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CLIENT INTAKE FORM
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Email
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Date of birth
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Address
Street Address
City
State
Country
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)
Did you have health insurance?
Yes
No
Choose Who Had Health Insurance
Did you receive form 1095A from Marketplace?
Yes
No
Who Received Form 1095A?
Are you a U.S. citizen, U.S. national, or U.S. resident alien?
Yes
No
Are you a qualifying dependent on another person's return?
Yes
No
Can anyone else claim your children on their return?
Yes
No
Were you separated for last 6 months of the year?
Yes
No
Do you owe any student loans?
Yes
No
Do you owe child support?
Yes
No
Do you have any outstanding debt with the IRS?
Yes
No
Do you have a payment arrangement with IRS?
Yes
No
Would like help with consolidating student loans?
Yes
No
Do you own a business?
Yes
No
Would like help with Business Startup?
Yes
No
Would you like to see, if you qualify for a Business Loans?
Yes
No
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
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
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
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Email:
[email protected]
Phone : (404) 857-8428
Address: 3295 River Exchange Dr. STE 400, Norcross GA 30092
