Client Intake Form Step 1 of 3 33% HOW DID YOU HEAR ABOUT US? Social Media FLYERS / DOOR HANGERS Direct Email Personal InformationWere You Referred By Anyone?Name First Middle Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country PhoneEmail Date Of Birth Date Format: MM slash DD slash YYYY DRIVERS LICENSE STATE & #YOUR FILING STATUS SINGLE MARRIED FILING JOINT MARRIED FILING SEPERATE HEAD OF HOUSEHOLD QUALIFYING WIDOW / WIDOWER WHO IS YOUR EMPLOYER?Work Phone NumberSPOUSES NAME ( PUT N/A IF THIS DOES NOT APPLY ) First Last RESIDENCE STATE ( LIST THE STATE YOU RESIDED IN 2019 )NON RESIDENCE STATE ( LIST ANY STATE IN WHICH YOU HAD TAXES WITHHELD, BUT WERE NOT A RESIDENT )DID YOU LIVE AT YOUR ABOVE LISTED ADDRESS FOR 6 MONTHS OR MORE? Yes No DID YOU FILE TAXES LAST YEAR? Yes No IF YES, DID YOU RECEIVE A REFUND? Yes No HOW DID YOU FILE YOUR TAXES LAST YEAR? SELF EMPLOYED W-2 CAN YOU GET A COPY OF YOUR PRIOR YEARS RETURN IF NEEDED? Yes No DO YOU NEED TO FILE FORM 8862? ( STATING THAT YOU WERE DISALLOWED EIC PREVIOUSLY? ) Yes No DID YOU HAVE HEALTH INSURANCE IN 2019? Yes No DID YOUR DEPENDENTS HAVE HEALTH INSURANCE THROUGH YOUR EMPLOYER, STATE, OR OBAMACARE? Yes No IF YES, WHICH DEPENDENTS? DEP #1 DEP #2 DEP #3 ALL DEPS DEPENDENT INFORMATIONIF YOU HAVE ANY DEPENDENTS, PLEASE LIST THEM BELOW. IF YOU HAVE MORE THAN 4 DEPENDENTS, LIST THE REMAINDER ON THE REVERSE SIDE. IF ANY OF YOUR DEPENDENTS DID NOT LIVE WITH YOU IN 2019, PLEASE NOTIFY YOUR PREPARERDEPENDENT #1Name First Last Date Of Birth Date Format: MM slash DD slash YYYY Relationship To YouDEPENDENT #2Name First Last Date Of Birth Date Format: MM slash DD slash YYYY Relationship To YouDEPENDENT #3Name First Last Date Of Birth Date Format: MM slash DD slash YYYY Relationship To YouDID ALL OF YOUR DEPENDENTS STAY WITH YOU AT LEAST 6 MONTHS? Yes No DID YOU FILE THESE SAME DEPENDENTS LAST YEAR? Yes No CHILD CARE PROVIDERIF YOU PAID FOR CHILD CARE FOR YOUR DEPENDENT CHILDREN, LIST THE CHILD CARE PROVIDERS BELOW WITH THE AMOUNTS PAID. IF YOU HAD MORE THAN ONE CHILD CARE PROVIDER IN YEAR 2019, PLEASE LIST ANY ADDITIONAL ONES ON THE BACKCHILD CARE PROVIDER NAME First Last CHILD CARE PROVIDER ADDRESS Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country TOTAL AMOUNT PAID ADDITIONAL INFORMATIONHOW MANY JOBS DID YOU WORK THIS YEAR? 1 2 3 DID YOU RECEIVE UNEMPLOYMENT INCOME? Yes No DID YOU ATTEND COLLEGE, NIGHT SCHOOL, INTERNET SCHOOLING, OR ANY POSTSECONDARY EDUCATIONAL FACILITY TO GAIN A SKILL OR DEGREE? Yes No DO YOU HAVE A 1098-T FORM FROM YOUR SCHOOL Yes No ARE YOU CURRENTLY PAYING OR OWE STUDENT LOANS? Yes No DO YOU OWN YOUR HOME? Yes No DO YOU OWE FOR HOME BUYERS CREDITS? Yes No DID YOU PAY CHURCH TITHES AND OFFERINGS? Yes No DO YOU OWE STUDENT LOANS? Yes No DO YOU OWE BACK CHILD SUPPORT? Yes No DO YOU OWE THE IRS? Yes No HOW WOULD YOU LIKE YOUR IRS REFUND CHECK ISSUED? PAPER CHECK DIRECT DEPOSIT Consent* I HEREBY STATE THAT THE FOREGOING INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND RECOLLECTION AND HOLD NO BEARINGS UPON PREPARERS OR COMPANY STAFFSignatureDate Date Format: MM slash DD slash YYYY
