Individual Intake Form

Subject *

Your Email *

First Name *

Last Name *

Social Security# *

Occupation

Date of Birth *

Cell Phone# *

Home Phone#

Home Address#

Marital Status: *

Single

Qualifying Surviving Spouse

Head of Household

Married Filing Jointly

Active Military Duty? *

Yes

Are you legally blind? *

Yes

Bank Name

Account Number

Qualifying Child Care expense incurred and paid

Please identify child associated with dependent care expense

Education Expense Paid

Please identify child associated with education expense

(if applicable)

#1 Entity Name

Charitable contribution

#1 Amount

Charitable contribution

#2 Entity Name

Charitable contribution

#2 Amount

Charitable contribution

#3 Entity Name

Charitable contribution

#3 Amount

Charitable contribution

Do you own or rent? *

Own

Rent

Please provide complete information
to receive appropriate deductions.

Did you file Sch. C last year? *

Yes

1. Dependent/s Information *

Yes

Did you: *

Move within the tax year?

Live in another state?

Income (W-2, 1099-R, 1099-G, 1099-SA, 1099-Misc.): Did you ... *

Receive W-2 Forms from ALL employers you worked for last year?

Receive alimony payments?

Receive Social Security income (1099-SA)?

Receive pension, annuity, ROTH, IRA, or other retirement income (1099-R)?

Receive royalties?

Receive 1099-Misc. income (prizes, awards,jury duty, etc.)?

Own your own business or work as self-employed (1099-NEC)?

None

Did you receive unemployment compensation (1099-Ci)? *

Yes

Did you receive a state tax refund? *

Yes

Did you take a distribution from any retirement account? *

Yes

Did receive gambling winnings (W2-Ci)? *

Yes

Do you own your own business or work as self-employed (1099-NEC) *

Yes

Investments (1099-B, 1099-INT and 1099-DIV): Did you ... *

Receive interest on savings, cash, U.S. Bonds or stock dividends (1099-INT/1099-DIV)?

Sell stock, mutual funds, or other securities (1099-B)?

Receive interest on a Partnership, S-Corp, Estate, or Trust (Kl)?

None

Contribute to a ROTH IRA $

Contribute to a Traditional IRA $

Contribute to a SEP $

Contribute to a Keogh $

Contribute to a Simple Retirement Plan $

Have a Health Savings Account (HSA)?

Yes

Sell your home or any other property (equipment, land, etc.)? *

Yes

Did you have health insurance coverage? *

Yes

Is your spouse covered by your plan? *

Yes

Did you have coverage through the Marketplace? *

Yes

Did you have coverage through your employer? *

Yes

Were your dependents covered by your plan? *

Yes

Upload any supporting financial documents

Other Expenses

List and state the amount of any other expenses e.g Job Expenses, Vehicle Registration Expense, Home Mortgage Interest, Property Taxes, Tax Preparation Fees and Child Care Fees.

Submit