Suffix (Dependent 4)

Social Security Number (Dependent 4)

Date of Birth (Dependent 4)

Relationship (Dependent 4)

If claiming son/daughter, where is the other parent of the dependent/dependents? Is the other parent providing any financial support?

If claiming niece, nephew, aunt, or uncle, how are you related to the dependent? Where are the parents?

If claiming brother or sister, how are you related to the dependent? Why are the parents not claiming the dependent/dependents?

If low income status, how are you able to provide for the dependents?

Did you pay someone to watch your child/children?

Are you married?

Can you provide separation/divorce paperwork?

Did you collect Social Security or retirement income?

Did you purchase health insurance through Healthcare.gov Marketplace?

If yes, did you receive a 1095-A Form from the Marketplace?

Were you ever disallowed the E.I.T.C. prior to this year?

Did you receive unemployment compensation (1099-G), regular or PUA, last year?

Did you make college tuition payments and receive a 1098-T Form last year?

Do you have any other income than your W-2(s)?

Do you have an IP PIN?

IP PIN

Do you owe any delinquent:

Refund Advance

Refund Method

Name of Bank

Routing Number

Account Number

Are you filing self-employed? (Schedule C)

Self-Employed's Name

Business Name (Optional)

Employer Identification Number (if applicable) or SSN

If you were not able to upload a Profit and Loss Statement, can you provide proof of income and expenses?

First Name (Household Employee)

Last Name (Household Employee)

Total amount you collectively received for the year from employer(s):

First Name (Employer1)

Last Name (Employer1)

Address (Employer1)

Total Amount Earned (Employer1)

Service Performed (Employer1)

First Name (Employer2)

Last Name (Employer2)

Address (Employer2)

Total Amount Earned (Employer2)

Service Performed (Employer2)

First Name (Employer3)

Last Name (Employer3)

Address (Employer3)

Total Amount Earned (Employer3)

Service Performed (Employer3)

First Name (Employer4)

Last Name (Employer4)

Address (Employer4)

Total Amount Earned (Employer4)

Service Performed (Employer4)

First Name (Employer5)

Last Name (Employer5)

Address (Employer5)

Total Amount Earned (Employer5)

Service Performed (Employer5)

Primary Taxpayer's Signature

Spouse's Signature

Date (Taxpayer Signature)

Date (Spouse Signature)

Username / Email Used for ID.me (Optional)

Identification for Taxpayer

Identification for Spouse

Social Security Card for Taxpayer

Social Security Card for Spouse

Social Security Card for Dependent 1

Social Security Card for Dependent 2

Social Security Card for Dependent 3

Social Security Card for Dependent 4

Head of Household (Lease / Utility Bills)

Dependent Birth Certificates

Dependent Social

W-2

Self Employment (Business Profit Statement / Bank Statement)

College Forms (1098-T / Receipts)

Healthcare Forms (1095-A Marketplace)

IP PIN (Paper from IRS)

Direct Deposit Documentation

Misc. Forms

Previous Year Tax Return

Signature (Final Authorization)

Date (Final Authorization)

I have reviewed the information above and agree to the authorization and terms.

Financial Guidance. Business Strategy. Growth Solutions.

Financial consulting · Business development · Tax services · Credit education · Business systems · Training · Mentorship · Tax professional development

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Disclaimer: A1 Biz Consulting provides financial guidance, business consulting, tax services/education, and credit education. Information provided is educational and does not guarantee financial, business, tax, credit, or income results. Individual results depend on circumstances, decisions, effort, and execution. Credit-related services are provided as credit education and strategy, not credit repair. Tax services and education are subject to applicable federal and state requirements, including Circular 230 where applicable.

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